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HomeMy WebLinkAboutResolution - 5711 - Addendum To Agreement - Canada Life Assurance Company - LT Disability Insurance - 11_20_1997RESOLUTION NO. 5711 Item #21 November 20, 1997 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 an Addendum to an Agreement by and between the City of Lubbock and Canada Life Assurance Company dated October 19, 1995 and all related documents. Said Agreement is attached hereto and incorporated in this Resolution as if fully set forth herein and shall be included in the minutes of the Council. Passed by the City Council this 20th day of November , 1997. WINDY SITT , MAYOR ATTEST: Ka 'e amell, City Secretary APPROVED AS TO CONTENT: Mary Andre s, Director of Human Resources APPROVED AS TO FORM: Amy s, si nt City Attorney ALSAWCANLIFE.RES ccdocs/November 13, 1997 RESOLUTION NO. 5711 Item #21 November 20, 1997 ADDENDUM TO THE AGREEMENT BY AND BETWEEN THE CITY OF LUBBOCK AND THE CANADA LIFE ASSURANCE COMPANY THIS ADDENDUM entered into this 20th day of November , 1997 by and between the CITY OF LUBBOCK, (hereinafter called the "Company") and Canada Life (hereinafter called "Administrator") to extend their agreement and include administration services for the purpose of the Short Term Disability Income Replacement Plan. WHEREAS, the Company and the Administrator have previously entered into an agreement dated October 19, 1995 for Long Term Disability Insurance (hereinafter called the "Agreement"), which is attached hereto as Exhibit "A"; and WHEREAS, the Company and the Administrator desire to extend the Agreement for a term of one (1) year; and WHEREAS the company is authorized to enter into this Agreement for the purpose of delegating certain of its authorities, rights and duties to an administrator for the purpose of extending the Agreement and adding the Short Term Income Replacement Plan; and WHEREAS the company desires the Administrator to administer weekly indemnity claims in accordance with the Short Term Income Replacement Plan (hereinafter called the "Plan") and the Administrator is willing to do so pursuant to the terms of this Agreement. (A copy of the provisions of the Plan are attached hereto as Exhibit "B".) NOW, THEREFORE THIS AGREEMENT WITNESSETH that in consideration of the premises and of the mutual obligations and agreements herein set forth, The Company and the Administrator agree as follows: 1. The Agreement executed between on the parties the 19th day of October, 1995 shall in all things remain in full force and effect in accordance with its terms, save and except the amendments heretofore set forth. Which amendments shall supersede the original Contract entered into between the parties and be effective for the balance of the term of said agreement. 2. The Agreement is hereby extended for a term of one (1) year to end November 31, 1998. 3. The Company hereby appoints the Administrator to carry out services for the purpose of the Plan and the Administrator hereby accepts such appointment. The duties and the responsibilities of the Administrator shall be limited to carrying out the terms of this Agreement and directions of the Company in furtherance thereof. 4. The Company hereby authorizes and directs the Administrator and the Administrator agrees to provide services related to the Plan as follows: 4 a. to pay benefits in accordance with the Plan as amended from time to time. The City of Lubbock will be responsible for paying benefits for the first 30 days of a claim. After 30 days, Canada Life will pay benefits in accordance with the Plan. b. to provide the Company with the necessary type and number of forms as might be requested by the Company in the continued efficient operation of the Administrator's duties. C. to receive and review notices of claim from members eligible to benefits under the Plan, to make appropriate claims investigations and to advise the Company with respect to payment of benefits. d. to maintain accurate and detailed records of all members who have received or who are in receipt of benefit payments which records shall be open at all reasonable times to inspection and audit by any person or persons designated in writing by the Company. e. to pay benefits when authorized to do so by the Company. f. to discuss claims with providers of hospital and medical services where appropriate. g. to maintain accurate and detailed accounts for receipts and disbursements and other transactions within the control of the Administrator, and all accounts, books and records relating thereto shall be open at all reasonable times to inspection and audit by any person or persons designated in writing by the Company. h. to provide annual reports and actuarial opinion to the Company at such intervals as the Company may direct regarding the financial experience under the Plan. Additional reports may be provided at a cost to be determined by the Administrator. i. to advise the Company with respect to the administration and operation of the Plan. j. to attend meetings with the Company as and when the Company may direct at a mutually convenient time and place. k. to provide suitably qualified staff to assist in the co-ordination of all services provided by the Administrator in the resolution of any problems relating to such activities. 1. to deduct from benefit payments taxes as directed by the Company or members as maybe required by law, to provide documentary evidence thereof to the member, and to remit taxes deducted to the appropriate authority. 5. Any premium or tax assessed against the Administrator in respect of the Plan shall be borne by the Company. 6. The Administrator in performing its administrative obligations under this Agreement with respect to third parties, including representatives of the employees and offices of the Company, is acting as a servicing agent of the Company and the rights and responsibilities of the parties shall be determined in accordance with the law of agency except as otherwise herein provided. 7. Claims payments under the Plan shall be made in accordance with the Plan, provided, however, that the Company may authorize and direct the Administrator to pay or deny a claim contrary to the usual interpretation applied by the Administrator. The Company shall assume full and sole responsibility for any claim, demand, or lawsuit brought against the Administrator as a result of payment or denial of a claim pursuant to such authorization or direction by the Company. 8. The Administrator shall take reasonable steps to recover either an overpayment or a payment of benefits for an ineligible person under the Plan; however, any legal action including court proceedings shall be initiated and paid for by the Company. 9. The Administrator shall not be responsible for any claim, demand or lawsuit brought against the Administrator for any loss which is the result of negligence or willful misconduct by the Company. The Company shall not be responsible for any claim, demand or lawsuit brought against the Company for any loss which is the result of negligence or willful misconduct by the Administrator. 