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HomeMy WebLinkAboutResolution - 2003-R0472 - Agreement To Provide Voluntary Accidental Death And Disemberment Insurance - 10_23_2003Resolution No. 2003—RO472 October 23, 2003 Item No. 19 RESOLUTION 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 •ected to execute for and on behalf of the City of Lubbock, an Agreement to provide luntary accidental death and dismemberment insurance, by and between the City of .bbock and AIG Life Insurance Company, and any other related documents. Said ;reement is attached hereto and incorporated in this Resolution as if fully set forth rein and shall be included in the minutes of the Council. assed by the City Council this 23rd day of October 2003. ARC MC IT GAL, MAYOR ATTEST: W APPROVED AS TO cott Studer, Director of Human I APPROVED AS TO FORM: Attorney gs:/cityatt&ccdo,s/John/Reso-AIG Life Ins Co Agrmnt September 23, 2003 ,r.. _ 11 •, AGREEMENT BY AND BETWEEN Resolution No. 2003-RO472 THE CITY OF LUBBOCK, TEXAS AND AIG LIFE INSURANCE COMPANY THIS AGREEMENT entered into this 1st day of December, 2003 by and between the CITY OF LUBBOCK, TEXAS, a municipal home rule corporation (hereinafter called "City") and AIG LIFE INSURANCE COMPANY (hereinafter called the "Company) to provide Voluntary Accidental Death and Dismemberment insurance. WHEREAS, the City desires to have services provided for Voluntary Accidental Death and Dismemberment Insurance, and WHEREAS, the Company has demonstrated that it can provide said services; and WHEREAS, the City and Company desire to enter into an Agreement to provide said services. NOW, THEREFORE, the parties agree as follows: The parties agree to abide by the terms and conditions of the Master Application for Group Accident Insurance Policy for Voluntary Accidental Death and Dismemberment Insurance which is attached to this Agreement as Exhibit 'W' and Exhibit "B" and is incorporated as if fully set forth herein. 2. In addition to the terms and conditions set out in Exhibit "A" and Exhibit "B", the parties further agree as follows: a. This Agreement is for a term of three (3) years from the effective date with a three year rate guarantee. b. 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: AIG Life Insurance Company 8144 Walnut Hill Lane #1600 Dallas, Texas 75231 (214) 932-2340 Fax (214) 932-2342 c. Notices or communication 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 City has been requested to send such communications to another address: The City Of Lubbock Human Resources Department PO Box 2000 Lubbock, TX 79457 (806) 775-2317 Fax: 806-775-3965 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 noticelcommunication is mailed. d. This contract shall be construed and enforced according to the laws of the State of Texas. v f e. The City may terminate the services of the Company at any time upon giving to the Company a 90 day written notice of its intention to do so. Such notice from the City must include the name and address of the new Company. The Company may resign at any time upon 90 days written notice to the City. The Company upon its resignation shall complete the processing of all services described in this Agreement that have commenced prior to the effective date of the termination of this Agreement. f. This Agreement shall consist of the Agreement, Exhibit A, and Exhibit B attached hereto. Order of precedence if there is a conflict is the Agreement, Exhibit A, and Exhibit B. SIGNED this the 7 day of 2003. 23rd October CITY OF LU Mayor ATTEST: Retfecca Garza City Secretary APPROVED AS TO CON NT: Scott Snider Director of Human Resources APPROVED AS TO FORM: ohn Knig Attorney at Law AIG LIFE INSURANCE COMPANY EXHIBIT A 2(J 3- Q_0LNL AiG��s=� AIG LIFE INSURANCE COMPANY 600 KING STREET WILMINGTON, DELAWARE 19801 (302) 594-2000 (Herein called the Company) MASTER APPLICATION FOR GROUP ACCIDENT INSURANCE POLICY Application is hereby made for a plan of accident insurance based on the following statements and representations: Identification of Policyholder: Name of Policyholder: City of Lubbock Address of Policyholder: 1625 131h Street, Lubbock, Texas 79457 Type of Business or Purpose of Organization: Municipality Name(s) of Affiliates(s) or Subsidiary(ies) to be covered: None Policy Number: PAI 805 9748 2. Classification of Eligible Persons: Class Description of Class All active full-time employees of the City of Lubbock working a minimum of 20 hours per week 2 All Eligible Spouses and Eligible Dependent Children of Class 1 Insureds Eligible Spouse - as used above, means the Insured's legal spouse. Eligible Dependent Children - as used above, means the Insured's unmarried children, including natural children.from the moment of birth, step, foster or adopted children while in the custody of the Insured and the Insured is a party to a proceeding in which the adoption of the child by the Insured is sought, and grandchildren if dependent on the Insured for federal income tax purposes, under age 19 (25 if attending an accredited institution of higher learning on a full time basis) and primarily dependent on the Insured for support and maintenance. Any unmarried Eligible Dependent Children of the Insured covered under the Policy before reaching the age limit specified above, who are incapable of self-sustaining employment by reason of mental or physical incapacity, and who are primarily dependent on the Insured for support and maintenance, may continue to be eligible under the Policy beyond that age limit for as long as the Policy is in force, but only;if they remain continuously covered under the Policy. The Company may request that the Insured submit satisfactory proof of the Eligible Dependent Child(ren)'s incapacity and dependency to the Company within 60 days before the Eligible Dependent Children) reach the age limit specified above. 'If the Insured fails to fumish the requested proof before the Eligible Dependent Children) reach the age.limit, coverage for the Eligible Dependent Child(ren) will not be extended past the age limit. If coverage is extended, the Company may request that the Insured submit satisfactory proof of the Eligible Dependent Child(ren)'s continued incapacity and dependency to the Company on an annual C11658 1 CAP -TX basis. If the Insured fails to furnish the requested proof within 31 days of the request, coverage for the Eligible Dependent Child(ren) will terminate at the end of that 31-day period. Continuation of Eligibility. If premium payments are continued on a basis that precludes individual selection, an Insured who ceases to be a member of any eligible class of persons as described above may still be regarded as in an eligible class of persons as follows: (1) if the Insured is on temporary lay- off or leave of absence (other than an authorized family or medical leave), for the full period of the lay- off or leave, but not for more than three months in a row; or (2) if the Insured is absent from work due to an authorized family or medical leave, for the full period of the leave, but not for more than three months in a row unless a longer period is agreed to by the Company and the Policyholder. 3. Principal Sum: Class Basic Amount Voluntary Amount N/A not less than $25,000 nor more than $100,000 in increments of $25,000 2 N/A (See the following description) For an Insured Dependent Child. If an Insured Dependent Child suffers a loss for which a benefit is payable under the Policy and there is an Insured Spouse on the date of the accident causing the loss, the Insured Dependent Child's Principal Sum is the lesser of $50,000 or 10% of the Insured's Principal Sum on the date of the accident causing the loss. If there is no Insured Spouse on the date of the accident causing the loss, the Insured Dependent Child's Principal Sum is the lesser of $50,000 or 20% of the Insured's Principal Sum on the date of the accident causing the loss. For an Insured Spouse. If an Insured Spouse suffers a loss for which a benefit is payable under the Policy and there is an Insured Dependent Child on the date of the accident causing the loss, the Insured Spouse's Principal Sum is 50% of the Insured's Principal Sum on the date of the accident causing the loss. If there is no Insured Dependent Child on the date of the accident causing the loss, the Insured Spouse's Principal Sum is 60% of the Insured's Principal Sum on the date of the accident causing the loss. In the event that a person is covered under the Policy as an Insured and as an Insured Dependent, the combined Principal Sum on that person may not exceed $100,000. 