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HomeMy WebLinkAboutResolution - 2014-R0267 - Agreement - Dearborn National Life Insurance Co.- Life, Accident, Etc. Insurance - 08_14_2014Resolution No. 2014-RO267 August 14, 2014 Item No. 6.10 RESOLUTION BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF LUBBOCK: THAT the Mayor of the City of Lubbock is hereby authorized and directed to execute for and on behalf of the City of Lubbock, a Service Agreement for Basic Life, Accident Death and Disability Insurance and Voluntary Life and Voluntary Accident Death and Disability Insurance as per Contract No. 11842, by and between the City of Lubbock and Dearborn National Life Insurance Company, and related documents. Said Service Agreement is attached hereto and incorporated in this resolution as if fully set forth herein and shall be included in the minutes of the City Council. THAT the City Manager, or his designee, may execute any routine documents and forms associated with said insurance coverage. Passed by the City Council on August 14, 2014 - W/// G E TSON, MAYOR (ATTEST: jReb*ca Garza, City IAPPROYED AS TO CONTENT: sa Hutcheson. Director of Human Resources VED AS TO FORM: Weaver, City Attorney ✓:ccdocs/RES.Risk Mgmt-Dearborn Life Ins. Co ly 21, 2014 Resolution No. 2014-RO267 CONTRACT 11842 City of Lubbock, TX Ancillary Benefits Plan for City Employees RFP 14-11842-DT This Service Agreement (this "Agreement") is entered into as of the 14'h day of August, 2014, ("Effective Date") by and between Dearborn National Life Insurance Company (the Contractor), and the City of Lubbock (the "City"). RECITALS WHEREAS, the City has issued a Request for Proposals 14-11842-DT Ancillary Benefits Plan for City Employees. WHEREAS, the proposal submitted by the Contractor has been selected as the proposal which best meets the needs of the City for this service; and WHEREAS, Contractor desires to perform as an independent contractor to provide Ancillary Benefits upon terms and conditions maintained in this Agreement; and NOW THEREFORE, for and in consideration of the mutual promises contained herein, the City and Contractor agree as follows: City and Contractor acknowledge the Agreement consists of the following exhibits which are attached hereto and incorporated herein by reference, listed in their order of priority in the event of inconsistent or contradictory provisions: 1. This Agreement 2. Exhibit A —Price Sheet 3. Exhibit B — General Requirements 4. Exhibit C — Insurance Exhibit C1 — Sample Life Policy Exhibit C2 - Sample Long Term Disability Policy S. Exhibit D — Insurance In the event of a conflict with respect to the coverage of insurance provided by the Policies and all matters relating thereto, the Policies take precedence over all documents identified above. Scope of Work Contractor shall provide the services that are specified in Exhibit B. The Contractor shall comply with all the applicable requirements set forth in Exhibit A and C attached hereto. Article 1 Services 1.1 Contractor agrees to perform services for the City that are specified under the General Requirements set forth in Exhibit B. The City agrees to pay the amounts stated in Exhibit A, to Contractor for performing services. 1.2 Contractor shall use its commercially reasonable efforts to render Services under this Agreement in a professional and business -like manner and in accordance with the standards and practices recognized in the industry. Non -appropriation clause. All funds for payment by the City under this Agreement are subject to the availability of an annual appropriation for this purpose by the City. In the event of non -appropriation of funds by the City Council of the City of Lubbock for the goods or services provided under the Agreement, the City will terminate the Agreement, without termination charge or other liability, on the last day of the then -current fiscal year or when the appropriation made for the then -current year for the goods or services covered by this Agreement is spent, whichever event occurs first. If at any time funds are not appropriated for the continuance of this Agreement, cancellation shall be accepted by the contractor on thirty (30) days prior written notice, but failure to give such notice shall be of no effect and the City shall not be obligated under this Agreement beyond the date of termination. Article 2 Miscellaneous. 2.1 This Agreement is made in the State of Texas and shall for all purposes be construed in accordance with the laws of said State, without reference to choice of law provisions. 2.2 This Agreement is performable in, and venue of any action related or pertaining to this Agreement shall lie in, Lubbock, Texas. 2.3 This Agreement and its Exhibits contains the entire agreement between the City and Contractor and supersedes any and all previous agreements, written or oral, between the parties relating to the subject matter hereof. No amendment or modification of the terms of this Agreement shall be binding upon the parties unless reduced to writing and signed by both parties. 2.4 This Agreement may be executed in counterparts, each of which shall be deemed an original. 2.5 In the event any provision of this Agreement is held illegal or invalid, the remaining provisions of this Agreement shall not be affected thereby. 2.6 The waiver of a breach of any provision of this Agreement by any parties or the failure of any parties otherwise to insist upon strict performance of any provision hereof shall not constitute a waiver of any subsequent breach or of any subsequent failure to perform. 2.7 This Agreement shall be binding upon and inure to the benefit of the parties and their respective heirs, representatives and successors and may be assigned by Contractor or the City to any successor only on the written approval of the other party. 2.8 All claims, disputes, and other matters in question between the Parties arising out of or relating to this Agreement or the breach thereof, shall be formally discussed and negotiated between the Parties for resolution. In the event that the Parties are unable to resolve the claims, disputes, or other matters in question within thirty (30) days of written notification from the aggrieved Party to the other Party, the aggrieved Party shall be free to pursue all remedies available at law or in equity. 2.9 At any time during the term of the contract, or thereafter, the City, or a duly authorized audit representative of the City or the State of Texas, at its expense and at reasonable times, reserves the right to audit Contractor's records and books relevant to all services the City under this Contract. In the event such an audit by the City reveals any errors or overpayments by the City, Company shall refund the City the full amount of such overpayments within thirty (30) days of such audit findings, or the City, at its option, reserves the right to deduct such amounts owing the City from any payments due Company. 2.10 The City reserves the right to exercise any right or remedy to it by law, contract, equity, or otherwise, including without limitation, the right to seek any and all forms of relief in a court of competent jurisdiction. Further, the City shall not be subject to any arbitration process prior to exercising its unrestricted right to seek judicial remedy. The remedies set forth herein are cumulative and not exclusive, and may be exercised concurrently. To the extent of any conflict between this provision and another provision in, or related to, this document, this provision shall control. IN WITNESS WHEREOF, this Agreement is executed as of the Effective Date. CITY OF LUBBOCK, TX: Glen Obyor ATTEST: - OAO-�� I - '5K Re cca Garza, City Secretary APP OV r-6ONTENT: Lei c on, Director of Human Resources and Risk Management APPPe0ytD AS O FORM: 614-fa Mitch Satterwhite, Assistant City Attorney COMPANY: Comp y' Signature 671VV14d' cn P--,17 Printed a e VP f CFO Title EXHIBIT A PRICE SHEET Coverage Dearborn National Monthly Rate Per $1,000 Basic Life $0.035 Accidental Death & $0.015 Dismemberment Supplemental Em to ee Life Age Rate Per $1,000 Under 30 $0.05 30-34 $0.06 35-39 $0.07 40-44 $0.11 45-49 $0.16 50-54 $0.26 55-59 $0.47 60-64 $0.77 65-69 $1.21 70-74 $2.14 75-79 $3.95 80-85 $6.72 EXHIBIT A PRICE SHEET Coverage Dearborn National Monthly Rate Per $1,000 Basic Life $0.035 Accidental Death & $0.015 Dismemberment Supplemental Em to ee Life Age Rate Per $1,000 Under 30 $0.05 30-34 $0.06 35-39 $0.07 40-44 $0.11 4549 $0.16 50-54 $0.26 55-59 $0.47 60-64 $0.77 65-69 $1.21 70-74 $2.14 75-79 $3.95 80-85 $6.72 Spouse Life Amount Rate Per $1,000 $5,000 $0.80 $10,000 $1.60 $15,000 $2.40 $20,000 $3.20 $25,000 $4.00 $30,000 $4.80 $35,000 $5.60 $40,000 $6.40 $45,000 $7.20 $50,000 $8.00 Dependent Child Life Amount Monthly Rate Per Unit $2,500 $0.50 $5,000 $1.00 $7,500 $1.50 $10,000 $2.00 Voluntary AD Rate Per $1,000 Employee Only $0.025 Employee and Spouse Only $0.038 Employee and Child(ren) Only $0.038 Employee, Spouse & Child(ren) $0.038 Retiree Life Age Rate Per $1,000 Under 30 $0.11 30-34 $0.12 35-39 $0.17 40-44 $0.26 45-49 $0.44 50-54 $0.78 55-59 $1.27 60-64 $1.44 65-69 $2.38 70-74 $4.12 75-79 $6.20 80 or Over $9.75 Retiree Life $3.06 Retiree Life $0.60 Retiree Dependent Coverage Amount Monthly Rate Per Unit Spouse $2,500 $1.25 Child(ren) $1,000 $1.25 LTD - Option 1 (180 day EP) Age Rate Per $100 of Monthly Covered Payroll Under 25 $0.14 25-29 $0.16 30-34 $0.17 35-39 $0.18 40-44 $0.25 45-49 $0.31 50-54 $0.42 55-59 $0.64 60-64 $0.79 65-69 $0.79 70 + $0.79 LTD - Option 2 (90 day EP) Age Rate Per $100 of Monthly Covered Payroll Under 25 $0.16 25-29 $0.18 30-34 $0.20 35-39 $0.21 40-44 $0.28 45-49 $0.36 50-54 $0.49 55-59 $0.74 60-64 $0.91 65-69 $0.91 70 + $0.91 Rate Guarantee • The Life will be guaranteed for 5 years (111115 - 12/31/19). • The LTD rates are guaranteed for 3 years with rate caps based on the incurred loss ratios for year 4 and 5 as indicated below. LTD - Year 4 and Year 5 Incurred Loss Ratio Maximum Renewal Rate Increase Allowed Under 85% 0% 85% -89% 10% 90% -99% 20% 100% or more To be negotiated between the City of Lubbock and Dearborn National EXHIBIT B City of Lubbock, TX RFP 14-11842-DT Ancillary Benefits General Requirements Products and Pricing Schedule 4(A) Group Employer -Paid Group Life/AD&D Insurance Minimum requirements: Employer -Paid Group Life Insurance /AD&D insurance — Policy must include coverage for all classifications of eligible employees as defined in the Summary Plan Description. The policy coverage should be quoted on a guaranteed issue basis for active and newly hired employees during the initial open enrollment period. The carrier/provider must have an A.M. Best rating of A VIII or better. Please include examples of any promotions or promotional materials. You can propose more than one product for each product line. Please complete the product evaluation form below for each product you are proposing. SCHEDULE OF BENEFITS ELIGIBILITY: Class 01 All eligible Active Employees ELIGIBILITY: Class 02 All eligible Retirees of the Policyholder are: ALL RETIRED EMPLOYEES WHO RETIRED ON OR AFTER DECEMBER 1, 1995 ELIGIBILITY: Class 03 All eligible Retirees of the Policyholder are: ALL RETIRED EMPLOYEES WHO RETIRED ON OR AFTER APRIL 1, 1988 BUT BEFORE DECEMBER 1, 1995 ELIGIBILITY: Class 02 All eligible Retirees of the Policyholder are: ALL RETIRED EMPLOYEES WHO RETIRED ON OR AFTER JANUARY 1, 1974 BUT BEFORE APRIL 1, 1988 ELIGIBILITY: Class 02 All eligible Retirees of the Policyholder are: ALL RETIRED EMPLOYEES WHO RETIRED PRIOR TO JANUARY 1, 1974 EXHIBIT B City of Lubbock, TX RFP 14-11842-DT Ancillary Benefits General Requirements Products and Pricing Schedule 4(A) Group Emplover-Paid Group Life/AD&D Insurance Minimum requirements: Employer -Paid Group Life Insurance /AD&D insurance — Policy must include coverage for all classifications of eligible employees as defined in the Summary Plan Description. The policy coverage should be quoted on a guaranteed issue basis for active and newly hired employees during the initial open enrollment period. The carrier/provider must have an A.M. Best rating of A VIII or better. Please include examples of any promotions or promotional materials. You can propose more than one product for each product line. Please complete the product evaluation form below for each product you are proposing. SCHEDULE OF BENEFITS ELIGIBILITY: Class OI All eligible Active Employees ELIGIBILITY: Class 02 All eligible Retirees of the Policyholder are: ALL RETIRED EMPLOYEES WHO RETIRED ON OR AFTER DECEMBER 1, 1995 ELIGIBILITY: Class 03 All eligible Retirees of the Policyholder are: ALL RETIRED EMPLOYEES WHO RETIRED ON OR AFTER APRIL 1, 1988 BUT BEFORE DECEMBER 1, 1995 ELIGIBILITY: Class 02 All eligible Retirees of the Policyholder are: ALL RETIRED EMPLOYEES WHO RETIRED ON OR AFTER JANUARY 1, 1974 BUT BEFORE APRIL 1, 1988 ELIGIBILITY: Class 02 All eligible Retirees of the Policyholder are: ALL RETIRED EMPLOYEES WHO RETIRED PRIOR TO JANUARY 1, 1974 Eligibility Waiting Period: (for all classes) Current Retirees: NONE New Retirees: NONE Policy Holder Contribution Class 2 & 3: Basic Life 0% of premium GROUP TERM LIFE INSURANCE CLASS O1 Employee Basic Life Benefit Amount Employee may elect coverage up to the guarantee issue level. CLASS 02 Employee Basic Life Benefit Amount Employee may elect a $5,000 benefit or a $2,000 benefit. CLASS 03 Employee Basic Life Benefit Amount $2,000 benefit. CLASS 04 Employee Basic Life Benefit Amount Employee's benefit amount is equal to the amount of coverage in force on the last day of being actively at work (either $2,000 or $5,000) CLASS 05 Employee Basic Life Benefit Amount $11,000 benefit. Reduction of Benefits (for all Classes) NONE Portability (for all Classes) Benefit Eligibility Basic Life Insured Eligibility Retiree Portability Benefit Duration Age 65 CURRENT PRICING (All rates per $1,000 per month unless otherwise stated) CLASS O1 Term Life: $0.035 CLASS O1 AD&D: $0.02 CLASS 02 Term Life: see voluntary rate schedule CLASS 03 Term Life: see voluntary rate schedule CLASS 04 Term Life: see voluntary rate schedule CLASS 05 Term Life: see voluntary rate schedule Basic Life and AD&D Employer -Paid Group Life Insurance Vendor Answer Guaranteed Issue m Policy portability under similar terms and conditions Length of time with carrier Minimum participation A M Best Rating of carrier (A VIII min) Life insurance waiver of premium notifications Limitations and exclusions Accelerated Death Benefit Line of Duty Benefit Benefit Reduction Schedule similar Seat Belt Benefit Air Bag Benefit Career Adjustment Benefit Child Care Benefit Higher Education Benefit Enrollment Guidelines Similar Multi -year quotes are preferred and will be considered first. Please complete the pricing form below and attach your premium schedule. The Bi-weekly costs will be determined from a random sample of 100 below: Item Employer -Paid Group Life Vendor Answer 1 Multi -year Rate Quote Years 2 Please attach a five year rate history Rates 3 Cost per $1000 $ 4 (B) Voluntary Group Term Life/AD&D Insurance Minimum requirements: Employee -Paid Group Life Insurance /AD&D insurance — Policy must include coverage for all classifications of eligible employees as defined in the Summary Plan Description. The carrier/provider must have an A.M. Best rating of A VIII or better. Please include examples of any promotions or promotional materials. You can propose more than one product for each product line. Please complete the product evaluation form below for each product you are proposing. SCHEDULE OF BENEFITS ELIGIBILITY: Class 01 All eligible new hires and existing employees and their dependents to enroll for coverage up to the guarantee issue level. Voluntary Life amounts elected above the guarantee issue level will require evidence of insurability. ELIGIBILITY: Class 02 All eligible Retirees of the Policyholder are: ALL RETIRED EMPLOYEES WHO RETIRED ON OR AFTER DECEMBER 1, 1995 ELIGIBILITY: Class 03 All eligible Retirees of the Policyholder are: ALL RETIRED EMPLOYEES WHO RETIRED ON OR AFTER APRIL 1, 1988 BUT BEFORE DECEMBER 1, 1995 ELIGIBILITY: Class 02 All eligible Retirees of the Policyholder are: ALL RETIRED EMPLOYEES WHO RETIRED ON OR AFTER JANUARY 1, 1974 BUT BEFORE APRIL 1, 1988 ELIGIBILITY: Class 02 All eligible Retirees of the Policyholder are: ALL RETIRED EMPLOYEES WHO RETIRED PRIOR TO JANUARY 1, 1974 Eligibility Waiting Period: (for all classes) New Employees: 14 days (one(1) full pay period) Current Retirees: NONE New Retirees: NONE Policy Holder Contribution (for all Classes): Voluntary Life 0% of premium CLASS 01 Guarantee Issue for Supplemental Life Coverage is: 1. $250,000 for employees 2. $50,000 for spouses $10,000 for children Must accept employees that have coverage over the Guarantee Issue amount. GROUP TERM LIFE INSURANCE Retiree Voluntary Life Benefit Amount (for all Classes) $10,000 Voluntary: Benefit amounts may be subject to Guarantee Issue limits based on participation levels as determined by Us. Any Guarantee Issue Limits established are only available during Your group's initial enrollment and for new employees who have met the Eligibility requirements. Employees must enroll within 31 days of their eligibility date to qualify for any established Guarantee Issue. Reduction of Benefits (for all Classes) NONE Portability (for all Classes) Benefit Eligibility Voluntary Life Insured Eligibility Retiree Portability Benefit Duration Age 65 Additional Purchase Option Maximum Additional Purchase Amount Up to $50,000 of basic term life insurance. DEPENDENT TERM LIFE INSURANCE Class 2 — Spouse Benefit Amount Voluntary: $2,500 Class 2 — Child(ren) Benefit Amount Voluntary: age live birth to 6 months - $0.00 6 months to 25 years - $1,000 Class 3 — Spouse Benefit Amount Voluntary: $2,000 Class 3 — Child(ren) Benefit Amount Voluntary: $1,000 Class 4 — Spouse Benefit Amount Voluntary: $2,000 Class 4 — Child(ren) Benefit Amount Voluntary: $2,000 Class 5 — Child(ren) Benefit Amount NONE RATE ADDENDUM (all rates per $1,000 per month) Class 01 Voluntary Spouse Life: $.80 per $5,000 Class 01 Voluntary Child Life: $ 2,500 benefit - $0.50 per family unit $ 5,000 benefit - $1.00 per family unit $ 7,500 benefit - $1.50 per family unit $10,000 benefit - $2.00 per family unit Class 01 Voluntary Accidental Death & Dismemberment: Individual Plan - $0.025 per family unit Family Plan - $0.038 per family unit Class 01 Voluntary Term Life: AGE RANGE RATE Under to 30 $.06 30 to 34 $.08 35 to 39 $.09 40 to 44 $.14 45 to 49 $.20 50 to 54 $.33 55 to 59 $.59 60 to 64 $.96 65 to 69 $1.51 70 to 74 $2.68 75 to 79 $4.94 80 to 84 $8.40 Class 02, 03 & 04 Voluntary Dependent Life (Spouse & Child(ren): $1.25 per family unit Class 02, 03 & 04 Voluntary Term Life: AGE RANGE RATE Under to 30 $.11 30 to 34 $.12 35 to 39 $.17 40 to 44 $.26 45 to 49 $.44 50 to 54 $.78 55 to 59 $1.27 60 to 64 $1.44 65 to 69 $2.38 70 to 74 $4.12 75 to 79 $6.20 80 to 84 $9.75 4 (c) Voluntary Short-term Disabilities Minimum requirements: Voluntary Short-term disability insurance — policy should include an "own occupation" definition of disability and waiver of premium for disability. The policy must cover on duty and off duty disability. The waiting period for benefits cannot be longer than 30 days. The benefit payout period must be at least 13 weeks. The benefit must be at least 50% of usual pay offset from other sources of income such as social security or workers compensation. However, the minimum benefit must be at least 40% of usual pay without any offsets. Please include other features of your policy in the evaluation below. The policy must have guaranteed issue for new hires and initial open enrollment period. The carrier/provider must have an A M Best rating of A VIII or better. Please include examples of any promotions or promotional materials. You can propose more than one product for each product line. Please complete the product evaluation form below for each product you are proposing. Short term Disability Vendor Answer Guaranteed Issue Yes or No OWN OCCUPATION Definition of Yes or No Portable under similar terms and conditions Yes or No WAIVER OF PREMIUM for disability Yes or No On duty and Off duty coverage Yes or No Length of time with carrier Minimum participation A M Best Rating of carrier (A VIII min) Waiting period for illness (30 days maximum Waiting period for injury (30 days maximum Coverage period (13 week minimum) Percent of usual pay (50% minimum) Minimum Percent of usual pay with Social ' Security, Workers Comp or other income offset (40% minimum) Other features: Please list other features of your policy. ` Minimum participation — greater consideration will be given for lower number of minimum participation. A M Best Rating — greater consideration will be assigned for higher A M Best rating. The minimum rating is A VIII. Waiting Periods — greater consideration will be assigned for shorter waiting periods. Coverage Periods — greater consideration will be assigned for longer coverage periods. Percent of usual pay — greater consideration will be assigned for higher percentages of usual pay. Pricing Item Voluntary Short -Term Disability Insurance 1 Multi -year Rate Quote (5 points per year. 2 Please attach a five year rate history 3 Bi Weekly Cost per Sample of 100 Vendor Answer Years Rates i Multi -year quotes are preferred and will be considered first. Please complete the pricing form below and attach your premium schedule. The Bi-weekly costs will be determined from a random sample of 100 below: 4(D) Long-term Disability Minimum requirements: Long-term disability insurance — policy should include an "any occupation" definition of disability and waiver of premium for disability. We would prefer a policy that has an own occupation test for disability for 2 years and any occupation test thereafter. The policy must cover on duty and off duty disability. The waiting period for benefits cannot be longer than 180 days. The benefit payout period must be at least 5 years, but would prefer until age 65. The benefit must be at least 50% of usual pay offset from other sources of income such as social security or workers compensation. However, the minimum benefit must be at least 40% of usual pay without any offsets. Please include other features of your policy in the evaluation below. The policy must have guaranteed issue for new hires and initial open enrollment period. The carrier/provider must have an A M Best rating of A VIII or better. Please include examples of any promotions or promotional materials. You can propose more than one product for each product line. Please complete the product evaluation form below for each product you are proposing. 5. SCHEDULE OF BENEFITS Disability Income Insurance — Monthly Income Benefits Monthly Benefit Your monthly benefit depends on the Option for which you are enrolled. Option 1: 60% of your monthly earnings, but not more than the Maximum Monthly Benefit. ... Option 2: 67% of your monthly earnings, but not more than the Maximum Monthly Benefit. ....... Your benefit may be reduced by the deductible sources of income and disability earnings. Some disabilities may not be covered or may be limited under this coverage. MAXIMUM Monthly Benefit: $5,000 Elimination Period Your elimination period depends on the Option for which you are enrolled. You are automatically enrolled in Option 1 unless you choose to enroll for Option 2. • Option 1: The longer of 180 days and the length of time for which you receive loss of time benefits, salary continuation or accumulation of sick leave. • Option 2: The longer of 90 days and the length of time for which you receive loss of time benefits, salary continuation or accumulated sick leave. Benefits begin the day after the Elimination Period is completed. Maximum Benefit Period Age at disability Under age 61 61 62 63 64 65 66 67 68 69 and over Maximum benefit period To your normal retirement age*, but not less than 60 months To your normal retirement age*, but not less than 48 months To your normal retirement age*, but not less than 42 months To your normal retirement age*, but not less than 36 months To your normal retirement age*, but not less than 30 months 24 months 21 months 18 months 15 months 12 months *Your normal retirement age is your retirement age under the Social Security Act where retirement age depends on your year of birth. No contributions are required for your coverage while you are receiving payments under this plan. Cost of Coverage: The long term disability plan is provided to you on a contributory basis. You will be informed of the amount of your contribution when you enroll. The above items are only highlights of coverage. For a full description please read the entire Group Insurance Certificate. CURRENT PRICING Option 1: Option 2: AGE RANGE RATE RATE <25 $.14 $.16 25 to 29 $.16 $.18 30 to 34 $.17 $.20 35 to 39 $.18 $.21 40 to 44 $.25 $.28 45 to 49 $.31 $.36 50 to 54 $.42 $.49 55 to 59 $.64 $.74 60 to 64 $.79 $.91 65 to 69 $.79 $.91 70 + $.79 $.91 Long term Disability Vendor Answer Guaranteed Issue Yes or No WAIVER OF PREMIUM for Yes or No disability Portable under similar terms and Yes or No conditions On duty and Off duty coverage Yes or No Length of time with carrier (1 point per Minimum participation A M Best Rating of carrier (A VIII min) Own Occupation test for wait period? Waiting period for illness (180 days maximum) Waiting period for injury (180 days maximum) Coverage period (5 year minimum) Percent of usual pay (50% minimum Minimum Percent of usual pay with Social Security, Worker's Comp or other income offset (40% minimum) Other features: Please list other features of your policy. Minimum participation — greater consideration will be given for lower number of minimum participation. A M Best Rating — greater consideration will be assigned for higher A M Best rating. The minimum rating is A VIII. Waiting Periods — greater consideration will be assigned for shorter waiting periods. Coverage Periods — greater consideration will be assigned for longer coverage periods. Percent of usual pay — greater consideration will be assigned for higher percentages of usual pay. Pricine Item Long term Disability Insurance 1 Multi -year Rate Quote (5 points per Years 2 Please attach a five year rate history Rates 3 Bi Weekly Cost per Sample of 100 $ Multi -year quotes are preferred and will be considered first. Please complete the pricing form below and attach your premium schedule. The Bi-weekly costs will be determined from a random sample of 100 below: EXHIBIT C BEST AND FINAL OFFER PROPOSAL Dearborn ` National, Strength. Independence, Solutions. GROUP BENEFITS PROPOSAL Prepared for City of Lubbock, Texas Proposal valid for two months following October 01, 2014 DEARBORN NATIONAL Jeff Jay SALES REPRESENTATIVE: 21fj4 6918 jefays bcbstx.com Visit us at: www.dearbornnational.com Underwritten by Dearborn National `' Life Insurance Company Dearborn NatIonaf Prepared for: City of Lubbock, Texas Group Life and Accidental Death and Dismemberment Insurance Group Life and Accidental Death and Dismemberment Insurance plans provide security to those families that have suffered the loss of a loved one. Basic Life Rate and Cost summary Proposed Effective Date*: October 01, 2014 Current Plan Basic Life • All Eligible Active Employees # of Lives Estimated Volume Rates Per Estimated $1,000 Monthly Monthly Premium 2,107 $21,070,000 $0.035 $737.45 • All Retireed Employees who retireed on or after January 1, 1974 but before April 1, 1988 # of Lives Estimated Volume Rates Per Estimated $1,000 Monthly Monthly Premium 46 $45,000 $0.600 $27.00 • All Retireed Employees who retireed on or after December 1, 1995 • All Retireed Employees who retireed on or after April 1, 1988 but before December 1, 1995 # of Lives Estimated Volume Rates Per Estimated $1,000 Monthly Monthly Premium 486 $1,936,000 $3.060 $5,924.16 