10. The Administrator shall use ordinary care and reasonable diligence in the exercise of its powers and the performance of its duties as Administrator and shall retain liability for any willful misappropriation or conversion and for negligence or wilful misconduct on the part of any employees, directors, managers, successors, assigns, owners, partners, members, independent contractors, or agents of the Administrator. 11. The services to be performed by the Administrator under this Agreement, upon approval of the Company, may be performed directly by it wholly or in part through a subsidiary or affiliate of the Administrator or under a contract with any organization of its choosing. 12. Notices or communications from the Company to the Administrator shall be addressed to the Administrator and shall be deemed to be duly given or served, if the same shall be sent by post office 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 Canada Life Assurance Company 6201 Powers Ferry Road Atlanta, GA 30339 Notices or communications from the Administrator 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 post office 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 Notices and communications described in this paragraph that are sent by post office mail will be deemed to be duly given or served on the third business day following the date the notice is mailed. 13. This contract shall be construed and enforced according to the laws of the State of Texas. 14. The Company may terminate the services of the Administrator at any time upon giving to the Administrator 60 days written notice of its intention to do so. The Administrator may resign at any time upon 60 days notice in writing to the Company. The Administrator 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. 15. The Company shall pay fees to the Administrator in accordance with Exhibit "C", which may be amended from time to time as agreed to by the Company and the Administrator. SIGNED THIS DAY, the Of NnxPmher )1997. CITY OF LUBBOCK: CANADA LIFE ASSURANCE COMPANY: WINDY SITTO MAYOR By: A ST: TITLE Kathicf arnell, City Secretary APPROVED AS TO ONTENT: Mary AndreWs, Managing Director of Human Resources APPROVED AS TO FORM: re 50;vnp Amy L/$Tis, Assistant City Akforney a A CANADA LIFE Now OUR STRENGTH SECURES YOUR FuTuRE EXHIBIT "A" City of Lubbock, Texas (Legal name of policy holder) requests that The Canada Life Assurance Company issue a plan of group insurance benefits specified as follows: Group Insurance benefits(s) being requested and percentage of premium the employer pays: "'Ai, % ❑ AD&D % ❑ Optional Term Life Weekly Indemnity Spousal Optional Term Life Long Term Disability 10-0 U Dependent Term Life Dental Fo '10L1Ot A TM J �x 1VM11 The insurance will become, effective an the Effective Date shown in this Request for Insurance j C al na -C, '6f that. led 8�401 to 1) Approval of the Request for Insurance in writing by Head Office of The Canada Life Assurance Co. 2) Adequate erimllment. iNkitit Dite ­12.01 a1m lodd time - on Navenber,4-r19 M Date." 01 a.rn-local time -fiovembe& 44Z�� on n 97 Sa� Opt I ot YIli in, �-A' wJ he.. ir J� J, P.n iolb APovEa.1�r. T CK kk k" 'iei1 URAI APPROVED] AS TO FORM qix ir r fo JJ Title: City Secretary V Rary-An drews,,,maniag ing Director n R7 4EF Urces Id G. Vandiver, Assistan TYPE OF ADMIIVISTRATION: [ ] Canada Life 44 Self Administered ADMINISTRATIVE DETAE S Payment of Premiums will be: [ ] monthly in advance [ ] other 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 [ ] Municipality [ ] Other: (Describe) Nature of business: Are any employees covered by this policy subject to a Collective Bargaining Agreement? [ ] Yes Q(] No The Canada Life Assurance Co. Page No. 2 3 ADMIIKISTRATIVE DETAILS (Continued) Participation and Contribution Information: Number Number Employee Contributions eligible Participating If Yes. Indicate amount or % Basic Life Optional Life Spousal Opt. Life Dependent Life AD&D WI LTD Dental [ ] No [ ] Yes ?b [ ] No [ ] Yes qb [ ] No [ ] Yes % [ ] No [ ] Yes [ ] No (] Yes [ ] No [ ] Yes qb [ ] No [ ] Yes % Employee [ ] No [ ] Yes % Dependent [ ] No [ ] Yes % Policyholder Address: City of Lubbock 1625 13th St. Lubbock, TX 79401 Contact person: Lou Lyn Moore 11tle: ]BENEFITS COORDINATOR Phone Number. 806-767-2317 Your Employer Identification Number: 75-6000590 Fax Number: 806-763-1461 Your ERISA plan number: Plan Year. Name, Address and Phone number of the Plan Administrator. MARY ANDREWS P.O. BOX 2000 LUBBOCK, TX 79457 (806) 767-2315 Agent of service of Legal Process for the Policyholder. The Canada Life Assurance Co. Page No. 3 M A.DNIMSTRATIVE DETAIM (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? [ ] Yes ki 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 11 No If yes, please provide details: Affiiated Associated or Subsidiary Companies: Are there any Affiliated or Subsidiary Companies being covered under this policy? [ ] Yes kj 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 [ ] Other: The Canada Life Assurance Co. Page No. 4 ADMINISTRATIVE DETAILS (Continued) Issue Mailing Instructions: Group Office lien! Initial billing: X Policy: X Booklet Certificates: X Plan Outline: X Administrative Mailing Instructions: Same Address smetal Claims: Billing: 7— Correspondence: T_ Special: Duplicate Statements produced: [ ] Yes jli No 2 sets at renewal only: [ ] Yes JA No -Extra copies sent to: (CC) Broker Register cards to employer: [ ] one [ ] two JA None Name of the initial Underwriter: �r4�' -31--- Group Representatives Signature: Dated The Canada Life Assurance Co. Page No. 5 LONG TERM DISABILITY SALES SPECIFICATIONS Eligible Employees: )M All full time employees working: 9130 hours [ ] hours/week. [ ] other: Waiting Period: Employees employed on the effective date: [ ] 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. [) other: 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 (] other: Annual Reconciliation Termination of Insurance: - Termination of insurance will take effect on JX] date of termination or [ ) at the end of the policy month. Salary Related Benefits - Definition of earnings: [ ] Cross 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: The Canada Life Assurance Co. Page No. 15 N LONG TERM DISABILITY (Continued) The amount of monthly benefit for each employee shall be 60 % of each employee's monthly rate of earnings to a maximum of $ D 9010 per month rounded to the next higher $1.00. Elimination Period: [ ] 90 days )j 180 days (] other days Employee Buy -Down to 90 days Elimination Period Maximum Benefit Period: 1� Age Graded ADEA i.e. (Standard) Age at Date Disability Commences Under 60 60 61 62 63 64 65 66 67 68 69 or over [ ] ADEA 5 year extension (6515/70 Benefit Duration): Age at Date Disability Commences Less than 60 60 - 64 65-69 70 and older [ ] To age 70: aximum Benefit Period to age 65 (a minimum of 60 monthly benefit payments will be made). 