4. Policy: Check one and only one: Accidental Death Benefit Only X Both Accidental Death and Accidental Dismemberment Benefits The following Riders are attached to and made part of the Policy as of the Policy Effective Date. Each Rider is subject to all provisions, limitations and exclusions of the Policy that are not specifically modified by the Rider. C11658 2 CAP -TX Y ' • t FORM NO. DESCRIPTION CLASS(ES) C11663 Child(ren)'s Additional Indemnity for 1 Dismemberment and Paralysis Benefit C11664 Coma Benefit 1 & 2 C11666 Common Disaster Benefit 1 C11667 Conversion Privilege 1 & 2 C11668 Day Care Benefit 1 C11671 Family Coverage 1 C11672 Family Extension Benefit 1 C11675 Felonious Assault Benefit 1 & 2 C11679 Paralysis Benefit 1 & 2 C11683 Rehabilitation Benefit 1 & 2 C11687 Seat Belt and Air Bag Benefit 1 & 2 C11688 Tuition Benefit 1 5. Premiums: It is hereby agreed and understood that the premium rate per $ 1.000 of Principal Sum is as follows for each class described above: Class Premium 1 Employee Only Coverage $.03 per Month 1+2 Family Coverage $.04 per Month Such premiums are due and payable in the following manner: On or before the 15t' day of the month immediately following the month in which the premium is earned. C11658 3 CAP -TX 6. Coverage Effective Date: Subject to the Policy provisions regarding the effective date of coverage for individuals, insurance will become effective as to each eligible _person for whom enrollment has been received by the Policyholder, if applicable, and for whom premium has been paid on the following date: the later of the Policy Effective Date shown in the Master Application or the date an Insured becomes a member of an eligible class as described in the Master Application. A change in coverage due to a change in the eligible person's class or election of Principal Sum amount will become effective on the latest of the following dates: (1) if individual enrollment for the change is required, the date the written enrollment form requesting the change is received by the Policyholder; (2) if the change requires a change in premium, the date the first changed premium is paid when due. However, a change applies only with respect to accidents that occur on or after the effective date of the change. 7. Policy Effective Date: December 1, 2000 Signed for the Policyholder Title Date Signed by Licensed Resident Agent (Where Required by Law) C11658 4 CAP -TX 0 __ AIG LIFE INSURANCE COMPANY AIG==_ = 600 KING STREET �_ WILMINGTON, DELAWARE 19801 (302) 594-2000 Policyholder: City of Lubbock (Herein called the Company) Policy Number: PAI 805 9748 GROUP ACCIDENT INSURANCE POLICY This Policy is a legal contract between the Policyholder and the Company. The Company agrees to insure eligible persons of the Policyholder (herein called Insured Person(s)) against loss covered by this Policy subject to its provisions, limitations and exclusions. The persons eligible to be Insured Persons are all persons described in the Classification of Eligible Persons section of the Master Application. This Policy is issued in consideration of the payment of the required premium when due and the statements set forth in the signed Master Application which is attached to and made part of this Policy, and in the individual enrollment forms, if any. This Policy begins on the Policy Effective Date shown in the Master Application and continues in effect as long as premiums are paid when due, unless otherwise terminated as further provided in this Policy. If this Policy is terminated, insurance ends on the date to which premiums have been paid. This Policy is governed by the laws of the state in which it is delivered. THIS IS NOT A POLICY OF WORKER'S COMPENSATION INSURANCE. THE EMPLOYER DOES NOT BECOME A SUBSCRIBER TO THE WORKER'S COMPENSATION SYSTEM BY PURCHASING THIS POLICY, AND IF THE EMPLOYER IS A NON -SUBSCRIBER, THE EMPLOYER LOSES THOSE BENEFITS WHICH WOULD OTHERWISE ACCRUE UNDER THE WORKER'S COMPENSATION LAWS. THE EMPLOYER MUST COMPLY WITH THE WORKER'S COMPENSATION LAW AS IT PERTAINS TO NON -SUBSCRIBERS AND THE REQUIRED NOTIFICATIONS THAT MUST BE FILED AND POSTED. The President and Secretary of AIG Life Insurance Company witness this Policy: President Secretary PLEASE READ THIS POLICY CAREFULLY. Non -Participating Policy C11656TX CAP TABLE OF CONTENTS Definitions.......................................................................................................................3 Policy Effective and Termination Dates........................................................................... 3 Insured's Effective and Termination Dates.......................................................... :........... 3 Premium..........................................................................................................................4 Benefits...........................................................................................................................4 PrincipalSum............................................................................................................4 ReductionSchedule..................................................................................................4 Limitation on Multiple Benefits...................................................................................4 Accidental Death Benefit...........................................................................................4 Accidental Dismemberment Benefit...........................................................................5 Exposure and Disappearance...................................................................................5 Exclusions....................................................................................................................... 6 ClaimsProvisions............................................................................................................7 General Provisions..........................................................................................................8 C11656TX 2 CAP DEFINITIONS Injury - means bodily injury caused by an accident occurring while this Policy is in force as to the person whose injury is the basis of claim and resulting directly and independently of all other causes in a covered loss. Insured - means a person: (1) who is a member'of an eligible class of persons as described in the Classification of Eligible Persons section of the Master Application; (2) who has enrolled for coverage under this Policy, if required; (3) for whom premium has been paid; and (4) while covered under this Policy. However, an Insured does not include any person covered under this Policy solely as an Insured Dependent as defined in the Family Coverage Rider. Immediate Family Member - means a person who is related to the Insured Person in any of the following ways: spouse, brother-in-law, sister-in-law, son-in-law, daughter-in-law, mother-in-law, father-in-law, parent (includes stepparent), brother or sister (includes stepbrother or stepsister), or child (includes legally adopted or stepchild). Insured Person - means an Insured or an Insured Dependent as defined in the Family Coverage Rider. Physician - means a licensed practitioner of the healing arts acting within the scope of his or her license who is not: 1) the Insured Person; 2) an Immediate Family Member; or 3) retained by the Policyholder. POLICY EFFECTIVE AND TERMINATION DATES Effective Date. This Policy begins on the Policy Effective Date shown in the Master Application at 12:01 AM Standard Time at the address of the Policyholder where this Policy is delivered. Termination Date. Either the Company or the Policyholder may terminate this Policy on any premium due date by giving 30 days advance written notice to the other party. This Policy may also, at any time, be terminated by mutual written consent of the Company and the Policyholder. This Policy terminates automatically on the premium due date if premiums are not paid when due. Termination takes effect at 12:01 AM Standard Time at the Policyholder's address on