Basic AD&D # of Lives Estimated Volume Rates Per Estimated $1,000 Monthly 2,107 $20,902,500 Monthly$0.015 Premium $313.54 Rate Guarantee Period: 60 months *Quote valid for two months following the proposed effective date Enhanced Product Services Offered with Group Term Life Insurance • Travel Assistance Services (Available to groups with 50 or more lives; Not available in all states) • Beneficiary Resource Services Important Notes: The above rates and premium estimates are based on the employee data submitted by you. Final rates and premiums will be based on the plan and employee data provided by you at inception. This proposal is subject to exclusions and limitations in the policy issued by us. In addition, if coverage was inforce prior to the effective date of coverage, the rates quoted are subject to revisions based on acceptance and review of the inforce carrier's policy. Changes in risk that may impact the rates quoted include, but are not limited to: • The composition of the group, employees or dependents, changes by more than 10% • The employer contribution changes • Any of the plan designs are changed • A change in applicable law requires a change in the insurance provided by the policy or the classes of persons eligible for insurance under the policy. Quote ID: 46495 2 of 49 Dearborn National` Prepared for: City of Lubbock, Texas Group Life Insurance Plan Design Summary Basic Term Life - Employee Eligibility All Retireed Employees who retireed on or after January All Eligible Active 1, 1974 but before April 1, Employees 1988 Number of Employees 2,107 46 Basic Life Benefit $10,000 $2,000 or $5,000 Guarantee Issue $10,000 $5,000 Waiver of Premium Included Not Included Elimination Period 6 Months Waiver Duration To Age 65 Portability To Age 65 To Age 65 Portability Maximum $10,000 $5,000 Conversion Included Included Accelerated Death Benefit* 75% of Benefit Amount Not Included Maximum $500,000 Age Reduction Schedule** 35% at age 65 None 50% at age 70 35% at age 75 Policyholder Contribution 100% 100% Participation Minimum 100% 100% *For groups with Basic and Supplemental or Voluntary Life coverage, the Accelerated Death Benefit maximum applies to all coverages **Benefits are reduced by the percentage indicated and are calculated from the original amount at the attainment of the age shown. Quote ID: 46495 3 of 49 Dearborn National Basic Term Life - Employee Eligibility Number of Employees Basic Life Benefit Guarantee Issue Portability Portability Maximum Conversion Age Reduction Schedule** Policyholder Contribution Participation Minimum Prepared for: City of Lubbock, Texas All Retireed Employees who retireed on or after December 1, 1995 399 $2,000 or $5,000 $5,000 To Age 65 $5,000 Included None 100% 100% All Retireed Employees who retireed on or after April 1, 1988 but before December 1, 1995 87 $2,000 $2,000 To Age 65 $2,000 Included None 100% 100% **Benefits are reduced by the percentage indicated and are calculated from the original amount at the attainment of the age shown. Quote ID: 46495 4 of 49 Dearborn Nationaf Basic AD&D - Employee Eligibility Basic AD&D Benefit Seat Belt Percentage Maximum Air Bag Percentage Maximum Education Benefit Percentage Annual Maximum Duration Repatriation Benefit Day Care Benefit Percentage Annual Maximum Duration Spouse Training Benefit Coma Benefit Percentage Maximum Duration Prepared for: City of Lubbock, Texas All Eligible Active Employees Same as Basic Life Included 10% $25,000 Included 5% $5,000 Included 3% $3,000 4 Years Actual costs to $5,000. Included 3% $5,000 5 Years $5,000 Included 1% $1,000 11 Months Quote ID: 46495 5 of 49 Dearborn NatIolil01' Prepared for: City of Lubbock, Texas Underwriting Considerations for Group Life Coverage Considerations • Voluntary AD&D Employee rate is $0.025 • Voluntary AD&D Family rate is $0.038 Underwriting Conditions • Employees must be legally working in the United States in order to be eligible for coverage. • Insured Persons enrolling more than 31 days after their initial eligibility date must submit satisfactory Evidence of Insurability for all benefit amounts. • Coverage for amounts in excess of the Guarantee Issue amount is not effective until the date we approve the application. • This proposal provides only basic information on the features of the policy. It is not intended to be a complete representation of all terms and conditions of the contract. A complete listing of the terms, conditions, limitations, exclusions and reduction of benefits is available upon request. In the event of conflict between this proposal and the policy, the terms of the policy will govern. • Product features and provisions may be slightly different due to state requirements. When sold, the actual policy for the state in which the policy is issued will reflect the state's requirements. • This proposal illustrates the cost of the insurance program and is based upon the information submitted by you. Actual cost will be determined after an application has been accepted and will depend upon data obtained when the program becomes effective. • The Supplemental Life guarantee issue amount shown in this proposal are offered to employees whose initial eligibility date (new hires) is on or after the effective date of coverage. • If the Supplemental Life Participation Minimum stated in the Plan Design Summary is met, all current amounts in force will be grandfathered, subject to the plan design maximums and the grandfathering limits stated in the Plan Design Summary. The Guarantee Issue amount shown in this proposal will only be offered to employees whose initial eligibility date (new hires) is on or after the effective date of coverage. Employees not previously covered, or those who have selected to increase their coverage, will need to provide satisfactory Evidence of Insurability. • Should the Supplemental Life Participation Minimum not be met, grandfathering will not apply and satisfactory Evidence of Insurability will be required for all amounts by all applicants, including those participating in the prior carrier's plan. Participation is measured based on the participation level achieved at initial enrollment with Dearborn National. A spouse application does not count toward the Participation Requirement. Transition of Coverage from Previous Carrier Most group life carriers have standardized provisions in their contracts that address issues concerning transition from one carrier to another. Each carrier has specific responsibilities to ensure that employees who are not actively at work at the time of the transition do not lose their coverage. The terminating carrier should retain responsibility for any employee who is disabled on the date of termination, regardless of whether or not the individual is on Waiver of Premium. It is recommended that this issue be discussed with the terminating carrier to verify how persons disabled on the effective date of our policy will be handled. Actively at Work Actively at work requirements will be waived, provided premiums are paid when due, for employees who: • Are covered on the day immediately preceding our policy effective date; and • Were on lay-off, non -medical leave of absence or sabbatical leave; and who are being provided an extension of benefits with their prior carrier Coverage will continue for the balance of the time provided for under the prior carrier's policy, but not to exceed 12 months. We do not agree to waive the actively at work provision on other employees. Quote ID: 46495 6of49 Dearborn National" Prepared for: City of Lubbock, Texas Voluntary Life and Accidental Death and Dismemberment Insurance Voluntary Life and Accidental Death and Dismemberment Insurance plans provide security to those families that have suffered the loss of a loved one. Voluntary Life Mate and Cost Summary Proposed Effective Date*: October 01, 2014 Current Plan Voluntary Life • All Eligible Active Employees Age Band Employee Rates Per 1 000 Monthly Below 20 $0.050 20-24 $0.050 25-29 $0.050 30-34 $0.060 35-39 $0.070 40-44 $0.110 45-49 $0.160 50-54 $0.260 55-59 $0.470 60-64 $0.770 65-69 $1.210 70-74 $2.140 75-79 $3.950 80-84 $6.720 85-89 $6.720 90-94 $6.720 95-99 $6.720 100 and above $6.720 Quote ID: 46495 7 of 49 Dearborn Nationca& • All Retireed Employees Voluntary AD&D Prepared for: City of Lubbock, Texas Age Band Employee Rates Per i 000 Monthly Below 20 $0.110 20-24 $0.110 25-29 $0.110 30-34 $0.120 35-39 $0.170 40-44 $0.260 45-49 $0.440 50-54 $0.780 55-59 $1.270 60-64 $1.440 65-69 $2.380 70-74 $4.120 75-79 $6.200 80-84 $9.750 85-89 $9.750 90-94 $9.750 95-99 $9.750 100 and above $9.750 Employee Age Band Rates Per 1 000 Monthly Employee $0.025 Voluntary Dependent Life • All Eligible Active Employees Spouse Age Band Rates Per 5 000 Monthly Composite $0.800 Dependent Child ren Rates per unit Life 0.500 • All Retired Employees who Retired on or after January 1, 1974 but before December 1, 1995 Spouse Age Band Rates Per unit Monthly Composite $1.250 Quote ID: 46495 8 of 49 De,,orn National Prepared for: City of Lubbock, Texas • All Retired Employees who Retired on or after December 1, 1995 Spouse Age Band Rates Per unit Monthly Composite $1.250 Dependent Child ren Rates per unit Life 1.250 Rate Guarantee Period: 60 Months *Quote valid for two months following the proposed effective date Enhanced Product Services Offered with Group Term Life Insurance • Travel Assistance Services (Available to groups with 50 or more lives; Not available in all states) • Beneficiary Resource Services Important Notes: The above rates and premium estimates are based on the employee data submitted by you. Final rates and premiums will be based on the plan and employee data provided by you at inception. This proposal is subject to exclusions and limitations in the policy issued by us. In addition, if coverage was in force prior to the effective date of coverage, the rates quoted are subject to revisions based on acceptance and review of the inforce carrier's policy. Changes in risk that may impact the rates quoted include, but are not limited to: • The composition of the group, employees or dependents, changes by more than 10% • The employer contribution changes • Any of the plan designs are changed • A change in applicable law requires a change in the insurance provided by the policy or the classes of persons eligible for insurance under the policy. Quote ID: 46495 9 of 49 Dearborn NQtIonal' Prepared for: City of Lubbock, Texas Group Life Insurance Plan Design Summary Voluntary Life - Employee Eligibility Number of Employees Voluntary Life Benefit Minimum Maximum Benefit Rounding Definition of Earnings Average Period Guarantee Issue Waiver of Premium Elimination Period Waiver Duration Portability Portability Maximum Conversion Accelerated Death Benefit* Maximum Age Reduction Schedule** Policyholder Contribution Participation Minimum All Eligible Active Employees All Retireed Employees 1,678 363 Amounts from 1 to 3 times Amounts from $10,000 to salary in increments of 1 times $10,000 in increments of salary $10,000 $1,000 $500,000 To Next Higher $1,000 Not Applicable Earnings w/Comm 12 Months $250,000 $250,000 Included Not Included 6 Months To Age 65 To Age 65 To Age 65 $500,000 $10,000 Included Included 75% of Benefit Amount Not Included $500,000 35% at age 65 35% at age 65 50% at age 70 50% at age 70 35% at age 75 35% at age 75 0% 0% 25% 25% * For groups with Basic and Supplemental or Voluntary Life coverage, the Accelerated Death Benefit maximum applies to all coverages **Benefits are reduced by the percentage indicated and are calculated from the original amount at the attainment of the age shown. Quote ID: 46495 10 of 49 Dearborn National Voluntary AD&D - Employee Eligibility Voluntary AD&D Benefit Seat Belt Percentage Maximum Air Bag Percentage Maximum Education Benefit Percentage Annual Maximum Duration Repatriation Benefit Day Care Benefit Percentage Annual Maximum Duration Spouse Training Benefit Common Disaster Benefit Coma Benefit Percentage Maximum Duration Prepared for: City of Lubbock, Texas All Full Time Active Employees that work a minimum of 40 hours per week Same as Voluntary Life Included 10% $25,000 Included 5% $5,000 Included 3% $3,000 4 Years Actual costs to $5,000 Included 3% $5,000 5 Years $5,000 Increases spouse amount to equal employee amount. Maximum $150,000 Included 1% $1,000 11 Months Quote ID: 46495 11 of49 nenrborn NQtIOnCtt Voluntary Dependent Life Eligibility Spouse Benefit Not to Exceed Spouse Guarantee Issue Child Benefit Birth - 14 days 15 Days - 6 months 6 Months - Maximum Child Maximum Age Student Maximum Age Child Guarantee Issue Dependent Portability Dependent Conversion Age Reduction Schedule Prepared for: City of Lubbock, Texas All Eligible Active Employees Amounts from $5,000 to $50,000 in increments of $5,000 Includes Domestic Partners 100% of Employee Amount $50,000 $0 $100 Amounts from $2,500 to $10,000 in increments of $2,500 26 26 $10,000 Included Included Same As Employee All Retired Employees who Retired on or after January 1, 1974 but before December 1, 1995 Amounts from $2,000 to $2,000 in increments of $2,000 Includes Domestic Partners 100% of Employee Amount $50,000 Not Included Included Included Same As Employee Quote ID: 46495 12 of 49 Dearborn National Voluntary Dependent Life Eligibility Spouse Benefit Not to Exceed Spouse Guarantee Issue Child Benefit Birth - 14 days 15 Days - 6 months 6 Months - Maximum Child Maximum Age Student Maximum Age Child Guarantee Issue Dependent Portability Dependent Conversion Age Reduction Schedule Prepared for: City of Lubbock, Texas All Retired Employees who Retired on or after December 1, 199S Amounts from $2,500 to $2,500 in increments of $2,500 Includes Domestic Partners 100% of Employee Amount $50,000 $0 $0 Amounts from $1,000 to $1,000 in increments of $1,000 26 26 $10,000 Included Included Same As Employee Quote ID: 46495 13 of 49 Dearborn NQt IO'nat' Prepared for: City of Lubbock, Texas