60 benefit payments 48 benefit payments 42 benefit payments 36 benefit payments 30 benefit payments 24 benefit payments 21 benefit payments 18 benefit payments 15 benefit payments 12 benefit payments um Benefit Period To age 65, but not less than 5 years 5 years To age 70, but not less than 1 year 1 year This option provides a benefit to age 70 regardless of age at disability; if disabled at age 70 or greater, the claimant will be entitled to a benefit duration of up to 12 months. []5year: This option provides that benefits will be paid for 5 years or to age 70, which ever comes first. If disability occurs at age 69 or older, benefits will be payable for up to 12 months. [ ] Other The Canada Life Assurance Co. Page No. 16 LONG TERM DISABELI TY (Continued) Survivor Benefit: 3 months (standard) [ ] other: months Offsets: [ ] Standard - Direct offset with [ ] Primary or *] Full Family [ ] Back door - Direct on primary and 70% on other benefits [ l All sources - 70% on all benefits FICA 'TAXES: Are employees subject to FICA tax? [ ] Yes [ ] No If No, explain: Minimum Benefit: [ ] $50 (.standard) [ ] $50 or 10 % [ ] other [1$100 [ ] $100 or 10% Own Occ: Indexing of Pre -Disability Earnings: ] 24 months [ ] Partial Residual [ ] lesser of 3 % or CPI (Standard) [ ] 36 months [ ] Partial [ ] Residual )M Option J_% (Tied to CPI) [ ] Own Occ to 65 [ ] Partial [ J Residual Increases to take effect on [ ] January 1st [ ] Anniversary date [ ] other: Mental & Nervous Limitation: Drug & Alcohol Limitation: �( 24 month limitation (standard) [ ] 24 month limitation (standard) [ l As any other illness XQ As any other illness Cola Type: Pre-existing Condition Exdudow [ ] Not applicable 13 3/12 (standard) [ ] Indexing after 5 years % [ ] 5/30 [ ] Indexing after 1 year % [ ] 6/12t24 [ ] Indexing for 5 years % [ ] Waived Increases to take effect on [ ] January 1st [ ] Anniversary date [ ] 5 day actively at work The Canada Life Assurance Co. page No. 17 LONG TERM DISABILITY (Continued) Options: N/A [ ] Rehire Provision: [ ] 6 months [ ] 12 months [ ] Retirement Contribution N/A % Maximum [ ] Medical Premium Supplement Coverage option s N/A The Canada Life Assurance Co. Page No. 18 STANDARD PROVISIONS Contract The whole contract is made up of: 1. This policy. 2. Any amendments to this policy. 3. 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. 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. 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. GD600-241 Notice of Claim Written notice of a claim must be given to us within thirty days of the date disability begins. 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 number. Claims 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 fifteen days after written notice of claim is sent, the claimant can send us written proof of claim without waiting for the claim forms. ?he Canada Ufe Assurance Company Page 35 Dated August 1st, 1995. I Proof of Loss Proof of loss must be given to us no later than ninety days after the end of the elimination period. If it 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 thirty 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 will be paid monthly 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 at that time. GD600-242 Payment of Claims All benefits will be payable to the person who is insured. 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 person fails 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 sixty 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. GD600-243 The Canada Life Assurance Company Page 36 Dated August 1st, 1995. 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 be 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. If a person who is insured 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 reduced 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 this policy is amended during a person's continuous period of disability, the amendment will have no effect on the amount of his insurance during that same continuous period of disability. The Canada Life Assurance Company Page 37 Dated August 1st, 1995. 1W TERM NATION 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 noticeat 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 31 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. GD600-245 The Canada Life Assurance Company Page 38 Dated August 1st, 1995. SELF -ADMINISTRATION 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. 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. GD600-249 Me Canada Life Assurance ConVany Page 39 Dated August 1st, 1995. •,F.,: .:5�: . 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F.....? ... ..=,€fir �,y yr . :;•yf:. :. :i•: �:•,':??:;}:: G##::?: }a5::.:}::::}:?::Tx<s..::,42.:4;T:.:a}s:a•:}:F.•x•,:ae4%.^}�i:.F:Ssjxk�}tt�}LY,{}}:a`.4r.-.S!as�`:'�fNf.'.{/.i�.JtX•.enee.€ranc.:.::.}.`.}t%.zaa:6i:.}T::G�a}}:k.i:#.:551;:2:�:t}::2}}i'F.,•}:}>1.irY.$:}::}xe!•.}.r'd26:axv:::`'rc:£xYw;rsa:2.}}.�'?.e'v:z:{:T::<.:»{.: No. H. DRAFT We, The Can da Life Assurance Company, agree to pay the benefits that become payable under this policy to the person pr persons entitled. This agreeme� is subject to the provisions on the attached pages which, together with this page, make up the policy. This policy wol take effect on August 1st, 1995. Policy Holder - CITY OF LUBBOCK Issued at our Mead Office at Atlanta, Georgia, as of August 1st, 1995. NOT VALID - DRAFT ONLY Assistant Registrar GROUP LONG TERM DISABILITY INCOME POLICY Not eligible for dividends WARNING This is a legal contract betwe6n the Policy Holder and The Canada Life Assurance Company READ YOUR POLICY CAREFULLY fa%}g.;;{rF?:.;Mc,,t..:::bi'bi/ff.Jf.S3`:'�.:;•c;•: {:rr.;:;srr: `::. .: .d. $:Cm:^}„•?TY•'.: ::c+..,;:. ..rr;•.:}r,.x;:::. :t:{•t;:;`{:.r•.+.^m^., ^:'Jr?.rr:Y}C!::: rS: o+RXF:f!•cR:R: .<•:rXx.•:rriJz>.;;4::;::tt•rr: {rr. f . .�:• %.+... r:. .. }`#:.•.}•.:.: •:4u€A' �; .. ..� ...,�. ; .:..T; ,. 'E':;rF.a?:'?;�e} • :•}{}: 23• • 3.. : r:.:,.. r...:.....ti'�'F..�`^fi;:::?. �.: ,.?•:::. �.:•.:•. Jr.6.:. ::.?•+•{:4$' f •:4••':'}�%•. ; ..,•?.• : •.v::•:. .. !. r.:..� ...� I.: •{:.,+;::,>.•}::: ry.W .i•:::..,•::.v .Y.. .. €..: ...t .. 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'•:y:•}}r:.v: r: S:'.ti ?Y�i}`:f:{}:S ti{:' n4.<.v..wfkfM}b+r. {,},4$, vJ/.2.}.,G4r::.Wk:4kQd.J1}.41naL.f¢:Lnr?iGn.:�+ik..v �l,fY.rr.}.-�'4{.u:.aia,::.�k.2tA24.{v:�wl +:.,224.2..4. w� �v1'%�$i3L4N..: w4.:•.2•fUn}•Si{' C�C;}q:l Lam' •f,4%AOCi2.>k:al'4:.{w:+:4Y �v f:'Y :] THE CANADA LIFE ASSURANCE COMPANY U.S. EMAD OFFICE: 6201 POWERS FERRY RD., NW, ATLANTA, GA 30339 6Fs/.:f: � .)}:T? r%�:"J,.9Ji::f;'f�' .rf/. i'fi:{ }QL'1i}: ti. 9' ..w'+ Cr :gX•:4Y :•Y. r . §f. .. '. .. ... %.. ... :.. '�S•J.{Uf-. f.3 r.t::Y : f:4::}:f.^•.?::%??}>if.+:fi5:4:{.i4.%:SSFJ{.':a{::?ic:Ffl.:::......rrr.,'•':i...ff?Y7f:,F::FY:.•:a :;x •{r. ..�,.:px<. ., . r:. . !%yf : ...::fi:;. ...y, .f3....... ...:i . }; �, :k,;•:j 4: .4 :::4.,.,.?r.:i?}S:R}S«;�;T:o:S{:#:?:}f<:'•?'t::'2:}Y;S;•.'• • � •: . n ..4.. �:s?:?4r::.: ... t.a:�:.::..T::. . �::::.:}:::+::�••:.. "�!z`.ss}:x:.}:<.f::T:�:i:.:. iT, t. : 77}}':' +F%Y:{ R•9:.. ... Y..... iv, .: : .�.. f::+?+v . .iv. . .SC + .. f{^:{. ; •f•;:`}:'.,i;i4i+.: .':Si4:.:. .}:f<€f:};+ ,•,, .T„?.