the date of termination. INSURED'S EFFECTIVE AND TERMINATION DATES Effective Date. An Insured's coverage under this Policy begins on the latest of: (1) the Policy Effective Date; (2) the date the first premium for the Insured's coverage is paid in accordance with the Premiums Section of the Master Application; (3) if individual enrollment is required, the date written enrollment is received by the Policyholder; (4) the date the person becomes a member of an eligible class of persons as described in the Classification of Eligible Persons section of the Application; or (5) the Coverage Effective Date described in the Master Application. Termination Date. An Insured's coverage under this Policy ends on the earliest of: (1) the date this Policy is terminated; (2) the premium due date if premiums are not paid when due; (3) the date the Insured requests, in writing, that his or her coverage be terminated; or (4) the date the Insured ceases to be a member of any eligible class(es) of persons as described in the Classification of Eligible Persons section of the Master Application. Termination of coverage will not affect a claim for a covered loss that occurred while the Insured's coverage was in force under this Policy. C11656TX 3 CAP PREMIUM Premiums. Premiums are payable to the Company at the rates and in the manner described in the Premiums section of the Master Application. The Company may change the required premiums due on any Policy anniversary date after the first Policy anniversary date, as measured- -annually from the Policy Effective Date, by giving the Policyholder at least 31 days advance written notice. The Company may also change the required premiums at any time when any change affecting rates is made in this Policy. Grace Period A Grace Period of 31 days will be provided for the payment of any premium due after the first This Policy will not be terminated for nonpayment of premium during the Grace Period if the Policyholder pays all premiums due by the last day of the Grace Period. This Policy will terminate on the last day of the period for which all premiums have been paid if the Policyholder fails to pay all premiums due by the last day of the Grace Period. If the Company expressly agrees to accept late payment of a premium without terminating this Policy, the Company does so in accordance with the Noncompliance with Policy Requirements provision of the General Provisions section. In such case, the Policyholder will be liable to the Company for any unpaid premiums for the time this Policy is in force. No grace period will be provided if the Company receives notice to terminate this Policy prior to a premium due date. BENEFITS Principal Sum. As applicable to each Insured, Principal Sum means the amount of insurance in force under this Policy as described in the Insured's enrollment form. Reduction Schedule. The amount payable for a loss will be reduced if an Insured Person is age 70 or older on the date of the accident causing the loss with respect to any Benefit provided by this Policy where the amount payable for the loss is determined as a percentage of his or her Principal Sum. The amount payable for the Insured Person's loss under that Benefit is a percentage of the amount that would otherwise be payable, according to the following schedule: AGE ON DATE OF ACCIDENT PERCENTAGE OF AMOUNT OTHERWISE PAYABLE 70-74 50% 75 and older 25% Premium for an Insured Person age 70, or older is based on 100% of the coverage that would be in effect if the Insured Person were under age 70. "Age" as used above refers to the age of the Insured Person on the Insured Person's most recent birthday, regardless of the actual time of birth. Limitation on Multiple Benefits. If an Insured Person suffers one or more losses from the same accident for which amounts are payable under more than one of the following Benefits provided by this Policy, the maximum amount payable under all of the Benefits combined will not exceed the amount payable for one of those losses, the largest: Accidental Death Benefit, Accidental Dismemberment Benefit, Paralysis Benefit, Coma Benefit. C11656TX 4 CAP Accidental Death Benefit. if Injury to the Insured Person results in death within 365 days of the date of the accident that caused the Injury, the Company will pay 100% of the Principal Sum. Accidental Dismemberment If Injury to the Insured Person results, within 365 days of the date of the accident that caused the Injury, in any one of the Losses specified below, the Company will pay the percentage of the Principal Sum shown below for that Loss: For Loss of Percentage of Principal Sum Both Hands or Both Feet.................................................................. 100% Sightof Both Eyes............................................................................ 100% One Hand and One Foot...................................................................100% One Hand and the Sight of One Eye ................................................. 100% One Foot and the Sight of One Eye .................................................. 100% Speech and Hearing in Both Ears .................................................... 100% One Hand or One Foot....................................................................... 50% Sightof One Eye................................................................................ 50% Speech or Hearing in Both Ears ......................................................... 50% Thumb and Index Finger of Same Hand ............................................. 25% "Loss" of a hand or foot means complete severance through or above the wrist or ankle joint. "Loss" of sight of an eye means total and irrecoverable loss of the entire sight in that eye. "Loss" of hearing in an ear means total and irrecoverable loss of the entire ability to hear in that ear. "Loss" of speech means total and irrecoverable loss of the entire ability to speak. "Loss" of thumb and index finger means complete severance through or above the metacarpophalangeal joint of both digits. If more than one Loss is sustained by an Insured Person as a result of the same accident, only one amount, the largest, will be paid. Exposure and Disappearance. If by reason of an accident occurring while an Insured Person's coverage is in force under this Policy, the Insured Person is unavoidably exposed to the elements and as a result of such exposure suffers a loss for which a benefit is otherwise payable under this Policy, the loss will be covered under the terms of this Policy. If the body of an Insured Person has not been found within one year of the disappearance, forced landing, stranding, sinking or wrecking of a conveyance in which the person was an occupant while covered under this Policy, then it will be deemed, subject to all other terms and provisions of this Policy, that the Insured Person has suffered accidental death within the meaning of this Policy. C11656TX 5 CAP 0 EXCLUSIONS This Policy does not cover any loss caused in whole or in part by, or resulting in whole or in part from, the following: 1. suicide or any attempt at suicide or intentionally self-inflicted injury or any attempt at intentionally self-inflicted injury; 2. sickness, disease or infections of any kind; except bacterial infections due to an accidental cut or wound, botulism or ptomaine poisoning; 3. travel or flight in or on (including getting in or out of, or on or off of) any vehicle used for aerial navigation, if the Insured Person is: a. riding as a passenger in any aircraft not intended or licensed for the transportation of passengers; b. performing, learning to perform or instructing others to perform as a pilot or crew member of any aircraft; C. riding as a passenger in an aircraft owned, leased or operated by the Policyholder or the Insured Person's employer; 4. declared or undeclared war, or any act of declared or undeclared war; 5. full-time active duty in the armed forces of any country or international authority, except the National Guard or organized reserve corps duty (unearned premium will be returned if the Insured Person enters military service); 6. the Insured Person being under the influence of drugs or intoxicants, unless taken under the advice of a Physician; 7. the Insured Person's commission of or attempt to commit a felony. C11656TX 6 