Underwriting Considerations for Group Life Coverage Underwriting Conditions • Employees must be legally working in the United States in order to be eligible for coverage. • Insured Persons enrolling more than 31 days after their initial eligibility date must submit satisfactory Evidence of Insurability for all benefit amounts. • Coverage for amounts in excess of the Guarantee Issue amount is not effective until the date we approve the application. • This proposal provides only basic information on the features of the policy. It is not intended to be a complete representation of all terms and conditions of the contract. A complete listing of the terms, conditions, limitations, exclusions and reduction of benefits is available upon request. In the event of conflict between this proposal and the policy, the terms of the policy will govern. • Product features and provisions may be slightly different due to state requirements. When sold, the actual policy for the state in which the policy is issued will reflect the state's requirements. • This proposal illustrates the cost of the insurance program and is based upon the information submitted by you. Actual cost will be determined after an application has been accepted and will depend upon data obtained when the program becomes effective. • The Voluntary Life guarantee issue amount shown in this proposal are offered to employees whose initial eligibility date (new hires) is on or after the effective date of coverage. • If the Voluntary Life Participation Minimum stated in the Plan Design Summary is met, all current amounts in force will be grandfathered, subject to the plan design maximums and the grandfathering limits stated in the Plan Design Summary. The Guarantee Issue amount shown in this proposal will only be offered to employees whose initial eligibility date (new hires) is on or after the effective date of coverage. Employees not previously covered, or those who have selected to increase their coverage, will need to provide satisfactory Evidence of Insurability. • Should the Voluntary Life Participation Minimum not be met, grandfathering will not apply and satisfactory Evidence of Insurability will be required for all amounts by all applicants, including those participating in the prior carrier's plan. Participation is measured based on the participation level achieved at initial enrollment with Dearborn National. A spouse application does not count toward the Participation Requirement. Transition of Coverage from Previous Carrier Most group life carriers have standardized provisions in their contracts that address issues concerning transition from one carrier to another. Each carrier has specific responsibilities to ensure that employees who are not actively at work at the time of the transition do not lose their coverage. The terminating carrier should retain responsibility for any employee who is disabled on the date of termination, regardless of whether or not the individual is on Waiver of Premium. It is recommended that this issue be discussed with the terminating carrier to verify how persons disabled on the effective date of our policy will be handled. Actively at Work • Actively at work requirements will be waived, provided premiums are paid when due, for employees who: • Are covered on the day immediately preceding our policy effective date; and • Were on lay-off, non -medical leave of absence or sabbatical leave; and who are being provided an extension of benefits with their prior carrier Coverage will continue for the balance of the time provided for under the prior carrier's policy, but not to exceed 12 months. We do not agree to waive the actively at work provision on other employees. Quote ID: 46495 14 of 49 Dearborn N( tion(I Prepared for: City of Lubbock, Texas Voluntary Short Term Disability Dearborn National's Group Voluntary Short Term Disability plans help replace lost income should an insured employee become disabled due to an accident or sickness, including pregnancy or complications from pregnancy. Voluntary Short Term Disability Rate and Cost Summary Proposed Effective Date*: October 01, 2014 Current Plan • All Full Time Active Employees Option 2 Age Band Rates Per $10 Weekly Benefit Monthly Below 20 $0.220 20-24 $0.222 25-29 0.22 30-34 $0.217 35-39 0. 40-44 $0.228 45-49 $0.248 50-54 $0.309 55-59 $0.414 60-64 $0.522 6 -69 $0.534 70-74 $0.604 75-79 $0.604 80-84 $0.604 85-89 0. 4 90-94 $0.604 9 -99 $0.604 100 and above 0. 04 Quote ID: 46495 15 of 49 Dearborn Naiiowd Prepared for: City of Lubbock, Texas • All Full Time Active Employees Option 1 Age Band Rates Per $10 Weekly Benefit Monthly Below 2 0. 20-24 $0.287 25-29 $0.298 30-34 $0.281 35-39 40-44 0. 45-49 0. 13 50- 4 $0.388 -59 $0.518 60-64 $0.653 6 -69 $0.667 70-74 $0.754 75-79 $0.754 8-4 0.74 -89 0. 4 90-94 $0.754 95-99 $0.754 100 an a ove $0.754 Rate Guarantee Period: 36 Months *Quote valid for two months following the proposed effective date Important Notes• The above rates and premium estimates are based on the employee data submitted by you. Final rates and premiums will be based on the plan and employee data provided by you at inception. This proposal is subject to exclusions and limitations in the policy issued by us. In addition, if coverage was inforce prior to the effective date of coverage, the rates quoted are subject to revisions based on acceptance and review of the inforce carrier's policy. Changes in risk that may impact the rates quoted include, but are not limited to: • The composition of the group, employees or dependents, changes by more than 10% • The employer contribution changes • Any of the plan designs are changed • A change in applicable law requires a change in the insurance provided by the policy or the classes of persons eligible for insurance under the policy. Quote ID: 46495 16 of 49 Dearborn NatIonaf Prepared for: City of Lubbock, Texas Voluntary Short Term Disability Plan Design Summary Eligibility Number of Employees VSTD Weekly Benefit Definition of Earnings Average Period Maximum Weekly Benefit Minimum Weekly Benefit Elimination Period Injury Sickness Benefits Begin Injury Sickness Maximum Period Payable Benefit Paid Survivor Benefit Worksite Modification Benefit Pre -Existing Condition Exclusion Occupational Injury/Sickness Definition of Disability Partial Disability Earnings Test Work Incentive Benefit Policyholder Contribution Employee Contribution Basis Participation Requirement Tax Services All Full Time Active Employees - 2 1,906 66.67% of weekly earnings Earnings w/Comm 12 Months $1,150 $25 7 Days 7 Days 8th Day 8th Day 13 weeks Until LTD Benefits Begin 3 weeks Included 12/12 Not Covered Total or Partial Disability 80% Included 0% Post -tax 25% W-2 Printing All Full Time Active Employees -1 201 60% of weekly earnings Earnings w/Comm 12 Months $1,150 $25 7 Days 7 Days 8th Day 8th Day 25 weeks Until LTD Benefits Begin 3 weeks Included 12/12 Not Covered Total or Partial Disability 80% Included 0% Post -tax 25% W-2 Printing Enhanced Product Services Offered with Voluntary Short Term Disability • W-2 Reporting for Claimants • Telephonic Claim Intake Underwriting Considerations for Voluntary Short Term Disability Underwriting Conditions • Employees must be legally working in the United States in order to be eligible for coverage. • Unless otherwise requested, Short Term Disability benefit payments will not begin until the employee's compensation payments from the employer, including but not limited to vacation pay, salary continuation or sick leave benefit payments, have ceased. • This proposal provides only basic information on the features of the policy. It is not intended to be a complete representation of all terms and conditions of the contract. A complete listing of the terms, conditions, limitations, exclusions and reduction of benefits is available upon request. In the event of conflict between this proposal and the policy, the terms of the policy will govern. • Product features and provisions may be slightly different due to state requirements. When sold, the actual policy for the state in which the policy is issued will reflect the state's requirements. • This proposal illustrates the cost of the insurance program and is based upon the information submitted by you. Actual cost will be determined after an application has been accepted and will depend upon data obtained when the program becomes effective. Quote ID: 46495 17 of 49 Dearborn NUtIonal Prepared for: City of Lubbock, Texas Voluntary Long Term Disability Dearborn National's Group Voluntary Long Term Disability plans provide long term income replacement security. Programs feature return to work claim management programs focused on personalized claim service. Voluntary Long Term Disability Rate and Cost Summary Proposed Effective Date*: October 01, 2014 Current Plan • All Active Full Time Employees Option 1 Age Band Rates Per $100 Monthly Covered Payroll Monthly Below 20 $0.140 20-24 $0.140 25-29 $0.160 30-34 $0.170 35-39 $0.180 40-44 $0.250 45-49 $0.310 50-54 $0.420 55-59 $0.640 60-64 $0.790 65-69 $0.790 70-74 $0.790 75-79 $0.790 80-84 $0.790 85-89 $0.790 90-94 $0.790 95-99 $0.790 100 and above $0.790 Quote ID: 46495 18 of 49 Dearborn Nationale Prepared for: City of Lubbock, Texas • All Active Full Time Employees Option 2 Age Band Rates Per $100 Monthly Covered Payroll Monthly Below 20 $0.160 20-24 $0.160 25-29 $0.180 30-34 $0.200 35-39 $0.210 40-44 $0.280 45-49 $0.360 50-54 $0.490 55-59 $0.740 60-64 $0.910 65-69 $0.910 70-74 $0.910 75-79 $0.910 80-84 $0.910 85-89 $0.910 90-94 $0.910 95-99 $0.910 100 and above $0.910 Rate Guarantee Period: 36 Months *Quote valid for two months following the proposed effective date Important Notes: The above rates and premium estimates are based on the employee data submitted by you. Final rates and premiums will be based on the plan and employee data provided by you at inception. This proposal is subject to exclusions and limitations in the policy issued by us. In addition, if coverage was inforce prior to the effective date of coverage, the rates quoted are subject to revisions based on acceptance and review of the inforce carrier's policy. Changes in risk that may impact the rates quoted include, but are not limited to: • The composition of the group, employees or dependents, changes by more than 10% • The employer contribution changes • Any of the plan designs are changed • A change in applicable law requires a change in the insurance provided by the policy or the classes of persons eligible for insurance under the policy. Quote ID: 46495 19 of 49 Dearborn NatIonal? Prepared for: City of Lubbock, Texas Voluntary Long Term Disability Plan Design Summary Eligibility LTD Benefit Definition of Earnings Average Period Maximum Monthly Benefit Minimum Monthly Benefit Elimination Period Accumulation of Elimination Period Maximum Period Payable Benefit Integration Own Occupation Period Partial Disability Income Earnings Test During Own Occ Period After Own Occ Period Pre -Disability Salary Indexing Work Incentive Benefit Offset Method Rehabilitative Incentive Income Offset Method Includes Day Care Benefit Expenses Per Child Months Mental Disorder Limitation Substance Abuse Limitation Special Conditions Limitation Limitation Basis Pre -Existing Condition Exclusion Survivor Benefit Worksite Modification Benefit Rehabilitation Benefit Maximum Duration Policyholder Contribution Employee Contribution Basis Participation Requirement All Active Full Time Employees 60% of monthly earnings Earnings w/Comm - 1 12 $5,000 $100 180 Days Up to 1/2 the Elimination Period SSNRA Primary and Family 24 Months with loss of duties and earnings Included 80% 60% Greater of 3% or average annual change in CPI-W 12 Months Proportionate Loss of Income 12 Months Proportionate Loss of Income $350 12 24 Months No Limitation 12 Months Per Lifetime 3/ 12 3 Months Greater of 2 times benefit amount or $1,500 5% $500 6 Months 0% Post -tax 57% All Active Full Time Employees 66.67% of monthly earnings Earnings w/Comm - 2 12 $5,000 $100 90 Days Up to 1/2 the Elimination Period SSNRA Primary and Family 24 Months with loss of duties and earnings Included 80% 60% Greater of 3% or average annual change in CPI-W 12 Months Proportionate Loss of Income 12 Months Proportionate Loss of Income $350 12 24 Months No Limitation No Limitation Per Lifetime 3/12 3 Months Greater of 2 times benefit amount or $1,500 5% $500 6 Months 0% Post -tax 57% Enhanced Product Services Offered with Voluntary Long Term Disability • Disability Resource Services • W-2 Reporting for Claimants Underwriting Considerations for Voluntary Long Term Disability Underwriting Conditions • Employees must be legally working in the United States in order to be eligible for coverage. • This proposal provides only basic information on the features of the policy. It is not intended to be a complete representation of all terms and conditions of the contract. A Quote ID: 46495 20 of 49 Dearborn NC1tIOnar Prepared for: City of Lubbock, Texas complete listing of the terms, conditions, limitations, exclusions and reduction of benefits is available upon request. In the event of conflict between this proposal and the policy, the terms of the policy will govern. Product features and provisions may be slightly different due to state requirements. When sold, the actual policy for the state in which the policy is issued will reflect the state's requirements. This proposal illustrates the cost of the insurance program and is based upon the information submitted by you. Actual cost will be determined after an application has been accepted and will depend upon data obtained when the program becomes effective. Quote ID; 46495 21 of49 Strength. Independence. Solutions. VOLUNTARY INSURANCE BENEFITS COMMUNICATION AND ENROLLMENT STRATEGY Employers want to provide comprehensive benefit programs to attract and retain valuable employees. Dearborn National has developed a flexible program of