•:�•:G .� a. r ��44f F. •:• ?:: •}.. ,J ......t.n... f.::. � .0 . .. t..} :.}:•: •+T'::f:s......,.4,:::::::::: {:.::i `H�.9.:7i�:?nft :}:a.}•{.:.:;:: y:.r •::.,. �r? :.,c {.:. •F.:?..{.,;: •..•::•:>'{•; };r•: :• •..i.•Y:::.J .::•`'•:. :..4.:::.. .,.i'.�ifi. ft �x:.k.r..u.....26.<-,........ %G:}:r.;,•,c •.y::. U :.. :.,::. .• p •:{t{; :'': ... ..: y.....•...,.:.,i%{+.:f.,4-.:!t.%.:<}.%::C:{4:<. .:d. +4:4:?.:{41f2}2•k::{. , � .f ....: ..n. .: .;....;.,:.,:..0.,:..4.+...2...4Y:•:{•.;},.�.,..{.k�`:.}.,C..lr:}:r,.:.,:..:2,.:<.!y::.::L:};.:.:}irJ{:i': {: i.::::::N .v::: •<.: .:<r:.: The Canada Life Assurance Company Page 1 Dated August 1st, 1995. TABLE OF CONTENTS Name of Provision Page Number IMPORTANT NOTICE ........... 4 AVISOIMPORTANTE .............................................. 4 DEFINITIONS................................................... 5 WHO MAY BECOME INSURED ....................................... 10 HOW AND WHEN INSURANCE TAKES EFFECT ............................ 11 AMOUNT OF INSURANCE ........................................... 12 DISABILITY INCOME BENEFIT ....................................... 14 WHEN DISABILITY INCOME BENEFITS CEASE ............................ 15 WAIVER OF PREMIUM ............................................. 16 RETURN TO WORK ............................................... 17 SURVIVOR BENEFIT .............................................. 18 REDUCTIONS ................................................... 19 FREEZE ON REDUCTIONS .......................................... 21 RIGHT OF RECOVERY ............................................. 22 LIMITATIONS................................................... 23 LIMITATION ON BENEFITS FOR MENTAL DISORDER ....................... 24 LIMITATION ON BENEFITS FOR ALCOHOLISM AND/OR DRUG ADDICTION ....... 25 EXCLUSIONS ............................... ........... ...... 26 PRE-EXISTING CONDITION EXCLUSION ................................ 27 CONTINUITY OF COVERAGE UPON CHANGE OF INSURERS .................. 28 WHEN A PERSON'S INSURANCE TERMINATES ............................ 30 PREMIUMS..................................................... 31 The Canada Life Assurance Company Page 2 Dated August 1st, 1995. a TABLE OF CONTENTS Name of Provision Page Number PERIOD OF GRACE 33 CURRENCY..................................................... 33 PLACE OF PAYMENT ................... ............ ........... 33 NOT ELIGIBLE FOR DIVIDENDS .. .. ............................... 33 WORKERS' COMPENSATION NOT AFFECTED ...... ...................... 33 CLERICAL ERROR ........................................... ... 33 BOOKLET -CERTIFICATE ............................................ 34 STANDARD PROVISIONS ........................................... 35 AMENDMENTS TO THE POLICY ...................................... 37 TERMINATION OF POLICY .......................................... 38 SELF -ADMINISTRATION ............................................ 39 C011-101 The Canada Life Assurance Company Page 3 10 Dated August 1st, 1995. a IMPORTANT NOTICE To obtain information or make a complaint:. 1. You may call The Canada Life Assurance Company's toll -free telephone number for information or to make a complaint at 1-800-554-4026 2. You may contact the Texas Department of Insurance to obtain information on companies, coverages, rights or complaints at: 1-800-252-3439 3. You may write the Texas Department of Insurance P.O. Box 149104 Austin, TX 78714-9104 FAX # (512) 475-1771 4. PREMIUM OR CLAIM DISPUTES: Should' you have a dispute concerning your premium or about a claim you should contact the company The Canada Life Assurance Company first. If the dispute is not resolved, you may contact the Texas Department of Insurance. 5. ATTACH THIS NOTICE TO YOUR AVISO IMPORTANTE Para obtener information o para someter una queja: 1. Usted puede llamar al numero de telefono gratis de Canada Life Assurance Company's para informacion o para someter una queja al 1-800-554-4026 2. Puede comunicarse con el Departamento de Seguros de Texas para obtener information acerca de companies, coberturas, derechos o quejas al 1-800-252-3439 3. Puede escribir al Departamento de Seguros de Texas P.O. Box 149104 Austin, TX 78714-9104 FAX # (512) 475-1771 4. DISPUTAS SOBRE PRIMAS O RECLAMOS: Si tiene una disputa concerniente a su prima o a un reclamo, debe comunicarse con la compania. The Canada Life Assurance Company primero. Si no se resuelve la disputa puede entonces comunicarse con el departamento (TDI). POLICY: 5. UNA ESTE AVISO A SU POLIZA: This notice is for information only and Este aviso es solo pars proposito de does not become a part or condition of information y no se convierte en parte o the attached document. condition del documento adjunto. The Canada Ufe Assurance Company Page 4 Dated August 1st, 1995. i DEFINITIONS All male terms will include the female term, unless stated otherwise. "You" and "your" mean the Policy Holder. "We", "our" and "us" mean The Canada Life 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 August 1st, 1995. "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. GD600-203 "Elimination period" is the period that the person must have actually been disabled during a continuous period of disability before he may receive payments under this policy. It will not include any period that is described in the Limitations provision. The elimination period under this policy is 180 days. ?he Canada Life Assurance Company Page 5 Dated August 1st, 1995. 11 "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 policy. 2. They are due to the same cause or causes. 3. The elimination period must be satisfied during a period of 198 consecutive days. 4. After the elimination period has been satisfied, they are separated by a period of six consecutive months or less during which the person was not disabled. However, if we cease to make payments to a person because he is no longer disabled and he becomes disabled again due to the same cause or causes within six months and after this policy has terminated, such disability will be considered by us to be part of the same continuous period of disability and we will pay benefits to him unless both of the following have occurred: 1. Replacement coverage has been obtained with another insurer. 2. There is legislation or regulation which stipulates that the new insurer should assume liability for such disability. "Retirement program" means a program which provides retirement benefits to employees and which is not funded wholly by employee contributions. The term will not include a profit-sharing plan, a thrift plan, an individual retirement account (IRA), a tax sheltered annuity (TSA), a stock ownership plan or a non -qualified plan of deferred compensation. GD600-204 "Mental disorder" means any psychiatric or emotional illness or disease. It includes each of the following. 1. Neurotic disorders such as but not limited to anxiety, dissociative disorders, phobias, depressions and obsessive compulsive disorders. 2. Psychotic disorders such' as but not limited to schizophrenia, paranoid psychosis and affective disorders. 