CAP CLAIMS PROVISIONS Notice of Claim. Written notice of claim must be given to the Company within 20 days after an Insured Person's loss, or as soon thereafter as reasonably possible. Notice given by or on behalf of the claimant to the Company at American International Companies ®, Accident and Health Claims Division, P. O. Box 15701, Wilmington, DE 19850-5701, with information sufficient to identify the Insured Person, is deemed notice to the Company. , Claim Forms. The Company will send claim forms to the claimant upon receipt of a written notice of claim. If such forms are not sent within 15 days after the giving of notice, the claimant will be deemed to have met the proof of loss requirements upon submitting, within the time fixed in this Policy for filing proof of loss, written proof covering the occurrence, the character and the extent of the loss for which claim is made. The notice should include the Insured's name, the Policyholder's name and the Policy number. Proof of Loss. Written proof of loss must be furnished to the Company within 90 days after the date of the loss. If the loss is one for which this Policy requires continuing eligibility for periodic benefit payments, subsequent written proofs of eligibility must be furnished at such intervals as the Company may reasonably require. Failure to furnish proof within the time required neither invalidates nor reduces any claim if it was not reasonably possible to give proof within such time, provided such proof is furnished as soon as reasonably possible and in no event, except in the absence of legal capacity of the claimant, later than one year from the time proof is otherwise required. Payment of Claims. Upon receipt of due written proof of death, payment for loss of life of an Insured Person will be made to the Insured Person's beneficiary as described in the Beneficiary Designation and Change provision of the General Provisions section. Upon receipt of due written proof of loss, payments for all losses, except loss of life, will be made to (or on behalf of, if applicable) the Insured Person suffering the loss. If an Insured Person dies before all payments due have been made, the amount still payable will be paid to his or her beneficiary as described in the Beneficiary Designation and Change provision of the General Provisions section. If any payee is a minor or is not competent to give a valid release for the payment, the payment will be made to the legal guardian of the payee's property. If the payee has no legal guardian for his or her property, all or part of the payment may be made, at the Company's option, to the person or persons who, in the Company's opinion, have assumed the custody and support of the minor or responsibility for the incompetent person's affairs. At the Company's option, the payment may be made in installments in an amount and at a frequency determined by the Company. Any payment the Company makes in good faith fully discharges the Company's liability to the extent of the payment made. Time of Payment of Claims. Benefits payable under this Policy for any loss other than loss for which this Policy provides any periodic payment will be paid immediately upon the Company's receipt of due written proof of the loss, but in no event more than 60 days from receipt of proof of loss. Subject to the Company's receipt of due written proof of loss, all accrued benefits for loss for which this Policy provides periodic payment will be paid at the expiration of each month during the continuance of the period for which the Company is liable and any balance remaining unpaid upon termination of liability will be paid immediately upon receipt of such proof. C 11656TX 7 CAP GENERAL PROVISIONS Entire Contract; Changes. This Policy, the Master Application, and any attached papers make up the entire contract between the Policyholder and the Company. In the absence of fraud, all statements made by the Policyholder, or any Insured Person will be considered representations and not warranties. No written statement made by an Insured Person will be used in any contest unless a copy of the statement is furnished to the Insured Person or his or her beneficiary or personal representative. No change in this Policy will be valid until approved by an officer of the Company. The approval must be noted on or attached to this Policy. No agent may change this Policy or waive any of its provisions. Incontestability. The validity of this Policy will not be contested after it has been in force for two year(s) from the Policy Effective Date, except as to nonpayment of premiums. After an Insured Person has been insured under this Policy for two year(s) during his lifetime, no statement made by the Insured Person, except a fraudulent one, will be used to contest a claim under this Policy. The Company may only contest coverage if the misstatement is made in a written instrument signed by the Insured Person and a copy is given to the Policyholder, the Insured Person or the beneficiary. Certificates of Insurance. The Company will provide certificates of insurance for delivery to each Insured describing the coverage provided, any limitations, reductions, and exclusions applicable to the coverage, and to whom benefits will be paid. Insured's Beneficiary Designation and Change. The Insured's designated beneficiary(ies) is (are) the person(s) so named by the Insured for the Policyholder's basic group life insurance policy as shown on the Policyholder's records kept on that policy, unless the Insured has named a beneficiary specifically for this Policy as shown on the Company's or, if agreed upon in advance by the Company, the Policyholder's records kept on this Policy. An Insured over the age of majority and legally competent may change his or her beneficiary designation at any time, unless an irrevocable designation has been made, without the consent of the designated beneficiary(ies), by providing the Company or, if agreed upon in advance by the Company, the Policyholder with a written request for change. When the request is received by the Company or, if agreed upon in advance by the Company, the Policyholder, whether the Insured is then living or not, the change of beneficiary will relate back to and take effect as of the date of execution of the written request, but without prejudice to the Company on account of any payment made by it prior to receipt of the request. If there is no designated beneficiary or no designated beneficiary is living after the Insured's death, the benefits will be paid, in equal shares, to the survivors in the first surviving class of those that follow: the Insured's (1) spouse; (2) children; (3) parents; or (4) brothers and sisters. If no class has a survivor, the beneficiary is the Insured's estate. Physical Examination and Autopsy. The Company at its own expense has the right and opportunity to examine the person of any individual whose loss is the basis of claim under this Policy when and as often as it may reasonably require during the pendency of the claim and to make an autopsy in case of death where it is not forbidden by law. C11656TX 8 CAP Legal Actions. No action at law or in equity may be brought to recover on this Policy prior to the expiration of 60 days after written proof of loss has been furnished in accordance with the requirements of this Policy. No such action may be brought after the expiration of three years after the time written proof of loss is required to be furnished. Noncompliance with Policy Requirements. Any express waiver by the Company of any requirements of this Policy will not constitute a continuing waiver of such requirements. Any failure by the Company to insist upon compliance with any Policy provision will not operate as a waiver or amendment of that provision. 