Voluntary, employee -funded benefits. By offering a valuable Voluntary program, an employer can significantly enhance its benefit portfolio at no additional cost. Offering Voluntary benefits I Z EMPLOYER ANNOUNCEMENT LETTER to your employees The group agrees to distribute a letter on its letterhead (paper empowers them to select or electronic) informing en'iployees that the Voluntary benefits the coverage that meets will be offered. This correspondence should be distributed three their needs and the needs to four vveeks before the enrollment. of their families. It is important that employees d POSTERS TO RAISE AWARENESS are aware of these benefits The group agrees to display awareness posters in gathering and understand their areas, cafeterias, break roorns or elevator banks, These posters value, This is accomplished will create a vareness of the upcoming benerit(s) being offered with a well -planned and inform employees where and when they can get more Communication and information and attend art enrollment meeting, The posters Enrollment strategy. Proper should bc on display two weeks before the enrollment meeting communication of benefits is held is important to the success of any Group Insurance [ HOLD ENROLLMENT MEETINGS Plan. It is essential that all Many employees need additional infromation to make a insureds have a thorough sound benefits selection. An enrollment meeting provides an understanding of exactly opportunity for employees to ask questions and receive ansavers what the coverage provides. from a benefit specialist. The group agrees to allow the broker/ enroller to conduct informational enrollment meetings. Offering of voluntary coverage, also includes (� DISTRIBUTE BENEFIT SUMMARIES the Communication and Enrollment Strategy as Group -specific Benefit Summaries provide detailed information outlined here. on available plans, empowering employees to make tho best decision for their individ! iai needs, The broker./enmller and grol.ip agrre to distribute Benefit Summaries to all employees during the o-nroilrment ieetings 'Ai t; dE'it'±i tilt :;°L' :iiia 1E (,i{?. t:1 •2 `i'::��;' 'i� l F:'�A' •"?' :.. 't�ci 4v: lf�n=:1 d i,'C•f t'i Dtii.':Jt� : S' LJc : �. ::) tltthj F.iFlir:a {j !'uf"to l7:a.. Quote ID: 46495 22 of 49 neal-born NQtIono,F Prepared for: City of Lubbock, Texas We Are Dearborn National Dearborn National° offers a broad selection of insurance and financial products that cover many markets - Voluntary and Employer Paid Group Benefits, Worksite, Individual and a wide array of enhanced product services. We serve groups and individuals, including some of the largest companies and most recognized names in the United States. A Strong Parent Company Our parent company, Health Care Service Corporation (HCSC), a Mutual Legal Reserve Company, is the largest non -investor owned health care insurance provider in the United States and the 41h largest overall. To learn more about our family of companies that make up HCSC, please visit www.hcsc.com. Strong Ratings The ratings of the Dearborn National companies speak to our commitment to managing our business well and remaining financially strong. Benefit programs in this proposal are underwritten by Dearborn National° Life Insurance Company. Dearborn National® Life Insurance Company is rated A+ (Superior)' by A.M. Best Company and A+ (Strong)2 by Standard & Poor's for financial strength in it's most recent report. A National Presence Through the underwriting companies of Dearborn National° Life Insurance Company, Dearborn National Life Insurance Company of New York, and Colorado Bankers Life Insurance Company°, we are licensed in all 50 states as well as the District of Columbia. 1 Affirmed December 19, 2013. A.M. Best Company rates the overall financial results of a company using a scale ofA++ (Superior) to F(In Liquidation). 2 Affirmed November 13, 2013. Standard & Poor's Insurer Financial Strength Rating uses a scale ranging from AAA (Extremely Strong) to R (Experienced Regulatory Action). Products and services marketed under the Dearborn National® brand and the star logo are underwritten and/or provided by Dearborn Nationale Life Insurance Company (Downers Grove, IL) in all states (excluding New York), the District of Columbia, the United States Virgin Islands, the British Virgin Islands and Puerto Rico. Quote ID: 46495 23 of 49 Dearborn NatIon.(A Prepared for: City of Lubbock, Texas Benefit Highlights Basic Life Eligibility Eligibility is as indicated in the Plan Design Summary. To be eligible, employees must be legally working in the United States and meet the eligibility requirements indicated in the Plan Design Summary. Insured Persons may have to complete a Waiting Period. Seasonal, part-time and temporary employees are not eligible. Effective Date If an insured person is absent from work due to injury or sickness on the last day of work prior to their effective date, the effective date of coverage will be delayed until 12:01 a.m. on the day coinciding with or next following their return to active work for a period of one day. Guarantee Issue Life Insurance Amounts up to the Guarantee Issue amount stated in the Plan Design Summary are offered with no need for Evidence of Insurability. Amounts in excess of the Guarantee Issue amount are subject to underwriting approval before becoming effective. Conversion Insureds who terminate employment, or lose a portion of their life coverage, may be able to convert their Life coverage to individual policies. Upon coverage termination administrators have 31 days after coverage ends to inform the insureds of their right to convert to an individual policy without evidence of insurability. Conversion does not apply to AD&D or Waiver of Premium amounts. Portability - Basic Life If Life coverage ceases for reasons other than retirement, sickness, injury or termination of the policy, eligible insured persons can purchase portable term life insurance without Evidence of Insurability. As long as premiums are paid, portable coverage continues until the insured reaches the maximum age indicated in the plan design summary. Accelerated Benefits Insureds who are diagnosed as being terminally ill can access a portion of their life insurance benefits while they are alive. The insured can accelerate a percentage of their life insurance amount, up to the maximum amount, as indicated in the Plan Design Summary. If life insurance benefits are subject to age reductions within 12 months of receiving proof of terminal illness, the accelerated death benefit will reduce accordingly. The minimum amount that can be accelerated and the definition of Terminally III are shown in the Additional Plan Features. Waiver of Premium We will continue coverage for insureds who become totally disabled and complete the Elimination Period shown on the Plan Design Summary. Life Insurance will be extended to the age as indicated in the Plan Design Summary, with no premium charge. The onset of the disability must occur before the insured reaches the age indicated in the Additional Plan Features and they must meet the definition of disability for the entire elimination period. The amount of insurance extended will be the amount of Life Insurance in force immediately prior to the date of the Total Disability. This amount is subject to any reductions under the policy. Quote ID: 46495 24 of 49 Dearborn NCLhonal` Prepared for: City of Lubbock, Texas Limitations and Exclusions Supplemental Life benefits, including Waiver of Premium, are not payable for a loss which is caused by a suicide or attempted suicide within one year of the effective date of coverage. Termination of Coverage The insured's life insurance will terminate on the earliest of the following dates: • The date the policy is terminated; • The date the insured stops making any required contribution toward payment of premiums; • The date the insured is no longer a member of an eligible class; • The date the insured requests termination of coverage. • The date the insured is no longer covered as a result of a disability, layoff, leave of absence, sabbatical or military leave. Extension of Coverage If an employee is no longer Actively at Work as a result of a disability, layoff, leave of absence, sabbatical or military duty, they may be able to continue to be eligible for group Life insurance coverage as follows: Disability - Until the end of the month following the period indicated in the Additional Plan Features after which the disability began, provided all premiums have been paid and the policy is still in force and has not been replaced with a new carrier. Layoff - Until the end of the month following the period indicated in the Additional Plan Features after which the layoff began, provided all premiums have been paid and the policy is still in force and has not been replaced with a new carrier. Leave of Absence - Until the end of the month following the period indicated in the Additional Plan Features after which the leave of absence began or the period of time in accordance with FMLA, provided all premiums have been paid and the policy is still in force and has not been replaced with a new carrier. Sabbatical - Until the end of the month following the period indicated in the Additional Plan Features after which the sabbatical began, provided all premiums have been paid and the policy is still in force and has not been replaced with a new carrier. Military Leave - Until the end of the month following the period indicated in the Additional Plan Features after which the disability began, provided all premiums have been paid and the policy is still in force and has not been replaced with a new carrier. Extension of Coverage for FMLA Leave If an insured is eligible for and receives approval for leave under the Family and Medical Leave Act of 1993 (FMLA) or any applicable state, family and medical leave law, insurance will continue (provided premium continues to be paid) for a period up to the later of: • The leave period permitted by FMLA and any amendments; or • The leave period permitted by applicable state law. Transition of Coverage from a Previous Carrier As an established group life insurance carrier, it has been our experience that most carriers have standardized procedures when it comes to determining responsibility for employee transition situations. Our position has been that the terminating carrier is responsible for anyone who was insured under their contract, but is disabled and does not meet the requirements of becoming Quote ID: 46495 25of49 Dearborn National Prepared for: City of Lubbock, Texas insured under our contract. This person may or may not be eligible for Waiver of Premium under the prior policy. It is our recommendation that this issue be discussed with the terminating carrier to identify any insured's who may not be eligible for coverage on the effective date of our policy. While awaiting the decision of the terminating carrier, it is recommended that the impacted employee apply for conversion. We will cover any eligible insureds who may be on vacation, leave of absence, observing a holiday, etc. on the effective date of our policy. Quote ID: 46495 26 of 49 Dearborn WitIOCIQl Prepared for: City of Lubbock, Texas Basic Accidental Death and Dismemberment Accidental Death and Dismemberment (AD&D) plan pays an additional benefit when a covered insured loses their life, or a limb due to an accident. Benefits are paid based on the following schedule. D&D SCHEDULE OF LOSSES BENEFIT AMOUNT Loss of Life 100% Loss of Both Hands or Both Feet 100% Loss of One Hand and One Foot 100% Loss of Speech and Hearing 100% Loss of Sight of Both Eyes 100% Loss of One hand and the Sight of One Eye 100% Loss of One Foot and the Sight of One Eye 100% Quadriplegia 100% Paraplegia 75% Hemiplegia 50% Loss of Sight of One Eye 50% Loss of One Hand or One Foot 50% Loss of Speech or Hearing 50% Loss of Thumb and Index Finger of Same Hand 25% Uniplegia 25% The following additional benefits are included with our Accidental Death & Dismemberment plan. For amount and availability of benefits, please refer to the Plan Design Summary. Seat Belt Benefit Pays an additional benefit, up to the percentage and maximum amounts indicated in the Plan Design Summary, if the covered insured dies in an automobile accident while wearing a properly worn seat belt. Air Bag Benefit Pays an additional benefit, up to the percentage and maximum amounts indicated in the Plan Design Summary, if the covered insured dies in an automobile accident while seated in a seat containing a factory installed air bag. Education Benefit Pays an additional benefit, up to the percentage and annual maximum indicated in the Plan Design Summary, if a covered insured dies in an accident and has qualified dependent children attending a school of higher learning. The benefit is payable for each insured child and up to four annual payments. Repatriation If a covered insured dies as a result of an accident more than 75 miles from their principal place of residence, the benefit pays the actual costs, up to the maximum amount indicated in the Plan Design Summary, for the preparation and transportation of the insured employee's body back to their home. Day Care Benefit If a covered insured dies as the result of an percentage and annual maximum indicated accident, a day care benefit, up to the in the Plan Design Summary, is payable for Quote ID: 46495 27 of 49 Dearborn NationaF Prepared for: City of Lubbock, Texas reimbursement of eligible day care expenses for each qualified dependent enrolled in a licensed day care facility. The benefit is payable each year up a maximum five years. Spouse Training Benefit If a covered insured dies as the result of an accident, a benefit is payable to the insured's spouse to cover their cost of education, up to the maximum amount indicated in the Plan Design Summary, if they enroll in a school of higher learning within one year of the insured's death. Coma Benefit