3. Personality disorders such as but not limited to sociopathic personality. "Pregnancy" includes childbirth or miscarriage and any disease or infirmity resulting from or aggravated by the pregnancy. It also includes therapeutic abortions or complications arising from any abortion. The Canada Life Assurance ConyxM Page 6 Dated August 1st, 1995. 9 "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. "Hospital" or "medical facility" means a facility licensed to provide full-time medical care and treatment under the direction of a full-time staff of licensed physicians. GD600-205 "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. UD8-2 "Monthly earnings" will be the annual earnings of the person divided by 12. UD8-3 "Indexed pre -disability monthly earnings" means the person's monthly earnings immediately prior to the date he became disabled, increased by a cost of living adjustment. The adjustment will be made starting on the 13th benefit payment and on each anniversary of that date. The amount of each adjustment will be the lesser of 3 % or the percentage increase in the Consumer Price Index. UDX-2 The Canada Life Assurance Company Page 7 Dated August 1st, 1995. Standard Definition of Disability - excluding aircraft crew "Disabled" and "disability" mean that, due to injury, disease, illness, pregnancy or mental disorder, the person is either totally disabled or partially disabled. The loss of a professional or occupational license does not, in itself, constitute disability. "Totally disabled" means that the person is unable to work and fulfills either of the two conditions below: Condition 1 - During the elimination period and for the next 24 months after the elimination period in a continuous period of disability, the person is unable to perform the substantial and material duties of his own occupation, or Condition 2 - After the elimination period plus the next 24 months in a continuous period of disability, the person is unable to perform the substantial and material duties of any occupation for which he is qualified in view of his age, education, experience, and physical and mental capacity. "Partially disabled" means that the person fulfills all of the three conditions below: Condition 1 - The person was totally disabled for the entire elimination period, and Condition 2 - The person is unable to perform with reasonable continuity the substantial and material duties of: a. his own occupation, for the first 24 months after the elimination period in a continuous period of disability, or b. any occupation for which he is qualified in view -of his age, education, experience, and physical and mental capacity, after the elimination period plus the: next 24 months in a continuous period disability, and Condition 3 - The person becomes employed and is unable to earn more than 80% of his indexed pre -disability monthly earnings. UD9-5 ?he Canada Life Assurance Company Page 8 Dated August 1st, 1995. Definition of Disability - aircraft crew only For any person employed as a pilot, co-pilot or crew member of any aircraft, the following definitions of disabled, disability, totally disabled, and partially disabled apply: "Disabled" and "disability" mean that, due to injury, disease, illness, pregnancy or mental disorder, the person is either totally disabled or partially disabled. The loss of a pilot's license or any other professional or occupational license does not, in itself, constitute disability. "Totally disabled" means that the person is unable to work and is unable to perform the substantial and material duties of any occupation for which he is qualified in view of his age, education, experience, and physical and mental capacity. "Partially disabled" means that the person fulfills all of the three conditions below: Condition 1 - The person was totally disabled for the entire elimination period, and Condition 2 - The person is unable to perform with reasonable continuity the substantial and material duties of any occupation for which he is qualified in view of his age, education, experience, and mental and physical capacity, and Condition 3 - The person becomes employed and is unable to earn more than 80% of his indexed pre -disability monthly earnings. UD9 10 GD600-206 ?he Canada Life Assurance Company Page 9 Dated August 1st, 1995. 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 XX hours per week on a regular basis as employees provided they are legal residents of the U.S. or Canada. Each person who is a member of such a class on the Effective Date or who becomes a member of such a class after the Effective Date may become insured on the earliest date on which he is a member of such a class. GD600-207 The Canada Life Assurance Company Page 10 Dated August 1st, 1995. HOW AND WHEN INSURANCE TAKES 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. 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. GD600-208 The Canada Life Assurance Company Page 11 Dated August 1 st, 1995. 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 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 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 continuous period of disability began. 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. No change will be made in the amount of insurance of a person during any one continuous period of disability. The amount of insurance shown in this provision will be'subject to reductions as outlined in the Reductions provision. GD600-210 ?he Canada Life Assurance Company Page 12 61 Darted August 1st, 1995. SCHEDULE CLASS MONTHLY BENEFIT 1. All eligible employees XX % of monthly earnings (rounded to the next higher $1.00 of benefit) to a maximum benefit of $X,XXX. GD600-211 The Canada Life Assurance Company Page 13 Dated August 1st, 1995. DISABILITY INCOME BENEFIT We will pay to a person who begins a continuous period of disability, the amount of insurance which applies to him under this policy at the date the period began. Our payment will be subject to all of the following conditions. 1. He is insured under this policy when the continuous period of disability begins. 2. Payments will be made for that part of a continuous period of disability that commences on the later of the following dates. a. . The date on which he has completed the elimination period. b. The date on which initial proof that the person is disabled is given to us at our Head Office. The proof must be given to us within 90 days after he has completed the elimination period. The proof must be satisfactory to us. 3. The payments will be made to him at the end of each month. 4. The amount of insurance which applies to him under this policy will be subject to reductions. These are outlined in the Reductions provision. 