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 is delivered is hereby amended to conform to the minimum requirements of those statutes. Workers' Compensation. This Policy is not in lieu of and does not affect any requirements for coverage by any Workers' Compensation Act or similar law. Clerical Error. Clerical error, whether by the Policyholder or the Company, will not void the insurance of any Insured Person if that insurance would otherwise have been in effect nor extend the insurance of any Insured Person if that insurance would otherwise have ended or been reduced as provided in this Policy. Records. The Company has the right to inspect at any reasonable time, any records of the Policyholder that may have a bearing on this insurance. Assignment. This Policy is non -assignable. An Insured may not assign any of his or her rights, privileges or benefits under this Policy. New Entrants. This Policy will allow from time to time, that new eligible Insured Persons of the Policyholder be added to the class(es) of Insured Persons originally insured under this Policy. Misstatement of Age. If premiums for the Insured Person are based on age and the Insured Person has misstated his or her age, there will be a fair adjustment of premiums based on his or her true age. If the benefits for which the Insured Person is insured are based on age and the Insured Person has misstated his or her age, there will be an adjustment of said benefit based on his or her true age. The Company may require satisfactory proof of age before paying any claim. C11656TX 9 CAP 0 AIG LIFE INSURANCE COMPANY AIGUF 600 KING STREET WILMINGTON, DELAWARE 19801 (302) 594-2000 Policyholder: City of Lubbock (Herein called the Company) Policy Number: PAI 805 9748 CHILD(REN)'S ADDITIONAL INDEMNITY FOR DISMEMBERMENT AND PARALYSIS BENEFIT RIDER This Rider is attached to and made part of the Policy as of the Policy Effective Date shown in the Policy's Master Application. It applies only with respect to accidents that occur on or after that date. It is subject to all of the provisions, limitations and exclusions of the Policy except as they are specifically modified by this Rider. Child(ren)'s Additional Indemnity for Dismemberment and Paralysis Benefit. The Company will pay a benefit under this Rider when an Insured has Family Coverage in effect under the Policy and an Insured Dependent Child suffers an accidental dismemberment or an accidental paralysis for which an Accidental Dismemberment benefit or a Paralysis benefit is payable under the Policy. This benefit is payable to or on behalf of an Insured Dependent Child. It is payable with respect to the one Benefit specified above which provides the larger benefit for all Injuries suffered by the Insured Dependent Child in the same accident. The amount payable under this Rider is an amount equal to the amount payable under the Accidental Dismemberment Benefit or Paralysis Benefit, subject to a maximum of $50,000. The President and Secretary of AIG Life Insurance Company witness this Rider: President Secretary C11663 CAP AIG�l�� Policyholder: City of Lubbock Policy Number: PAI 805 9748 AIG LIFE INSURANCE COMPANY 600 KING STREET WILMINGTON, DELAWARE 19801 (302) 594-2000 (Herein called the Company) COMA BENEFIT RIDER This Rider is attached to and made part of the Policy as of the Policy Effective Date shown in the Policy's Master Application. It applies only with respect to accidents that occur on or after that date. It is subject to all of the provisions, limitations and exclusions of the Policy except as they are specifically modified by this Rider. Coma Benefit. If Injury renders an Insured Person Comatose within 90 days of the date of the accident that caused the Injury, and if the Coma continues for a period of 30 consecutive days, the Company will pay a monthly benefit of 1 % of the Principal Sum. No benefit is provided for the first 30 days of Coma. The benefit is payable monthly as long as the Insured Person remains Comatose due to that Injury, but ceases on the earliest of: (1) the date the Insured Person ceases to be Comatose due to that Injury; (2) the date the Insured Person dies; or (3) the date the total amount of monthly Coma benefits paid for all Injuries caused by the same accident equals 100% of the Principal Sum. The Company will pay benefits calculated at a rate of 1/30th of the monthly benefit for each day for which the Company is liable when the Insured Person is Comatose for less than a full month. Only one benefit is provided for any one month of Coma, regardless of the number of Injuries causing the Coma. The Company reserves the right, at the end of the first 30 consecutive days of Coma and as often as it may reasonably require thereafter, to determine, on the basis of all the facts and circumstances, that the Insured Person is Comatose, including, but not limited to, requiring an independent medical examination provided at the expense of the Company. Coma/Comatose - as used in this Rider, means a profound state of unconsciousness from which the Insured Person cannot be aroused to consciousness, even by powerful stimulation, as determined by a Physician. The President and Secretary of AIG Life Insurance Company witness this Rider: President Secretary C11664 CAP AIG LIFE INSURANCE COMPANY AlGLI=�600 KING STREET F �' WILMINGTON, DELAWARE 19801 (302) 594-2000 Policyholder: City of Lubbock (Herein called the Company) Policy Number: PAI 805 9748 COMMON DISASTER BENEFIT RIDER This Rider is attached to and made part of the Policy as of the Policy Effective Date shown in the Policy's Master Application., It applies only with respect to accidents that occur on or after that date. It is subject to all of the provisions, limitations and exclusions of the Policy except as they are specifically modified by this Rider. Common Disaster Benefit. If an Insured with Family Coverage in effect under the Policy and his or her Insured Spouse both suffer accidental death in the same accident within 90 days of the accident such that an Accidental Death benefit is payable under the Policy for both persons, the Insured Spouse's Principal Sum is increased to equal the lesser of: (1) $100,000; or (2) 100% of the Insured's Principal Sum. The President and Secretary of AIG Life Insurance Company witness this Rider: President Secretary C 11666 CAP Policyholder: City of Lubbock Policy Number: PAI 805 9748 AIG LIFE INSURANCE COMPANY 600 KING STREET WILMINGTON, DELAWARE 19801 (302) 594-2000 (Herein called the Company) CONVERSION PRIVILEGE RIDER This Rider is attached to and made part of the Policy as of the Policy Effective Date shown in the Policy's Master Application. It applies only with respect to individual coverage that ends on or after that date. It is subject to all of the provisions, limitations and exclusions of the Policy except as they are specifically modified by this Rider. Conversion Privilege (Applies to the Accidental Death Benefit and Accidental Dismemberment Benefit only.) If an Insured Person's coverage ends (prior to age 70) because he or she is no longer a member of any eligible class of persons as described in the Classification of Eligible Persons section of the Master Application, coverage may be converted to an individual accidental death and dismemberment policy (herein called an Individual Policy). However, an Insured Dependent may convert only if he or she is the age of majority or over on the date coverage ends. The Company must receive a written application and payment of the required premium within 31 days after coverage ends under the Policy. No evidence of insurability is required to obtain the Individual Policy. The Individual Policy will be a type the Company regularly makes available on its effective date. The initial premium for the Individual Policy will be based on the Insured Person's attained age, risk class, and amount of insurance provided, at the time of application for the Individual Policy. Coverage under the Individual Policy will take effect on 'the later of: (1) the date the application and required premium payment are received by the Company; or (2) the date that the Insured Person's coverage under the Policy ends. In the event that the application and required premium are not received prior to termination of coverage under the Policy, coverage is not provided from the date coverage ends under the Policy until the date coverage under the Individual Policy becomes effective. Coverage -under the Individual Policy may not be less -than $100,000 and may not exceed the greater of: (1) the amount for which the Insured Person was covered under the Policy; or (2) $500,000. The President and Secretary of AIG Life Insurance Company witness this Rider: President Secretary C 11667 CAP � l F AIGL- AIG LIFE INSURANCE COMPANY a s 600 KING STREET WILMINGTON, DELAWARE 19801 Policyholder: City