HomeMy WebLinkAboutResolution - 6568 - Contract - Canada Life Assurance Company - Group Term Life & Accident Insurance - 10_14_1999Resolution No. 6568
Oct. 14. 1999
Item No. 77
RESOLUTION
BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF LUBBOCK:
THAT the Mayor of the City of Lubbock BE and is hereby authorized and
directed to execute for and on behalf of the City of Lubbock a contract for a Group Term
Life and Accident Insurance Policy, by and between the City of Lubbock and Canada
Life Assurance Company of Atlanta, Georgia and related documents. Said contract is
attached hereto and incorporated in this resolution as if fully set forth herein and shall be
included in the minutes of the City Council.
Passed by the City Council this 14th day of October , 19 99 .
Y SI ON, MAYOR
ATTEST:
Victor Kihnan, Purchasing Manager
APPROVED AS TO FORM:
`44� '�t- //
William de Haas
Competition and Contracts Manager/Attorney
gs:ccdocs/Canada Life Assurance Co.res
October 4, 1999
,t
THE CANADA LIFE ASSURANCE COMPANY
® CANADA LIFE 6201 Powers Ferry Rd., NW
OUR STRENGTH SECURES YOUR FUTURE"' Atlanta, GA 30339
Resolution No. 6568
Oct. 14, 1999
Group Insurance Application
Item No. 77
1. APPLICANT INFORMATION
Policy Number (For interne[ use only)
Full Legal Name of Group (to appear on Policy)
Tax Identification Number
Business Telephone
The City of Lubbock
75-6000590
0 775-2317
Street Address
City, State, Zip + 4
FAX Number
1625 13th St.
Lubbock,TX 79401
0 775-3316
Delivery Address (if different from above)
City, State, Zip + 4
❑ Corporation
❑ Partnership
P. O. Box 2000
Lubbock,TX 79457
® Other Municipality
Nature of Business
City
Affiliates to Be Insured: None
Full Legal Name and Address of Each Affiliate
City, State, Zip + 4
Nature of Business
2. REQUESTED COVERAGE
Coverage(s):
Employer Contribution:
ProtectPlussM
Employer Contribution:
® Basic Life
100 %
® Employee Life
0 %
® AD&D
100 %
® Employee AD&D
0 %
❑ Dependent Life
%
® Dependent Life
0 %
❑ Dental
%
® Dependent AlD&D
0 %
❑ Long Term Disability
%
❑ Short Term Disability
%
3. Requested Effective Date 12 / 01 / 99
4. Number of Eligible Employees 1780
5. Will the requested insurance replace existing insurance
❑ No K] Yes
6. A Premium Deposit of. 9 q'1=1=j�. included. This is the estimated first month's premium. The Premium Deposit will be applied to
the first premium when due. The check is made payable to The Canada Life Assurance Company.
If a policy is not issued, the premium
deposit will be refunded in full. Do not cancel existing coverage until you receive written notice of approval
from the Head Office of The
Canada Life Assurance Company.
The insurance coverage requested and the requested effective date must be approved by The Canada Life Assurance Company under its current
rules and practices including Actively at Work, Evidence of Insurability and Pre-existing Conditions provisions. No insurance agent or broker has
authority to guarantee acceptability of the requested insurance coverage. All materials describing this coverage must be approved in writing by
The Canada Life Assurance Company prior to distribution to your employees.
Premium rates quoted were based on the data submitted to The Canada Life Assurance Company. Final premium rates will be determined on the
basis of the actual composition of the group of persons who become insured. ,`
Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.
I represent that the statements contained in this application are true and complete to the best of my knowledge and belief, and I understand that
they form the basis for The Canada Life Assurance Company's approval of the coverage requested.
1 . _
Print Print Name of Applicant's Authorized Representative MaWMW
! Signature of Applicant's Authorized Representative �'1'itle V ! uate
w T.nhhnek. Tpwgn October 14. 1999
Signature of Witness and /or Agent
97APP U.S. Rev. 02197
200NJ
City'-Tecretary
e CANADA LIFE
TYPE OF ADMINISTRATION:
[ ] Canada Life
[XX] Self Administered
ADMINISTRATIVE DETAILS
Payment of Premiums will be:
[XX] monthly in advance
[ ] other
BILLING OPTIONS: NOT APPLICABLE - SELF-ADMINISTERED
NN - regular billing not produced, renewal bill not produced.
ND -A - regular billing not produced, detailed renewal bill in alpha order.
ND-N - regular billing not produced, detailed renewal bill in numeric order.
NL-A - regular billing not produced, list renewal bill in alpha order.
NL-N - regular billing not produced, list renewal bill in numeric order.
NS-A - regular billing not produced, summary renewal bill in alpha order.
NS-N - regular billing not produced, summary renewal bill in numeric order.
DD-A - detailed regular billing, detailed renewal bill in alpha order.
DD-N - detailed regular billing, detailed renewal bill in numeric order.
LD-A - list regular billing, detailed renewal bill in alpha order.
LD-N - list regular billing, detailed renewal bill in numeric order.
LL-A - list regular billing, list renewal bill in alpha order.
LL-N - list regular billing, list renewal bill in numeric order.
SD -A - summary regular billing, detailed renewal bill in alpha order.
SD-N - summary regular billing, detailed renewal bill in numeric order.
SL-A - summary regular billing, list renewal bill in alpha order.
SL-N - summary regular billing, list renewal bill in numeric order.
SS -A - summary regular billing, summary renewal bill in alpha order.
SS-N - summary regular billing, summary renewal bill in numeric order.
Is the Policyholder:
[ ] Corporation
[XXJ Municipality
[ ] Other: (Describe)
ILL CANADA LIFE
ADMINISTRATIVE DETAILS (Continued)
Participation and Contribution Information:
Number
Number
Employee Contributions
eligible
Participating
If Yes, Indicate amount or
%
Basic Life 780
[XX] No [ ] Yes 0
%
Optional Life $,0
1:. '1 6
[ ] No [XX] Yes 100
%
Spousal Opt. Life t
[ ] No [XX] Yes 100
%
Dependent Life
64_
[ ] No [XX] Yes 100
%
AD&D 1780"' °°
1780'
[XX] No [ ] Yes 0
%
WI
[ ] No [ ] Yes
%
LTD
[ ] No [ ] Yes
Dental
Employee [ ] No [ ] Yes %
Dependent [ ] No [ ] Yes
Policyholder Address: THE CITY OF LUBBOCK
P.O. BOX 2000
LUBBOCK TX 79457
Contact person: LOU MOORS Title: HUMAN RESOURCES MANAGER
Phone Number: (806)767-2317 Your Employer Identification Number: 75-6000590
Fax Number: (806) 775-3316 Your ERISA plan number: N/A - MUNICIPALITY Plan Year:
Name, Address and Phone number of the Plan Administrator:
CITY OF LUBBOCK
1625 13TH STREET
LUBBOCK TX 79401
Agent of service of Legal Process for the Policyholder: SAME
The Canada Life Assurance Co.
Page No. 2
CANADA LIFE
ADMINISTRATIVE DETAILS (Continued)
Prior Coverage:
a) Is the insurance coverage applied for to replace any similar form of coverage now or previously in force with
another Insurer?
[XX] Yes [ ] No
b) Is it intended that the insurance coverage applied for be in addition to or supplemented by or supplemental to
any other coverage now in force or to be in force with this or any other Insurer?
[ ] Yes [XX] No
If yes, please provide details:
Affiliated Associated or Subsidiary Companies:
Are there any Affiliated or Subsidiary Companies being covered under this policy?
[ ] Yes [XX] No
If Yes, please list the Affiliated or Subsidiary companies names:
Reinstatement (All benefits except LTD):
Employees whose insurance is canceled due to termination of employment may become insured if they are
reemployed.
[ ] within six months [XX] Other: NO REINSTATEMENT
The Canada Life Assurance Co.
10CANADA LIFE
ADMINISTRATIVE DETAILS (Continued)
Issue Mailing Instructions:
Group Office Client Broker
Initial billing: XX
Policy: XX _
Booklet Certificates: XX _
Plan Outline: XX _
Administrative Mailing Instructions:
Same Address Special
Claims: XX _
Billing: XX _
Correspondence: XX _
Special:
Duplicate Statements produced
2 sets at renewal only:
Extra copies sent to:
[ ] Yes [XX] No
[ ] Yes [XX] No
Register cards to employer: [ ] one [ J two [XXJ None
Name of the Initial Underwriter: JULIA CONNOR
Group Representatives Signature: Dated
OCANADA LIFE
LIFE INSURANCE SALES SPECIFICATIONS
Eligible Employees:
[XX] All full time employees working:
[ ] other:
Waiting Period:
[ ] 20 hours [XX] 40 hours/week.
Employees employed on the effective date:
[XX] No waiting period
[ ] Same as for those employed after the effective date
Employees employed after the effective date:
[ ] Completion of days/ months of continuous employment
[ ] First of the month following days/months of continuous employment.
[XX] other: THE FIRST DAY OF THE NEXT FULL BI-WEEKLY PAY PERIOD
Changes in Amount of Insurance:
A change in class or rate of earnings shall take place on:
[ ] on the date of change
[ ] the first of the policy month following date of change
[XX] other: THE FIRST DAY OF THE NEXT FULL BI-WEEKLY PAY PERIOD
Termination of Insurance:
Termination of insurance will take effect on [ ] date of termination or [ ] at the end of the policy month.
[XX] OTHER: THE LAST DAY OF THE CURRENT FULL BI-WEEKLY PAY PERIOD
The Canada Life Assurance Co.
Page No. 5
Salary Related Benefits - Definition of earnings:
A-CANADA LIFE
[XX] Gross excluding bonus, commissions, overtime, Dividends and profit sharing.
If an income is based on commissions:
[XX] (i) If employed two calendar years or more, the average gross annual earnings during the
preceding two calendar years as set out on his W2 Taxation form.
If employed less than two calendar years, the amount estimated by us based on reasonable
expectation of earned income.
or
[ ] (ii) If employed two calendar years or more, the average gross annual earnings during the
preceding three calendar years as set out on his W2 Taxation form.
[ ] (iii) Other:
Termination of Insurance:
Retirement shall constitute termination of life benefits: [ ] Yes [XX] No
[ ] Benefit based on earnings:
The amount of insurance is % of the employee's yearly earnings to a maximum of $
and shall be rounded to the [ ] next higher $1,000 [ ] nearest $1,000 [ ] Other
The maximum amount of insurance without evidence of insurability is $
[XX] Flat $ amount: FLAT $10,000
Group Life Insurance and AD&D [XX] shall [ ] shall not terminate at specific ages. If decreases or termination
are to take place, they are as follows:
[ ] To 65% on an employee's 65th birthday, to 45% at age 70, to 30% at age 75 and to 20% at age 80 and over.
[ J To 65 % on an employee's 70th birthday, to 45 % at age 75, to 30 % at age 80 and 20 % at age 85 and over.
[XX] Other: (describe) AT AGE 70 BENEFITS ARE REDUCED TO 32% OF THE PRE AGE 70
AMOUNT. AT AGE 75 THE BENEFITS ARE 35% OF THE PRIOR REDUCED AMOUNT. AT AGE
80 THE BENEFITS ARE 35% OF THE PRIOR REDUCED AMOUNT AND AT AGE 85 BENEFITS
ARE 35% OF THE PRIOR REDUCED AMOUNT.
Do all classes use the same reduction provision [XX] Yes [ ] No If no, list which classes reduce differently and
what reduction provision they are subject to:
Will Retirees be covered under this plan? [ ] No [XX] Yes If Yes, How many Retirees will be participating
in this plan,ff 7 3 fi] Also if Yes, what is the Retiree life schedule?
CLASS
DESCRIPTION
BENEFIT
1
ALL EMPLOYEES RETIRING AFTER 12-1-95
$5,000
2
ALL EMPLOYEES RETIRING BETWEEN 4-1-88 AND 121-95
$2,000
3
ALL EMPLOYEES RETIRING BETWEEN 1-1-74 AND 4-1-88
VARIED — SCHEDULE
ATTACHED
4
ALL EMPLOYEES RETIRING PRIOR TO 1974
VARIED — SCHEDULE
ATTACHED
The Canada Life Assurance Co.
Page No. 6
ACCIDENTAL DEATH and DISMEMBERMENT
SALES SPECIFICATIONS
The schedule is the same as Life Insurance Schedule: [XX] Yes [ ] No
If no, Benefits are:
Coverage will be [XX] 24 hours or [ ] non occupational.
Termination of Insurance:
Retirement shall constitute termination of service for Accidental Death and Dismemberment Benefits.
OPTIONAL LIFE SALES SPECIFICATIONS
Eligible Employees:
[XX] All full time employees working: [ ] 20 hours [IX] 40 hours/week.
[XX] other: ALL ELIGIBLE RETIREES
Participation:
Number of full time employees presently employed 1780
Number of full time employees who will be participating in the plan 1,15_ 6
Number of Dependents eligible for benefits(" - -",
enefits� -ate.
Number of Dependents who will be participating in the planjJ26 ) .
Waiting Period:
Employees employed on the effective date:
[XX] No waiting period
[ ] Same as for those employed after the effective date
Employees employed after the effective date:
[ ] Completion of days/ months of continuous employment
[ ] First of the month following days/months of continuous employment.
[XX] other: THE FIRST DAY OF THE NEXT FULL, BI-WEEKLY PAY PERIOD
Changes in Amount of Insurance:
A change in class or rate of earnings shall take place:
[ ] on the date of change
[ ] 1st of the policy month following date of change
[XX] other: THE FIRST DAY OF THE NEXT FULL BI-WEEKLY PAY PERIOD
The Canada Life Assurance Co.
Pace No.7
A CANADA LIFE
' V
CANADA LIFE
Effective date of coverage will be:
[ ] Date of Approval
[ ] 1st of the policy month
[XX] OTHER: THE FIRST DAY OF THE NEXT FULL BI-WEEKLY PAY PERIOD
Termination of Insurance:
Termination of insurance will take effect on [ ] date of termination or [ ] at the end of the policy month.
OTHER: [XX] THE LAST DAY OF THE BI-WEEKLY PAY PERIOD
The Canada Life Assurance Co.
Evidence of Insurability: CANADA LIFE
Evidence of Insurability will required on:
[ ] All amounts over $
[XX] Other: EMPLOYEES: $250,000 RETIREES: $100,000.
Are any employees to be grandfathered: [XX] Yes [ ] No If yes, please list: WE AGREED TO AN OPEN
ENROLLMENT FOR ACTIVE EMPLOYEES (NOT RETIREES). BUT THE DATE OF THE
ENROLLMENT HAS NOT YET BEEN FINALIZED. THEREFORE WE WILL BE
GRANDFATHERING ALL CURRENT AMOUNTS UNTIL THE ENROLLMENT.
Guaranteed Issue Amount:
The following guaranteed issue amount had been approved by underwriting: $ $250,000 / $100,000
This applies to ACTIVE EMPLOYEES / RETIREES
Salary Related Benefits - Definition of earnings:
[XX] Gross excluding bonus, commissions, overtime, Dividends and profit sharing.
If an income is based on commissions:
[ ] (i) If employed two calendar years or more, the average gross annual earnings during the
preceding calendar years as set out on his W2 Taxation form.
If employed less than two calendar years, the amount estimated by us based on reasonable
expectation of earned income.
or
[ ] (ii) If employed two calendar years or more, the average gross annual earnings during the
preceding three calendar years as set out on his W2 Taxation form.
[ ] (iii) Other:
[ ] Benefit based on earnings:
The amount of insurance is % of the employee's yearly earnings to a maximum of $
and shall be rounded to the [ ] next higher $1,000 [ ] nearest $1,000 [ ] other
[ ] Flat $ amount:
[ ] Other: 1 2, OR 3 TIlAES AN EMPLOYEES ANNUAL SALARY ROUNDED TO THE NEXT
HIGHEST $1,000 TO A MAXIMUM OF FIVE TIMES OF THE ANNUAL SALARY OR $500,000
WHICHEVER IS LESS.
Optional Accidental Death and Dismemberment is included for equal amounts: [ ] Yes [XX] No
Optional Life reduction schedule is the same as Basic Lifer [XX] Yes [ ] No
[ ] To 65 % on an employee's 65th birthday, to 45 % at age 70, to 30 % at age 75 and to 20 % at age !80 and over.
[ ] To 65% on an employee's 70th birthday, to 45% at age 75, to 30% at age 80 and 20% at age 85 and over.
If no, the Optional Life Reduction schedule is
The Canada Life Assurance Co.
Paee No. 9
O CANADA LIFE
DEPENDENT LIFE AND OPTIONAL SPOUSAL LIFE SALES SPECIFICATIONS
Definition of Dependent:
[ ] Spouse
[ ] Unmarried children up to age and if a full time student.
DEPENDENT LIFE:
Spouse amount $
Child amount $
Definition of a Dependent for Optional Spousal Life:
[XX] Spouse
[XX] Unmarried children up to age 19 and 25 if a full time student.
OPTIONAL SPOUSAL LIFE:
Optional spousal amount $5,000 TO $50,000 IN INCREMENTS OF $5.000 NOT TO EXCEED 50% OF
THE EMPLOYEE'S AMOUNT.
Optional child amount $ 2,500, $5,000, $7,500 OR $10,000
Other:
The Canada Life Assurance Co.
Page No. 10
s ADDITIONAL DETAILS ACANADA LIFE
• Deposit of written notice of changes in insurance amounts will be accomplished via an employee / retiree
census once each policy year.
• Canada Life will provide 90 days written notice of termination of any policy or of changes in rates.
• A 60 day grace period will be in effect for all premium payments.
• Canada Life will accept the current Beneficiary Designation / Basic Life enrollment forms.
The Canada Life Assurance Co.
Resolution No.6568
Oct. 14, 1999
Item No. 77
AGREEMENT BY AND BETWEEN
THE CITY OF LUBBOCK, TEXAS AND
THE CANADA LIFE ASSURANCE COMPANY
THIS AGREEMENT entered into this ff day of December. 1999 by and between the
CITY OF LUBBOCK, TEXAS, a municipal home rule corporation (hereinafter called "City")
and CANADA LIFE ASSURANCE COMPANY (hereinafter called "Company") to provide
services for the purpose of a Group Term Life Insurance Plan.
WHEREAS, the City desires to have services provided for group term life insurance; and
WHEREAS, the Company has demonstrated that it can provide said services; and
WHEREAS, the City and the Company desire to enter into an Agreement to provide said
services.
NOW, THEREFORE, the parties agree as follows:
1. The parties agree to abide by the terms and conditions of the "Group Term Life
Insurance Plan" which is attached hereto as Exhibit "A" which is incorporated as if
fully set forth herein.
2. This Agreement is for a term of two (2) years from the effective date and may be
extended for one (1) additional one (1) year term at the mutual agreement of both
parties.
3. Notice or communications from the City to the Company shall be addressed to the
Company and shall be deemed to be duly given or served, if the same shall be sent by
United States mail, telegraph, telex, FAX or other similar or analogous means, to the
address shown below, unless the City has been requested to send such communications
to another address:
The Canada Life Assurance Company
6201 Powers Ferry Road
Atlanta GA 30339
Notices or communications from the Company to the City shall be addressed to the
City and shall be deemed to be duly given or served if the same shall be sent by United
States mail, telegraph, telex, FAX or other similar or analogous means, to the address
shown below, unless the Company has been requested to send such communications to
another address:
The City of Lubbock
P O Box 2000
Lubbock TX 79457
Notice and communication described in this paragraph that are sent by United States
mail will be deemed to be duly given or served on the third business day following the
date the notice is mailed.
4. This contract shall be construed and enforced according to the laws of the State of
Texas. Venue shall be Lubbock County, Texas.
5. The City may terminate the services of the Company at any time upon giving to the
Company 90 days written notice of its intention to do so. The Company may resign at
any time upon 90 days notice in writing to the City. The Company upon its resignation
shall complete the processing of all services described in this Agreement which have
commenced prior to the effective date of the termination of this Agreement.
SIGNED THIS DAY THE 14th of October ,1999.
pr �
/ a, mw
APPROVED AS TO CONTENT:
CANADA LIFE ASSURANCE
COMPANY:
................. 1! ��/
By 7-4.4 k
/Z 6G104i il- G O/ ZGc 7Vt
TITLE
,---7 0,,�- A4. av)CAjMt4-
Mary Andrews,
Managing Director of Human Resources
APPROVED AS TO FORM:
William de Haas,
Competition and Contracts Manager
Resolution No. 6568
Oct. 14, 1999
GENERAL ADMINISTRATIVE DETAILS Item No. 77
TYPE OF ADMINISTRATION: Payment of Premiums will be:
[XXI Self Administered [XX) monthly in arrears
Are any employees covered by this policy subject to a Collective Bargaining Agreement? [ ] Yes [XX] No
Policyholder Address: THE CITY OF LUBBOCK
P.O. BOX 2000
LUBBOCK, TX 79457
Contact person: MARY ANDREWS Title: DIRECTOR OF HUMAN RESOURCES
Phone Number: (806)775-2317 Your Employer Identification Number: 75-6000590
Fax Number: (806) 775-3316 Your ERISA plan number: N/A - MUNICIPALITY Plan Year: _
Name, Address and Phone number of the Plan Administrator:
CITY OF LUBBOCK
1625 13TH STREET
LUBBOCK, TX 79401
Agent of service of Legal Process for the Policyholder: SAME
Reinstatement (All benefits except LTD): NO REINSTATEMENT
The Canada Life Assurance Co.
4
Page No. 1
EMPLOYER PAID LIFE INSURANCE SALES SPECIFICATIONS
Eligible Employees:
All full time employees working: gQhours/week.
Waiting Period:
Employees employed _0 the effective date:
[XX] No waiting period
Termination of Insurance:
Termination of insurance will take effect on
[XXI OTHER: THE LAST DAY OF THE CURRENT FULL„ BI-WEEKLY PAY PERM
Salary Related Benefits - Definition of earnings:
Gross excluding bonus, commissions, overtime, Dividends and profit sharing.