5. If the period during which a person is entitled to receive benefits under this policy is not a complete number of months, we will make a partial payment for that period that is not a complete month. The partial payment will be calculated as one -thirtieth of his monthly benefit for each day of the period that is not a complete month. The monthly payment with respect to a person under this policy will not be less than $0, except as described in the Return to Work provision. UB27-1 GD600-333 Tice Canada Life Assurance Company Page 14 Dated August 1st, 1995. n WHEN DISABILITY INCOME BENEFITS CEASE The payments to a person will continue during the continuous period of disability until the earliest time shown below. 1. The date on which he ceases to be disabled as defined in this policy. The person will cease to be insured under this policy at that time if he does not then return to active work for you. 2. The date of his death. 3. The end of the maximum benefit payment period that is shown in the following Table. TABLE Age at Date Disability Commences Under 60 60 61 62 63 64 65 66 67 68 69 or over GD600-213 The Canada Life Assurance Company Page 15 aximum Benefit Period to age 65 (a minimum of 60 monthly benefit payments will be made). 60 benefit payments 48 benefit payments 42 benefit payments 36 benefit payments 30 benefit payments 24 benefit payments 21 benefit payments 18 benefit payments 15 benefit payments 12 benefit payments Dated August 1st, 1995. WAIVER OF PREMIUM We will waive the payment of each premium falling due under this policy with respect to a person while he is actually disabled during a continuous period of disability, subject to both of the following conditions: He has completed the elimination period. 2. His claim has been admitted by us. GD600-216 The Canada Life Assurance Company Page 16 V Dated August 1st, 1995. a RETURN TO WORK If a disabled person returns to work, we will pay benefits under this policy provided he remains disabled under the terms of this policy and has satisfied the elimination period. The amount of the benefit otherwise payable under this policy will be reduced as described in the Reductions provision of this policy. Income from employment will be treated as follows for the purposes of the Reductions provision: 1. During the first 12 months of a return to work, income he is receiving from any employment will not be included as a source of income under the Reductions provision. 2. During the next 12 months, 25 % of the gross monthly income he is receiving from any employment will be included as a source of income under the Reductions provision. 3. For any additional period, 50% of the gross monthly income he is receiving from any employment will be included as a source of income under the Reductions provision. However, if at any time, the total of: the monthly benefit he is receiving from this policy, 2. the sources described in the Reductions provision of this policy, other than income from employment, and 3. any earnings from employment, exceeds 100% of his indexed pre -disability monthly earnings, then the benefit under this policy will be further reduced. We will reduce his monthly benefit so that his total monthly income from all such sources does not exceed 100% of his indexed pre -disability monthly earnings. We will stop making benefit payments to him on the earlier of the following dates: 1. The date on which he would otherwise cease to be disabled as defined in this policy. 2. The date on which he would otherwise cease to receive benefits under this policy. GD600-329 The Canada Life Assurance Company Page 17 l Dated August 1st, 1995. SURVIVOR BENEFIT Definition As used in this provision: "eligible survivor" means: 1. The spouse of a person, if living at the date of his death. 2. If the spouse has died prior to the date of death of the person, the children of the person provided they are under age 25. Benefit If a person who is disabled in accordance with the terms of this policy dies, we will make one lump sum payment to his eligible survivor. The payment will be made provided that both of the following conditions have been met: 1. The person had completed a continuous period of disability of 180 days or the elimination period, whichever is greater. 2. The person had been receiving or was entitled to receive payments under this policy immediately prior to his death. The payment to be made to the eligible survivor will be 3 times the full monthly benefit the person received prior to his death or would have been entitled to receive if his death had not occurred. This will not include any reduction made to the monthly benefit in accordance with the other terms of policy. If the payment becomes due to the children of a person, we will make the payment to the children or to an individual legally entitled to receive payment on behalf of the children. GD600-330 The Canada Life Assurance Company Page 18 Dated August 1st, 1995. REDUCTIONS Benefits Due to Disability From Other Sources If a person is entitled to receive payments under this policy, the amount of the payments will automatically be reduced by the amount of any income the person earns or is entitled to apply for and receive with respect to his disability under any or more of: 1. Any retirement program that is funded in whole or in part by you. 2. Your life insurance plan. 3. The Social Security Act, the Canada Pension Plan, the Quebec Pension Plan or any similar plan or act. This includes dependents benefits by reason of such disability. 4. The Railroad Retirement Act. This includes dependents benefits by reason of such disability. 5. Any Workers' Compensation Law. 6. Any No -Fault Motor Vehicle Coverage. This 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. 7. Any employee benefit, union or labor-management trustee plans that are funded in whole or in part by you. 8. Any program or coverage required or provided by law or any government agency. 9. Income from employment, as described in the Return to Work provision of this policy. Benefits Due to Retirement If a person is receiving payments under this policy, such payments will be further reduced by either one or both of: Any income the person is entitled to apply for and receive with respect to his retirement under the Social Security Act, the Railroad Retirement Act, the Canada Pension Plan or the Quebec Pension Plan. 2. Any income the person receives with respect to his retirement under any retirement program that is funded in whole or in part by you. GD600-309 The Canada Life Assurance Company Page 19 Dated August 1st, 1995. Conditions If a person receives a lump sum settlement for any of the benefits shown above, our payments under this policy will be reduced by the amount that he would normally receive if the payments were being made on a monthly basis. If, at the time of calculating the amount of any payments to be made under this policy, the benefit which a person is entitled 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 policy until such time as the benefit under such source has been awarded or denied. However, such estimate will not be used if, within six. months of becoming disabled, the person meets both the following conditions. 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 policy by an estimate of the amount of the benefit under another source, we will adjust the amount of the payments under this policy 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 lump sum refund of the amount by which we have underpaid the payments the person is entitled to under this policy. 