of Lubbock (302) 594-2000 Policy Number: PAI 805 9748 (Herein called the Company) DAY CARE BENEFIT RIDER This Rider is attached to and made part of the Policy as of the Policy Effective Date shown in the Policy's Master Application. It applies only with respect to accidents that occur on or after that date. It is subject to all of the provisions, limitations and exclusions of the Policy except as they are specifically modified by this Rider. Day Care Benefit. If an Insured suffers accidental death such that an Accidental Death benefit is payable under the Policy and the Insured had Family Coverage in effect under the Policy on the date of the accident causing death, the Company will pay a benefit on behalf of any Insured Dependent Child under age 13 who was insured under the Policy on the date of the accident causing death and who: (1) is enrolled in a Day Care Center on the date of the Insured's death; or (2) enrolls in a Day Care Center within 90 days after the Insured's death. The benefit is payable for each year of the Insured Dependent Child's enrollment in a Day Care Center. The total amount of the benefit each year is equal to the least of: 1. the actual cost of care for that Insured Dependent Child charged by that Day Care Center for that year, 2. 3% of the Insured's Principal Sum on the date of the accident causing death; or 3. $3,000. The applicable portion of the yearly benefit for each period of enrollment is payable upon receipt of due proof of enrollment, but not more frequently than monthly. The benefit is not payable for any period of enrollment in a Day Care Center before the date of the accident that caused the Insured's death. The benefit is not payable for any period of enrollment after the earlier of: (1) the date the Insured Dependent Child reaches 13 years of age; or (2) the date four (4) years after the later of the date of the Insured's death or the date the Insured Dependent Child first enrolls in a Day Care Center. Day Care Center - as used in this Rider, means a facility that is duly licensed, certified or accredited by the jurisdiction in which it is located to provide child care and is operating in compliance with applicable laws and regulations of the jurisdiction. The President and Secretary of AIG Life Insurance Company witness this Rider: President Secretary C11668 CAP 0 AIG1- __ AIG LIFE INSURANCE - _ COMPANY 600 KING STREET Policyholder: City of Lubbock WILMINGTON, DELAWARE 19801 Policy Number: PAI 805 9748 (302) 594-2000 (Herein called the Company) FAMILY COVERAGE RIDER This Rider is attached to and made part of the Policy as of the Policy Effective Date shown in the Policy's Master Application. It is subject to all of the provisions, limitations and exclusions of the Policy except as they are specifically modified by this Rider. Insured Dependent's Effective Date. An Insured Dependent's coverage under the Policy begins on the latest of: (1) the date the Insured's coverage under the Policy begins; (2) the date the first premium for the Insured Dependent's coverage is paid; (3) if individual enrollment is required, the date the Insured enrolls the dependent for Family Coverage; (4) the date the person becomes a member of any eligible class of persons as described in the Classification of Eligible Persons section of the Master Application; or (5) the Coverage Effective Date described in the Master Application. If a husband and wife are both eligible to enroll for coverage under the Policy, one, but not both, may purchase Family Coverage. The other spouse may elect single coverage only. Insured Dependent's Termination Date. An Insured Dependent's coverage under the Policy ends on the earliest of: (1) the date the Insured's coverage under the Policy ends; (2) the premium due date if premiums for the Insured Dependent are not paid when due; (3) the date the Insured requests, in writing, that coverage for the Insured Dependent be terminated; or (4) the date the Insured Dependent ceases to be a member of any eligible class of persons as described in the Classification of Eligible Persons section of the Master Application. Insured Dependent's Principal Sum. As applicable to each Insured Dependent, Principal Sum means the amount of insurance in force under the Policy as described in the Insured's enrollment form. In the event that a person is covered under the Policy as an Insured and as an Insured Dependent, the combined Principal Sum on that person may not exceed $100,000. Insured Dependent's Beneficiary Designation and Change. The Insured Dependent's beneficiary is the Insured unless the Insured has named (a) different beneficiary(ies) for the Insured Dependent's coverage as shown on the Company's or, if agreed upon in advance by the Company, the Policyholder's records kept on the Policy. An Insured over the age of majority and legally competent may change the beneficiary designation for an Insured Dependent's coverage at any time, unless an irrevocable beneficiary designation has been made, without the consent of the Insured Dependent or the designated beneficiary(ies), by providing the Company or, if agreed upon in advance by the Company, the Policyholder with a written request for change. When the request is received by the Company, or, if agreed upon in advance by the Company, the Policyholder, whether the Insured or the Insured Dependent is then living or not, the change of beneficiary will relate back to and take effect as of the date of execution of the written request, but,without prejudice to the Company on account of any payment made by it prior to receipt of the request. _ C11671 23 CAF If no beneficiary is living on the date of an Insured Dependent's death, the beneficiary is the Insured's estate. Insured Dependent Child - means the Insured's Eligible Dependent Child as described in the Classification of Eligible Persons section of the Master Application: (1) whom the Insured has elected to cover under the Policy; (2) for whom premium has been paid; and (3) while covered under the Policy. Insured Dependent - means an Insured Spouse or an Insured Dependent Child. Insured Spouse - means the Insured's Eligible Spouse as described in the Classification of Eligible Persons section of the Master Application: (1) whom the Insured has elected to cover under the Policy; (2) for whom premium has been paid; and (3) while covered under the Policy. The President and Secretary of AIG Life Insurance Company witness this Rider: President Secretary C11671 24 CAP a_ AIG LIFE INSURANCE COMPANY A' a 600 KING STREET WILMINGTON, DELAWARE 19801 (302) 594-2000 Policyholder: City of Lubbock (Herein called the Company) Policy Number: PAI 805 9748 FAMILY EXTENSION BENEFIT RIDER This Rider is attached to and made part of the Policy as of the Policy Effective Date shown in the Policy's Master Application. It applies only with respect to accidents that occur on or after that date. It is subject to all of the provisions, limitations and exclusions of the Policy except as they are specifically modified by this Rider. Family Extension Benefit. If an Insured suffers accidental death such that an Accidental Death benefit is payable under the Policy and the Insured had Family Coverage in effect under the Policy on the date of the accident causing death, coverage for his or her Insured Dependents who remained insured under the Policy from the date of the accident to the date of death will be continued without premium payment. Coverage will be continued until the earliest of: 1. the date following 6 months from the date of the Insured's death; 2. the date the Insured Dependent otherwise ceases to be a member of an eligible class of persons as described in the Classification of Eligible Persons section of the MasterApplication; or 3. the date the Policy ends. In the event an Insured Dependent, whose coverage is being extended under the Family Extension Benefit, suffers a loss for which a benefit is payable under the Policy, the Insured Dependent's Principal Sum will be determined as of the date of the accident which caused the Insured's death. The President and Secretary of AIG Life Insurance Company witness this Rider: President Secretary C11672 CAP AIG LIFE INSURANCE COMPANY AIG 600 KING STREET WILMINGTON, DELAWARE 19801 (302) 594-2000 Policyholder: City of Lubbock (Herein called the