Termination of Insurance:
Retirement shall constitute termination of life benefits: [I Yes [XXJ No
Amount of Insurance:
[xq Flat $ amount: FLAT $10,000
Reduction of Insurance:
Group Life Insurance and AD&D shall reduce or terminate at specific ages. If decreases or termination
are to take place, they are as follows:
AT AGE 70, BENEFITS ARE REDUCED TO 32% OF THE PRE AGE 70 AMOUNT, AT AGE 75, THE
BENEFITS ARE 35% OF THE PRIOR REDUCED AMOUNT, AT AGE 80, THE BENEFITS ARE 35%
OF THE PRIOR REDUCED AMOUNT AND AT AGE 85, BENEFITS ARE 35% OF THE PRIOR
REDUCED AMOUNT.
Do all classes use the same reduction provision [XX] Yes
Retiree Coverage
Will Retirees be covered under this plan? [XX] Yes
What is the Retiree life schedule?
CLASS
DESCRIPTION
BENEFIT
1
ALL EMPLOYEES RETIRING AFTER 12-1-95
$5,000
2
ALL EMPLOYEES RETIRING BETWEEN 4-1-88 AND 12-1-95
$2,000
3
ALL EMPLOYEES RETIRING BETWEEN 1-1-74 AND 4-1-88
VARIED — SCHEDULE
ATTACHED
The Canada Life Assurance Co.
Page No. 2
4 ALL EMPLOYEES RETIRING PRIOR TO 1974 VARIED — SCHEDULE
ATTACHED
Premium Rates:
ACTIVE EMPLOYEES: $.17 / $1,000
RETIRED EMPLOYEES CLASSES 1 - 4: $4.00 / $1,000
The Canada Life Assurance Co.
Page No. 3
EMPLOYER PAID ACCIDENTAL DEATH and DISMEMBERMENT
SALES SPECIFICATIONS
The schedule is the same as Life Insurance Schedule: [XX] Yes [ ] No
Coverage will be [XX] 24 hours or [ ] non occupational.
Termination of Insurance:
Retirement shall constitute termination of service for Accidental Death and Dismemberment Benefits.
Premium Rates:
ACTIVE EMPLOYEES: $.05 / $1,000
RETIREES: NOT ELIGIBLE FOR AD&D
The Canada Life Assurance Co.
Page No. 4
OPTIONAL LIFE SALES SPECIFICATIONS
Eligible Employees:
All full time employees working: 40 hours/week. AND
ALL I IB . F F — SCHEDULE ATTACHED.
Waiting Period:
Employees employed �m the effective date:
[XX] No waiting period
Employees employed jf= the effective date:
[XX] .THE FIRST DAY OF THE NEXT FULL, BI-WEEKLY PAY PERIOD
Changes in Amount of Insurance:
A change in class or rate of earnings shall take place:
[XX] THE FIRST DAY OF THE NEXT FULL. BI-WEEKLY PAY PERIOD
Effective date of coverage will be:
[XX] THE FIRST DAY OF THE NEXT EUL, BI-WEEKLY PAY PERIOD
Termination of Insurance:
Termination of insurance will take effect on
THE LAST DAY OF THE BI-WEEKLY PAY PERIOD
Evidence of Insurability:
Evidence of Insurability will required on:
EMPLOYEES: $250,000 RETIREES: $10,000.
I ' 4 . 1 ' '
i._: ►r WA471 011jel MIM V1 a V *9 102..►I: • _ ut ►Y
Guaranteed Issue Amount:
The following guaranteed issue amount had been approved by underwriting: $ $250,000 / $10,000
This applies to ACTIVE EMPLOYEES / RETIREES
Salary Related Benefits - Definition of earnings:
Gross excluding bonus, commissions, overtime, Dividends and profit sharing.
The Canada Life Assurance Co.
Page No. 5
Optional Accidental Death and Dismemberment is included for equal amounts: [XX] No
Optional Life reduction schedule is the same as Basic Life: [XX] Yes
Premium Rates:
Age
Employee
Retiree
Under 30
$.09
$.11
30 - 34
$.10
$.12
35 - 39
$.13
$.17
40 - 44
$.20
$.26
45 - 49
$.33
$.44
50 - 54
$.56
$.78
55 - 59
$.91
$1.27
60 - 64
$1.14
$1.44
65 - 69
$1.98
$2.38
70 - 74
$3.21
$4.12
75 - 79
$4.94
$6.20
80 - 84
$8.40
$9.75
Children) per $2,500
$.50
N/A
Spouse rate equals employee's
$5000
.80
$10,000
1.60
$15,000
2.40
$20,000
3.20
$25,000
4.00
$30,000
4.81
$35,000
5.61
$40,000
6.41
$45,000
7.21
$50,000
8.01
The Canada Life Assurance Co.
Page No. 6
r
DEPENDENT LIFE AND OPTIONAL SPOUSAL LIFE SALES SPECIFICATIONS
Definition of a Dependent for Optional Spousal Life:
[XX] Spouse
[XXJ Unmarried children up to age 19 and 25 if a full time student.
OPTIONAL SPOUSAL LIFE:
Optional spousal amount _$5.000 TO $50,000 IN INCREMENTS OF $5.000 NOT TO ExcEED 50 o OF
THE EMPLOYEE'S AMOUNT.
Optional child amount $ 2,500, $5,000, $7.500 OR $10,000
The Canada Life Assurance Co.
Page No. 7
CANADA LIME
No. G.77777
Resolution No. 6568
Oct. 14, 1999
Item No. 77
We. The Canada Life Assurance Company, agree to pay the benefits that become payable under this
policy to the person or persons entitled.
Ibis agreement is subject to the provisions on the attached pages which, together with this page, make
up the policy.
PLEASE NOTE THAT THIS SAMPLE CONTRACT IS PROVIDED FOR INFORMATIONAL
PURPOSES ONLY AND DOES NOT CONSTITUTE AN OFFER OF INSURANCE. SOME
TERMS, PROVISIONS, OR BENEF rS SHOWN IN THIS SAMPLE MAY BE UNAVAH.Aur F
TO SOME GROUPS OR MAY BE AVAhL.ABLE ONLY AT AN ADDITIONAL AN
ACTUAL POLICY MAY CONTAIN TERMS OR PROVISIONS NOT SHOWN IN THIS
SAMPLE. ALL PROVISIONS ARE SUBJECT TO THE PRIOR APPROVAL OF OUR
UNDERWRITING DEPARTMENT.
This policy will take effect on, December 1, 1999
Policyholder- The City of Lubbock
Issued at our Head Office at Atlanta, Georgia, as of ."be c emb e r 1 , . s 19 9 9
Secretary Assistant Registrar President
GROUP LIFE POLICY
Not eligible for dividends
WARNING
This is a legal contract between the Policyholder
and The Canada Life Assurance Company
READ YOUR POLICY CAREFULLY
GL400-200
THE CANADA LIFE ASSURANCE COMPANY
HOME OFFICE: 330 UNIVERSITY AVE., TORONTO, ONTARIO, CANADA MSG 1M
U. S. HEAD OFFICE: 6201 POWERS FERRY RD., NW, ATLANTA, GA 30339
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The Canada Life Assurance Company Page No. 1 Dated Sample - Void.
TABLE OF CONTENTS
DEFINITIONS........................................................................................................... 4
WHO MAY BECOME INSURED................................................................................... 5
HOW AND WHEN A PERSON'S INSURANCE TAKES EFFECT ....................................... 6
AMOUNT OF INSURANCE.......................................................................................... 7
WHEN A PERSON'S INSURANCE TERNDNATFS.......................................................... 9
WAIVER OF PRENHUM BENEFIT FOR DISABLED PERSONS......................................10
ACCELERATEDBENEFIT........................................................................................13
CONVERSION......................................................................................................... 16
PREMIUMS............................................................................................................. 18
PERIODOF GRACE................................................................................................. 21
CURRENCY...................................:........................................................................ 22
PLACE OF PAYMENT.............................................................................................. 22
NOT ELIGIBLE FOR DIVIDENDS............................................................................... 22
CLERICALERROR.................................................................................................. 22
INCONTESTABILITY............................................................................................... 22
BENEFICIARY........................................................................................................ 23
ASSIGNIVIF.NT......................................................................................................... 23
INSURANCE PAYABLE............................................................................................ 23
BOOKI..ET-CERTIFICATE........................................................................................ 23
AGEAND SEX......................................................................................................... 24
OPTIONAL SETTLEMENTS AT DEATH..................................................................... 24
STANDARDPROVISIONS......................................................................................... 25
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4
AMENDMENTS TO THE POLICY.............................................................................. 26
CONTRACT............................................................................................................ 27
TERMINATION OF POLICY..................................................................................... 28
SELF-ADMINISTRATION......................................................................................... 29
DEPENDENTS TERM INSURANCE............................................................................ 30
OPTIONAL INSURANCE........................................................ Errorl Bookmark not defined.
DEPENDENTS INSURANCE...................................................................................... 42
GIA OO-201
The Canada Life Assurance Company Page No. 3 Dated Sample - Void.
DEFINITIONS
All male terms will include the female term, unless stated otherwise.
'You' and 'your" mean the Policyholder.
'We". 'our' and 'us' mean The Canada Life Assurance Company.
"Person' means an employee.
"Actively at work' means that a person is either:
2. actually performing his normal duties, if it is a scheduled work day; or
2. capable of performing his normal duties, if he is not at work due to a non-scheduled
work day, holiday or vacation day;
at his normal place of employment or at some other location where your business requires him to be.
"Effective Date" means January 1st, 1998.
"Policy month' means a period of one month commencing on the Effective Date or on the first day of
each month thereafter.
'Policy year' means a period of one year commencing on the Effective Date or on any anniversary
thereof.
'Employee' means anyone who is employed by you.
GL400-202
"Annual earnings" as used to determine the benefits of a person under this policy will be calculated as
his amoral gross base earnings as an employee. They exclude any income he receives such as but not
limited to commissions, bonuses, dividends, overtime and profit sharing.
GL40G-204
The Canada Life Assurance Company Page No. 4 Dated Sample - Void.
WHO MAY BECOME INSURED
The class or classes of persons who may be insured under this policy are all of the full-time
employees who work at least 30 hours per week on a regular basis as employees.
Each person who is a member of such a class on the Effective Date may become insured on
that date.
Each person who becomes a member of such a class after the Effective Date may become
insured on the earliest date after the Effective Date on which both of the following conditions have
been met:
1. He has completed at least 30 days of continuous service as an employee.
2. He is a member of such a class.
Each person who ceases to be insured because of the termination of his employment and who is
re-employed by you within six months after such termination may become insured again on the earliest
date (but not earlier than the 32nd day after the date of such termination) on which he is a member of
such a class. However, the above will not apply to any person to whom a policy has been issued in
accordance with the Conversion provision.
GL404-205
The Canada Life Assurance Con;pany Page No. 5 Dated Sample - Void.
HOW AND WHEN A PERSONS INSURANCE TAKES EFFECT
A person will automatically become insured under this policy on the earliest date on which he
may become innued provided that he is then actively at work. If he is not actively at work on the date on
which he would otherwise become insured he will become insured only when he is again actively at work.
An application to become insured must be completed on a form approved for that purpose by us.
It must be promptly deposited with us at our Head Office.
GL400-206
The Canada Life Assurance Company Page No. 6 Dated Sample - Void.
AMOUNT OF INSURANCE
The amount of insurance with respect to each person who is insured will be based on the
Schedule shown below.
You must deposit written notice with us at our Head Office of any change in the class or
carnings of a person which would affect the amount of his insurance.
A decrease in the amount of his insurance will take effect on the date stated in the notice.
An increase in the amount of his insurance will take effect on the date stated in the notice
provided that he is then actively at work. If he is not actively at work on the date on which the amount
of his insurance would otherwise increase, the increase will take effect only when he is again actively at
work.
When we are calculating the amount of a benefit based on earnings that has become payable
with respect to a person under this policy, we will use whichever of the following amounts was the
smallest at the time the loss was incurred or the disability commenced.
1. The person's actual earnings as defined in the Definitions provision.
2. The level of earnings on which the premium for the person's benefit was being paid.
GIAOO-207
The Canada Life Assurance Company Page No. 7 Dated Sample - Void.
INSURANCE SCHEDULE
I All Eligible Employees, An amount equal to 200 % of the person's annual earnings
(rounded to the neat higher $ I,000 of benefit) to a
maximum benefit of $500,000.
REDUCTIONS
Notwithstanding the above, on and after each of the birthdays listed below a person's insurance
will be reduced to a percentage of the amount of insurance calculated in accordance with the preceding
Schedule. The percentages are indicated in the following table:
65th
70th
75th
80th or over
GL400-208
65 %
45 %
30%
20 %
The Canada Life Assurance Company Page No. 8 Dated Sample - Void.
WI IEN A PERSONS INSURANCE TERNIINATES
All of a person's insurance under this policy will terminate at the earliest time shown below.
1. When the person's employment terminates. A person's employment will terminate
when he is no longer actively at work. However, if a person is not actively at work
due to disease, pregnancy or injury his insurance will be continued in force under this
policy until the date on winch we receive written notice from you that the person's
innurance is to be terminated.
2. When the person ceases to be a member of a class or classes of persons who may be
insured.
3. On the date on which this policy is no longer in,force.
4. If a person is absent from work due to a temporary lay-off or due to a leave of absence,
the earlier of:
a. The date on which we receive written notice from you that the person's
insurance is to be terminated.
b. The last day of the month that follows the month in which his absence from
work began.
5. When the person goes on strike, or is locked -out. This will not apply if either.
a. There is a written agreement between you and us that all persons will continue
to be insured during the strike or lock -out.
b. There is applicable statutory legislation or regulation requiring the continuation
of insurance during a strike or lock -out.
6. The day before he enters active full-time service in any naval, military or air force.
7. On the date on which the person requests, in writing, to have his insurance terminated.
8. On the date on which the person retires unless otherwise stated in the Who May
Become Insured provision of this policy.
If an event that is described above occurs, you must deposit written notice with us at our Head
Office within 31 days. Failure to give written notice within such 31 day period will not continue
insurance in force with respect to a person beyond the time it would otherwise have been terminated as
shown above.
GL400-209
77ie Canada Life Assurance Con pang Page No. 9 Dated Sample - Void.
If a person becomes disabled prior to his 60th birthday and while he is insured under this policy
then, as of the effective date of disability:
1. The insurance on his We provided by the other terms of this policy will be deemed to
have terminated and instead will be continued in force under this provision for the
amount then in effect while he is disabled.
2. No premium payment will be required for the insurance continued in force wider this
provision.
The termination of this policy after his effective date of disability will not affect the
continuation of his insurance under this provision.
"Disabled" and 'disability' mean the person is not able to perform with reasonable continuity
the substantial and material duties of any occupation for which he is qualified in view of his age,
education, training, experience, station in life and physical and mental capacity due to injury. disease,
illness, pregnancy or mental disorder.
"Effective date of disability' means the date a person becomes disabled provided that the
disability has been continuous for whichever of the following periods is the shorter.
1. A period of at least 6 consecutive months.
2. The period until his death.
All proof of disability that we require must be given to as at our Head Office. The proof must
be satisfactory to us. We will have the dght to have a physician designated by us examine a person
who is disabled as often as we may reasonably require.
GIAOO-210
The Canada Life Assurance Company Page No. 10 Dated Sample - Void.
WAIVER OF PREMIUM BENEFIT FOR DISABLED PERSONS (Continued)
1. We must receive initial proof that a person is disabled no later than 12 months after the
effective date of disability. This proof must be satisfactory to us.
2. If a person dies prior to submitting initial proof of disability as required in Condition 1,
proof that it continued until the date of his death must be given to us no later than 12
months after his death.
3. The insurance on the life of a person will be subject to any reductions in amount or
termination of insurance included in the policy at his effective date of disability which
would have applied to him prior to age 70 if he were not disabled.
4. Any amount of insurance continued in force under this provision that becomes payable
will be reduced as follows:
a. By any amount paid under the terms of the Conversion provision of this policy,
because a person died within the 31 day period in which he was entitled to
apply for a policy of individual life insurance.
b. By any amount of insurance paid under a policy that was issued to him under
the Conversion provision of this policy after he became disabled, unless such
policy was surrendered to us without claim in exchange for a full refund of
premamns paid under it.
The insurance continued in force under this provision with respect to a person will tote on
the earliest of the following:
1. The date on which he ceases to be disabled.
2. Three months after the date we request further proof that he is still disabled if such
proof is not received by us within this period. We may ask for further proof as often as
we may reasonably require.
3. The date on which he attains his 65th birthday.
GIAOO-211
Me Canada life Assurance Company Page No. 11 Dated Sample - Void.
WAIVER OF PREMM BENEFIT FOR DISABLED PERSONS (Continued)
If the insurance with respect to a person is continued in force under this provision and is then
terminated because he ceases to be disabled or fails to submit any proof of disability that we require,
one of the following events will occur.
1. If this policy is in force and he is a member of a class or classes of persons who may be
insured under this policy and he is actively at work, he will immediately become
insured under the other terms of this policy.
2. If this policy is in force but either he is not a member of a class or classes of persons
who may be insured under this policy or he is not actively at work, he will be entitled
to the same conversion rights that he would have been entitled to if his insurance had
terminated due to the termination of his employment.
3. If this policy is not in force, he will be entitled to the same conversion rights that he
would have been entitled to if his insurance had terminated due to the termination of
this policy.
The period that a conversion right will apply to as described in clauses 2 and 3 will be the 31
days following the date the insurance ender this provision is terminated.
If insurance with respect to a person is continued in force under the terms of this provision and
is then terminated because his 65th birthday has occurred, he will be entitled to the same conversion
tights to which he would have been entitled if his insurance had terminated because he is no longer a
member of a class or classes of persons who may be insured..
GLAOO-212
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NOTE: This Accelerated Benefit applies only to persons whose amount of insurance is equal
to or greater than $20,000.
ACCELERATED BENEFIT
BIIVEFITS PAID UNDER THIS PROVISION MAY BE TAXABLE. IF SO, THE PERSON OR
HIS BEN MCIARY MAY INCUR A TAX OBLIGATION. AS WITS ALL TAX MATTERS, THE
PERSON SHOULD CONSULT A PROFESSIONAL TAX ADVISOR TO ASSESS THE EFFECT
OF TSIS BENEFIT. BF1NEl M OF THIS PROVISION ARE NOT PAYABLE IF THE POLICY
IS NOT IN EFFECT.
This Accelerated Benefit provides that a portion of the proceeds otherwise payable under this
policy as a result of death may be paid in advance of death in certain circumstances as outlined below.
If a person is diagnosed as having a Terminal Condition while msuued under this policy we may.
at the request of such person or his legal representative, and subject to your agreement and lute agreement
of any assignee and irrevocable beneficiary of the person's fife insurance, make an Accelerated Benefit
payment in accordance with the terms of this provision.
The Accelerated Benefit payment will be made in one hump sum subject to the Conditions section
below and will be equal to the lesser of the following.
1. An amount selected by the person up to 50 % of the amount of insurance applicable to the
person in accordance with the other terms of the policy, subject to a minimum of
$10,000.
2. $50,000.
U the life insurance applicable to the person would otherwise reduce or terminate in accordance
with the other terms of the policy within 12 months of the date of application for this benefit, then the
benefit will be based on such reduced amount. If a person's insurance would od=wise terminate within
12 months of the date of application for this benefit, a benefit will not be payable under this provision.
Payment of this benefit does not guarantee that the person's full death benefit'will eventually be
paid. The person must still be insured under the policy at the time of his death for the remainder of his life
insurance benefit to be paid. A person may only receive a benefit payment tinder this provision once
during his lifetime.
Definitions
'Terminal Condition' means a medical condition that a duty licensed health can provider expects
to result in flee person's death within 12 months from the date of application for the Accelerated Benefit
and from which the person is not expected to recover.
The Canada life Assurance Company Page No. 13 Dated Sample - Void.
'Interest' means the prime interest rate, as of the date this benefit is paid, plus one percent.
However, in no event wM the interest rate exceed the greater of (1) the current yield on 90 day treasury
bMs. or Q the current rnaaanum statutory adjustable policy loan interest rate.
GL400-292
Conditions
Payment of an Accelerated Benefit under this provision is subject to all of the foIIowing conditions
being rnet.
1. Accelerated Benefits are payable only once with respect to a person.
2. The person or his legal representative must request in writing to have this benefit paid while
insurance on the person is In effect.
3. The person must be eligible for the Waiver of Premium Benefit For Disabled Persons
provision, included in this policy. However, this benefit may be payable priior to the person
having satisfied the requirement of being disabled for a continuous period of 6 months.
4. We must receive satisfactory proof that the person has been diagnosed as having a Terminal
Condition.
5. The person must be living at the time this benefit is to be paid.
6. We must obtain your permission prior to paying this benefit. We must also obtain the
permission of the person's irrevocable beneficiary or assignee for the life insurance proceeds
otherwise payable under the policy, prior to paying this benefit..
7. The amount of life insurance otherwise payable on the person's death in accordance with the
other terms of this policy wM be reduced by the smut of this benefit together with, Interest
calculated ated from the date this benefit is paid. Such reduction will also apply to any amount the
person would otherwise be eligible to apply for under the Conversion provision.
Emdusions
The Accelerated Benefit will not be payable with respect to an Insured if his Terminal Condition
resulted fiu n or was in any manner or degree associated with, or occasioned by the Insured attempting to
take his own life whether he was in possession of his faculties or not at the time.
GL400-283
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CONVERSION
A person will have the right to buy an individual life insurance policy without submitting
evidence of insurability upon any of the following events:
t . The termination of his employment.
2. His membership in a class or classes has been terminated and this policy is in force.
3. The termination of this policy. He must have been insured under this policy for at least
5 years.
4. An amendment to this policy cancels the insurance an the class of persons of which he
is a member. He must have been insured under this policy for at least 5 years.
The policy will only be issued to him if a written application and the first premium dae for the
policy are received by our Head Office within 31 days of such termination or reduction_ This 31 day
period is the conversion period. The policy will not take effect until the end of the conversion period.