If a covered insured is injured in an accident, becomes comatose within 31 days of the accident, and remains comatose for a period of at least 60 days, we will pay a percentage of the insured's benefit amount, on a monthly basis. The percentage, monthly maximum and number of months are as indicated in the Plan Design Summary. Reduction Schedule Benefits reduce according to the schedule indicated in the Plan Design Summary. All reduction percentages are from the original amount. Exclusions Unless specifically covered in the policy, or required by state law, we will not pay any AD&D benefit for any loss that, directly or indirectly, results in any way from or is contributed to by: • Disease of the mind or body, or any treatment thereof; • Infections, except those from an accidental cut or wound; • Suicide or attempted suicide; • Intentionally self-inflicted injury; • War or act of war; • Travel or flight in any aircraft while a member of the crew; • Commission of or participation in a felony; • Under the influence certain drugs, narcotics or hallucinogens unless properly used as prescribed by a physician; • Intoxication as defined in the jurisdiction where the accident occurred; • Participation in a riot. Quote ID: 46495 28 of 49 Dearborn National Prepared for: City of Lubbock, Texas Enhanced Product Services Included with Group Term Life Beneficiary Resource Services TM: A Wellness Plan for Life When a loved one dies, families often face complex issues ranging from estate planning, legal questions, funeral planning, coping with grief and financial uncertainties. That's why Dearborn National offers Beneficiary Resource Services, a program that combines family wellness and security at the most difficult of times. Services include grief and financial counseling, funeral planning, legal support as well as online will preparation. Beneficiary Resource Services is provided by Bensinger, DuPont & Associates (BDA). Services for insureds and their families. Online Will Preparation- A will is one of the most important documents every adult should have, and creating one has never been easier. Insureds and their families will have access to a full legal library with many estate planning documents, including an online will. Insureds can create their own wills online in a safe and secure way, right from their homes. The will can be saved and updated as family situations change. Creating a will provides security and peace of mind for several reasons: • Appoints a guardian for children • Controls where property and assets go • Provides family security • Without one, the state can make these decisions Funeral Planning - Insureds and beneficiaries have access to an online funeral planning site that features a variety of helpful tools and information, such as: • A downloadable funeral planning guide for insureds to document vital information their loved ones will need when making final arrangements • Calculators to estimate and compare expenses for various types of funeral arrangements • Information on funeral requirements and various religious customs • Directories to locate funeral homes and cemeteries in the insured's area Services for beneficiaries (and their families) after a death claim or for those that qualify for an accelerated death benefit Unlimited Phone Contact - Available for up to one year with a grief counselor, legal advisor or financial planner. Face -to -Face Working Sessions* - Five face-to-face working sessions are available to the insured person or beneficiary. All five sessions may be used with one grief counselor or legal advisor, or they may be split among the two types of counselors or advisors in geographically accessible locations. A one -hour financial consultation on the phone is also available. *May include face-to-face sessions, over -the -phone sessions or time taken for research or document preparation. Referrals and Support Services - BDA maintains a comprehensive directory of qualified and accessible grief counselors and legal and financial consultants. Follow Up - Counselors will initiate follow-up calls when necessary for up to one full year from the date of initial contact. Quote ID: 46495 29 of 49 nearborn Nationay Prepared for: City of Lubbock, Texas RDA's nationwide network of experienced professionals can offer counseling for individuals facing difficult emotional, financial or legal issues. BDA's counselors are available 24 hours a day, 365 days a year. All calls are completely confidential. Travel Resource Services' In today's global economy, the need for world travel is now greater than ever. However, a trip, whether for business or pleasure, can be disrupted by the unexpected. A medical emergency, a lost prescription or even emergencies involving a spouse, child or traveling companion can jeopardize a trip. To provide the support people need while traveling on business or pleasure, we provide Travel Resource ServiceS2, a program that assists travelers if the unexpected happens. Services are available to insureds and their families traveling 100 or more miles from their primary residence, and include: • Medical Search and Referral • Medical Evacuation/Return Home • Dependent Children Assistance • Return of Mortal Remains • Emergency Message Relay • Emergency Cash • Legal Assistance/Bail • Pre -Trip Information • Medical Monitoring • Traveling Companion Assistance • Visit by Family Member/Friend • Replacement of Medication and Eyeglasses • Emergency Travel Arrangements • Locating Lost or Stolen Items • Interpretation/Translation 1 Travel Assistance Services are provided to groups with 50 or more employees; Not available in all states. Z We contract with Europ Assistance USA, Inc. to provide the Travel Resource Services. We do not provide any part of the Travel Resource Services. Quote ID: 46495 30 of 49 Dearborn National Prepared for: City of Lubbock, Texas Additional Plan Features Basic Life All Retireed All Retireed All Retireed Employees Employees All Eligible Employees who retireed who retireed Active who retireed on or after on or after Employees on or after April 1, 1988 January 1, December but before 1974 but 1, 1995 December before April 1, 1995 1, 1988 Option Current Plan Current Plan Current Plan Current Plan Waiver of Premium - Definition of Any Occupation Not Applicable Not Applicable Not Applicable Disability Waiver of Premium - Maximum Qualifying 60 Not Applicable Not Applicable Not Applicable Age Waiver of Premium - Specific Conditions Not Applicable Not Applicable Not Applicable Not Applicable Benefit Extended Insurance Benefit - Definition of Not Applicable Not Applicable Not Applicable Not Applicable Disability Extended Insurance Benefit - Maximum Not Applicable Not Applicable Not Applicable Not Applicable Qualifying Age Extended Insurance Not Applicable Not Applicable Not Applicable Not Applicable Benefit - Duration FMLA Extension Included Included Included Included Extension Disability 12th Month 12th Month 12th Month 12th Month Layoff Next month Next month Next month Next month Leave Next month Next month Next month Next month Sabbatical 6th Month 6th Month 6th Month 6th Month Military Leave 12th Month 12th Month 12th Month 12th Month Accelerated Death - Minimum $15,000 Not Applicable Not Applicable Not Applicable Accelerated Death Benefit - Definition of 12 Months Not Applicable Not Applicable Not Applicable Terminal Illness Quote ID: 46495 31 of49 Dearborn National Prepared for: City of Lubbock, Texas Benefit Highlights Voluntary Life Eligibility Eligibility is as indicated in the Plan Design Summary. To be eligible, employees must be legally working in the United States and meet the eligibility requirements indicated in the Plan Design Summary. Insured Persons may have to complete a Waiting Period. Seasonal, part-time and temporary employees are not eligible. Effective Date If an insured person is absent from work due to injury or sickness on the last day of work prior to their effective date, the effective date of coverage will be delayed until 12:01 a.m. on the day coinciding with or next following their return to active work for a period of one day. Guarantee Issue Voluntary Life Insurance Amounts up to the Guarantee Issue amount stated in the Plan Design Summary are offered with no need for Evidence of Insurability. Amounts in excess of the Guarantee Issue amount are subject to underwriting approval before becoming effective. Conversion Insureds who terminate employment, or lose all or a portion of their coverage for other reasons may be able to convert all or a portion of their Life coverage to individual policies. Upon coverage termination administrators have 31 days after coverage ends to inform the insureds of their right to convert to an individual policy without evidence of insurability. Conversion does not apply to AD&D or Waiver of Premium amounts. Portability If Voluntary Life coverage ceases for reasons other than retirement, sickness, injury or termination of the policy, eligible insured persons can purchase portable term life insurance without Evidence of Insurability. As long as premiums are paid, portable coverage continues until the insured reaches the maximum age indicated in the plan design summary. Accelerated Benefits Insureds who are diagnosed as being terminally ill can access a portion of their life insurance benefits while they are alive. The insured can accelerate a percentage of their life insurance amount, up to the maximum amount, as indicated in the Plan Design Summary. If life insurance benefits are subject to age reductions within 12 months of receiving proof of terminal illness, the accelerated death benefit will reduce accordingly. The minimum amount that can be accelerated and the definition of Terminally III are shown in the Additional Plan Features. Waiver of Premium We will continue coverage for insureds who become totally disabled and complete the Elimination Period shown on the Plan Design Summary. Voluntary Life Insurance will be extended to the age as indicated in the Plan Design Summary, with no premium charge. The onset of the disability must occur before the insured reaches the age indicated in the Additional Plan Features and they must meet the definition of disability for the entire elimination period. The amount of insurance extended will be the amount of Life Insurance Quote ID: 46495 32 of 49 Dearborn National* Prepared for: City of Lubbock, Texas in force immediately prior to the date of the Total Disability. This amount is subject to any reductions under the policy. Consolidated Claim Management for Life and Long Term Disability For those insured under our Life and Long Term Disability programs, we have a seamless claim process for filing claims for Waiver of Premium and Long Term Disability. The claimant simply completes one claim form, and we handle the rest. Reduction of Benefits The Insured's Voluntary life insurance amount will reduce upon reaching the ages as indicated in the Plan Design Summary. All reduction percentages are calculated from the original amount. Limitations and Exclusions Voluntary Life benefits, including Waiver of Premium, are not payable for a loss which is caused by a suicide or attempted suicide within one year of the effective date of coverage. Termination of Coverage The insured's Voluntary life insurance will terminate on the earliest of the following dates: • The date the policy is terminated; • The date the insured stops making any required contribution toward payment of premiums; • The date the insured is no longer a member of an eligible class, requests termination of coverage. • The date the insured is no longer covered as a result of a disability, layoff, leave of absence, sabbatical or military leave. Extension of Coverage If an employee is no longer Actively at Work as a result of a disability, layoff, leave of absence, sabbatical or military duty, they may be able to continue to be eligible for Voluntary Life insurance coverage as follows: Disability - Until the end of the month following the period indicated in the Additional Plan Features after which the disability began, provided all premiums have been paid and the policy is still in force and has not been replaced with a new carrier. Layoff - Until the end of the month following the period indicated in the Additional Plan Features after the layoff began, provided all premiums have been paid and the policy is still in force and has not been replaced with a new carrier. Leave of Absence - Until the end of the month following the period indicated in the Additional Plan Features after which the leave of absence began or the period of time in accordance with FMLA, provided all premiums have been paid and the policy is still in force and has not been replaced with a new carrier. Sabbatical - Until the end of the month following the period indicated in the Additional Plan Features after the sabbatical began, provided all premiums have been paid and the policy is still in force and has not been replaced with a new carrier. Military Leave - Until the end of the month following period indicated in the Additional Plan Features after which the disability began, provided all premiums have been paid and the policy is still in force and has not been replaced with a new carrier. Quote ID: 46495 33 of 49 Dearborn Nationf' Prepared for: City of Lubbock, Texas Extension of Coverage for FMLA Leave If an insured is eligible for and receives approval for leave under the Family and Medical Leave Act of 1993 (FMLA) or any applicable state, family and medical leave law, insurance will continue (provided premium continues to be paid) for a period up to the later of: • The leave period permitted by FMLA and any amendments; or • The leave period permitted by applicable state law. Transition of Coverage from a Previous Carrier As an established group life insurance carrier, it has been our experience that most carriers have standardized procedures when it comes to determining