Company) Policy Number PAI 805 9748 FELONIOUS ASSAULT BENEFIT RIDER This Rider is attached to and made part of the Policy as of the Policy Effective Date shown in the Policy's Master Application. It applies only with respect to accidents that occur on or after that date. It is subject to all of the provisions, limitations and exclusions of the Policy except as they are specifically modified by this Rider. Felonious Assault Benefit (Percentage of Principal Sum Amount) (Not Applicable to Insured Dependents). The Company will pay a benefit under this Rider when the Insured suffers one or more losses for which benefits are payable under the Accidental Death Benefit, Accidental Dismemberment Benefit, Paralysis Benefit, Coma Benefit, provided by the Policy as a result of a Felonious Assault: 1. that is directed at the Policyholder, its property or assets, or the Insured while he or she is acting on behalf of the Policyholder as a member or representative; and 2. that is not a moving violation as defined under the applicable state motor vehicle laws; and 3. that is not an act of an Immediate Family Member or an individual who resides with the Insured on a permanent basis. The amount payable under this Rider is 10% of the largest benefit payable under any one of the Benefits specified above due to the assault. Only one benefit is payable under this Rider for all losses as a result of the same Felonious Assault. Felonious Assault - as used in this Rider, means any willful or unlawful use of force upon the Insured: (1) with the intent to cause bodily injury to the Insured; and (2) that results in bodily harm to the Insured; and (3) that is a felony or a misdemeanor in the jurisdiction in which it occurs. The President and Secretary of AIG Life Insurance Company witness this Rider: President Secretary C11675 CAP _ AIG LIFE INSURANCE COMPANY �' 600 KING STREET AIGUH WILMINGTON, DELAWARE 19801 (302) 594-2000 Policyholder: City of Lubbock (Herein called the Company) Policy Number: PAI 805 9748 PARALYSIS BENEFIT RIDER This Rider is attached to and made part of the Policy as of the Policy Effective Date shown in the Policy's Master Application It applies only with respect to accidents that occur on or after that date. It is subject to all of the provisions, limitations and exclusions of the Policy except as they are specifically modified by this Rider. Paralysis Benefit. If Injury to the Insured Person results, within 365 days of the date of the accident that caused the Injury, in any one of the types of paralysis specified below, the Company will pay the percentage of the Principal Sum shown below for that type of paralysis: Type of Paralysis Percentage of Principal Sum Quadriplegia...................................................... ................ .... 100% ....... .... Paraplegia........................................................................................ 100% Hemiplegia....................................................................................... 100% "Quadriplegia" means the complete and irreversible paralysis of both upper and both lower limbs. "Paraplegia" means the complete and irreversible paralysis of both lower limbs. "Hemiplegia" means the complete and irreversible paralysis of the upper and lower limbs of the same side of the body. "Limb" means entire arm or entire leg. If the Insured Person suffers more than one type of paralysis as a result of the same accident, only one amount, the largest, will be paid. The President and Secretary of AIG Life Insurance Company witness this Rider: President Secretary C11679 CAP r AIGLIFN�� Policyholder: City of Lubbock Policy Number: PAI 805 9748 AIG LIFE INSURANCE COMPANY 600 KING STREET WILMINGTON, DELAWARE 19801 (302) 594-2000 (Herein called the Company) REHABILITATION BENEFIT RIDER This Rider is attached to and made part of the Policy as of the Policy Effective Date shown in the Policy's Master Application: It applies only with respect to accidents that occur on or after that date. It is subject to all of the provisions, limitations and exclusions of the Policy except as they are specifically modified by this Rider. Rehabilitation Benefit. If an Insured Person suffers an accidental dismemberment or an accidental paralysis for which an Accidental Dismemberment or Paralysis benefit is payable under the Policy, the Company will reimburse the Insured Person for Covered Rehabilitative Expenses that are due to the Injury causing the dismemberment or paralysis. The Covered Rehabilitative Expenses must be incurred within two years after the date of the accident causing that Injury, up to a maximum of $5,000 for all Injuries caused by the same accident. Hospital - as used in this Rider, means a facility that: (1) is operated according to law for the care and treatment of injured people; (2) -has organized facilities for diagnosis and surgery on its premises or in facilities available to it on a prearranged basis; (3) has 24 hour nursing service by registered nurses (R.N.); and (4) is supervised by one or more Physicians. A Hospital does not include: (1) a nursing, convalescent or geriatric unit of a hospital when a patient is confined mainly to receive nursing care; (2) a facility that is, other than incidentally, a rest home, nursing home, convalescent home or home for the aged; nor does it include any ward, room, wing, or other section of the hospital that is used for such purposes; or (3) any military or veterans hospital or soldiers home or any hospital contracted for or operated by any national government or government agency for the treatment of members or ex - members of the armed forces. Medically Necessary Rehabilitative Training Service- as used in this Rider, means any medical service, medical supply, medical treatment or Hospital confinement (or part of a Hospital confinement) that: (1) is essential for physical rehabilitative training due to the Injury for which it is prescribed or performed; (2) meets generally accepted standards of medical practice; and (3) is ordered by a Physician. Covered Rehabilitative Expense(s) - as used in this Rider, means an expense that: (1) is charged for a Medically Necessary Rehabilitative Training Service of the Insured Person performed under the care, supervision or order of a Physician; (2) does not exceed the usual level of charges for similar treatment, supplies- or services in the locality where the expense is incurred (for a Hospital room and board charge, does not exceed the most common charge for Hospital semi -private room and board in the Hospital where the expense is incurred); and (3) does not include charges that would not have been made if no insurance existed. C11683TX CAP V � + • Exclusions. In addition to the Exclusions in the Exclusions section of the Policy, Covered Rehabilitative Expenses do not include any expenses for or resulting from an Injury for which the Insured Person is entitled to benefits paid or payable by Workers' Compensation or other similar law. Texas Department of Human Services Reimbursement Benefits paid on behalf of an Insured Person must be paid to the Texas Department of Human Services, if such Insured Person is eligible for benefits under this Rider and is also entitled for benefits for the same expense from the Texas Department of Human Services. Benefits paid on behalf of Dependent Children must be paid to the Texas Department of Human Services after written notice to the Company at the Company's home office, if: 1. the Insured is possessory conservator of the child under an order issued in Texas or is not entitled to possession of or access to the child; and is required by court order or court -approved agreement to pay child support; and 2. the Texas Department of Human Services is paying benefits on behalf of the child under Chapter 31 or Chapter 32 of the Human Resources Code; and 3. the Company is notified through an attachment to the claim for insurance benefits when the claim is first submitted to the Company that the benefits must be paid directly to the Texas Department of Human Services. The President and Secretary of AIG Life Insurance Company witness this Rider: President Secretary C11683TX CAP AIG LIFE INSURANCE COMPANY 600 KING STREET WILMINGTON, DELAWARE 19801 (302) 594-2000 Policyholder: City of Lubbock (Herein called the Company) Policy