If he should die during the conversion period, and prior to becoming insured under a policy
again, an amount of insurance equal to the maximum ammmt for which he was entitled to convert will
be paid as a death benefit.
The premium for the individual policy will be determined by the policy type, the person's risk
classification, our published rates in effect and the person's age (nearest birthday) at the time of
conversion_
The policy may be on any Plan, other than term insurance, with level premiums and level
death benefit, which we are then issuing. It may not include any provision for disability, accidental
death or other special benefid.
GIAOO-213
The Canada Life Assumnce Company Page No. 16 Dated Sample - Void.
Reimbursement by Policy Holder
If we have paid an Accelerated Benefit under this policy and this policy tetmmates prior to the
death of the person, you will reimburse us for any such benefit payment wade wider this provision
togedier with Interest for the period from the date such benefit was paid to the date you reimburse us if
either of the following are true.
1. The person does not qualify for the Waiver of Premium Benefit for Disabled Persons
provision included in this policy.
2. Mus policy does not contain a Waiver of Premium Benefit for Disabled Persons
provision.
ICITE 1-113M
The Canada life Assurance Company Page No. 15 Dated Sample - Void.
The amount of insurance he may select under die policy h subject to the following limits.
I. It may not be less than the minimum amount for which we then issue such a policy.
2. If he ceased to be insured because of reason 1 or 2 shown in the Who May Convert
section of this provision, it may not be more than the amount of insurance that has been
terminated reduced by any amount of Ne insurance for which he may be or may
became entitled under this or any group insurance policy within the conversion period.
3. It may not exceed the amount of reduction ender the group policy.
4. If he ceased to be i mmDd because of reason 3 or 4 shown In the Who May Convert
section of this provision, it may not be more than the smaller of the foriowin�g amounts.
a. The amount of insurance that applied to him at the time it terminated reduced
by any amount of life insurance for which be may be or may become entitled to
under any group insurance policy within the conversion period.
b. $2,000
5. it may not, in any event, exceed She maximum amount of insurance he is eligible to
convert as stated in clause 2 or 4 above reduced by any amount of life insurance
currently in force and previously converted under this policy.
You will be required to give each person at least 15 days writnotice prior to the date on
which his right to convert would expire. If the person has not received such notice dw person will
have an additional 15 days from die date he is notified in which to convert. The life insurance
coverage will not extend beyond the 31st day after die date the group insurance terminates, and die
right to convert will not extend more than 60 days beyond the initial 31 day conversion period.
OL400-214
The Canada Life Aswa= Company Page No. 17 Dated Sample - Void.
I "9 D16 1 F.
Premiums are due each month in advance ham the Effective Date.
, Each premium due with respect to amount of basic life insurance in force on the life of a
person will be calculated on a basis that is established by us and will be $0.25 per $1,000 of insurance.
Each premium due with respect to die amount of basic life insurance in force on the life of a
person's dependents will be calculated on a basis that is established by us and will be $0.55 per month
on the date on which such premium is due.
Each premium due with respect to the amount of optional life insurance in force on the life of a
person will be calculated on a basis that is established by as and will be cornputed based on the
following:
I. The Table of Optional Insurance Premiums set forth in this provision.
2. The amount of optional insurance in force on the We of each insured person on the date
on which the premium is due.
It is our right to change the preceding premium rate(s) shown above as follows:
1. As of January 1st, 1999 and any date on which a premium is due after such date.
2. At any time this policy is amended to change either one or both of:
a. The class or classes of persons who may be insured under this policy.
b. The amount of the benefits payable under this policy.
3. At any time the number of persons or the volume of the amount of insurance payable
under this policy changes by more than 25%.
4. At any time there is a change in federal or on legislation or regulation which affects
the benefits or provisions of this policy.
We must give you written notice at least 60 days prior to the date of a change.
If you request, and we agree. the frequency of premium payment may be changed, as of any
date on which a premium is due. You may change the frequency to yearly, half -yearly, quarterly or
monthly. U the frequency of premium payment is to be changed to one other than monthly, the terms
of the first paragraph of this provision will be read as N they had been changed to provide for the new
premium frequency.
GLA00-215
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e ii 1 +I . 1 .
If, at any time prior to the date that a toss is incurred or a disability commences, we leam that
the amount of insurance that should be in force under this policy is not the amount on which the
premium was based, an adjustment premiums will be paid by you or a refund will be made to you so
that the actual premiums for the true amount of insurance will be paid.
If there is any change in the amount of insurance in force under this policy between the dates
on which premiums are due, an adjustment premium or a rdUnd will be due. The adjustment pmamiurn
or the refund will be due on whichever of the following dates apply:
1. If the amount of insurance changes on or prior to the 15th day of a policy month, the
first day of such policy month.
2- If the amount of insurance changes after the 15th day of a policy month, the first day of
the next policy month. However, an adjustment premium or refuted will not be due if,
on the first day of the next policy month, a regular premium is due.
If we do not receive written notice of a change due to a decrease in or the termination of an
amount of insurance within 60 days of the date such change occurred, we will limit the refund to 2
months premium.
The amount of insurance with respect to an insured individual will be decreased or terminated
in accordance with the other terms of this policy. The payment of premiums with respect to an
individual's insurance after the date of such decrease or termination will not continue to provide
insurance of the amount which was in effect with respect to such individual prior to such decrease or
continue insurance is force with respect to such individual after such termination, whether or not all or
part of such premium is refunded.
Refunds will be applied in or toward the payment of any outstanding premiums and adjustment
premmnns- Any balance will be held at your credit, without interest, and will be applied in or toward
payment of succeeding premiums and adjustment premiums as and when they fall due. However, you
may, at any tim withdraw in cash any amount so held at your credit.
The Canada Life Assurmwe Company Page No. 19 . ` Dated Sample - Void.
11 1 ,1 1 i I a
H this policy is terminated in accordance with the Termination of Policy provision, you will
pay to us all adjustment premiums that are due and have not been paid. You will also pay to us a pro
rats premium for the period (if say) elapsed from the date on which the last unpaid premium was due
to the date on which this policy is terminated.
We shall not be required to accept the payment of any premium otherwise than firm you.
GIAOD-217
The Canada Life Assurance Company Page No. 20 Dated Sample - Void.
PERIOD OF GRACE
A period of grace will be allowed for the payment of each premium after the first and each
adjustment premium. The period of grace for the payment of each premium will be 31 days after the
date on which it is due. The period of grace for the payment of each adjustment premium will be 31
days after the date on which it is due. The period of grace for the payment of each &*stment
premium will be 31 days after the date on which the neat premium is due unless we, by wrimon notice
to you, limit the days of grace. Such limit will not be less than 31 days after the date dw notice is
delivered to you. The policy will remain in force during the period of grace unless terminated in
accordance with the Termination of Policy provision. In any event, premiums are payable for any
period of grace during which the policy continues in force.
GIAUO-218
The Canada Life Assurance Company Page No. 21 ., - Dated Sample - Void.
• 1ji-�-_az
All amounts payable under this policy must be paid in United States currency.
PLACE OF PAYMENT
All amounts payable by us will be payable at our. office in Atlanta, Georgia.
NOT ELIGIBLE FOR DIVIDENDS
This policy is not eligible for dividends and will not take part in the distribution of our wuplus.
CLERICAL ERROR .
Clerical error in keeping the records will not invalidate insurance otherwise validly in force nor
continue insurance otherwise validly terminated. Upon discovery of any such error an adjustment of
premiams will be made.
INCONTESTABILITY
There will be no contest of the validity of this policy, except for the failure to pay premiums,
after it has been in force for two years from the date of issue. Statements made by a person as to his
insurability may be used in a contest of the validity of his insurance only under the following
conditions:
1. The statements must relate to the insurance in question.
2. The statements must be in written form and signed by the person.
3. The insurance must have been in force prior to the contest for less than two years
during the lifetime of the person.
GL400-220
The Canada We Assurance Company Page No. 22 Dated Sample - Void.
Ajul_m1
BENEFICIARY
A person may, at any time, by a writing signed by him and deposited with us at our Head
1. Appoint one or more beneficiaries to receive all or part of the insutwce on his life
under this policy.
2. Change such appointment.
Such appointment or change shall take effect as at the date of its execution, whether or not the
person is living at the time it is deposited with us at our Head Office, but without prejudice to us on
account of any payment by us prior thereto. The interests of a beneficiary who dies before the person
will accrue to the surviving beneficiaries or, if none, to the estate of the person. If, at the death of the
person, there is no beneficiary for all or part of his insurance under this policy, the amount of his
insurance for which there is no beneficiary will be payable to his estate.
ASSIGNMENT
An assignment of insurance by a person will not be binding on us unless the assignment or a
copy of it is filed with us at our Head Office together with your consent in writing to the assignment.
We are not responsible for the validity or the effect of such assignor nr
INSURANCE PAYABLE
The amount due on the death of an insured person will be payable on receipt by us at our Head
Office of due proof of his death. We will be entitled to a proper discharge in respect of any payment
made by us.
BOOKLET -CERTIFICATE
We will issue booklet -certificates to you that summarize the essential prontidow of this policy.
You must deliver them to each person who is insured.
The provisions of this policy will govern if there is any discrepancy between the following:
1. The provisions of the booklet -certificate delivered to a person who is insured.
2. The provisions of this policy.
If a booklet -certificate is issued to a person who for any reason is not entitled to insurance
under dus policy, such booklet -certificate will be of no effect.
GI AOO-222
Tile Canada fife Asswwwe ConTany Pagd No. 23 Dated Sample —Void.
; A It I{ I ■
AGE AND SEX
The true date of birth of a person will be used to determine:
1. The commencement or termination of insnrance on his life.
2. The amount of insurance on his life.
3. Any other right or benefit with respect to him.
If we learn that his date of birth or sex has been misstated, a premium will be paid or a refund
will be made so that you will pay us the actual premiums for the insurance that applies to him based on
his true age and sex.
OPTIONAL SETTLEMENTS AT DEATH
A person shall have the following rights:
1. To elect that the amount of insurance which would otherwise be payable in one sum on
Ins death will be payable in such a manner as may be agreed to by us in writing.
2. To awoke any such election.
If there is no election in effect, the beneficiary will have the right, after the person's death, to
make such an election but may not revoke it without our consent.
GIAOO-223
The Canada Life Assurance Company Page No. 24 _Dated Sample - Void.
.1 ■
STANDARD PROVISIONS
Tune Limit on Certain Defenses
After a person has been insured under this policy for two years, no misstatement of the person
except a fraudulent misstatement will be used to reduce or deny a claim.
GC500-310
Claim Forms
When we receive a written notice of a claim, we will send the claimant our claim forms to file
proof of loss. If the claim forms are not received within 15 days after written notice of claim is sent,
the claimant can send us written proof of claim without waiting for the claim forms.
Time of Payment of Claim
When we receive satisfactory proof of claim, benefits payable under this policy for any loss
other than for loss of time will be paid as they are inmuTed.
Payment of Claims
Indemnity for loss of life will be payable in accordance with the beneficiary designation and the
provisions respecting such payment which may be prescribed herein and effective at the time of
payment. If no such designation or provision is then effective, such indemnity shall be payable to the
estate of the insured person. Any other accrued indemnities unpaid at the insured person's death may,
at our option, be paid either to such beneficiary or to such estate. All other indemnities will be payable
to the insured person.
GC500-311
Legal Actions
No action at law or in equity may be brought to recover under this policy until 60 days after
written proof of loss has been given to us. No such action may be brought more than three years after
the time within which proof of loss is required to be given.
Conformity with State Statutes
Any provision of this policy which, on its effective date, is in conflict with the statutes of the
State in which this policy was delivered or issued for delivery is hereby amended to conform to the
minimum requirements of such statute.
GC500-312
The Canada Life Assurance Company Page No. 25 Dated Sample - Void.
Tbis policy may be amended at any tune by written agreement between you and us without the
consent of or notice to any other individual. Any amendment to this policy must be in writing and
attached to the policy. The amendment must bear the signature or a reproduction of the signature of
one or both of our President or Secretary and the signature of our Registrar or one of our Assistant
Registrars.
If a person is not actively at work on the effective date of the amendment, the effective date
with respect to that person will be on the day that he is again actively at work. However, if the
amendment reduces the amount of insurance to which he is entitled, the effective date will be the
effective date of the amendment.
If an insured dependent (if any) is confined in a hospital on the effective date of the
amendment, the effective date with respect to that insured dependent will be on the first day after the
date of his discharge from the hospital, however, if the amendment reduces the amount of insurance to
which the dependent is entitled, the effective date will be rive effective date of the amendment.
The Canada Life Assurance Company Page No. 26 Dated Sample - Void.
4 h I 1 ■
CONTRAM
RAM
The whole contract is made up of:
1. This policy.
2. Any amendments to this policy.
3. The Group Insurance Application.
You will not be considered to be our agent for any purpose under this policy.
All stag made by any of the persons who are insured will be deemed representations and
not warranties. No statement made by any person who is insured will be used in any contest unless:
1. It is contained in a written instrument signed by the person.
2. A copy of the written instrument has been given to the person.
Only our President or Secretary may modify this policy or waive any of our rights or
requkements-
Any change in this policy must be in writing and be attached to it. The change must bear the
signature or a reproduction of the signature of one or both of the above officers. It must also bear the
signature of our Registrar or one of our Assistant Registrars and your signature.
GIAOO-219
The Canada Life Assurance Company Page No. 27 Dated Sample - Void.
TERMIIYATION OF POLICY
If you give us written notice that this policy is to be terminated, it will terminate on the later of:
1. The date that is stated in the notice.
2. The date on which we receive the notice at our Head Office.
We may terminate this policy as of the date on which any premium is due if, at any time, the
number of persons who are insured is less than 20 or is less than 100% of the number of persons who
are then members of the class or classes of persons who may become insured under this policy as of the
date on which any premium is due. We may also, for any other reason, terminate this policy as of the
date on which any premium is due.
We must give you at least 60 days written notice prior to the date on which this policy is to
terminate.
This policy will terminate, in any event, at the end of the period of grace allowed for the
payment of any premium or adjustment premium if such premium is still unpaid at that time.
You will be required to give each person at least 15 days written notice prior to the date on
which this policy is to terminate. Failure to give written notice within such 15 day period will not
continue insurance in force with respect to a person beyond the time this policy would otherwise have
terminated.
GIA00-226
The Canada Life Assurance Con;pany Page No. 28 Dated Sample - Void.
i
�Ij- $ 1 yff.1 IIMII1 . 01 j
At your request this policy is self-administered. For that reason it is provided that:
1. All documents and notices that would otherwise be deposited with us at our Head
Office in accordance with the terms of this policy will be held by you.
This will not apply to any of the following:
a. Evidence of msurabil V required by us under this policy.
b. An application for an individual policy of insurance as provided for under any
Conversion provision of this policy.
C. Notice required by us to process any claims.
2. Whenever we request, you will furnish us with all of the documents relating to a
person's insurance which have been completed in accordance with the terms of this
policy and are being held by you.
3. We may inspect and examine your records which pertain to a peroon in so far as the
records affect his insurance or his eligibility for insurance.
4. All premium payments that would otherwise be calculated by us at our Head Office in
accordance with the terms of this policy will be calculated by you on a basis provided
by us.
5. Whenever we request, you will deposit with us at our Head Office a statement listing
the following:
a. Each person who is then insured.
b. The Class of each person under the Schedule.
C. The amount of the benefits that apply to each person.
d. The date of birth of each person.
C. If applicable, the earnings of each person.
GIAOO-224
The Canada Life Assurance Company Page No. 29 Dated Sample - Void.
DEPENDENTS TERM INSURANCE
Def anions
"Dependent" means:
1. The spouse of a person. This will include a divorced or separated spouse where a
granting of a judgment absolute of divorce or of separate support has been given until
such time as provided by said judgment.
2. Each unmarried child or stepchild of a person, over 14 days of age, provided that the
child relies fully on the person for support and maintenance and fits the following
description:
a. The child is under 19 years of age.
b. The child is at least 19 years of age but under 23 years of age and he/she is
attending an accredited educational institute, college or university on a full-time
basis.
However, for the purposes of this provision, dependent shall exclude:
1. Anyone who is residing outside of Canada and the United States of America.
2. Anyone who is in full-time service in any naval, military or air force.
3. A child who does not rely fully on the person for support or maintenance.
4. A child may not be insured as a dependent of more than one person.
5. Any person who is insured under this policy.
•GL400-250
The Canada Life Assurance Company Page No. 30 Dated Sample - Void.
DEPENDENTS INSURANCE (Continued)
How and When A Dependent's Insurance Takes Effect
A dependent will become insured under this policy on whichever of the following dates is
applicable:
1. With respect to a person who has a dependent at the time he becomes insured under
this policy:
a. If the application for dependent's insurance is completed on or before the
earliest date on which the person may become insured, dependent's insurance
will take effect on that earliest date.
b. If the application for dependent's insurance is completed no more than 30 days
after the earliest date on which the person may become insured, dependent's
insurance will take effect on the date on which the application has been
completed.
C. If the application for dependent's insurance is completed more than 30 days
after the earliest date on which the person may become insured, dependent's
insurance will take effect on the date on which we have, in writing, either
approved evidence of the dependent's insurability or waived such requirement.
2. With respect to a person who has no dependents at the time he becomes insured under
this policy and later acquires a dependent:
a. If the application for dependent's insurance is completed no more than 30 days
after he acquires a dependent, the date on which the application has been
completed.
b. If the application for dependent's insurance is completed more than 30 days
after acquiring a dependent, the date on which we have, in writing, either
approved evidence of the dependent's insurability or waived such requirement.
The application to become insured must be completed on a form approved for that purpose by
us. Each comrpleted application must be deposited with us at our Head Office.
Insurance of any dependent child of a person who is acquired while he has any other
dependents insured under this policy will automatically take effect on the date such dependent is
acquired.
If, at the time insurance on the life of a dependent who is not a new -born child would otherwise
take effect, such dependent is confined in a hospital, insurance on the life of such dependent will not
take effect until such dependent is discharged from the hospital.
Any evidence required under this provision must be provided without expense to us.
GIAOO-251
The Canada Life Assurance Company Page No. 31 Dated Sample - Void.
DEPENDENTS DOURANCE (Continued)
Amount of insurance
The amount of insurance on the life of each insured dependent will be based on the Schedule
shown below.
CLASS
Spouse
Each Dependent Child
6 months of age or over
Each Dependent Child
imder 6 months of age
GL400-252
Schedule
AMOUNT OF LIFE INSURANCE
$5,000.
$2.000.
$1,000.
The Canada Life Assurance Con pang Page No. 32 Dated Sample - Void.
DEPENDENTS INSURANCE (Continued)
When Dependents Insurance Terminates
A dependent's insurance under this policy will terminate on die earliest date shown below.
1. When he ceases to be a dependent as defined in this policy.
2. On termination of the insurance under this policy on the life of the person of whom he
is a dependent, unless the insurance of the person is being continued in force pursuant
to the Waiver of Premium Benefit for Disabled Persons provision.
3. On the date on which the person asks to have the insurance on his dependents
terminated.
You must notify us in writing within 31 days after the date on which an event described in
clause 1,2 or 3 occurs.
GIA00-253
The Canada Life Assurance Company Page No. 33 Dated Sample - Void.
Conversion of Dependents Insurance
If the spouse of a person ceases to be insured under the Dependent's Insurance provision, he
will have the right to buy an individual life insurance policy without submitting evidence of insurability
upon any one of the following events:
1. The termination of the person's employment.
2. The person's membership in a class or classes has been terminated and this policy is in
force.
3. The termination of this policy. The person must have been insured under this policy
for at least 5 years.
4. An amendment to this policy which cancels the insurance on the class of persons of
which the person is a member. The person must have been insured under this policy
for at least 5 years.
5. The death of the person.
6. The spouse ceases to be a dependent within the meaning of this provision.
7. The person of whom he is a dependent becomes subject to the terms of the Waiver of
Premium Benefit for Disabled Persons provision.
The policy will be issued to the spouse only if a written application and the first premium due
for this policy are received by our Head Office within 31 days of such termination.
The 31 day period is the conversion period. The individual policy will not take effect until the
end of this conversion period.
If the spouse should die during the conversion period, and prior to becoming insured under a
policy again, the amount of insurance for which the spouse was entitled to convert will be paid as a
death benefit.
The premium for the individual policy will be determined by the policy type and amount,
spouse's risk classification, our published rates in effect and the spouse's age (nearest birthday) at the
time of conversion.
The policy may be on any plan, other than term insurance, with level premiums and level death
benefit, which we are then issuing. It may not include any provision for disability, accidental death or
other special benefit.
The Canada Life Assurance Company Page No. 34 Dated Sample - Void.
The amount of insurance that the spouse may select under the policy is subject to the following
limits.
1. It may not be less than the minimum amount for which we then issue such a policy.
2. If the spouse ceased to be insured because of reason 1, 2, S. 6 or 7 shown in the Who
May Convert section of this provision, it may not be more than the amount of
insurance that has been terminated.
3. If the spouse ceased to be insured because of reason 3 or 4 shown in the Who May
Convert section of this provision, it may not be more than the smaller of the following
amounts.
a. The amount of insurance that applied to the spouse at the time it terminated
reduced by any amount of life insurance for which the spouse may be or may
become entitled under this or any group insurance policy within the conversion
period.
b. $2,000
4. It may not, in any event, exceed the maximum amount of insurance the spouse is
eligible to convert as stated in clause 2 or 3 above reduced by any amount of life
insurance currently in force and previously converted under this policy.
You will be required to give each person at least 15 days written notice prior to the date on
which the spouse's right to convert would expire. If the spouse has not received such notice he will
have an additional 15 days from the date he is notified in which to convert. The cafe Insurance
Coverage will not extend beyond the 31st day after the date the group insurance terminates, and the
right to convert will not extend more than 31 days beyond the initial 31 day conversion period.
The premium for the policy shall be based on the following:
1. Our rates at the date on which the policy takes effect.
2. The plan and amount of the policy.
3. The attained age of the spouse.
4. The class of risk to which the spouse belongs.
GIAOO-254
The Canada Life Assurance Company Page No. 35 Dated Sample - Void.