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. GD600-310 The Canada Life Assurance Company Page 20 Dated August 1st, 1995. FREEZE ON REDUCTIONS We will not reduce the amount of payments under this policy due to cost of living increases in the payments a person receives from any of the sources described in the Reductions provision. This will not apply to any increase in earnings from any employment. GD600-226 Me Canada Life Assurance Company Page 21 Dated August 1st, 1995. a RIGHT OF RECOVERY A person will be required to reimburse us for any benefits we pay him if both of the following conditions are met. 1. Benefits are paid or payable under this policy with respect to him. 2. He has a right to and does recover damages from any person, organization, or legal entity that is or may be liable for any injury, accident, illness or other event giving rise directly, or indirectly, to the disability for which benefits are payable. The term damages will include any lump sum or periodic payments with respect to past, present or future loss of income. A person will reimburse us in the amount of any benefits we have paid out of the damages recovered, which damages, when added to the benefits paid under this policy, are in excess of 100% of his lost income. If a person receives a lump sum payment or periodic payments under judgment or settlement for damages we will stop making payments under this policy. Payments will only resume when the payments which would otherwise be payable under this policy equal the amount we are entitled to be reimbursed. If a claim for damages is settled, a person will be required to reimburse us the amount that reasonably reflects the benefits that would otherwise be payable by us; notwithstanding the actual terms of the settlement. A person must: 1. Notify us of any action started against a third party. 2. Notify us of any judgment or settlement which results from such action. 3. Provide us with all documents pertaining to such action that we may reasonably request with respect to either: a. The issues of liability. b. The calculation or allocation of damages. A person's lawyer may represent our rights of recovery. However, we reserve the right to: 1. Appoint another lawyer to act on our behalf. 2. Commence an action to pursue our rights of recovery directly against a third party. The person agrees to fully co-operate with us in pursuing our claim against the third party. GD600-332 The Canada Life Assurance Company Page 22 Dated August 1st, 1995. LIMITATIONS No amount of insurance will be payable under this policy with respect to the disability of a person during any of the following periods. 1. Any period while the person is not under the continuing care of a physician. 2. With respect to mental disorder, any period while the person is not under the continuing care of a specialist in psychiatric care. 3. With respect to alcoholism and/or drug addiction, any period while the person is not being actively supervised by and receiving continuing treatment from a rehabilitation center or a designated institution approved for such treatment by an appropriate body in the governing jurisdiction or, if none, by us. 4. Any period in which the person fails to submit to any medical examination requested by US. 5. Any period while the person is confined in a penal or correctional institution as a result of a conviction for a criminal or other public offense. GD600-340 The Canada Life Assurance Company Page 23 Dated August 1st, 1995. LIMITATION ON BENEFITS FOR MENTAL DISORDER Benefits for disability due to mental disorder will not exceed 24 months of monthly benefit payments unless the person is disabled as defined in this policy and meets one of the following situations. 1. The person is confined in a hospital or medical facility at the end of the 24 month period. The monthly benefit will be paid during the confinement. If the person is still disabled when he is discharged, the monthly benefit will be paid for a recovery period of up to 90 days. If the person becomes reconfined during the recovery period for at least 14 days in a row, benefits will be paid for the confinement and another recovery period of up to 90 more days. 2. The person continues to be disabled and becomes confined in a hospital or medical facility: a. after the 24 month period; and b. for at least 14 days in a row. The monthly benefit will be payable during the confinement. GD600-335 Me Canada Life Assurance Company Page 24 Dated August 1st, 1995. MEMATION ON BENEFITS FOR ALCOHOLISM AND/OR DRUG ADDICTION Benefits for disability due to alcoholism and/or drug addiction will not exceed 24 months of monthly benefit payments unless the person is disabled as defined in this policy and meets one of the following situations. 1. The person is confined in a hospital or medical facility at the end of the 24 month period. The monthly benefit will be paid during the confinement. If the person is still disabled when he is discharged, the monthly benefit will be paid for a recovery period of up to 90 days. If the person becomes reconfined during the recovery period for at least 14 days in a row, benefits will be paid for the confinement and another recovery period of up to 90 more days. 2. The person continues to be disabled and becomes confined in a hospital or medical facility: a. after the 24 month period; and b. for at least 14 days in a row. The monthly benefit will be payable during the confinement. GD600-308 Me Canada Life Assurance Company Page 25 Dated August 1st, 1995. EXCLUSIONS No amount of insurance will be payable under this policy for any disability that is caused by, contributed to by, or resulting from 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. Committing or attempting to commit a felony. GD600-229 The Canada Life Assurance Company Page 26 Dated August 1st, 1995. PRE-EXISTING CONDITION EXCLUSION No amount of insurance will be payable under this policy for any disability which is caused by, contributed to by, or resulting from a pre-existing condition. A pre-existing condition is any injury, disease, illness, pregnancy or mental disorder for which a person did any of the following within 90 days prior to the date on which he became insured under this policy. 1. He visited or consulted a physician, hospital or medical facility. 2. He took tests or received treatment. This includes (but is not limited to) taking pills, injections or other medication to treat any condition. This exclusion will not apply to a continuous period of disability starting after the person has been insured under this policy for at least one year. GD600-336 The Canada Life Assurance Company Page 27 Dated August 1st, 1995. CONTINUITY OF COVERAGE UPON CHANGE OF INSURERS In order to prevent loss of coverage for a person when this policy replaces a group disability policy you had in force with another insurer immediately prior to the Effective Date, we will provide the following coverage. A person will automatically become insured under this policy on the Effective Date, subject to all of the following conditions: 1. He was insured under such prior insurer's group disability policy immediately prior to the Effective Date. 2. He is not actively at work on the Effective Date. 3. He is a member of a class or classes of persons who may be insured under this policy. 