Number: PAI 805 9748 SEAT BELT AND AIR BAG BENEFIT RIDER This Rider is attached to and made part of the Policy as of the Policy Effective Date shown in the Policy's Master Application. It applies only with respect to accidents that occur on or after that date. It is subject to all of the provisions, limitations and exclusions of the Policy except as they are specifically modified by this Rider. Seat Belt Benefit (Percentage of Principal Sum Amount). The Company will pay a benefit under this Rider when the Insured Person suffers accidental death such that an Accidental Death benefit is payable under the Policy and the accident causing death occurs while the Insured Person is operating, or riding as a passenger in, an Automobile and wearing a properly fastened, original, factory -installed seat belt. The amount payable under this Rider is the lesser of: (1) $10,000; or (2) 10% of the Insured Person's Principal Sum. Air Bag Benefit (Percentage of Principal Sum Amount). The Company will pay an additional benefit under this Rider if a Seat Belt Benefit is payable under this Rider and if the Insured Person is positioned in a seat protected by a properly functioning, original, factory -installed Supplemental Restraint System that inflates on impact. The additional amount payable under this Rider is the lesser of: (1) $5,000; or (2) 5% of the Insured Person's Principal Sum. Verification of the actual use of the seat belt, at the .time of the accident, and that the Supplemental Restraint System inflated properly upon impact must be a part of an official report of the accident or be certified, in writing, by the investigating officer(s). Automobile - as used in this Rider, means a self-propelled private passenger motor vehicle with four or more wheels which is of a type both designed and required to be licensed for use on the highways of any state or country. Automobile includes, but is not limited to, a sedan, station wagon, or jeep -type vehicle and, if not used primarily for occupational, professional or business purposes, a motor vehicle of the pickup, panel, van,. camper or motor home type. Automobile does not include a mobile home or any motor vehicle which is used in mass or public transit. Supplemental Restraint System - as used in this Rider, means an air bag which inflates for added protection to the head and chest areas. The President and Secretary of AIG Life Insurance Company witness this Rider: President - __ -1f _X_ Secretary C11687 CAP 0 A I G L I� Policyholder: City of Lubbock Policy Number: PAI 805 9748 AIG LIFE INSURANCE COMPANY 600 KING STREET WILMINGTON, DELAWARE 19801 (302) 594-2000 (Herein called the Company) TUITION BENEFIT RIDER This Rider is attached to and made part of the Policy as of the Policy Effective Date shown in the Policy's Master Application. It applies only with respect to accidents that occur on or after that date. It is subject to all of the provisions, limitations and exclusions of the Policy except as they are specifically modified by this Rider. Tuition Benefit. If an Insured suffers accidental death such that an Accidental Death benefit is payable under the Policy, and the Insured had Family Coverage in effect under the Policy on the date of the accident causing death, the Company will pay the following benefit: A. For the Insured Dependent Children under Age 25. The Company will pay a benefit to or on behalf of any Insured Dependent Child under age 25 who was insured under the Policy on the date of the accident causing death and who, on the date of the Insured's death: (1) is a full-time student in any Institution of Higher Learning above grade 12; or (2) is in grade 12 and subsequently enrolls as a full-time student in an Institution of Higher Learning within 365 days after the date of the Insured's death. The benefit will be paid for each year of the Insured Dependent Child's continuous enrollment as a full-time student in an Institution of Higher Learning, to a maximum of four (4) consecutive years. The total amount of the benefit each year is equal to the least of. 1. the actual tuition (exclusive of room and board) charged by that institution for enrollment during that year for that Insured Dependent Child; 2. 5% of the Insured's Principal Sum on the date of the accident causing death; or 3. $5,000. The applicable portion of the yearly benefit for each term of enrollment is payable upon receipt of proof of enrollment for that term. An Insured Dependent Child who ceases to be enrolled as a full-time student becomes permanently ineligible for the benefit, even if he or she reenrolis at a later date. The benefit is not payable for any term of enrollment as a full-time student that begins before the date of the Insured's death B. For the Insured Spouse. The Company will pay a benefit to or on behalf of any Insured Spouse who was insured under the Policy on the date of the accident causing death and who, for the purpose of obtaining an independent source of support or to enrich his or her ability to earn a living: (1) is enrolled in any Institution of Higher Learning or professional or trade training program on the date of the Insured's death; or (2) subsequently enrolls in an Institution of Higher Learning or professional or trade training program within 30 months after the date of the Insured's death. The benefit will be paid for each year of the Insured Spouse's continuous enrollment in an Institution of Higher Learning or professional or trade training program, to a maximum of four (4) consecutive years. The total amount of the benefit for all institutions and programs combined each year is equal to the least of: C11688 CAP C' LM T'`f a � � � � • 1. the total actual tuition (exclusive of room and board) charged by those institutions or programs for enrollment during that year for the Insured Spouse;. 2. 5% of the Insured's Principal Sum on the date of the accident causing death; or 3. $5,000. The applicable portion of the yearly benefit for each term of enrollment is payable upon receipt of proof of enrollment for that term. An Insured Spouse who ceases to be enrolled as described above becomes permanently ineligible for the benefit, even if he or she reenrolls at a later date. The benefit is not payable for any term of enrollment that begins before the date of the Insured's death. Institution of Higher Learning - as used in this Rider, means any accredited institution that provides education or training beyond the 12th grade level, including, but not limited to, any state university, private college, or trade school. The President and Secretary of AIG Life Insurance Company witness this Rider: President Secretary C11688 CAP 0 GMMi AIG LIFE li iSUR.42YCE CONfPArY LNIpORTANT NOTICE AVISO 1IMPORTANTE To obtain information or make.a complaint: Para obtener information o para someter una queja: You may call AIG Life Insurance Company's toll -free number for information or to make a complaint at: 1-800-553-6938 You may contact the Texas Department of Insurance to obtain information on companies, coverages, rights or complaints at: 1-800-252-3439 You tray write the Texas Department oflnsurance: P. O. Box 149104 Austin, TX 78714-9104 Fax #(512)475-1771 PREINUUM OR CLAW DISPUTES: Should you have a dispute concerning your premium or about a claim you should contact the Company first. If the dispute is not resolved, you may contact the Texas Department of Insurance. ATTACH THIS NOTICE TO YOUR POLICY: This notice is for information only and does` not i ea me a pan or condition- of the attached document. 53593(AIG) listed puede llamar al numero de telefono gratis de AIG Life Insurance Company pars information o para someter una queja al: 1-800-553-6938 Puede comunicarse con el Departamenco de Seguros de Texas pars obtener information acerca de companies, cobetturas, derechos o quejas al: 1-800-252-3439 Puede escribir al Departamento de Seguros de Texas: P. O. Box 149104 Austin, TX 78714-9104 Fax !#(512) 475-1771 DISPUTAS SOME PRItii IAS O RECLAMOS: Si tiene una disputa concerniente a su prima o a un reclamo, debe comunicarse con la compania primero. Si no se resuelve la disputa, puede entonces comunicarse con el departamento(TDI). UNA ESTE AVISO A SU POLIZA Este aviso es solo pars proposito de information y no se convierte en parte o condition del documento adjunto. (1195