DEPENDENTS INSURANCE (Continued)
Payment of Dependents Insurance
The amount due on the death of an insured dependent of a person shalt be payable to the
person, if living, otherwise to his estate, on receipt by us at our Head Office of due proof of the death
of the dependent.
Continuation of Insurance During Disability of a Person
If insurance on the life of a person is continued in force pursuant to the Waiver of Premium
Benefit for Disabled Persons provision, insurance on the life of his dependents shall also be continued
in force without payment of any further premiums. No insurance on the life of any of his dependents
will be continued beyond the date on which such insurance terminates pursuant to the When
Dependents Insurance Terminates section.
If the insurance on the life of the dependents of a person is continued in force under the terms
of this section and is then terminated because the person ceases to be disabled or fails to submit any
proofs of disability required to be submitted during his lifetime then:
1. If this policy is in force, the dependents of the person shall be entitled to the same
conversion rights to which the dependents would have been entitled if the insurance had
terminated due to the termination of employment of the person.
2. If this policy is not in force, the dependents of the person shall be entitled to the same
conversion rights (if any) to which the dependents would have been entitled if the
insurance had terminated due to the termination of this policy.
Termination of the Dependents Insurance Provision
If any premium or adjustment premium has not been paid at the end of its days of grace, this
provision will terminate at that time.
If you give us written notice that this provision is to be terminated, this
provision will terminate on the latest of:
1. The date stated in the notice.
2. The date of receipt by us at our Head Office of the notice.
3. The end of the period to which premiums have been paid.
If, on the date on which any premium is due, the number of persons whose dependents are
insured under this provision, is less than 75 % of the number of insured persons with dependents, we
may terminate this provision by giving you written notice within 31 days after such date. We may also,
for any other reason, terminate this provision as of the date on which any premium is due, by giving
you written notice at least 31 days prior thereto.
The Canada Life Assurance Company Page No. 36 Dated Sample - Void.
All of the other provisions of the policy which are not inconsistent with this Dependents
Insurance provision will apply to this provision.
10K z
The Canada Life Assurance Company Page No. 37 Dated Sample - Void.
III 1 1 4 e ■
DEPENDENTS INSURANCE
Definitions
'Dependent' means:
1. The spouse of a person. This will include a divorced or separated spouse where a granting of a
judgment absolute of divorce or of separate support has been given until such time as provided
by said judgment.
2. Each unmarried child or stepchild of a person, over 14 days of age, provided that the child
reties fully on the person for support and maintenance and fits the following
description:
a. The child is under 19 years of age.
b. The child is at least 19 years of age but under 23 years of age and he/she is attending
an accredited educational institute. college or university on a full-time basis.
However, for the purposes of this provision, dependent shall exclude:
I. Anyone who is residing outside of Canada and the United States of America.
2. Anyone who is in full-time service in any naval, military or air force.
3. A child who does not rely fully on the person for support or maintenance.
4. A child may not be insured as a dependent of more than one person.
5. Any person who is insured under this policy.
GL400-250
The Canada Life Assurance Company Page No. 38 Dated Sample - Void.
DEPENDENTS INSURANCE (Continued)
How and When Dependents Insurance Takes Effect
A dependent will become insured on the earliest date on which he may become insured
provided that all of the following conditions have been met.
1. An application for each dependents' insurance must be completed on a form approved
for that purpose by us and be promptly deposited with us at our Head OMce.
2. The person is ensured for insurance under this policy.
3. We have, in writing, either approved evidence of the dependent's insurability or
waived such evidence.
If. at the time insurance on the life of a dependent who is not a new -born child would otherwise
take effect, such dependent is confined in a hospital, insurance on the life of such dependent will not
take effect until such dependent is discharged from the hospital.
GI AOO-251
The Canada Life Assurance Company Page No. 39 Dated Sample - Void.
DEPENDENTS INSURANCE (Continued)
Amount of Insurance
The amount of insurance on the life of each insured dependent will be based on the Schedule
shown below.
You will be required to deposit with us at our Head Office written notice of any change which
would affect the amount of insurance on the life of a dependent.
A change in a dependent's amount of insurance to a smaller amount will take effect no earlier
than the date on which we receive the notice frown you.
of:
A change in a dependent's amount of insurance to a larger amount will take effect on the latest
1. The date on which we receive the notice from you.
2. The date stated in the notice.
3. The date on which we have, in writing, either approved evidence of the dependent's
insurability or waived such evidence.
When we are calculating the amount of a benefit based on earnings that has become payable
with respect to a person under this policy, we will use whichever of the following amounts was the
smallest at the time the loss was incurred or the disability commenced..
1. The person's actual earnings as defined in the Definitions provision.
2. The level of the person's earnings on which the premium for his dependents benefit
was being paid.
The Canada Life Assurance Company Page No. 40 Dated Sample - Void.
DEPENDENTS INSURANCE (Continued)
CLASS
Spouse
Each Dependent Child
Schedule
REDUCTIONS
AMOUNT OF LIFE INSURANCE
$2<)Q00
$5,000
Notwithstanding the above, on and after a dependent's 65th birthday, the amount of insurance
will be 65 % of the amount applicable to him immediately prior to such birthday.
GL400-252
The Canada Life Assurance Company Page No. 41 Dated Sample - Void.
DEPENDENTS INSURANCE (Continued)
Payment of Dependents Insurance
The amount due on the death of an insured dependent of a person shall be payable to the
person, if living, otherwise to his estate, on receipt by us at our Head Office of due proof of the death
of the dependent
When Dependents Lamn-ance Terminates
A dependent's insurance under this policy will terminate on the earliest date shown below.
1. On the date on which the person asks to have the insurance on his dependents
terminated.
2. On the date on which this provision is no longer in force
3. When the dependent ceases to be a dependent as defined in this provision.
4. On termination of the insurance under this policy on the life of the person of whom he
is a dependent.
5. On the date the insurance on the life of the person of whom he is a dependent becomes
subject to the Waiver of Premium Benefit for Disabled Persons provision.
6. In the case of the spouse of a person, the date of the person's 70th birthday.
You must notify us in writing within 31 days after the date on which an event described in
clauses 1, 2 or 3 occurs.
GL 00-156
The Canada Life Assurance Con pmiy Page No. 42 Dated Sample - Void.
DEPENDENTS INSURANCE (Continued)
Suicide
No payment will be made under this provision with respect to a dependent who commits
suicide if his.death occurs within two years after the date on which he became insured or the person of
whom he is a dependent elected an increased amount of insurance. Our liability with respect to such
optional insurance of a dependent will be limited to an amount equal to the premiums paid thereon.
Termination of the Dependents Insurance Provision
If any premium or adjustment premium has not been paid at the end of its days of grace, this
provision will terminate at that time.
If you give us written notice that this provision is to be terminated, this provision will terminate
on the latest of:
1. The date stated in the notice.
2. The date of receipt by us at our Head Office of the notice.
3. The end of the period to which premiums have been paid.
We may, for any reason, terminate this provision as of the date on which any prernium is due,
by giving you written notice at least 31 days prior thereto.
All of the other provisions of the policy which are not inconsistent with this Optional
Dependents Insurance provision will apply to this provision.
GIAOO-161
Time Canada Life Assurance Conywq Page No. 43 Dated Sample - Void.
CAA �T A T ANAD'A Resolution No. 6568
LIFE Item No. 7799
No. H.nM
We, The Canada Life Assurance Company, agree to pay the benefits that become payable under this
policy to the person or persons entitled.
This agreement is subject to the provisions on the attached pages whici . together with this page, make up
the policy.
This policy will take effect on December 1, 1999
PLEASE NOTE THAT THIS SAMPLE CONTRACT IS PROVIDED FOR INFORMATIONAL
PURPOSES ONLY AND DOES NOT CONS ITMIZ AN OFFER OF INSURANCE. SOME TERMS,
PROVISIONS, OR BENEFITS SHOWN IN THIS SAMPI E MAY BE UNAVAILABLE TO SOME
GROUPS OR MAY BE AVAILABLE ONLY AT AN ADDITIONAL PRE11+ 1U1%L AN ACTUAL
POLICY MAY CONTAIN TERMS OR PROVISIONS NOT SHOWN IN THIS SAMPLE. ALL
PROVISIONS ARE SUBJECT TO THE PRIOR APPROVAL OF OUR UNDERVvIUTING
DEPARTMENT.
Policyholder - The City of L-ubbock
Issued at our Head Office at Atlanta, Georgia, as of Dec emb e r 1, . 19 9 9
EZN�6161M
Secretary Assistant Registrar
GROUP ACCIDENT AND SICKNESS POLICY
Not eligible for dividends
WARNING
This is a legal contract between the Policyholder
and The Canada Life Assurance Company
READ YOUR POLICY CAREFULLY
GC500-198
THE CANADA LIFE ASSURANCE COMPANY
HOME OFFICE: 330 UNIVERSITY AVE., TORONTO, ONTARIO, CANADA M5G 1R8
U. S. HEAD OFFICE: 6201 POWERS FERRY RD., NW, ATLANTA, GA 30339
The Canada Life Assurance Company Page No. 1 Dated Sample - Void.
TABLE OF CONTENTS
DEFIIVITIONS........................................................................................................... 3
WHO MAY BECOME INSURED ...................................................................................4
HOW AND WHEN A PERSON'S INSURANCE TAKES EFFECT ....................................... S
AMOUNTOF INSURANCE........................................................................................... 6
WHEN A PERSON'S INSURANCE TERNDNATES ............................. 0...... 0.................:... 9
PREMIUMS.............................................................................................................10
PERIOD OF GRACE.................................................................................................12
CURRENCY........................................................................................................... 12
PLACEOF PAYMENT.............................................................................................. 12
NOT ELIGIBLE FOR DIVIDENDS..............................................................................12
WORKERS' COMPENSATION NOT AFFECTED ...................................................0......12
CLERICALERROR..................................................................................................12
BOOKLET -CERTIFICATE, ........................................................................................13
STANDARD PROVISIONS......................................................................................... 14
AMENDMENTS TO THE POI.ICY..............................................................................17
TERMINATION OF POLICY..................................................................................... is
SELF ADM[INISTRATION..................................................................0..........0...........19
ACCIDENTAL DEATH AND D151WE iBERMENT BENEFIT .... :......................... ........ .... 20
SHORT TERM INCOME REPLACEMENT BENEFIT .................................................... 23
The Canada Life Assurance Company Page No. 2 Dated Sample - Void.
it-M 3: d: '11 ^ ■
DEFE MONS
All male terms will include the female term, unless stated otherwise.
"You" and "your" mean the Policyholder.
"We'. "our' and 'us' mean The Canada We Assurance Company.
"Person" means an employee.
"Actively at work" means that a person is either:
1. actually performing his normal duties, if it is a scheduled work day; or
2. capable of performing his normal duties, if he is not at work due to a non-scheduled
work day, holiday or vacation day;
at his normal place of employment or at some other location where your business requires him to be.
"Effective'Date" means January 1st, 1998.
"Policy month" means a period of one month commencing on the Effective Date or on the first day of
each month thereafter.
"Policy year" means a period of one year commencing on the Effective Date or on any anniversary
thereof.
"Employee" means anyone who is employed by you.
GC500-302
"Annual earnings" as used to determine the benefits of a person under this policy will be calculated as
his annual gross base earnings as an employee. They exclude any income he receives such as but not
limited to commissions, bonuses, dividends, overtime and profit sharing.
"Weekly Earnings" will be the annual earnings of a person divided by 52.
GC500-303
The Canada Life Assurance Company Page No. 3 Dated Sample - Void.
WHO MAY BECOME INSURED
The class or classes of persons who may be insured under this policy are all of the full-time
employees who work at least 30 hours per week on a regular basis as employees.
Each person who is a member of such a class on the Effective Date may become insured on
that date.
Each person who becomes a member of such a class after the Effective Date may become
insured on the earliest date after the Effective Date on which both of the following conditions have
been met:
1. He has completed at least 30 days of continuous service as an employee.
2. He is a member of such a class.
Each person who ceases to be insured because of the termination of his employment and who is
re-employed by you within six months after such termination, may become insured again on the earliest
date on which he is a member of such a class.
GC500-202
The C nada Life Assurance Company Page No. 4 Dated Sample - Void.
HOW AND WSEN A PERSON'S INSURANCE TAEES EFFECT
A person will automatically become insured under this policy on the earliest date on which he
may become insured provided that he is then actively at work_ U he is not actively at work on the date
on which he would otherwise become insured he will become insured only when he is again actively at
work.
An application to become insured must be completed on a form approved for that purpose by
us. It must be promptly deposited with us at our Head Office.
GC500-304
The Canada Life Assurance Company Page No. 5 Dated Sample - Void.
1 i.: it ii 1 - •
The amount of insurance with respect to each person who is insured will be based on the
Schedule shown below.
You must deposit written notice with us at our Head Office of any change in the class or
earnings of a person which would affect the amount of his insurance.
A decrease in the amount of his insurance will take effect on the date stated in the notice.
An increase in the amount of his insurance will take effect on the date stated in the notice
provided that he is then actively at work. If he is not actively at work on the date on which the amount
of his insurance would otherwise increase, the increase will takc effect only when he is again actively at
work.
When we are calculating the amount of a benefit based on earnings that has become payable
with respect to a person under this policy, we will use whichever of the following amounts was the
smallest at the time the loss was incurred or the disability commenced.
1. The person's actual earnings as defined in the Definitions provision.
2. The level of earnings on which the premium for the person's benefit was being paid.
GC500-305
The Canada Life Assurance Company Page No. 6 Dated Sample - Void.
INSURANCE SCHEDULE
I All Eligible Employees An amount equal to 200% of the person's annual earnings
(rounded to the next higher $1,000 of benefit) to a maximum
benefit of $500,000.
REDUCTIONS
Notwithstanding the above, on and after each of the birthdays listed below a person's insurance
will be reduced to a percentage of the Principal Sum calculated in accordance with the preceding
Schedule. The percentages are indicated in the following table:
65th
70th
75th
80th or over
65 %
45 %
30%
20 %
The Canada Life Assurance Company Page No. 7 Dated Sample - Void.
All Eligible Employees An amount equal to 60 % of the person's weeldy earnings
(rounded to the next higher $1.00 of benefit) to a maximum
benefit of $100.
GC500-306
The Canada Life Assurance Company Page No. 8 Dated Sample - Void.
WHEN A PERSON'S INSURANCE TERNIINATES
All of a person's insurance under this policy will terminate at the earliest time shown below.
1. When the person's employment terminates. A person's employment will terminate
when he is no longer actively at work. However, if a person is not actively at work
due to disease, pregnancy or injury his insurance will be continued in force under this
policy until the date on which we receive written notice from you that the person's
insurance is to be terminated.
2. When the person ceases to be a member of a class or classes of persons who may be
insured.
3. On the date on which this policy is no longer in force.
4. If a person is absent from work due to a temporary lay-off or due to a leave of absence,
the earlier of:
a. The date on which we receive written notice from you that the person's
insurance is to be terminated.
b. The last day of the month that follows the month in which his absence from
work began.
5. When the person goes on strike, or is locked -out- This will not apply if either:
a. There is a written agreement between you and us that all persons will continue
to be insured during the strike or lock -out.
b. There is applicable statutory legislation or regulation requiring the continuation
of insurance during a strike or lock -out.
6. The day before he enters active full-time service in any naval, military or air force.
7. On the date on which the person requests, in writing, to have his insurance terminated.
8. On the date on which the person retires unless otherwise stated in the Who May
Become Insured provision of this policy.
If an event that is described above occurs, you must deposit written notice with us at our Head
Office within 31 days. Failure to give written notice within such 31 day period will not continue
insurance in force with respect to a person beyond the time it would otherwise have been terminated as
shown above.
GC500-212
The Canada Life Assurance Company Page No. 9 Dated Sample - Void.
Premiums are due each month in advance from the Effective Date. Each premium due will be
calculated on a basis that is established by us and will be as follows:
1. For the Accidental Death and Dismemberment provision, $0.04 per $1,000 of Principal
Sum for each person.
2. For the Short Term Income Replacement provision, $0.67 per $10 of Short Term Income
Replacement Benefit for each person.
It is our right to change the premium rates shown above as follows:
1. As of January 1st, 1999 and any date on which a premium is due after such date.
2. At any time that the terms and conditions of this policy are changed.
3. At any time the number of persons or the composition of the group of persons who are
insured under this policy changes by more than 25 % Failure to remit a complete census
listing may result in a change in the premium rate(s).
4. At any time there is a change in federal or state legislation or regulation which affects the
benefits or provisions of this policy.
We must give you written notice at least 60 days prior to the date of a change.
If you request, and we agree, the frequency of premium payment may be changed, as of any
date on which a premium is due. You may change the frequency to yearly, half -yearly, quarterly or
monthly. If the frequency of premium payment is to be changed to one other than monthly, the terms
of the first paragraph of this provision will be read as if they had been changed to provide for the new
premium frequency.
If, at any time prior to the date that a loss is incurred or a disability commences, we learn that
the amount of insurance that should be in force under this policy is not the amount on which the
premium was based, an adjustment premium will be paid by you or a refund will be made to you so
that the actual premiums for the true amount of insurance will be paid.
If there is any change in the amount of insurance in force under this policy between the dates
on which premiums are due, an adjustment premium or a refund will be due. The adjustment premium,
or the refund will be due on whichever of the following dates apply:
1. If the amount of insurance changes on or prior to the 15th day of a policy month, the
first day of such policy month.
The Canada Life Assurance Company Page No. 10 Dated Sample - Void.
2. If the amount of insurance changes after the 15th day of a policy month, the first day of
the next policy month. However, an adjustment premium or refund will not be due if,
on the fast day of the next policy month, a regular premium is due.
GC500-308
If we do not receive written notice of a change due to a decrease in or the termination of an
amount of insurance within 60 days of the date such change occurred, we will Imut the refund to 2
months premium.
The amount of insurance with respect to an insured individual will be decreased or terminated
in accordance with the other terms of this policy. The payment of premiums with respect to an
individual's insurance after the date of such decrease or termination will not continue to provide
insurance of the amount which was in effect with respect to such individual prior to such decrease or
continue insurance m force with respect to such individual after such termination, whether or not all or
part of such premium is refunded.
Refunds will be applied in or toward the payment of any outstanding premiums and adjustment
premiums. Any balance will be held at your credit, without interest, and will be applied in or toward
payment of succeeding premiums and adjustment premiums as and when they fall due. However, you
may, at any time, withdraw in cash any amount so held at your credit.
If this policy is terminated in accordance with the Termination of Policy provision, you will
pay to us all adjustment premiums that are due and have not been paid. You will also pay to us a pro
rats premium for the period (if any) elapsed from the date on which the last unpaid premium was due
to the date on which this policy is terminated.
We shall not be required to accept the payment of any premium otherwise than from you.
GC500-309.
Tile Canada "e Assurance Company Page No. 11 Dated Sample - Void.
nee 3; 1 ..1. - ■
PERIOD OF GRACE
A period of grace will be allowed for the payment of each premium after the first and each
adjustment premium. The period of grace for the payment of each premium will be 31 days after the
date on which it is due. The period of grace for the payment of each adjustment premium will be 31
days after the date on which it is due. The period of grace for the payment of each adjustment
premium will be 31 days after the date on which the next premium is due unless we, by written notice
to you, limit the days of grace. Such limit will not be less than 31 days after the date the notice is
delivered to you. The policy will remain in force during the period of grace unless terminated in
accordance with the Termination of Policy provision. In any event, premiums are payable for any
period of grace during which the policy continues in force.
CURRENCY
All amounts payable under this policy must be paid in United States currency.
PLACE OF PAYMENT
All amounts payable by us will be payable at our office in Atlanta, Georgia.
NOT ELIGIBLE FOR DIVIDENDS
Ibis policy is not eligible for dividends and will not tape part in the distribution of our surplus.
WORKERS' COMPENSATION NOT AFFECTED
This policy is not in place of, and does not affect any requirement for coverage by, Workers'
Compensation Insurance.
CLERICAL ERROR
Clerical error in keeping the records will not invalidate insurance otherwise validly in force nor
continue insurance otherwise validly terminated. Upon discovery of any such error an adjustment of
premiums will be made.
GC500-226
The Cmwda Life Assurance Company Page No. 12 Dated Sample - Void.
BOOM LT -CERTIFICATE
We will issue booklet -certificates to you that summarize the essential provisions of this policy.
You must deliver them to each person who is insured.
The provisions of this policy will govern if there is any discrepancy between the following:
1. The provisions of the booklet -certificate delivered to a person who is insured.
2. The provisions of this policy.
If a booklet -certificate is issued to a person who for any reason is not entitled to insurance
under this policy, such booklet -certificate will be of no effect.
CC500-227
The Canada Life Assurance Company Page No. 13 Dated Sample - Void.
STANDARD PROVISIONS
Contract
The whole contract is made up of:
1. This policy.
2. Any amendments to this policy.
3. The Group Insurance Application.
You will not be considered to be our agent for any purpose under this policy.
All statements made by any of the persons who are insured will be deemed representations and
not warranties. No statement made by any person who is insured will be used in any contest unless:
1. It is contained in a written instrument signed by the person.
2. A copy of the written instrument has been given to the person.
Only our President or Secretary may modify this policy or waive any of our rights or
requirements.
Any change in this policy must be in writing and be attached to it. The change must bear the
signature or a reproduction of the signature of one or both of the above officers. It must also bear the
signature of our Registrar or one of our Assistant Registrars and your signature.
Time Limit on Certain Defenses
After a person has been insured under this policy for two yews, no misstatement of the person
except a fraudulent misstatement will be used to reduce or deny a claun.
Notice of Claim
Written notice of a claim must be given to us within 30 days of the occurrence or
commencement of any loss covered by this policy. If this is not possible, we must be notified as soon
as it is reasonably possible to do so. Notice must be given to us at our Head Office or to an agent of
ours. The notice should include the name of the person with respect to whom the claim is made and
the group policy member.