4. Premiums are paid with respect to him. If such a person becomes disabled the benefits payable will be the lesser of the following: 1. The benefits which would have been paid under the prior insurer's policy had coverage remained in force. 2. The benefits payable under this policy. This will be reduced by any benefits for which the prior insurer is liable. Benefits may be payable to a person who becomes disabled due to a pre-existing condition, subject to all of the following conditions: 1. He was insured under such prior insurer's group disability policy immediately prior to the Effective Date. 2. He was actively at work on the Effective Date. 3. He was insured under this policy on the Effective Date. GD600-231 The Canada Life Assurance Company Page 29 Dated August 1st, 1995. Such benefits will be determined as follows: 1. We will apply the pre-existing condition exclusion under this policy. If the person satisfies our pre-existing condition exclusion, he will be paid the benefits payable under our policy without regard to the prior policy. 2. If the person cannot satisfy this policy's pre-existing condition exclusion, the prior policy's pre-existing condition exclusion will be applied. a. If the person satisfies the prior policy's pre-existing condition exclusion, he will be paid the lesser of the following: 1) The benefits which would have been payable under the prior policy. 2) The benefits payable under this policy. The continuous time the person was insured under both policies will be taken into consideration. b. If the person cannot satisfy the pre-existing condition exclusion of either policy, no benefits will be paid. You must furnish us with a copy of any such prior insurer's policy. All of the other terms and conditions of this policy will apply to a person covered under this provision. GD600-232 ?he Canada Life Assurance Company Page 29 Dated August 1st, 1995. WHEN A PERSON'S INSURANCE TERMINATES All of a person's insurance under this policy will terminate at the earliest time shown below: 1. When the person's employment terminates. 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 that is stated in a 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 regulations which requires the continuation of insurance during a strike or lock -out. 6. The day before he enters service in any naval, military or airforce. 7. On the date on which the person requests, in writing, to have his insurance terminated. GD600-233 If, at the time the insurance of a person would otherwise terminate, he is disabled, his insurance will not terminate until the earliest time applicable according to the When Disability Income Benefits Cease provision. 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. GD600-234 The Canada Life Assurance Company Page 30 Dated August 1st, 1995. a PREMIUMS 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 O.XXX% of your insured payroll. UD51-2 It is our right to change the premium rate shown above as follows: As of the first anniversary of the Effective Date, 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 composition of the group of persons who are insured under this policy changes by more than 25%. 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 at Ieast thirty-one days written notice 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. CcT7.1i:��►�c�� If, at any time prior to the date that 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. If the change occurs on or prior to the 15th day of a policy month, the first day of such policy month. 2. If the change occurs 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 first day of the next policy month, a regular premium is due. ?he Canada Life Assurance Company Page 31 Dated August 1st, 1995. A If we do not receive notice of a change due to a decrease in or the termination of an amount of insurance on or prior to the first day of a policy year that follows the date of the change, we will limit the refund to the amount that is due for the period from the first day of the current policy year to the date on which we receive the notice. The amount of insurance with respect to a person will be decreased or terminated in accordance with the other terms of this policy. The payment of premiums with respect to a person'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 person prior to such decrease or continue insurance in force with respect to such person 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. GD600-236 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 rata 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 will not be required to accept the payment of any premium otherwise than from you. GD600-237 The Canada Life Assurance Company Page 32 Dated August 1st, 1995. 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 thirty-one days after the date on which it is due. The period of grace for the payment of each adjustment premium will be thirty-one 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 thirty-one 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 This policy is not eligible for dividends and will not take 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. GD600-238 7)<ie Canada Life Assurance Company Page 33 Dated August l st, 1995. BOOKLET -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. GD600-239 ?he Canada Life Assurance Company I Page 34 Dated August 1st, 1995. EXHIBIT "B" The Short Term Income Replacement Plan which The Canada life Assurance Company is covering under this Administrative Agreement is the City of Lubbock's current self funded plan. The Short Term Income Replacement Plan provisions replace and are similar to the benefit provisions which, prior to December 1, 1997, were provided with respect to employees of the City of Lubbock under the self funded arrangement. The applicable Plan provisions are attached. The Canada Life Assurance Company will administer the Plan in accordance with the attached. The Canada Life Assurance Company is acting solely as Administrator of this Plan as described in the Addendum to the Agreement by and Between the City of Lubbock and Canada Life to which this Exhibit is attached. EXHIBIT "C" The Company shall remit the following monthly fees from the effective date of this agreement. 1. An amount equal to the paid claims for the month. 2. Monthly charge equal to $1.10 per employee per month. The above fees will be collected by the Administrator on a monthly basis as they are incurred. The Administrator has the right to change the above fees or the basis used to determine such fees to a basis other than as described above, on December 1, 1999 or on any anniversary thereof.