responsibility on employee transition situations. Our position has been that the terminating carrier is responsible for anyone who was insured under their contract, but is disabled and does not meet the requirements of becoming insured under our contract. This person may or may not be eligible for Waiver of Premium under the prior policy. It is our recommendation that this issue be discussed with the terminating carrier to identify any insured's who may not be eligible for coverage on the effective date of our policy. While awaiting the decision of the terminating carrier, it is recommended that the impacted employee apply for conversion. We will cover any eligible insureds who may be on vacation, leave of absence, observing a holiday, etc. on the effective date of our policy. Quote ID: 46495 34 of 49 MCL of National Prepared for: City of Lubbock, Texas Voluntary Accidental Death and Dismemberment Our Voluntary Accidental Death and Dismemberment (AD&D) plan pays an additional benefit when a covered insured loses their life, or a limb due to an accident. Benefits are paid based on the following schedule. AD&D SCHEDULE OF LOSSES BENEFIT AMOUNT Loss of Life 100% Loss of Both Hands or Both Feet 100% Loss of One Hand and One Foot 100% Loss of Speech and Hearing 1000/0 Loss of Sight of Both Eyes 1000/0 Loss of One Hand and the Sight of One Eye 100% Loss of One Foot and the Sight of One Eye 100% Quadriplegia 100% Paraplegia 75% Hemiplegia 50% Loss of Sight of One Eye 50% Loss of One Hand or One Foot 50% Loss of Speech or Hearing 50% Loss of Thumb and Index Finger of Same Hand 25% Uniplegia 25% The following additional benefits are included with our Accidental Death & Dismemberment plan. For amount and availability of benefits, please refer to the Plan Design Summary. Seat Belt Benefit Pays an additional benefit, up to the percentage and maximum amounts indicated in the Plan Design Summary, if the covered insured dies in an automobile accident while wearing a properly worn seat belt. Air Bag Benefit Pays an additional benefit, up to the percentage and maximum amounts indicated in the Plan Design Summary, if the covered insured dies in an automobile accident while seated in a seat containing a factory installed air bag. Education Benefit Pays an additional benefit, up to the percentage and annual maximum indicated in the Plan Design Summary, if a covered insured dies in an accident and has qualified dependent children attending a school of higher learning. The benefit is payable for each insured child and up to four annual payments. Repatriation If a covered insured dies as a result of an accident more than 75 miles from their principal place of residence, the benefit pays the actual costs, up to the maximum amount indicated in the Plan Design Summary, for the preparation and transportation of the insured employee's body back to their home. Day Care Benefit If a covered insured dies as the result of an accident, a day care benefit, up to the percentage and annual maximum indicated in the Plan Design Summary, is payable for Quote ID: 46495 35 of 49 MOXborn NQtI®nal° Prepared for: City of Lubbock, Texas reimbursement of eligible day care expenses for each qualified dependent enrolled in a licensed day care facility. The benefit is payable each year up a maximum five years. Spouse Training Benefit If a covered insured dies as the result of an accident, a benefit is payable to the insured's spouse to cover their cost of education, up to the maximum amount indicated in the Plan Design Summary, if they enroll in a school of higher learning within one year of the insured's death. Common Disaster Benefit If a covered insured dies as the result of an accident, and their insured spouse dies in the same accident, or separate accidents occurring within 24 hours of each other, we will increase the insured spouse's benefit to equal the benefit of the insured, up to the maximum amount shown in the Plan Design Summary. Coma Benefit If a covered insured is injured in an accident, becomes comatose within 31 days of the accident, and remains comatose for a period of at least 60 days, we will pay a percentage of the insured's benefit amount, on a monthly basis. The percentage, monthly maximum and number of months are as indicated in the Plan Design Summary. Reduction Schedule Benefits reduce according to the schedule indicated in the Plan Design Summary. All reduction percentages are from the original amount. Exclusions Unless specifically covered in the policy, or required by state law, we will not pay any AD&D benefit for any loss that, directly or indirectly, results in any way from or is contributed to by: • Disease of the mind or body, or any treatment thereof; • Infections, except those from an accidental cut or wound; • Suicide or attempted suicide; • Intentionally self-inflicted injury; • War or act of war; • Travel or flight in any aircraft while a member of the crew; • Commission of or participation in a felony; • Under the influence certain drugs, narcotics or hallucinogens unless properly used as prescribed by a physician; • Intoxication as defined in the jurisdiction where the accident occurred; • Participation in a riot. Quote ID: 46495 36 of 49 Dearborn National,. Prepared for: City of Lubbock, Texas Voluntary Dependent Life Insurance Dependent Effective Date of Coverage If the insured meets the effective date requirements, then the dependents are eligible for coverage unless confined to a hospital. If hospitalized dependent coverage will become effective on the date the eligible dependent is no longer hospital confined. Spouse Coverage A covered spouse , which includes Domestic Partners where permitted, will be covered for the amount indicated in the Plan Design Summary. In order for a spouse to be covered, the eligible insured person must also be covered. A spouse cannot be insured for more than 100% of the amount the insured person is eligible for. Spouse Guarantee Issue Spouse amounts up to the Guarantee Issue amount stated in the Plan Design Summary are offered with no need for Evidence of Insurability. Amounts in excess of the Guarantee Issue amount are subject to underwriting approval before becoming effective. Dependent Child Coverage Eligible Dependent Children will be covered for the amounts as indicated in the Plan Design Summary. Dependent children are covered until reaching the ages indicated in the Plan Design Summary. Portability If Voluntary Life coverage ceases for reasons other than the employees retirement or termination of the policy, eligible insured dependents can purchase portable term life insurance without Evidence of Insurability. As long as premiums are paid, portable coverage continues until the spouse reaches the maximum age indicated in the plan design summary. Conversion Dependents whose coverage terminates may be able to convert their Voluntary Life coverage to individual policies. Upon coverage termination administrators have 31 days after coverage ends to inform the dependents of their right to convert to an individual policy without evidence of insurability. Conversion does not apply to amounts. Termination of Dependent Life Insurance Dependent Life insurance will end on the earliest of the following: • The date the insured person is no longer covered under the policy; • The date the Policy is terminated; • The date any required premiums cease to be paid; or • The date the dependent is no longer an eligible dependent under the policy. Quote ID: 46495 37 of 49 Dectrbom NOMonal Prepared for: City of Lubbock, Texas Enhanced Product Services Included with Group Term Life Beneficiary Resource Services TM: A Wellness Plan for Life When a loved one dies, families often face complex issues ranging from estate planning, legal questions, funeral planning, coping with grief and financial uncertainties. That's why Dearborn National offers Beneficiary Resource Services, a program that combines family wellness and security at the most difficult of times. Services include grief and financial counseling, funeral planning, legal support as well as online will preparation. Beneficiary Resource Services is provided by Bensinger, DuPont & Associates (BDA). Services for insureds and their families. Online Will Preparation- A will is one of the most important documents every adult should have, and creating one has never been easier. Insureds and their families will have access to a full legal library with many estate planning documents, including an online will. Insureds can create their own wills online in a safe and secure way, right from their homes. The will can be saved and updated as family situations change. Creating a will provides security and peace of mind for several reasons: • Appoints a guardian for children • Controls where property and assets go • Provides family security • Without one, the state can make these decisions Funeral Planning - Insureds and beneficiaries have access to an online funeral planning site that features a variety of helpful tools and information, such as: • A downloadable funeral planning guide for insureds to document vital information their loved ones will need when making final arrangements • Calculators to estimate and compare expenses for various types of funeral arrangements • Information on funeral requirements and various religious customs • Directories to locate funeral homes and cemeteries in the insured's area Services for beneficiaries (and their families) after a death claim or for those that qualify for an accelerated death benefit Unlimited Phone Contact - Available for up to one year with a grief counselor, legal advisor or financial planner. Face -to -Face Working Sessions* - Five face-to-face working sessions are available to the insured person or beneficiary. All five sessions may be used with one grief counselor or legal advisor, or they may be split among the two types of counselors or advisors in geographically accessible locations. A one -hour financial consultation on the phone is also available. *May include face-to-face sessions, over -the -phone sessions or time taken for research or document preparation. Referrals and Support Services - BDA maintains a comprehensive directory of qualified and accessible grief counselors and legal and financial consultants. Follow Up - Counselors will initiate follow-up calls when necessary for up to one full year from the date of initial contact. Quote ID: 46495 38 of 49 Dern NatIOnaY Prepared for: City of Lubbock, Texas RDA's nationwide network of experienced professionals can offer counseling for individuals facing difficult emotional, financial or legal issues. BDA's counselors are available 24 hours a day, 365 days a year. All calls are completely confidential. Travel Resource Services' In today's global economy, the need for world travel is now greater than ever. However, a trip, whether for business or pleasure, can be disrupted by the unexpected. A medical emergency, a lost prescription or even emergencies involving a spouse, child or traveling companion can jeopardize a trip. To provide the support people need while traveling on business or pleasure, we provide Travel Resource Servicesz, a program that assists travelers if the unexpected happens. Services are available to insureds and their families traveling 100 or more miles from their primary residence, and include: • Medical Search and Referral • Medical Evacuation/Return Home • Dependent Children Assistance • Return of Mortal Remains • Emergency Message Relay • Emergency Cash • Legal Assistance/Bail • Pre -Trip Information • Medical Monitoring • Traveling Companion Assistance • Visit by Family Member/Friend • Replacement of Medication and Eyeglasses • Emergency Travel Arrangements • Locating Lost or Stolen Items • Interpretation/Translation 1 Travel Assistance Services are provided to groups with 50 or more employees; Not available in all states. Z We contract with Europ Assistance USA, Inc. to provide the Travel Resource Services. We do not provide any part of the Travel Resource Services. Travel Resource Services' In today's global economy, the need for world travel is now greater than ever. However, a trip, whether for business or pleasure, can be disrupted by the unexpected. A medical emergency, a lost prescription or even emergencies involving a spouse, child or traveling companion can jeopardize a trip. To provide the support people need while traveling on business or pleasure, we provide Travel Resource Services', a program that assists travelers if the unexpected happens. Services are available to insureds and their families traveling 100 or more miles from their primary residence, and include: • Medical Search and Referral • Medical Evacuation/Return Home • Dependent Children Assistance • Return of Mortal Remains • Emergency Message Relay • Emergency Cash • Legal Assistance/Bail • Pre -Trip Information • Medical Monitoring • Traveling Companion Assistance • Visit by Family Member/Friend • Replacement of Medication and Eyeglasses • Emergency Travel Arrangements • Locating Lost or Stolen Items • Interpretation/Translation 1 Travel Assistance Services are provided to groups with 50 or more employees; Not available in all states. z We contract with Europ Assistance USA, Inc. to provide the Travel Resource Services. We do not provide any part of the Travel Resource Services. Quote ID: 46495 39 of 49 Dearborn h National" Prepared for: City of Lubbock, Texas Quote ID: 46495 40 of 49 Dearborn National Prepared for: City of Lubbock, Texas Additional Plan Features Voluntary Life All Eligible All Retireed Active Employees Employees Option Current Plan Current Plan Waiver of Premium - Definition of Disability Any Occupation Not Applicable Waiver of Premium - Maximum Qualifying 60 Not Applicable Age Waiver of Premium - Specific Conditions Not Applicable Not Applicable Benefit Extended Insurance Benefit - Definition of Not Applicable Not Applicable Disability Extended Insurance Benefit - Maximum Not