GC500-310
The Canada Life Assurance Company Page No. 14 Dated Sample - Void.
claim Forms
When we receive a written notice of a claim, we will send the claimant our claim forms to file
proof of loss. If the claim forms are not received within 15 days after written notice of claim is seat,
the claimant can send us written proof of claim without waiting for the claim forms.
Proof of Loss
Proof of loss must be given to us no later than 90 days after the occurrence or commencement
of any loss covered by this policy. If ft is not possible to give proof within the time required, it must
be given as soon as reasonably possible.
Proof of continued disability and regular attendance of a physician must be given to us within
30 days of the date we request the proof. The proof must cover.
1. The date disability began.
2. The cause of disability.
3. The severity of the disability.
Time of Payment of Claim
When we receive satisfactory proof of claim, benefits payable under this policy for any loss
other than for loss of time will be paid as they are incurred.
Benefits payable for loss of time will be paid weekly during any period for which we are liable.
Any balance which remains unpaid at the end of the period for which we are liable will be paid
immediately upon receipt of such proof.
Payment of Claims
Indemnity for loss of life will be payable in accordance with the beneficiary designation and the
provisions respecting such payment which may be prescribed herein and effective at the time of
payment. If no such designation or provision is then effective, such indemnity shall be payable to the
estate of the insured person. Any other accrued indemnities unpaid at the insured person's death may,
at our option, be paid either to such beneficiary or to such estate. All other indemnities will be payable
to the insured person.
Physical Examination
We will have the right and opportunity, at our own expense. to have a physician of our choice
examine anyone in respect of whom a claim is berg made. We will have the right to do this when and
as often as we may reasonably require. The benefits with respect to which the claim was made will not
be paid during any period in which the person fails to submit to any medical examination requested by
US.
GC500-311
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Legal Actions
No action at law or in equity may be brought to recover under this policy until 60 days after
written proof of loss has been ,given to us. No such action may be brought more than three years after
the time within which proof of loss is required to be given.
Conformity with State Statutes
Any provision of this policy which, on its effective date, is in conflict with the statutes of the
State in which this policy was delivered or issued for delivery is hereby amended to conform to the
minimum requirements of such statute.
GC500-312
The Canada Life Assurance Company Page No. 16 Dated Sample - Void.
AMENDMENTS TO THE POLICY
Ibis policy may be amended at any time by written agreement between you and us without the
consent of or notice to any other individual. Any amendment to this policy mast be in writing and
attached to it. The amendment must bear the signature or a reproduction of the signature of one or
both of our President or Secretary. It must also bear the signature of our Registrar or one of our
Assistant Registrars, and your signature.
H an insured person is not actively at Work on the effective date of the amendment, the
effective date with respect to that person will be on the date that he is again actively at work.
However, if the amendment reduces the amount of insurance to which the person is entitled, the
effective date will be the effective date of the amendment.
It is understood that, if any income replacement benefit is included in this policy and is
amended during a person's continuous period of disability, the amendment will have: no effect on such
income replacement benefit during that same continuous period of disability.
GC500-313
The Canada Life Assurance Company Page No_ 17 Dated Sample - Void.
TERMINATION OF POLICY
If you give us written notice that this policy is to be terminated, it will terminate on the later of:
1. The date that is stated in the notice.
2. The date on which we receive the notice at our Head Office.
We may terminate this policy as of the date on which any premium is due if, at any time, the
number of persons who are insured is less than 20 or is less than 100% of the number of persons who
are then members of the class(es) of persons who may become insured under this policy as of the date
on which any premium is due. We may also, for any other reason, terminate this policy as of the date
on which any premium is due.
We must give you at least 60 days written notice prior to the date on which this policy is to
terminate.
This policy will terminate, in any event, at the end of the period of grace allowed for the
payment of any premium or adjustment premium if such premium is still unpaid at that time.
You will be required to give each person at least 15 days written notice prior to the date on
which this policy is to terminate. Failure to give written notice within such 15 day period Will not
continue ins •trance in force with respect to a person beyond the time this policy would otherwise have
terminated.
GC500-234
Ae Canada Life Assurance Con pang Page No. 18 Dated Sample - Void.
SELF-ADAUN STRAUON
At your request this policy is self-administered. For that reason it is expressly provided that:
1. All documents and notices that would otherwise be deposited with us at our Head
Office in accordance with the terms of this policy will be held by you. This will not
apply to any evidence of insurability required by us under this policy nor to any notice
required by us to process any claim.
2. Whenever we request, you will furnish us with all of the documents relating to a
person's insurance which have been completed in accordance with the terms of this
policy and are being held by you.
3. We may inspect and examine your records which pertain to a person in so far as the
records affect his insurance or his eligibility for insurance.
4. All premium payments that would otherwise be calculated by us at our Head Office in
accordance with the terms of this policy will be calculated by you on a basis provided
by us.
5. Whenever we request, you will deposit with us at our Head Office a statement listing
the following:
a. Each person who is then insured.
b. The Class of each person under the Schedule.
C. The amount of the benefits that apply to each person.
d. The date of birth of each person.
e_ If applicable, the earnings of each person.
GC500-315
The Canada Life Assurance Company Page No. 19 Dated Sample - Void.
ACCIDENTAL DEATH AND DISMEMBERMENT BENEFTT
We will pay the amount descn'bed in the Schedule of Losses if a person suffers any such Loss,
subject to all of the following conditions.
1. The Loss is caused solely by an accident.
2. The Loss is not excluded by the terms of the Exclusions section of this provision.
3. The accident must occur while the insurance on the person is in force under this Provision.
4. The Loss must occur within 365 days after the date on which the accident occurred.
5. The maximum amount payable will be subject to the terms of the Limitations section of this
provision.
Any amount payable under this provision will be paid to the person except in the case of loss of
life, in which case, payment will be made to the Beneficiary.
"Principal Sum" is the amount which applies to the person under the Amount of Insurance
provision at the time of the accident.
"Loss" means, with regard to:
1. An arm, leg, hand or foot, the total and irrecoverable loss of its use.
2. A thumb and index finger or all four fingers of one hand, complete severance at or above the
metacarpophalangeal joints.
3. Toes, complete severance at or above the metacarpophalangeal joints.
4. An eye, the total and irrecoverable loss of sight.
5. Speech, the complete and irrecoverable loss of speech.
6. Hearing, the complete and irrecoverable loss of hearing.
"Beneficiary" will be as determined under the Beneficiary provision of the Group Life
Insurance Policy.
GC500-350
The Canada Life Assurance Company Page No. 20 Dated Sample - Void.
W N. 1. i ! y4 . ■
SCHEDULE OF LOSSES
Life.......................................................................................... The Principal Sum
The sight of both eyes....................................................................
The Principal Sum
Either both hands in both feet..........................................................
The Principal Sum
One hand and tm foot...................................................................
The Principal Sum
The sight of one eye and either one hand or tx foot
.............................. The Principal Sum
Speech and hearing in both ears ........................................................
The Principal Sum
Either one arm in one leg..........................................Three-quarters
of the Principal Sum
Either one hand Qr one foot ............................................... Onefialf of the Principal Sum
The sight of one eye ........................................................ One-half of the Principal Stun
Speech al hearing in both ears ........................................... One-half of the Principal Sum
Both the thumb And index finger of one hand ..................... One -quarter of the Principal Sum
All four fmgers of one hand .......................................... One -quarter of the Principal Sum
All of the toes of one foot ............................................. One -eighth of the Principal Sum
1. The total amount payable under this provision in respect of all Losses suffered by a
person as the result of any one accident will not exceed the Principal Sum.
2. If, as the result of any one accident, a person suffers more than one of the Losses
shown in the Schedule of Losses with respect to any one limb, payment will be made
only for the Loss for which the largest amount is payable.
GC500-351
The Canada Life Assurance Company Page No. 21 Dated Sample - Void.
No amount of Benefit will be payable under this provision if the Loss resulted either directly or
indirectly from, or was in any manner or degree associated with, or occasioned by, any one or more
Of.
1. Intentionally self-inflicted injury.
2. War, declared or undeclared, or any act of war.
3. Active participation in any riot or violent disorder.
4. "The person either taking or attempting to take his own life whether he is in possession of his
mental faculties or not at the time.
5. Bodily or mental infirmity or illness or disease of any kind, or medical or surgical treatment
thereof.
6. Poisoning in any form, inhalation of gas or fumes.
7. Travel or flight in any aircraft except solely as a passenger in a powered civil aircraft having a
valid and current airworthiness certificate and operated by a duly licensed or certified pilot while
such aircraft is being used for the sole purpose of transportation only. Descent from any aircraft in
flight will be deemed to be part of such flight.
In addition, no payment will be made under this provision if the loss, or injury leading to the
loss, occurs while:
1. In the course of operating a motor vehicle;
a. under the influence of any intoxicant, or
b. if the person's blood alcohol concentration is in excess of 100 milligrams of
alcohol per 100 milliliters of blood.
2. Committing or attempting to commit a felony.
GC500-352
Me Canada Life Assurance Company Page No. 22 Dated Sample - Void.
SHORT TERM INCOME REPLACE BENEFIT
We will pay to a person, who begins a continuous period of disability while he is insured under
this provision, after he has completed the elimination period the Amount Of Insurance which applies to
the person under the amount of insurance provision at the date on which such period began, subject to
all of the following conditions.
1. An absence from work for half or less than half of any one day will not be considered a
day of disability for the purpose of this provision.
2. The amount of insurance which applies to him under this provision will be subject to
reductions. These are outlined in the Reductions section of this provision.
3. If the period during which a person is entitled to receive benefits under this policy is
not a complete number of weeks, the amount of benefit payable with respect to him for
each day that is in excess of a complete number of weeks will be at the rate of one -
seventh of the weekly benefit which is applicable to him.
The maximum benefit payment period is 26 weeks. This period will commence on the first day
immediately following completion of the Elimination Period.
The person will cease to be insured under this provision at the end of the maximum benefit
payment period if he does not then return to active work for his employer.
The maximum benefit payment period will be applied separately to each continuous period of
disability.
"Disabled" and "disability" mean the person is not able to perform with reasonable continuity
the substantial and material duties of his own occupation in the usual or customary way due to injury,
disease, illness, pregnancy or mental disorder.
"Elimination Period" is the period that the person must have actually been disabled during a
continuous period of disability before he may receive benefit payments under this provision. The
elimination period is 1 days if such disability is the result of an accident, otherwise 8 days.
However, if the insured person becomes confined to a licensed hospital during the elimination
period, benefit payments will begin on the date of confinement. For the purposes of this provision,
"confined to a licensed hospital" means:
1. The insured person has been hospitalized for a period of not less than 24 consecutive
hours in such hospital, or
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1 p.. M: A. 1.1 I : ■
2. The insured person receives out -patient surgery in such hospital.
GC500-375
The Canada Life Assurance Company Page No. 24 Dated Sample - Void.
"Physician" means an individual who is operating within the scope of his license and is either:
1. Licensed to practice medicine and prescribe and administer drugs or to perform
surgery; or
2. Legally qualified as a medical practitioner and required to be recognized, under this
policy for insurance purposes, according to the insurance statutes or the insurance
regulations of the governing jurisdiction.
It will not include an employee or his spouse, daughter, son, father, mother, sister or brother (as an
attending physician).
"Continuous Period of Disability" includes all periods of disability that meet all of the following
conditions.
1. They commence while the person is insured under this provision.
2. They are related to the same cause or causes.
3. They are not separated by a period of more than 14 consecutive days during which the
person was not disabled.
"Pregnancy" includes child -birth or miscarriage and any disease or infamity resulting from or
aggravated by the pregnancy. It also includes therapeutic abortions or complications arising from any
abortion.
If a person has begun a continuous period of disability prior to the time his insurance under this
policy would otherwise terminate, his Short Term Income Replacement Benefit will be continued in
force under this provision as long as he is entitled to such benefit with respect to that continuous period
of disability.
GC500-376
The Canada Life Assurance Company Page No. 25 Dated Sample - Void.
1. No amount of benefit will be payable under this provision with respect to the disability of a
person during any of the following periods.
a. Any period beyond the maximum benefit payment period.
b. Any period of disability during which a person is not under the continuing care of a
physician.
C. Any period while the person is either permanently or temporarily outside of the United
States or Canada. If he becomes disabled while he is outside the United States or
Canada his disability will not be deemed to commence until the date on which he
returns to the United States or Canada.
d. For any period that the person refuses another job offered by you without a reduction
m earnings for which he is reasonably suited, unless the disability prevents him from
performing the duties of the alternate job.
C. For any period that the person has been paid (in a harp sum or otherwise) a severance
allowance because his employment was terminated.
2. No amount of benefit will be payable under this provision for any disability that resulted either
directly or indirectly from, or was in any manner or degree associated with, or occasioned by,
any one or more of:
a. Any cause which entitles the person to apply for and receive indemnity or
compensation under any Worker's Compensation Law.
b. The person either, taking or attempting to take his own life whether he is in possession
of his mental faculties or not at the time.
C. War, declared or undeclared, or any act of war.
d. Active participation in any riot or violent disorder.
C. Committing or attempting to commit a felony.
GOOD-377
The Canada Life Assurance Company Page No. 2b Dated Sample - Void.
If the person becomes entitled to receive benefits in accordance with the terms of this
provision, the amount of the Short Term Income Replacement Benefit payments will be reduced by the
amount of any payments, including retroactive and/or hemp sum awards, which the person is eligible to
apply for and receive with respect to the disability from the following sources:
1. Any retirement program that is funded in whole or in part by you.
2. The Social Security Act, The Railroad Retirement Act, the Canada Pension Plan or the
Quebec Pension Plan. This includes dependents benefits by reason of such disability.
3. Any other program or coverage required or provided by law or government agency.
4. Any other periodic payments from you.
5. Any No -Fault .Motor Vehicle Coverage, including benefits for lost income. This
reduction will not apply if either:
a. State law or regulation does not allow any reduction of group disability benefits
by benefits received under No -Fault Motor Vehicle Coverage.
b. The No -Fault Motor Vehicle Coverage, according to its rules or according to
an election of a person who is insured, determines its benefits after the benefits
paid or due under this policy have been paid.
If, at the time of calculating the amount of any payments to be made under this provision, the
benefit which a person is eligible to apply for and receive under any other source described in this
provision has not been awarded nor denied, we will estimate the amount of such benefit. The estimate
will be used to reduce the amount of the payments .under this provision until such time as the benefit
under such source has been awarded or denied. This estimated reduction will be used to reduce the
amount of the payments under this provision even if the benefit which a person is entitled to apply for
and receive has not been applied for. However, such estimate will not be used if the person meets both
the following conditions.
1. The person has applied for the benefit under the other source; and
2. The person completes and signs our Reimbursement Agreement. This agreement states
that the person promises to repay to us any overpayment caused by an award of the
benefit under the other source.
If we have reduced payments under this provision by an estimate of the amount of the benefit
under another source, we will adjust the amount of the payments under this provision when we receive
written notice that the amount of the benefit received under such source differs from the estimate or
that the benefit has been denied.
If the amount of the benefit received under another source is less than was estimated or the
benefit has been denied, we will make a hnnp sum refund of the amount by which we have underpaid
The Canada Life Assurance Company Page No. 27 Dated Sample - Void.
the payments the person is entitled to under this provision. If the amount of the benefit received under
another source is more than was estimated the person must make repayment to us of the amount of the
overpayment.
GC500-378
The Canada Life Assurance Company Page No. 28 Dated Sample - Void.
x
CANADA LIFE
No. 77777P
Resolution No.
Oct. 14, 1999
Item No. 77
We, The Canada Life Assurance Company, agree to pay the benefits that become payable under this policy
to the person or persons entitled.
This agreement is subject to the provisions on the attached pages which, together with this page, make up the
policy.
The consideration for this policy is the Request for Group Insurance and the payment by the Policyholder of
the premiums required herein.
PLEASE NOTE THAT THIS SAMPLE CONTRACT IS PROVIDED FOR INFORMATIONAL
PURPOSES ONLY AMID DOES NOT CONSTITUTE AN OFFER OF INSURANCE. SOME TERMS,
PROVISIONS, OR BE-4EFITS SHOWN IN THIS SAMPLE MAY BE UNAVAILABLE TO SOME
GROUPS OR MAY BE AVAILABLE ONLY AT AN ADDITIONAL PREMIUM. AN ACTUAL
POLICY MAY CONTAIN TERMS OR PROVISIONS NOT SHOWN IN IIHS SAMPLE.. ALL
PROVISIONS ARE SUBJECT TO THE PRIOR APPROVAL OF OUR UNDERWRITING
DEPARTMENT.Errorl Bookmark not defined.
This policy will take effect on,' De c emb e r 1, 1 19 9 9
Policyholder- The City of Lubbock
Issued at our Head Office at Atlanta, Georgia, as of " De c e mb e r 1, 19 9 9
Secretary Assistant Registrar President
GROUP.TEILM LIFE POLICY
Not eligible for dividends
WARNING
This is a legal contract between the Policyholder
and The Canada Life Assurance Company
READ YOUR POLICY CAREFULLY
IF YOU HAVE QUESTIONS ABOUT THIS POLICY, CALL 1(800)554-4026
GL400-300
THE CANADA LIFE ASSURANCE COMPANY
U. S. HEAD OFFICE: 6201 POWERS FERRY RD., NW, ATLANTA, GA 30339
The Canada Life Assurance Company Page No. 1 Dated Sample - Void.
TABLE OF CONTENTS
Name of Provision Page Number
DEFINITIONS........................................................................................................... 4
WHO MAY BECOME INSURED................................................................................... S
HOW AND WHEN A PERSON'S TERM INSURANCE TAKES EFFECT .............................6
AMOUNT OF INSURANCE.......................................................................................... 7
SUICIDE.................................................................................................................10
WAIVER OF PREMIUM BENEFIT FOR DISABLED PERSONS......................................11
ACCELERATED BENEFIT........................................................................................ 14
CONVERSION......................................................................................................... 17
WHEN A PERSON'S TERM INSURANCE TERMINATES .............................................. 19
PORTABILITY OF TERM INSURANCE...................................................................... 21
PREMIUMS............................................................................................................. 22
TABLE OF INSURANCE PREMIUMS......................................................................... 24
PERIODOF GRACE................................................................................................. 25
CURRENCY............................................................................................................ 25
PLACEOF PAYMENT.............................................................................:................ 2S
NOT ELIGIBLE FOR DIVLDENDS.............................................................................. 25
CLERICALERROR.................................................................................................. 25
INCONTESTABILITY............................................................................................... 26
BENEFICIARY........................................................................................................ 27
ASSIGNMENT......................................................................................................... 27
INSURANCEPAYABLE............................................................................................ 27
BOOKLET-CERTLFICATE........................................................................................ 28
AGE....................................................................................................................... 28
The Canada Life Assurance Company Page No. 2 Dated Sample - Void.
TABLE OF CONTENTS
Name of Provision Page Number
OPTIONAL biETTIANEM AT DEATH..................................................................... 28
STANDARD PROVISIONS......................................................................................... 29
AMENDMENTS TO THE POLICY.............................................................................. 30
CONTRACT............................................................................................................ 30
CONFORMITY WITH STATE STATUTES ................................................................... 32
TERNUNATION OF POLICY ........................... ............................... ....... ............... ..... 32
SELF-ADNIINISTRATION................................. .,....................................................... 33
DEPENDENTS TERM INSURANCE............................................................................ 34
ACCIDENTAL DEATH AND DISMEMBERMENT BENEFIT
..................... 43
ACCIDENTAL DEATH AND DISNEMBERMU T STANDARD PROVISIONS ................... 54
GIA00-201
Me Canada Life Assurance Company Page No. 3 Dated Sample - Void.
DEFINITIONS
"You" and 'your' mean the Policyholder.
'We', 'our" and "us" mean The Canada Ike Assurance Company.
"Person" means an employee.
"Actively at work" means that a person is either.
1. actually performing the person's normal duties, if it is a scheduled work day; or
2. capable of performing the person's normal duties, if the person is not at work due to a
non-scheduled work day, holiday or vacation day:
at the person's normal place of employment or at some other location where your business requires the
person to be.
"Effective Date" means Jamiary 1st, 1998.
"Policy month" means a period of one month commencing on the Effective Date or on the first day of
each month thereafter.
'Policy year' means a period of one year commencing on the Effective Date or on any anniversary
thereof.
"Employee" means anyone who is employed by you.
*Annual earnings" as used to determine the benefits of a person under this policy will be calculated as the
person's annual gross base earnings as an employee. They exclude any income the person receives such
as but not limited to commissions, bonuses, dividends, overtime, and profit sharing.
GL400-301
Me Canada Life Assurance Company Page No. 4 Dated Sample - Void.
WHO MAY BECOME INSURED
The class or classes of persons who may be insured under this policy are all of the full-time
employees who work at least 30 hours per week on a regular basis as employees. For the purposes of
this policy, a temporary or seasonal employee is not considered to be a fullfime employee.
Each person who is a member of such a class on the Effective Date may become insured on
that date.
Each person who becomes a member of such a class after the Effective Date may become
insured on the earliest date after the Effective Date on which both of the following conditions have
been met:
1. The person has completed at least 30 days of continuous service as an employee.
2. The person is a member of such a class.
Each person who ceases to be insured because of termination of employment and who is
re-employed by you within six months after such termination, may become insured again on the earliest
date (but not earlier than the 32nd day after the date of such termination) on which the person is a
member of such a class. However, the above will not apply to any person to whom a policy has been
issued in accordance with the Conversion provision.
GL400-302
The Canada 14re Assurance Company Page No. 5 Dated Sample - Void_
How AND WHEN A PERSON'S TERM INSURANCE TAKES EFFECT
A person will becoine insured for insurance on the earliest date on which he/she may become
insured provided that all of the following conditions have been met:
1. An application to become insured must be completed on a form approved for that purpose
by us and be promptly deposited with us at our Head Office.
2. The person is a member of a class who may be insured.
3. The person is actively at work.
4. The date on which we have, in writing, approved evidence of insurability if required as
described below. A person will be required to provide evidence of insurability
satisfactory to us if either one of the following conditions apply.
a. The amount of insurance initially applied for exceeds the Guaranteed Issue I an
shown in the Amount of Insurance provision.
b. The person applies to become insured under this policy more than 31 days after
the earliest date on winch he/she may have become insured under this policy.
Any evidence required under this clause must be provided without expense to us.
C. The person was eligible to apply for similar coverage under a policy or plan of
insurance replaced by this policy but did not apply for such coverage within 31
days of the date he/she became eligible under the prior policy or plan.
If the person is not actively at work on the date on which he/she would otherwise become insured,
he/she will become insured only when he/she is again actively at work.
GIAOD-303
The Canada Life Assurance Company Page No. 6 Dated Sample - Void.
AMOUNT OF INSURANCE
The amount of insurance on the life of each insured person will be based on the Schedule
shown below.
You will be required to deposit with us at our Head Office written notice of any change which
would affect the amount of insurance on the life of a person.
A change in a person's amount of insurance to a smaller amount will take effect no earlier than
the date on which we receive the notice from you.
A change in a person's amount of insurance to a Larger amount will take effect on the latest of:
1. Zhe date on which we receive the notice from you.
2. The date stated in the notice.
3. The date on which the person is actively at work.
4 _ The date on which we have, in writing, either approved evidence of his/her insurability
or waived such evidence.
Any evidence required under this provision must be provided without expense to us.
When we are calculating the maximum amount of a benefit based on earnings that has become
payable with respect to a person under this policy, we will use whichever of the following amounts was
the smallest at the time the loss was incurred or the disability commenced.
I. The person's actual earnings as defined in the Definitions provision.
2. The level of earnings on which the premium for the person's benefit was being paid.
GL400-304
The Canada Life Assurance Company Page No. 7
Dated. Sample - Void.
lc I
1. All Eligible Employees
AMOUNT OF INSURANCE (Continued)
An amount equal to 100% of the person's
annual earnings (rounded to the next higher
$1,000 of benefit) to a maximum benefit of
the lesser of $500,000 or 5 times the person's
annual eauni�gs
Guarantee Issue Limit - $50,000. Note: A person will be required to provide evidence of insurability
satisfactory to us if any one of the following conditions apply.
a) The amount of insurance initially applied for exceeds $50,000
b) The person applies for an increased amount of insurance after the date on which he/she
initially became insured under this policy.
c) The person applies to become insured under this policy more than 31 days after the
earliest date on which he/she may have become insured under this policy.
d) The person was eligible to apply •for similar coverage under a policy or plan of
insurance replaced by this policy but did not apply for such coverage within 31 days of
the date he/she became eligible under the prior policy or plan.
REDUCTIONS
Notwithstanding the above, on and after each of the birthdays listed below a person's insurance
will be reduced to a percentage of the amount of insurance calculated in accordance with the preceding
Schedule. The percentages are indicated in the following table:
65th
70th
75th
80th or over
GL400-305
65 %
45 %
30 %
20 %
The Canada life Assurance Company Page No. 8 Dated Sample - Void.
1. AR Eligible Employees
AMOUNT OFI (Continued)
INSURANCE SCHEDLq
An amount equal to 100% of the person's
annual earnings (rounded to the next higher
$1,000 of benefit) to a maximum benefit of
the lesser of $500,000 or 5 times the
person's annual earnings
it is provided that the amount of Accidental Death and Dismemberment insurance on a person
must equal the amount of life insurance provided under this policy
REDUCTIONS
Notwithstanding the above, on and after each of the birthdays listed below a person's insurance
will be reduced to a percentage of the Principal Sum calculated in accordance with the preceding
Schedule(s). The percentages are indicated in the following table:
i Birthd Percentage
65th
70th
75th
80th or over
GL400-306
65 %
45 %
30 %
20%
The Canada Life Assurance Company Page No. 9 Dated Sample - Void.
SUICIDE
No payment will be made under this policy with respect to a person who commits suicide if the
person's death occurs within two years after the date on which helshe became insured under this policy
or elected an increased amount of insurance under this policy. Our liability with respect to such
insurance of a person will be limited to an amount equal to the premiums paid thereon.
GL400-307
Me Canada Life Assurance Company Page No. 10 Dated Sample - Void.
WAIVER OF PREM M BENEFIT FOR DISABLED PERSONS
This prevision does not apply to any insurance provided under the Acciderrtat Death and
Dismemberment provision.
If a person becomes disabled prior to the person's 60th birthday and while he/she is insured
under this policy then, as of the effective date of disability:
1. The insurance on the person's life provided by the other terms of this policy will be
deemed to have terminated and instead will be continued in force under this provision
for the amount then in effect while the person is disabled.
2. No premium payment will be required for the insurance continued in force under this
provision.
The termination of this policy after the person's effective date of disability will not affect the
continuation of the person's insurance under this provision.
"Disabled" and "disability' mean the person is not able to perform the substantial and material
duties of any occupation for which the person is qualified in view of the persona age; education,
experience and physical and mental capacity, due to injury, disease, illness, pregnancy or mental
disorder.
"Effective date of disability" means the date a person becomes disabled provided that the
disability has been continuous for whichever of the following periods is the shorter:
1. A period of at least 6 consecutive months.
2. The period until his death.
All proof of disability that we require must be given to us at our Head Office. The proof must
be satisfactory to us. We will have the right "to have a physician designated by us examine a person
who is disabled as often as we may reasonably require.
GIAOO-308
Me Canada Life Assurance Company Page No. 11 Dated Sample - Void.
u 11 1, 1 ,. ■
WAIVER OF PREMIUM BENEFIT FOR DISABLED PERSONS (Continued)
1. We must receive initial proof that a person is disabled no later than 12 months after the
effective date of disability. This proof must be satisfactory to us.
2. ff a person dies prior to submitting initial proof of disability as required in Condition 1,
proof that it continued until the date of the person's death must be given to us no later
than 12 months after the person's death.
3. The insurance on the life of a person will be subject to any reductions in amount or
terminations of insurance included in the policy at the person's effective date of
disability which would have applied to him/her prior to age 70 if he/she were not
disabled.
4. Any amount of insurance continued in force under this provision that becomes payable
will be reduced as follows:
a. By any amount paid under the terms of the Conversion provision of this policy,
because a person died within the 31 day period in which he/she was entitled to
apply for a policy of individual life insurance.
b. By any amount of insurance paid under a policy that was issued to the person
under the Conversion provision of this policy after he/she became disabled,
unless such policy was surrendered to us without claim in exchange for a full
refund of premiums paid under it.
The insurance continued in force under this provision with respect to a person will terminate on
the earliest of the following:
1. The date on which the person ceases to be disabled.
2. Three months after the date we request further proof that the person is still disabled if
such proof is not received by us within this period. We may ask for further proof as
often as we may reasonably require.
3. The date on which the person attains age 65.
4. The date on which the person begins to receive retirement benefits which he/she is
eligible to receive as a result of past employment with you or another employer,
whether or not the retirement benefits were fiunded in whole or in part by you or a
previous employer or entirely by the person. This also includes retirement under any
plan of a federal, state, municipal or association retirement plan.
GL400-309
The Canada Life Assurance Company Page No. 12 Dated Sample - Void.
WAIVER OF PREMN BENEFIT FOR DISABLED PERSONS (Continued)
If the insurance with respect to a person is continued in force under this provision and is then
terminated because he/she ceases to be disabled or fails to submit any proof of disability that we
require, one of the following events will occur.
1. If this policy is in force and the person is a member of a class or classes of persons who
may be insured under this policy and the person is actively at work, he/she will
immediately become insured under the other terms of this policy.
2. If this policy is in force but either the person is not a member of a class or classes of
persons who may be insured under this policy or the person is not actively at work,
he/she will be entitled to the same conversion rights that he/she would have been
entitled to if insurance had terminated due to the termination of employment.
3. ff this policy is not in force, the person will be entitled to the same conversion rights
that he/she would have been entitled to if insurance had terminated due to the
termination of this policy.
The period that a conversion right will apply to as described in clauses 2 and 3 will be the 31
days following the date the insurance under this provision is terminated.
< If insurance with respect to a person is continued in force under the terms of this provision and
is then terminated because the person's 65th birthday has occurred, the person will be entitled to the
same conversion rights to which he/she would have been entitled if insurance had terminated because
he/she is no longer a member of a class or classes of persons who may be insured.
GIAOO-310
Me Canada Life Assurance Company Page No. 13 Dated Sample - Void.
NOTE: This Accelerated Benefit applies only to persons whose amount of insurance is equal
to or greater than $20,000.
ACCELERATED BENEFIT
BENEFITS PAID UNDER THIS PROVISION MAY BE TAXABLE. IF SO, THE PERSON OR
HIS BENEFICIARY MAY INCUR A TAX OBLIGATION. AS WITH ALL TAX MATTERS, THE
PERSON SHOULD CONSULT A PROFESSIONAL TAX ADVISOR TO ASSESS THE EFFECT
OF THIS BENEFIT. BENEFITS OF THIS PROVISION ARE NOT PAYABLE IF THE POLICY
IS NOT IN EFFECT.
This Accelerated Benefit provides that a portion of the proceeds otherwise payable under this
policy as a result of death may be paid in advance of death in certain circumstances as outlined below.
Benefit
If a person is diagnosed as having a Terminal Condition while insured under this policy we may,
at the request of such person or his legal representative, and subject to you agreement and the agreement
of any assignee and irrevocable beneficiary of the person's life insurance, make an Accelerated Benefit
payment in accordance with the terms of this provision.
The Accelerated Benefit payment will be made in one hump sum subject to the Conditions section
below and will be equal to the lesser of the following.
1. An amount selected by the person up to 50;10 of the amount of insurance applicable to the
person in accordance with the other terms of the policy, subject to a minimum of
$10,000.
2. $50,000.
If the life insurance applicable to the person would otherwise reduce or terminate in accordance
with the other terms of the policy within 12 months of the date of application for this benefit, then the
benefit will be based on such reduced amount. If a person's insurance would otherwise terminate within
12 months of the date of application for this benefit, a benefit will not be payable under this provision.
Payment of this benefit does not guarantee that the person's full death benefit will eventually be
paid. The person must still be insured under the policy at the time of his death for the remainder of his life
insurance benefit to be paid. A person may only receive a benefit payment under this provision once
during his lifetime.
Definitions
"Terminal Condition" means a medical condition that a duly licensed health care provider expects
to result in the person's death within 12 months from the date of application for the Accelerated Benefit
and from which the person is not expected to recover.
?ize CanadaUfe Assurance Company Page No. 14 Dated Sample - Void.
'Interest' means the prime interest rate, as of the date this benefit is paid, plus one percent.
However, in no event will the interest rate exceed the greater of (i) the current yield an 90 day treasury
bills. or (n) the current maximum statutory adjustable policy loan interest rate.
GL400-282
Conditions
Payment of an Accelerated Benefit under this provision is subject to all of the following conditions
being met.
1. Accelerated Benefits are payable only once with respect to a person.
2. The person or his legal representative must request in writing to have this benefit paid while
insurance an the person is in effect.
3. The person must be eligible for the Waiver of Premium Benefit For Disabled Persons
provision, included in this policy. However, this benefit may be payable prior to the person
having satisfied the requirement of being disabled for a continuous period of 6 months.
4. We must receive satisfactory proof that the person has been diagnosed as having a Terminal
Condition.
5. The person must be living at the time this benefit is to be paid.
6. We must obtain your permission prior to paying this benefit. We must also obtain the
permission of the person's irrevocable beneficiary or assignee for the life insurance proceeds
otherwise payable under the policy, prior to paying this benefit.
7. The amount of life insurance otherwise payable on the person's death in accordance with the
other terms of this policy will be reduced by the amount of this benefit together with Interest
calculated from the date this benefit is paid. Such reduction will also apply to any amount the
person would otherwise be eligible to apply for under the Conversion provision.
Exclusions
The Accelerated Benefit will not be payable with respect to an Insured if his Terminal Condition
resulted from or was in any manner or degree associated with, or occasioned by the Insured attempting to
take his own life whether he was in possession of his faculties or not at the time.
GL400-283
The Canada Life Assurance Company Page No. 15 Dated Sample - Void.
Reimbursement by Policy Holder
If we have paid an Accelerated Benefit under this policy and this policy terminates prior to the
death of the person, you will reimburse us for any such benefit payment made under this provision
together with Interest for the period from the date such benefit was paid to the date you reimburse us if
either of the following are true.
1. The person does not qualify for the Waiver of Premium Benefit for Disabled Persons
provision inchided in this policy.
2. This policy does not contain a Waiver of Premnan Benefit for Disabled Persons
provision.
CiIF., KO&Mr
The Canada Life Assurance Company Page No. 16
Dated Sample - Void.
CONVERSION
The insurance provided under the Accidental Death and Dismemberment Benefit may not be converted.
A person will have the right to buy an individual life insurance policy without submitting
evidence of insurability upon any of the following events:
1. The termination of the person's employment.
2. His membership in the class or classes has been terminated and this policy is in force.
3. The termination of this policy . The person must have been insured under this policy
for at least 5 years.
4. An amendment to this policy cancels the insurance on the class of persons of which
helshe is a member. The person must have been insured under this policy for at least 5
years -
The policy will only be issued to the person N a written application and the fast premium due
for the policy are received by our Head Office within 31 days of such termination. This 31 day period
is the conversion period. The policy will not take effect until the end of the conversion period.
If the person should die during the conversion period, and prior to becoming insured under a
policy again, an amount of insurance equal to the maximum amount for which the person was entitled
to convert will be paid as a death benefit -
The premium for the individual policy will be determined by the policy type, the person's risk
classification, our published rates in effect and the person's age (nearest birthday) at the time of
conversion.
The policy may be on any Plan,
death benefit, which we are then issuing.
death or other special benefit.
GIAOO-316
other than term insurance, with level premiums and level
It may not include any provision for disability, accidental
The Canada Life Assurance Company Page No. 17 Dated. Sample - Void.
limits.
CONVERSION (Continued)
The amount of insurance the person may select under the policy is subject to the following
1. It may not be less than the minimum amount for which we then issue such a policy.
2. If the person ceased to be insured because of reason 1 or 2 shown in the Who May
Convert section of this provision, it may not be more than the amount of insurance that
has been terminated reduced by any amount of life insurance for which the person may
be or may become entitled under this or any group insurance policy within the
conversion period.
3. If the person ceased to be insured because of reason 3 or 4 shown in the Who May
Convert section of this provision, it may not be more than the smaller of the following
amounts.
a. The amount of insurance that applied to the person at the time it terminated
reduced by any amount of life insurance for which he/she may be or may
become entitled to under any group insurance policy within the conversion
period.
b. $2,000
4. It may not, m any event, exceed the maximum amount of insurance the person is
eligible to convert as stated in clause 2 or 3 above reduced by any amount of life
insurance currently in force and previously converted under this policy.
You will be required to give each person at least 15 days written notice prior to the date on
which the person's right to convert would expire. If the person has not received such notice the person
will have an additional 15 days from the date the person is notified in which to convert. The life
insurance coverage will not extend beyond the 31st day after the date the group insurance terminates,
and the right to convert will not extend more than 60 days beyond the initial 31 day conversion period.
GIA00-317
The Canada Life Assurance Company Page No. 18 Dated Sample - Void.
wEEN A PERSON'S TERM INSURANCE ITMIUNATES
All of a person's insurance under this policy will terminate at the earliest time shown below.
1. When the person's employment terminates. A person's employment will terminate
when the person is no longer actively at work. However, if a person is not actively at
work due to disease, pregnancy or injury, the person's insurance will be continued in
force under this policy until the earlier of:
a. the date on which we receive written notice from you that the person's
insurance is to be terminated.
b. the end of the 6 month period following the date on which the person's
employment terminated.
2. When the person ceases to be a member of a class or classes of persons who may be
insured.
3. On the date on which this policy is no longer in force.
4. If a person is absent from work due to a temporary lay-off or due to a leave of absence,
the earlier of.
a. The date on which we receive written notice from you that the person's
insurance is to be terminated.
b. The last day of the month that follows the month in which the person's absence
frorn work began.
S. When the person goes on strike, or is locked -out. This will not apply if either:
a. There is a written agreement between you and us that all persons will continue
to be insured during the strike or loci[ -out.
b. There is applicable statutory legislation or regulation requiring the continuation
of insurance during a strike or lock -out.
6. The day before the person enters active full-time service in any naval, military or air
force.
7. On the date on which the person requests, in writing, to have his/her insurance
terminated.
8. On the date on which the person retires.
If an event that is described above occurs, you must deposit written notice with us at our Head
Office within 31 days. Failure to give written notice within such 31 day period will not continue
Me Canada Life Assurance Company Page No. 19 Dated Sample - Void.
�'p III � - �1- - • it � ■
insurance in force with respect to a person beyond the time it would otherwise have been terminated as
shown above.
GLAOO-318
The Canada Life Assurance Company Page No. 20 Dated Sample - Void.
PORTABILITY OF TERM INSURANCE
A person will have the right to elect to become insured under the Group Portable Insurance Trust
Policy subject to the following terms and conditions.
1. The person's insurance under this policy has terminated due to termination of
employment.
2. The person applies to becme insured under the Group Portable Insurance Trust Policy
prior to the expiration of the 31 day period immediately following the date the persWs
insurance terminated under this policy.
3. The person satisfies the eligibility requirements of the Group Portable Insurance Trust
Policy.
4. The Group Portable Insurance Trust Policy is a group term insurance policy issued to
provide insurance for persons whose insurance terminates under a policy containing
this Portability of Insurance provision. The Group Portable Insurance Trust Policy
does not include any provision for disability, accidental death or dismemberment or
other special benefits.
GL400-319
Tice Canada We Assurance Company Page No. 21 Dated Sample - Void.
PREMIUMS
Premiums are due each month in advance from the Effective Date.
Each premium due with respect to the amount of term life insurance in force on the life of a
person will be calculated on a basis that is established by us and will be computed based on the
following:
1. The Table of Term Insurance Premiums set forth in this provision.
2. The amount of insurance in force on the life of each insured person on the date on
which the premium is due.
Each premium due with respect to the Accidental Death and Dismemberment in force with
respect to a person (and each insured dependent if applicable) will be calculated on a basis that is
established by us and will be $0.02 per $1,000 of Principal Sum for each person.
Each premium due with respect to the amount of dependent term life insurance in force on the
life of a person will be calculated on a basis that is established by us and will be computed based on the
following:
The Table of Term Insurance Premiums set forth in this provision.
2. The amount of insurance in force on the life of each insured dependent on the date on
which the premium is due.
It is our right to change the preceding premium rate(s) shown above as follows:
1. As of January 1st, 1999 and any date on which a premium is due after such date.
2. At any time this policy is amended to change the terms of this policy.
3. At any time the number of individuals changes by more than 25 % or an affiliated,
associated or subsidiary company of yours becomes eligible under this policy.
4. At any time there is a change in federal or state legislation or regulation which affects
the benefits or provisions of this policy.
Premiums with respect to each insured individual under this policy will change when the
individual attains an age that qualifies the individual in the next higher age bracket shown in the Table
of insurance Premiums.
We must give you written notice at least 60 days prior to the date of a change.
GIAOO-320
The Canada i',ife Assurance Company Page No. 22 Dated Sample - Void.
PREMIUMS (Continued)
If, at any time prior to the date that a loss is incurred or a disability commences, we learn that
the amount of insurance that should be in force under this policy is not the amount on which the
premium was based, an adjustment premium will be paid by you or a refund will be made to you so
that the actual premiums for the true amount of insurance will be paid.
U there is any change in the amount of insurance in force under this policy between the dates
on which premiums are due, an adjustment premium or a refund will be due. The adjustment premium
or the refund will be due on whichever of the following dates apply:
1. If the amount of insurance changes on or prior to the 15th day of a policy month, the
first day of such policy month.
2. H the amount of insurance changes after the 15th day of a policy month, the first day of
the next policy month. However, an adjustment premium or refimd will not be due if,
on the first day of the neat policy month, a regular premium is due.
If we do not receive written notice of a change due to a decrease in or the termination of an
amount of insurance within 60 days of the date such change occurred, we will limit the refund to 2
months premium.
The amount of insurance with respect to an insured individual will be decreased or terminated
in accordance with die other terms of this policy. The payment of premiums with respect to an
individual's insurance after the date of such decrease or termination will not continue to provide
insurance of the amount which was in effect with respect to such individual prior to such decrease or
continue insurance in force with respect to such individual after such termination, whether or not all or
part of such premium is refunded.
Refunds will be applied in or toward the payment of any outstanding premiums and adjustment
premiums. Any balance will be held at your credit, without interest, and will be applied in or toward
payment of succeeding premiums and adjustment premun ns as and when they fall due. However, you
may, at any time, withdraw in cash any amount so held at your credit.
U this policy is terminated in accordance with the Termination of Policy provision, you will
pay to us all adjustment premiums that are due and have not been paid. You will also pay to us a pro
rats premium for the period (if any) elapsed from the date on which the last unpaid premium was due
to the date on which this policy is terminated.
We shall not be required to accept the payment of any premium otherwise than from you.
GIAOO-321
The Canada Life Assurance Company Page No. 23 Dated Sample - Void.
TABLE OF INSURANCE PREMIUMS
Age of Employee
(and Spouse if applicable)
coincident with or last
preceding the date the
premium is due
Under 30
30 to 34
35 to 39
40 to 44
45 to 49
50 to 54
55 to 59
60 to 64
65 to 69
70 to 74
75 to 79
80 to 84
85 to 89
90 to 94
95 to 99
Monthly Rate per $1,000
Insurance
$.10
.11
.15
.23
39
.65
1.06
1.32
2.29
3.72
5.72
8.33
13.31
19.57
41.60
$.20 per $1,000 Insurance
.06 per $1,000 of Principal Sum for each person.
GL400-322
The Canada Life Assurance Company Page No. 24 Dated Sample - Void.
PERIOD OF GRACE
A period of grace will be allowed for the payment of each premium after the first and each
adjustment premium. The period of grace for the payment of each premium will be 31 days after the
date on which it is due. The period of grace for the payment of each adjustment premium will be 31
days after the date on which it is due. The period of grace for the payment of each adjustment
premium will be 31 days after the date on which the next premium is due unless we, by written notice
to you, limit the days of grace. Such limit will not be less than 31 days after the date the notice is
delivered to you. The policy will remain is force during the period of grace unless terminated in
accordance with the Termination of Policy provision. In any event, premiums are payable for any
period of grace during which the policy continues in force.
K01i�y1
All amounts payable under this policy must be paid in United States currency_
PLACE OF PAYMENT
All amounts payable by us will be payable at our office in Atlanta, Georgia.
NOT ELIGIBLE FOR DIVIDENDS
This policy is not eligible for dividends and will not take part in the distribution of our surplus.
CLERICAL ERROR
Clerical error in keeping the records will not invalidate insurance otherwise validly m force nor
continue insurance otherwise validly terminated. Upon discovery of any such error an adjustment of
premiums will be made.
The Canada Life Assurance Company Page No. 25 Dated Sample - Void.
INCONTESTABILM
There will be no contest of the validity of this policy, except for the faff= to pay premiums,
after it has been in force for two years from the date of issue. Statements made by a person as to
his/her insurability may be used in a contest of the validity of his/her insurance only under the
Moving conditions:
1. The statements must relate to the insurance in question.
2. The statements must be in written form and signed by the person.
3. The insurance must have been in force prior to the contest for less than two years
during the lifetime of the person.
GIAOO-323
The Canada Life Assurance Company Page No. 26
Dated Sample - Void.
1.1WIDay-211
A person may, at any time, by a writing signed by the person and deposited with us at our
Head Office:
l . Appoint one or more beneficiaries to receive all or part of the insurance on the person's
life under this policy.
2. Change such appointment.
Such appointment or change shall take effect as at the date of its execution, whether or not the
person is living at the time it is deposited with us at our Head Office, but without prejudice to us on
account of any payment by us prior thereto. The interests of a beneficiary who dies before the person
will accrue to the surviving beneficiaries or, if none, to the estate of the person. If, at the death of the
person, there is no beneficiary for all or part of the person's insurance under this policy, the amount of
insurance for which there is no beneficiary will be payable to the person's estate.
i -1 C99 a3—MV
An assignment of insurance by a person will not be binding on us unless the assignment or a
copy of it is filed with us at our Head Office together with your consent in writing to the assignment.
We are not responsible for the validity or the effect of such assignment.
INSURANCE PAYABLE
The amount due on the death of an insured person will be payable on receipt by us at our Head
Office of due proof of the person's death. We will be entitled to a proper discharge in respect of any
payment made by us.
The Canada Life Assurance Company Page No. 27 Dated Sample - Void.
BOOKLET -CERTIFICATE
We wdl issue booklet -certificates to you that summarize the essential provisions of this policy.
You must deliver them to each person who is insured.
The provisions of this policy will govern if there is any discrepancy between the following:
1. The provisions of the booklet -certificate delivered to a person who is insured.
2. The provisions of this policy.
If a booklet -certificate is issued to a person who for any reason is not entitled to insurance
under this policy, such booklet -certificate will be of no effect.
GL400-324
AGE
The true date of birth of a person will be used to determine:
1. The commencement or termination of insurance on the person's life.
2. The amount of insurance on the person's life.
3. Any other right or benefit with respect to the person.
If we learn that the person's date of birth has been misstated, a premium will be paid or a
refund will be made so that you will pay us the actual premiums for the insurance that applies to the
person based on the person's true age.
OPTIONAL SETTLEMENTS AT DEATH
A person shall have the following rights:
1. To elect that the amount of insurance which would otherwise be payable in one sum on
the person's death will be payable in such a manner as may be agreed to by us in
Wig•
2. To revoke any such election.
If there is no election in effect, the beneficiary will have the right. after the person's death, to
make such an election but may not revoke it without our consent.
GIA00-325
The Canada Life Assurance Company Page No. 28
Dated Sample - Void.
STANDARD PROVISIONS
Time Limit on Certain Defenses
After a person has been insured under this policy for two years, no misstatement of the person
except a fraudulent misstatement will be used to reduce or deny a claim.
GC500-310
Claim Forms
When we receive a written notice of a claim, we will send the claimant our claim forum to file
proof of loss. If the claim forms are not received within 15 days after written notice of claim is sent,
the claimant can send us written proof of claim without waiting for the claim forms.
Time of Payment of Claim
When we receive satisfactory proof of claim, benefits payable under this policy for any loss
other than for loss of time will be paid as they are incurred.
Payment of Claims
Indemnity for loss of life will be payable in accordance with the beneficiary designation and the
provisions respecting such payment which may be prescribed herein and effective at the time of
payment. If no such designation or provision is then effective, such indemnity shall be payable to the
estate of the insured person. Any other accrued indemnities unpaid at the insured person's death may,
at our option, be paid either to such beneficiary or to such estate. All other indemnities will be payable
to the insured person.
GC500-311
Legal Actions
No action at law or in equity may be brought to recover under this policy until 60 days after
written proof of loss has been given to us. No such action may be brought more than three years after
the time within which proof of loss is required to be given.
GC500-312
The Canada Life Assurance Company Page No. 29 Dated Sample - Void.
AMENDMENTS TO THE POLICY
This policy may be amended at any time by written agreement between you and us without the
consent of or notice to any other individual. Any amendment to this policy must be in writing and
attached to the policy. The amendment must bear the signature or a reproduction of the signature of
one or both of our President or Secretary.
If a person is not actively at work on the effective date of the amendment, the effective date
with respect to that person will be on the day that the person is again actively at work. However, if the
amendment reduces the amount of insurance to which the person is entitled, the effective date will be
the effective date of the amendment.
If an insured dependent (if any) is confined at home or in a hospital or other medical institution,
the effective date of the amendment with respect to an insured dependent will be on the first day on
which both of the following conditions have been met:
1. The dependent is not confined at home or in a hospital or other medical facility.
2. The dependent is performing the usual and customary duties or activities of an
individual in good health and of the same age and sex.
However, if the amendment reduces the amount of insurance to which the dependent is entitled, the
effective date will be the effective date of the amendment.
CONTRACT
The whole contract is made up of:
1. This policy.
2. Any amendments to this policy.
3. The Group Insurance Application.
4. The applications of the persons who are insured.
You will not be considered to be our agent for any purpose under this policy.
All statements made by any of the persons who are insured will be deemed representations and
not warranties. No statement made by any person who is insured will be used in any contest unless:
1. It is contained in a written instrument signed by the person.
2. A copy of the written instrument has been given to the person.
Only our President or Secretary may modify this policy or waive any of our rights or
requirements.
The Canada Life Assurance Company Page No. 30 Dated Sample - Void.
Any change in this policy must be in writing and be attached to it. The change must bear the
signature or a reproduction of the signature of one or both of the above officers.
GIAOD-326
The Canada Life Assurance Company Page No. 31 . ,i Dated Sample - Void.
CONFORMITY WITH STATE STATUTES
Any provision of this policy which, on its effective date, is in Conflict with the statutes of the
State m which this policy was delivered or issued for delivery is hereby amended to conform to the
minimum requirements of such statute.
TERBMATION OF POLICY
If you give us written notice that this policy is to be terminated, it will terminate on the later of
1. The date that is stated in the notice.
2. The date on which we receive the notice at our Head Office.
We may terminate this policy as of the date on which any premium is due if, at any time, the
number of persons who are insured is less than 20.
We may also, for any other reason, terminate this policy as of the date on which any premium
is due.
We must give you at least 60 days written notice prior to the date on which this policy is to
terminate.
This policy will terminate, in any event, at the end of the period of grace allowed for the
payment of any premium or adjustment premium if such premium is still unpaid at that time.
You will be required to give each person at least 15 days written notice prior to the date on
which this policy is to terminate. Failure to give written notice within such 15 day period will not
continue insurance in force with respect to a person beyond the time this policy would otherwise have
terminated.
GL40Q-327
The Canada Life Assurance Company Page No. 32
Dated Sample - Void.
SELF ADMINISTRATION
At your request this policy is self-administered. For that reason it is provided that
1. All documents and notices that would otherwise be deposited with us at our Head
Office in accordance with the terms of this policy will be held by you.
This will not apply to any of the following:
a. Evidence of insurability required by us under this policy.
b. An application for an individual policy of insurance as provided for under any
Conversion provision of this policy.
C. Notice required by us to process any claims.
2. Whenever we request, you will furnish us with all of the documents relating to a
person's insurance which have been completed in accordance with the terms of this
policy and are being held by you.
3. We may inspect and examine your records which pertain to a person in so far as the
records affect the person's insurance or eligibility for insurance.
4. All premium payments that would otherwise be calculated by us at our Head Office in
accordance with the terms of this policy will be calculated by you on a basis provided
by us.
5. Whenever we request, you will deposit with us at our Head Office a statement listing
the following:
a. Each person who is then insured.
b. The Class of each person under the Schedule.
C. The amount of the benefits that apply to each person.
d. The date of birth of each person.
e. If applicable, the earnings of each person.
The Canada Life Assurance Company • Page No. 33 Dated Sample - Void.
DEPENDENTS TERM INSURANCE
Definitions
"Dependent" means:
1. The spouse of a person. This will include a divorced or separated spouse where a
granting of a judgment absolute of divorce or of separate support has been given until
such time as provided by said judgment.
2. Each unmarried child or stepchild of a person, over 14 days of age, provided that the
child relies filly on the person for support and maintenance and fits the following
description:
a. The child is under 19 years of age.
b. The child is at least 19 years of age but under 23 years of age and he/she is
attending an accredited educational institute, college or university on a full-time
basis.
However, for the purposes of this provision, dependent shall exclude:
1. Anyone who is residing outside of Canada and the United States of America.
f
2. Anyone who is in full-time service in any naval, military or air force.
3. A child who does not rely fully on the person for support or maintenance.
4. A child may not be insured as a dependent of more than one person.
5. Any person who is insured under this policy.
GL400-329
The Canada Life Assurance Company Page No. 34 Dated Sample - Void.
DEPENDENTS TERM INSURANCE (Continued)
How and When Dependents Term Insurance Takes Effect
A dependent will become insured on die earliest date on which he/she may become insured
provided that all of the following conditions have been met.
1. An application for insurance for each dependent must be completed on a form approved
for that purpose by us and be promptly deposited with us at our Head Office.
2. The person is insured for insurance under this policy.
3. We have, m writing, approved evidence of insurability if required as described below. A
dependent will be required to provide evidence of insurability satisfactory to us if either
one of the following conditions apply.
a. The amount of insurance initially applied for exceeds the Guaranteed Law
Amount shown in dze Amount of Dependents Insurance section of this provision.
b. The person applies to have his/her dependents insured under this policy more
than 31 days after the earliest date on which his/her dependents may nave become
insured under this policy. Any evidence required under this clause must be
provided without expense to us.
C. The person was eligible to apply to have his/her dependents covered under a
policy or plan of insurance replaced by this policy but did not apply for such
coverage within 31 days of the date he/she bey eligible to apply under the
prior policy or plan.
4. The dependent is performing the usual and customary duties or activities of an individual
in good health and of the same age and sex.
Insurance of any dependent child of a person who is acquired while he/she has any other
dependents insured under this policy will automatically take effect on the date such dependent is acquired.
1f, at the time insurance on the life of a dependent who is not a new -born child would otherwise
take effect, such dependent is confined at home or in a hospital or other medical 'institution, inisurance on
the life of such dependent will not take effect with respect to such dependent until both of the following
conditions have been met.
1. The dependent is not confined at home or in a hospital or other medical facility.
2. The dependent is performing the usual and customary duties or activities of an individual
in good health and of the same age and sex.
GL400-329
The Canada Life Assurance Company Page No. 35 Dated Sample - Void.
1 II !. I 1. 111 ■
DEPENDENTS TERM INSURANCE (Continued)
Amount of Dependents Insurance
The amount of insurance on the life of each insured dependent will be based on the Schedule
shown below.
You will be required to deposit with us at our Head Office written notice of any change which
would affect the amount of insurance on the life of a dependent.
A change in a dependent's amount of insurance to a smaller amount will take effect no earlier
than the date on which we receive the notice from you.
A change in a dependent's amount of insurance to a larger amount will take effect on the latest of:
1. The date on which we receive the notice from you.
2. The date stated in the notice.
3. The date on which we have, in writing, approved evidence of the dependent's
insurability. Any evidence required mist be provided without expense to us.
4. The dependent is performing the usual and customary duties or activities of an individual
in good health and of the same age and sex.
If, at the time a dependents's amount of insurance would change to a larger amount, such dependent is
confined at home or in a hospital or other medical institution, insurance on the life of such dependent will
not take effect with respect to such dependent until both of the following conditions have been met.
1. The dependent is not confined at home or in a hospital or other medical facility.
2. The dependent is performing the usual and customary duties or activities of an individual
in good health and of the same age and sex.
When we are calculating the maximum amount of a benefit based on earnings that has became
payable with respect to a person under this policy, we will use whichever of the following amounts was
the smallest at the time the loss was incurred or the disability commenced.
1. The person's actual earnings as defined in the Definitions provision.
2. The level of earnings on which the premium for the person's benefit was being paid.
GIAOO-330
The Canada Life Assurance Company Page No. 36 w Dated Sample - Void.
., p. • ". 1 :1: 111
DEPENDENTS TERM INSURANCE (Continued)
Schedule
Spouse
Each Dependent Guild
$250.000
$5,000
Guarantee Issue Limh - $50,000. Note: A person will be required to provide evidence of insurability
satisfactory to us if any one of the following conditions apply.
a) The amount of insurance initially applied for exceeds $50.000
b) The person applies for an increased amount of insurance after the date on which helshe
initially became insured under this policy.
c) The person applies to have his/her dependents become insured under this policy more
than 31 days after the earliest date on which his/her dependents have become insured
under this policy.
d) The person was eligible to apply to have his/her dependents covered under a policy or
plan of insurance replaced by this policy but did not apply for such coverage within 31
days of the date he/she became eligible to apply under the prior policy or plan.
REDUCTIONS
Notwithstanding the above, on and after a person's 70th birthday, his/her dependents insurance
will be reduced to 50% of the amount applicable to his/her dependents immediately prior to such birthday.
It is provided that the amount of insurance on a dependent determined in accordance with the
pr axftg Schedule(s) may not exceed SO% of the amount applicable to the person.
GIAO -331
The Canada Life Assurance Company Page No. 37 Dated Sample - Void.
DEPENDENTS TERM INSURANCE (Continued)
Payment of Dependents Term insurance
The amount due on the death of an insured dependent of a person shall be payable to the person,
if living, otherwise to the person's estate, on receipt by us at our Head Office of dine proof of the death of
the dependent.
Suicide
No payment will be made under this provision with respect to a dependent who commits suicide if
the dependent's death occurs within two years after the date on which the dependent became insured or
the person of whom he/she is a dependen elected an increased amount of insurance. Our liability with
respect to such insuumnee of a dependent will be limited to an amount equal to the premiums paid thereon.
When Dependents Insurance Terminates
A dependent's insurance under this policy will terminate on the earliest date shown below.
1. On the date on which the person asks to have the insurance on his/her dependents
terminated.
2. On the date on which this provision is m longer in force
3. When the dependent ceases to be a dependent as defined in this provision.
4. On termination of the insurance under this policy on the life of the person of whom he/she
is a dependent.
5. On the date the insurance on the life of the person of whom he/she is a dependent
becomes subject to the terms of any disability benefit included in this policy.
6. In the case of the spouse of a person, the 75th birthday of the insured person of whom the
spouse is a dependent.
7. The death of the person.
You must notify us in writing within 31 days after the date on which an event described above
GIAOO-332
The Canada Life Assurance Company Page No. 38 .
Dated Sample - Void.
1 � �A• ��1' 111 ■
DEPENDENTS TERM INSURANCE (Continued)
Portability of Dependents Term Insurance
A person will have the right to elect to have his/her dependents insured under another group insurance
policy designated by us subject to the following terms and conditions.
1. The person's insurance under this policy has terminated and the person has elected to
become insured under the Group Portable Insurance Trust Policy in accordance with the
terns and conditions of the Portability of Insurance provision of this policy.
2. Each dependent who was insured under this policy on the date the person's insurance
under this policy terminated must satisfy thg eligibility requirements of the Group
Portable Insurance Trust Policy.
3. The Group Portable Insurance Trust Policy will be a group term insurance policy. It will
not include any provision for disability, accidental death or dismemberment or other
special benefit.
GL 400-333
77te Cwurda Life Assurance Company Page No. 39
Dated Sample - Void.
a. 1 .I 1 i.l a
DEPENDENTS TERM INSURANCE (Continued)
Conversion of Dependents Term Insurance
If the spouse of a person ceases to be insured under the Dependent's Insurance provision, he/she
will have the right to buy an individual life insurance policy without submitting evidence of insurability
upon any one of the following events:
1. The termination of the person's employment.
2. The person's membership in the class or classes has been termumted and this policy is in
force.
3. The termination of this policy. The person must have been insured under this policy for
at least 5 years.
4. An amendment to this policy which cancels the insurance on the class of persons of which
the person is a member. The person must have been insured under this policy for at least
5 years.
5. The death of the person.
6. The spouse ceases to be a dependent within the meaning of this provision.
7. The person of whom he/she is a dependent becomes subject to the terms of the Waiver of
Premium Benefit for Disabled Persons provision.
The policy will be issued to the spouse only if a written application and the first premium due for
this policy are deceived by air Head Office within 31 days of such termination. The 31 day period is the
conversion period. The individual policy will not take effect until the end of this conversion period.
If the spouse should die during the conversion period, and prior to becoming insured under a
policy again, the amount of insurance for which the spouse was entitled to convert will be paid as a death
benefit.
The premium for the individual policy will be determined by the policy type and amount, spouse's
risk classification, our published rates in effect and the spouse's age (nearest birthday) at the time of
conversion.
GIA00-337
The Canada Life Assurance Company Page No. 40
Dated Sample - Void.
DEPENDENTS TERM INSURANCE (Continued)
The policy may be on any plan, other than term insurance, with level premiums and level death
benefit, which we are then issuing. It may not include any provision for disability, accidental death or
other special benefit.
UM
The amount of insurance that the spouse may select under the policy is subject to the following
1. It may not be less than the minimum amount for which we ten issue such a policy.
2. If the spouse ceased to be insured because of reason 1, 2, 5, 6 or 7 shown in the Who
May Convert section of this provision, it may not be more than the amount of insurance
that has been terminated, reduced by any amount of insurance for which the spouse may
be or may become entitled during the conversion period.
3. If the spouse ceased to be insured because of reason 3 or 4 shown in the Who May
Convert section of this provision, it may not be more than the smaller of the following
amounts.
a. The amount of insurance that applied to the spouse at the time it terminated
( reduced by any amount of life insurance for which the spouse may be or may
become entitled under this or any group insurance policy within the conversion
period.
b. $2,000
4. It may not, in any event, exceed the maximum amount of insurance the spouse is eligible
to convert as stated in clause 2 or 3 above reduced by any amount of life insurance
currently in force and previously converted under this policy.
You will be required to give each person at least 15 days written notice prior to the date on which
the spouse's right to convert would expire. If the spouse has not received such notice he/she will have an
additional 15 days from the date he/she is notified in which to convert. The Life Insurance Coverage will
not extend beyond the 31st day after the date the group insurance terminates, and the right to convert will
not extend more than 31 days beyond the initial 31 day conversion period.
t F-971MK
The Canada Life Assurance Company Page No. 41 Dated Sample - Void.
DEPENDENTS TERM INSURANCE (Continued)
The premium for the policy shall be based on the following:
1. Our rates at the date on which the policy takes effect.
2. The plan and amount of the policy.
3. The attained age of the spouse.
4. The class of risk to which the spouse belongs. .
Termination of the Dependents Term Insurance Provision
ff any premium or adjustment premiuzn has not been paid at the end of its days of grace, this
provision will terminate at that time.
If you give us written notice that this provision is to be terminated, this provision will terminate
on the latest of:
1. The date stated in the notice.
2. The date of receipt by us at our Head Office of the notice.
3. The end of the period to which premiums have been paid.
We may. for any reason, terminate this provision as of the date on which any premium is due, by
giving you written notice at least 31 days prior thereto.
All of the other provisions of the policy which are not inconsistent with this Dependents Insurance
provision will apply to this provision.
GIAOO-339
Tare Canada Life Assurance ConWany Page No. 42 Dated Sample - Void.
ACCIDENTAL DEATH AND DISMEMBERMENT BENEFIT
Insurance provided under this Benefit is not subject to The Waiver of hvndwn Benefit For Disabled
Personr, Extended Death Benefit For Disabled Persons, Accelerated Benefit and Conversion provisions.
We will pay the amount described in the Schedule of Losses if an Insured suffers any such
Loss, subject to all of the following conditions.
1. The Loss is caused solely by an accident.
2. The Lass is not excluded by the terms of the Exclusions section of this provision.
3. The accident must occur while the insurance on the Insured is in force under this
provision.
4. The Loss must occur within 365 days after the date on which the accident occurred.
5. The maximum amount payable will be, subject to the terms of the Limitations section of
this provision.
Any amount payable under this provision will be paid to the person except in the case of loss of
' . life, in which case, payment will be made to the Beneficiary.
Seat Belt Benefit
We will pay an additional accidental death benefit, called the Seat Belt Benefit, if an Insured's death is
the result of an automobile accident and the Insured was wearing a seat belt at the time of the accident.
The following rules apply:
1. The Seat Belt Benefit equals the lesser of (i) $50,000 or (ii) the amount of the Accidental Death
and Dismemberment Insurance Benefit paid because of the Insured's accidental death (i.e. the
Principal Sum).
2. We must receive satisfactory written proof that the Insured's death resulted from an automobile
accident and that the Insured was wearing a seat belt at the time of the accident. A copy of the
police accident report should be submitted with the claim.
The Seat Belt Benefit will be payable to the person's beneficiary, in the case of the person's death, as
determined under the Beneficiary provision or to the person in the case of an insured dependent's
death.
"Seat Belt" means a properly installed seat belt, lap and shoulder restraint, or other restraint approved
by the National Highway Traffic Safety Administration.
"Automobile" means a motor vehicle licensed for use on public highways.
The Canada Life Assurance Company .. Page No. 43 Dated Sample - Void.
Surgical Reattachment Benefit
In the event an accidental injury which results in a Loss in accordance with the terms of this policy, we
will reimburse an amount equal to 50% of the amount that would otherwise be payable for a Loss if a
dismembered part is surgically reattached. The balance of the amount that would otherwise have been
payable will be paid if after 365 days the reattachment has failed to the extent that toss of use then
exists.
Felonious Assault
Employee coverage only
In the event of an accidental injury which results in.a Loss payable in accordance with the terms of this
policy. we will pay an additional 25 % of the amount of benefit payable if the Insured incurs a Loss as
the result of a Felonious Assauh inflicted upon the Insured. The Felonious Assault must be inflicted by
someone other than fellow employees or members of the Insured's family andwhile the Insured is
working for you or on your premises. A report of the criminal activity is required to- have been filed
with the appropriate law enforcement authority within 48 hours of the incident. A certified copy of this
report must accompany the claim for benefits. The criminal and civil codes where the Felonious
Assault or attempt was perpetrated shall be the basis for interpretation of the terms used in this
paragraph -
Repatriation Benefit
In the event accidental Loss of Life is sustained by a person not less than 50 miles from the Insured's
normal place of residence and indemnity for such Loss becomes payable in accordance with the terms
of this policy, we will reimburse expenses incurred for the transportation of the body of the deceased
person to the first resting place (including, but not limited to, a funeral home or the place of interment)
in proximity to the normal place of residence of the deceased, including charges for the preparation of
the body for such transportation, not to exceed in the aggregate the amount of $10,000 for all such
expenses. Reimbursement for such expenses will be made to the Beneficiary.
Education Benefit
In the event accidental Loss of Life is sustained by an Insured and indemnity for such Loss becomes
payable in accordance with the terms of this policy, we will reimburse the expenses incurred according
to the Education Benefit stated below for each of the person's Insured Dependent children who are
enrolled as full-time students and are under the age of 25:
1. in an accredited institution for higher learning above the secondary school level as defined in the
country of residence; or
2. at the secondary school level but who will enroll as full-time student(s) in an accredited institution
for higher learning within 365 days after the date of death of the Insured.
The Canada Life Assurance Company Page No. 44 Dated Sample - Void.
Accredited Institution for higher learning means any university, college or trade school.
The maximum Education Benefit is equal to the reasonable and necessary expenses actually incurred,
subject to the lesser of 3 % of the Insured's principal sum or $5,000 for each year the Dependent
chdd(ren) descn'bed above continues his education on a full-time basis in an institution for higher
learning, but not to exceed a maximum of 4 years which must run consecutively, with respect to any
one Dependent child.
The benefit will be reimbursed annually upon receipt of satisfactory proof that the Dependent child is
attending as a full-time student an institution for higher Iearning, but reimbursement will not be made
for expenses incurred prior to the death of the Insured, or for mom, board or other ordinary living,
traveling or clothing expenses.
In the event the Dependent child satisfies the requirements indicated above, such child will be deemed
the beneficiary with respect to benefits payable under this provision. If none of the Insured's insured
Dependent children satisfy the above requirements, we will pay an amount of $2,500 to the legal
guardian of the Dependent child.
Child Care Bewfri
Employee coverage only
In the event accidental Loss of Life is sustained by an Insured and indemnity for such Loss becomes
payable in accordance with the terms of this policy, we will reimburse annually the reasonable and
necessary child care expenses actually incurred subject to a benefit of 5% of the Insured's Principal
Sum and to a maximum benefit of $5,000 per year. The maximum benefit payable is $20,000 for all
years and all Dependent Children.
The Child Care Benefit is payable only if:
1. the Insured Employee has elected coverage under this policy for Dependent Child(ren); and
2. such coverage is in effect on the date of the accidental injury; and
3. the Insured Employee has a Dependent Children) under the age of 13 for whom Child Care
expenses are incurred within 365 days of the Loss of Life.
In the event the Insured's Dependent Child satisfies the requirement indicated above, the Child Care
Benefit will be payable to the surviving Spouse if the Spouse is the legal custodian of the child and the
child is dependent upon the Spouse. If there is no surviving Spouse or the child does not reside with
the Spouse, benefits payable under this provision will be payable to the child's legally appointed
guardian. If none of the Insured's Dependent children satisfy the above requirements, we will pay an
amount of $2,500 to the legal guardian of the Dependent child.
Psychological Therapy
In the event of an accidental injury which results in a Loss payable in accordance of the terms of this
policy which also results in a Physician determining that Psychological Therapy is required by the
Insured or an insured Dependent, we will reimburse the Reasonable and Customary Psychological
Therapy charges incurred to a maximum benefit of 5 % of the Principal Sum. This benefit is in
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addition to the Prinicpal Sum and any other benefits provided under the Accidental Death and
Dismemberment provision.
The Psychological Therapy payments will be made until the earlier of:
1. the maximum Psychological Therapy Benefit has been paid; or
2. two years have elapsed from the date of the Loss.
For purposes of this provision, the following definitions apply:
Reasonable and Customary means the lessor of:
1. the usual charge made by the Insured's Physician or other. health care provider for a given service
or supply; or
2. the charge we determine to be the prevailing charge made by Physicians or other health care
providers for a given service or supply in the geographical area where it is furnished to the Insured.
Psychological Therapy means treatment or counseling by a therapist or counselor, who is licensed,
registered, or certified to provide such treatment, whether on an out -patient basis or while a patient is
at a medical facility licensed to provide such treatment.
Psychological Therapy must be recommended as medically necessary by a Physician.
Rehabilitation Benefit
In the event an Insured sustains an accidental injury which results in a Loss and such injury requires
that the Insured participate in a rehabilitation program in order to be qualified to engage in an
occupation in which he would not have engaged except for such injury, we will reimburse the
reasonable and necessary expenses actually incurred by the Insured, within 3 years from the date of the
accident for, such program.
The benefit will be paid annually to the Insured employee upon receipt of satisfactory proof that the
Insured is participating in an acceptable rehabilitation program.
A rehabilitation program means a program of vocational rehabilitation acceptable to us that will lead to
returning to work for you or another employer.
Reimbursement for the total of all expenses incurred by the Insured will not exceed $10,000 as the
result of any one accident. Reimbursement will not be made for room, board or other ordinary living,
traveling or clothing expenses.
Occupational Training Benefit
In the event accidental Loss of Life is sustained by an Insured and indemnity for such Loss becomes
payable in accordance with the terms of this policy, we will reimburse the reasonable and necessary
expenses actually incurred, within 3 years from the date of the death of the Insured by the insured
spouse of the person who engages in a formal occupational training program, satisfactory to us, in
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order to become specifically qualified for active employment in an occupation for which he would not
otherwise have sufficient qualifications, not to exceed in the aggregate the amount of $10,000 for all
such expenses.
The benefit will be reimbursed annually to the insured employee's spouse upon receipt of satisfactory
proof that the insured spouse is participating in an acceptable occupational training program.
Occupational Training program means a program of vocational training acceptable to us that will lead
the insured spouse to become qualified for an occupation.
Reimbursement will not be made for room, board or other ordinary living, traveling or clothing
expenses.
Fan* Ylransportadon Benefit
In the event of an accidental injury which results in a Loss payable in accordance with the terms of this
policy, when an Insured is confined as an inpatient in a Hospital located from a point of not less than
150 miles from his normal place of residence and such Insured is under the Regular Care and
Attendance of a family member who meets the guidelines below and Appropriate Evaluation and
Treatment of a legally qualified physician or surgeon, other than himself, we will reimburse the
reasonable expenses actually incurred by all members of the immediate family of the Insured for hotel
accommodation in the vicinity of the Hospital and transportation by the most direct route to the
Insured, not to exceed in the aggregate the amount of $1,000 for all such expenses. Receipts for such
expenses must accompany the claim for benefits. Payment will not be made for board or other ordinary
living, traveling or clothing expenses. H transportation occurs in a vehicle or device other than one
operated under license for the conveyance of passengers for hire, then reimbursement of transportation
expenses will be limited to a maximum of $.20 per mile traveled..
Hospital means a facility accredited by JCAHO (Joint Commission on Accreditation of Health Care
Organizations) to provide medical evaluation and treatment of patients under the direction of an active
staff of licensed physicians.
Regular Care and Attendance means care given by a person who is at least 18 years of age who is the
spouse, son, daughter, father, mother, brother, sister, son-in-law, daughter-in-law, father-in-law,
mother-in-law, brother-in-law, sister-in-law, grandfather or grandmother of the Insured.
Physician means a qualified doctor of medicine, other than the Insured or a member of the Insured's
family, who is both licensed by at least one state to practice medicine and who is providing the Insured
with the appropriate care within the area of his or her medical training and qualifications.
Common Disaster Benefit
In the event of a Loss of Life sustained by both the insured and his insured Dependent spouse which
becomes payable in accordance with the terms of this policy as a result of a Common Accident, the
combined amount payable will be two times the larger of the two Principal Sums. The amount payable
will be paid only to a surviving Dependent Child. In no event will the amount payable under this
policy exceed, in the aggregate, $500,000.
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t
Common Accident means the same accident.
Health Cont7inuation Benefit
Employee coverage only
In the event of a Loss of We sustained by the Insured which becomes payable in accordance with the
terms of this policy, we will reimburse the insured Dependents who decx to continue group medical
and/or dental coverage provided through the Employer within 60 days of the Insured's death, equal to
the lessor of:
1. the cost of the annual premium charged and paid for the continued medical and/or denial coverage;
or
2. of the Insured's Principal Sum; or
3. $5,000.
This benefit is payable annually for a maximum of three consecutive years. The benefit will be
discontinued on the earliest of:
1. the date the Policyholder ceases to provide group medical and/or dental coverage under which the
Insured Dependent continues coverage;
2. the date the Insured Dependent becomes covered under any other group medical and/or dental plan
without a pre-existing conditions limitation. In the event the plan does contain a pre-existing
conditions limitation, the benefit will be discontinued on the date the pre-existing conditions
limitation no longer applies.
3. the date the Insured Dependent becomes eligible for Medicare
4. the date the Insured Dependents otherwise cease to be members of an eligible class(es) of persons'
5. the date the continued coverage would otherwise terminate with respect to the Insured Dependent.
This benefit does not provide for the continuation of Accidental Death and Dismemberment benefits, or
any other additional Plan benefits applicable to insured Dependents under the plan. Such benefits will
terminate upon the death of the Insured Employee.
Home Alteration and Vehicle Modification Benefit
In the event an Insured sustains the Loss of or Loss of Use of Both Feet or Legs or becomes a
Quadriplegic. Paraplegic or Hemiplegic, for which indemnity becomes payable in accordance with the
terns of this policy, and he subsequently requires the use of a wheelchair to be ambulatory, we will
reimburse the reasonable and necessary expenses as deemed appropriate by us actually incurred within
3 years of the date of the accident causing such Loss for:
a) the cost of alterations to the Insured's principle residence and/or
b) the cost of modification to 1 motor vehicle utilized by the Insured, when such modifications are
approved by the licensing authorities where required,
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for the purpose of making them wheelchair accessible.
Receipts for such alteration(s) must accompany the claim for benefits. Payment by us for the total of
all expenses will not exceed $10,000 as the result of any one accident.
Exposure and Disappearance
In the event of an accidental injury in which an Insured has been unavoidably exposed to the elements
such accidental injury will result in a Loss payable in accordance with the terms of this policy
If, as a result of the accidental destruction or disappearance of a conveyance in which an Insured is
riding, the Insured disappears and if his body is not found within one year of the date of the report of
the disappearance of the Insured, then it will be presumed that the Insured has suffered loss of life due
to accidental bodily injury. We will only presume the person to be dead if there is no evidence to the
contrary and supporting documentation from the appropriate court is provided to us.
Annual Coma Bereft
In the event of an accidental injury which results in a Loss payable in accordance with the terms of this
policy, in which the Insured is in a coma continuously for at least 31 days we will pay an Annual Coma
Benefit. The Annual Coma Benefit will be payable annually for each month of continuous coma, but in
no event shalt be more than 100 months of Annual Coma Benefit be paid on behalf of any insured
person or insured dependent. No Annual Coma Benefit will be payable after the comatose condition
has ceased, whether by death, recovery or any other change of condition.
The Annual Coma Benefit will be the lesser of 1 `Y of the the Principal Sum for each month that the
Insured is in a coma or 1 % of the difference between the Prinicipal Sum and the amount of any benefits
paid for any Loss arising out of the same accident. In no event shall the total amount paid for all
benefits exceed the Principal Sum.
The Annual Coma Benefit for an insured Dependent will be paid to the Insured employee. The Annual
Coma Benefit for an insured employee will be paid according to the Beneficiary provisions of this
Policy
If, after qualifying for an Annual Coma Benefit, the Insured suffers another Loss covered under the
terms of this policy, due to the same accident that caused the comatose condition, the benefit paid for
such other Loss will be the benefit stated in the Table of Losses reduced by the total amount of benefits
paid, including the Annual Coma Benefits paid, with respect to such Insured as a result of that accident.
If the comatose Insured continues to qualify for an Annual Coma Benefit after such other Loss, the
amount of Annual Coma Benefit will be redetermined using the calculation stated above.
We will require monthly proof of the continuing comatose condition. We retain the right to investigate
to determine whether the coma exists and continues.
For the purposes of this provision, Coma and/or comatose mean a profound state of unconsciousness
from which the Insured cannot be aroused to consciousness, even by powerful stimulation, as
determined by a Physician.
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Chi &vn's Additional Indemnity for Dismemberment
If an Insured has elected to cover his Dependent children) and a covered dependent child sustains a Loss
as a result of an accidental injury which results in a Loss payable in accordance with the terms of this
policy, the benefit payable will be two times the benefit normally payable subject to a maximum of
$100,000.
Common Carrier
In the event the Insured sustains an accidental injury which results in a Loss payable in accordance with
the terms of this policy. the benefit payable will be two times the benefit normally payable if the
Insured's injury is sustained:
1. while the Insured is a fare -paying passenger in a public conveyance which is licensed to transport
people; or
2. as a direct result of the burning of the hotel, theater, school or government building within which the
Insured is present at the time the fire begins.
Cost of Living Accumulation Benefit
Every two years, on the anniversary date the Policy, each insured employee's original Principal Sum will
be automatically increased by 5% to a maximum of 25% as long as the employee remains insured and
actively at work under the plan.
Travel Accident
In the event of an accidental injury which results in a Loss payable in accordance with the terms of this
policy in which the Insured sustains the loss while traveling on company business, we will pay two times
the amount normally payable subject to a maximum Principal Sum of $500,000.
For the purposes of this provision, Traveling on Company Business means the start of a business trip
whether from home or from work which ends when the Insured returns home or to work whichever
occurs first For purposes of this definition, the following do not qualify as company business:
1. Daily commuting to and from work.
2. Vacation travel, including, but not limited to, a business trip which has been extended for vacation
purposes. In this instance, the return trip home will be excluded from coverage.
If, in the event of any one accident, two or more Insured's suffer one or more of the Losses shown in the
Schedule of Losses, an aggregate maximum benefit for any and all Losses of no more than $2,000.000
will be paid.
GL400-400
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Definitions
"Principal Sum" is the amount which applies to the Insured under the Amount of Insurance
provision at the time of the accident
"Loss" means, with regard to:
1. An arm, leg, hand or foot, the total and irrecoverable loss of its use, provided the loss is
continuous for 12 consecutive months and such loss of use is determined to be
permanent at the end of such time.
2. A thumb and index finger or all four fingers of one hand, complete severance at or above
the metacarpophalangeal joints.
3. Toes, complete severance at or above the metacarpophalangeal joints.
4. An eye, the total and irrecoverable loss of sight
5. Speech, the complete and irrecoverable loss of speech.
6. Hearing, the complete and irrecoverable loss of hearing.
-- ---fi, --i tag the paralysis
continuous for 12 consecutive months from the date of the loss.
8. Paraplegia, the total paralysis of both lower limbs provided the loss is continuous -for 12
consecutive months from the date of the loss.
9. Hemiplegia, the total paralysis of upper and lower limbs on one side of the body
provided the loss is continuous for 12 consecutive months from the date of the loss.
"Beneficiary" will be as determined under the Beneficiary provision.
"Insured" means a person.
"Physician" means a qualified doctor of medicine, other than You or a member of Your family,
who is both licensed by at least one state to practice medicine and who is providing You with appropriate
medical care within the area of his or her medical training and qualifications.
G%400-401
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ACCIDENTAL DEATH AND DISMEMBERMENT BENEFIT (Continued)
SCHEDULE OF LOSSES
Nature of Loss Amount BMW
We.......................................................................................... The Principal Sum
The sight of both eyes.................................................................... The Principal Sum
Either both hands gr both feet ................. :........................................ The Principal Sum
One hand and = foot................................................................... The Principal Sum
The sight of one eye and either one hand or !me foot .............................. The Principal Sum
Speech and hearing in both ears ........................................................ The Principal Sum
Either one arm or one leg .........................................Three-quarters of the Principal Sum
Either one hand or one foot ............................................... One-half of the Principal Sum
The sight of one eye ........................................................ One-half of the Principal Sinn
Speech 41 hearing in both ears ........................................... One-half of the Principal Sum
Both the thumb wd index finger of one hand ..................... One -quarter of the Principal Sum
Both thumbs of both hands ............................................ One -quarter of the Principal Sum
All four fingers of one hand .......................................... One -quarter of the Principal Sum
All of the toes of one foot ............................................. One -eighth of the Principal Sum
Quadriplegia............................................................................... The Principal Sum
Paraplegia.................................................................................. The Principal Sum
Hemiplegia................................................................................. The Principal Sum
1. The total amount payable under this provision m respect of all Losses suffered by an
Insured as the result of any one accident will not exceed the Principal Sum.
2. If, as the result of any one accident, an Insured suffers more than one of the Losses
shown in the Schedule of Losses with respect to any one limb, payment will be made
only for the Loss for which the largest amount is payable.
GL400-402
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ACCIDENTAL DEATH AND DISMEMBERMUM BENEFIT (Continued)
No amount of Benefit will be payable under this provision if the Loss resulted either directly or
indirectly from, or was in any manner or degree associated with, or occasioned by, any one or more
Of.
1. Intentionally self-inflicted injury.
2. War, declared or undeclared, or any act of war.
3. Active participation in any riot or violent disorder_
4. The Insured either taking or attempting to take his/her own life whether he/she is m
possession of his/her mental faculties or not at the time.
5. Bodily or mewl infirmity or illness or disease of any kind, or medical or surgical
treatment thereof.
6. poisoning in any form, inhalation of gas or fumes.
7. Travel or flight in any aircraft except solely as a passenger in a powered civil aircraft
having a valid and current airworthiness certificate and operated by a duly licensed or
i certified pilot while such aircraft is being used for the sole purpose of transportation only.
Descent from any aircraft in flight will be deemed to be part of such flight.
8. Committing or attempting to commit a felony, or engaging in any unlawful act or illegal
occupation, or commiting or provoking an unlawful act.
9. Any period while an Insured is confined to a penal or correctional institution.
In addition, no payment will be made under this provision if the loss, or injury leading to the loss,
occurs while:
In the course of operating a motor vehicle;
a. under the influence of any intoxicant or
b. if the Insured's blood alcohol concentration is in excess of 100 milligrams of
alcohol per 100 milliliters of blood.
GIAOO-403
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ACCIDENTAL DEATH AND DISMEMBERMENT STANDARD PROVISIONS
Time Limit on Certain Defenses
After an Insured has been insured under this policy for two years, no misstatement of the
person except a fraudulent misstatement will be used to reduce or dewy a chdin.
Notice of Claim
Written notice of a claim must be given to us within 30 days of the occurrence or
commencement of any loss covered by this policy. If this is not possible, we must be notified as soon
as it is reasonably possible to do so. Notice must be given to us at our Head Office or to an agent of
ours. The notice should include the name of the Insured with respect to whom the claim is made and
the group policy number.
Clain Forms
When we receive a written notice of a claim, we will send the claimant our claim forms to file
proof of loss. If the claim forms are not received within 15 days after written notice of claim is sent,
the claimant can send us written proof of claim without waiting for the claim forms.
Proof of Loss
Proof of loss must be given to us no later than 90 days after the occurrence or commencement
of any loss covered by this policy. if it is not possible to give proof within the time required, it must
be given as soon as reasonably possible. Claims for reimbursement of expenses incurred must be
accompanied by receipts satisfactory to us evidencing payment of such expenses.
Tian of Payment of Claim
When we receive satisfactory proof of claim, benefits payable under this policy for any loss
will be paid as they are incurred.
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ACCIDENTAL DEATH AND DISBUMBEPMENT STANDARD PROVISIONS (Continued)
Payment of Claims
Indemnity for loss of life will be payable in accordance with the beneficiary designation and the
provisions respecting such payment which may be prescribed herein and effective at the time of
payment. If no such designation or provision is then effective, such indemnity shall be payable to the
estate of the insured person. Any other accrued indemnities unpaid at the insured person's death may,
at our option, be paid either to such beneficiary or to such estate. All other indemnities will be payable
to the insured person.
Physical Examination
We will have the right and opportunity, at our own expense, to have a physician of our choice
examine anyone in respect of whom a claim is being made. We will have the right to do this when and
as often as we may reasonably require. The benefits with respect to which the claim was made will not
be paid during any period in which the Insured fads to submit to any medical examination requested by
US.
Legal Actions
No action at law or in equity may be brought to recover under this policy until 60 days after
written proof of loss has been given to us. No such action may be brought more than three years after
the time within which proof of loss is required to be given.
L GIA00-404
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