Applicable Not Applicable Qualifying Age Extended Insurance Benefit - Duration Not Applicable Not Applicable FMLA Extension Included Included Extension Disability 12th Month 12th Month Layoff Next month Next month Leave Next month Next month Sabbatical 6th Month 6th Month Military Leave 12th Month 12th Month Accelerated Death - Minimum $15,000 Not Applicable Accelerated Death Benefit - Definition of 12 Months Not Applicable Terminal Illness Quote ID: 46495 41 of49 Dearborn National Prepared for: City of Lubbock, Texas Benefit Highlights Voluntary Short Term Disability Insurance Eligibility Eligibility is as indicated in the Plan Design Summary. To be eligible, employees must be legally working in the United States and regularly working the minimum number of hours as agreed. Employees may have to complete a Waiting Period. Seasonal, part-time and temporary employees are not eligible. Elimination Period Elimination Period is the period of time from the onset of disability until benefits begin. The elimination period is indicated in the Plan Design Summary. Unless otherwise indicated, benefits begin upon exhaustion of all other sick leave, vacation, PTO or other salary continuation plans. Total Disability is not required during the elimination period and can be satisfied with days of Partial or Total Disability. Additionally, there is no earnings loss requirement during the elimination period. Trial Work Day Period To encourage employees to return to work, employees may attempt to return to work full-time during their elimination period, without being required to restart the elimination period. Employees can temporarily return to work for a period of up to 1/2 the elimination period, maximum 14 days, and not have to begin their elimination period again if they stop working due to the same condition. Maximum Period Payable Voluntary STD benefits are payable for the complete number of weeks indicated on the Plan Design Summary, or until LTD benefits are payable, whichever occurs first. The Maximum Period shown does not include the elimination period. Survivor Benefit If a disabled employee dies after receiving disability benefits for more than three consecutive weeks, we will pay the beneficiary of the disabled employee a lump sum benefit equal to the amount shown in the Plan Design Summary. Worksite Modification Benefit This benefit assists in covering the cost of modifying the disabled employee's worksite to allow that employee to return to work. Once all parties agree on the modification to be performed, we will reimburse the employer the actual cost of the modification, up to the greater of two times the employee's weekly benefit, or $1,500, unless otherwise indicated. Pre -Existing Condition Limitation Benefits are not payable for disability caused by conditions that existed on the employee's effective date as indicated below: • A sickness or injury for which the employee received medical treatment, or advice was rendered, prescribed or recommended whether or not the sickness was diagnosed at all or within the number of months shown in the Plan Design Summary prior to the employee's effective date, and • Begins within the number of months shown in the Plan Design Summary of the employee's effective date. Definition of Disability Disabled means that the employee is Totally Disabled or Partially Disabled due to an injury or sickness. The employee must be under the regular care of a doctor who is appropriate for the disabling condition. Loss of professional license or certification does not in and of itself mean the employee is Disabled. Total Disability To be considered Totally Disabled, the insured must be unable to perform the material and substantial duties of their regular occupation and have a loss of income. Quote ID: 46495 42 of 49 vearborn Nationals Prepared for: City of Lubbock, Texas Partial Disability To be considered Partially Disabled, the insured must have suffered an injury or sickness, is able to perform some but not all of the material and substantial duties of their regular occupation, and as a result is earning between 20% and the percentage of their pre - disability income indicated in the Plan Design Summary. Work Incentive Benefit If the employee meets the definition of Partial Disability, they are eligible to receive a Work Incentive Benefit. To encourage disabled employees to return to work in some capacity, we standardly offer a Work Incentive Benefit on all Voluntary STD contracts. The Work Incentive Benefit pays the full monthly benefit as long as the combination of the benefit plus earnings does not exceed 100% of their pre -disability income. If benefits are due for a period of less than one week, payments will be made at a daily rate of 1/7th of the weekly benefit. Extension of Coverage for FMLA Leave If an insured employee is eligible for and received approval for leave under the Family and Medical Leave Act of 1993 (FMLA) or any applicable state family and medical leave law, insurance will continue (provided premium continues to be paid) for a period up to the later of: • The leave period permitted by FMLA and any amendments; or • The leave period permitted by applicable state law. Exclusions • Loss of professional license, occupational license or certification; • Pre -Existing condition; • Commission of, participation in, or an attempt to commit an assault or felony; • Intentionally self-inflicted injuries; • Attempted suicide, regardless of mental capacity; • Cosmetic surgery, except when required due to injury or sickness • Occupational injury or sickness • Participation in a war, declared or undeclared, or any act of war Quote ID: 46495 43of49 Dearborn National'' Prepared for: City of Lubbock, Texas Enhanced Product Services Included with Voluntary Short Term Disability Insurance Telephonic Claim Reporting To streamline Voluntary STD claim intake, we offer a telephonic claim intake process. To initiate the claim, the employee calls us toll -free and answers a few simple questions. After the claim number is assigned and medical record release authorization is obtained, we contact the employer and physician as needed. Online Claim Status Through our Benefits Manager web portal, employers have online access to Voluntary STD claim information. Two reports are available - Pending Disability Claim Report includes new claims awaiting evaluation, claims awaiting payment, and claims in the appeal process. Experience Disability Claim Report includes claims on which payments have been made and are still open, closed, or in the appeal process. W-2 Reporting Upon request, we will prepare and mail W-2 Wage and Tax Statements to employees at no additional charge to the employer. If we have agreed to pay the employer's share of FICA taxes, we will prepare and mail W-2 Wage and Tax Statements. We prepare W-2 Wage and Tax Statements using the applicable insuring company's federal tax identification number. A signed FICA Match / W2 Tax Agreement is required on all disability cases. Quote ID: 46495 44 of 49 Dearborn National Prepared for: City of Lubbock, Texas Benefit Highlights Voluntary Long Term Disability Insurance Eligibility Eligibility is as indicated in the Plan Design Summary. To be eligible, employees must be legally working in the United States and regularly working the minimum number of hours as agreed. Employees may have to complete a Waiting Period. Seasonal, part-time and temporary employees are not eligible. Elimination Period Elimination Period is the period of time from the onset of disability until benefits begin. The elimination period is indicated in the Plan Design Summary. Total Disability is not required during the elimination period and can be satisfied with days of Partial or Total Disability. Additionally, there is no earnings loss requirement during the elimination period Trial Work Day Period To encourage employees to return to work, employees may attempt to return to work full- time during their elimination period, without being required to restart the elimination period. Employees can temporarily return to work for a period up to 1/2 the elimination period and do not have to begin their elimination period again if they stop working due to the same condition. Maximum Period Payable Voluntary Long Term Disability Benefits are payable based on the following schedule. Social Security Normal Retirement Age (SSNRA) The maximum period of payment will be determined according to the following table: Age When Disability Begins Maximum Period Payable Less than age 60 To Social Security Normal Retirement Age (SSNRA) Age 60 60 months or to SSNRA, whichever is greater Age 61 48 months or to SSNRA, whichever is greater Age 62 42 months or to SSNRA, whichever is greater Age 63 36 months or to SSNRA, whichever is greater Age 64 30 months or to SSNRA, whichever is greater Age 65 24 months Age 66 21 months Age 67 18 months Age 68 15 months Age 69 and over 12 months Definition of Disability Disabled means that the employee is Totally Disabled or Partially Disabled due to an injury or sickness. The employee must be under the regular care of a doctor who is appropriate for the disabling condition. Loss of professional license or certification does not in and of itself mean the employee is Disabled. Total Disability During the Own Occupation Period as indicated in the Plan Design Summary, Totally Disabled means the insured must be unable to perform the material and substantial duties of their regular occupation and/or* have disability earnings less than 20% of their pre - disability income. Quote ID: 46495 45 of 49 Dearborn NQtIoncd Prepared for: City of Lubbock, Texas After the own occ period, Totally Disabled means the insured must be unable to engage in any gainful occupation and/or* have disability earnings less than 20% of their pre -disability income. * See Plan Design Summary for class specifics Partial Disability During the Own Occupation Period as indicated in the Plan Design Summary, Partially Disabled means the insured must have suffered an injury or sickness and as a result is earning between 20% and the percentage of their pre -disability income as indicated in the Plan Design Summary. Following the own occupation period, Partially Disabled means the insured is gainfully employed and earning between 20% and the percentage of their pre - disability income indicated in the Plan Design Summary. During the elimination period, there does not need to be a loss of income to be considered either Partially or Totally Disabled. Recurrent Disability If disability for which benefits were payable ends but recurs due to the same or related causes less than 6 months after the end of a prior disability, it will be considered a resumption of the prior disability. Such recurrent disability shall be subject to the provisions of the policy that were in effect at the time the prior disability began. Disability which recurs more than 6 months after the end of a prior disability is subject to: • A new Elimination Period; • A new Maximum Period Payable; and • The other provisions of the policy that are in effect on the date the disability recurs. Disability must recur while the employee's coverage is in force under the policy. Voluntary LTD Monthly Benefit If the employee meets the definition of Total Disability, they are eligible to receive a Voluntary LTD Monthly Benefit. Work Incentive Benefit If the employee meets the definition of Partial Disability, they are eligible to receive a Work Incentive Benefit. To encourage disabled employees to return to work in some capacity, a Work Incentive Benefit is offered to all Partially Disabled employees. For the number of months indicated in the Plan Design Summary, we will pay the full monthly benefit as long as the combination of the benefit plus earnings does not exceed 100% of their indexed pre -disability income. After this period, our benefit will be calculated by multiplying the benefit times the adjusted loss of salary ratio. Rehabilitative Incentive Income A unique standard feature of the Voluntary LTD contract is the Rehabilitation Incentive Income feature. If we identify a partially disabled employee as a candidate for a rehabilitation program, we will work with them to structure a voluntary rehabilitation plan that assists the employee in returning to employment. The Plan details the vocational rehabilitation services available to the employee. While the employee is participating in a voluntary rehabilitation plan, and continues to meet the obligations of the program, we will allow the employee to retain a combination of benefits and disability income in excess of 100% of their indexed pre -disability income, for 12 months. After 12 months, we will offset the Voluntary LTD benefit by multiplying the benefit times the adjusted loss of salary ratio. Quote I D : 46495 46 of 49 Dearborn NQtIonol' Prepared for: City of Lubbock, Texas Pre -Existing Condition Exclusion Benefits are not payable for a disability caused by a condition that existed on the employee's effective date as indicated below: • A sickness or injury for which the employee received medical treatment, or advice was rendered, prescribed or recommended whether or not the sickness was diagnosed at all or misdiagnosed within the number of months prior to the employee's effective date as indicated in the Plan Design Summary, and • The condition results in a Disability that begins within the number of months after the employee's effective date as indicated in the Plan Design Summary . Continuity of Coverage (No Loss/No Gain) If an employee was insured under the prior policy on the day before this policy's effective date due to a continuance or extension of coverage, the employee may have limited coverage under this policy even if they do not satisfy the actively at work requirement. Coverage will be extended to the earlier of the end of the month the employee becomes actively at work, end of any extension period under the prior policy, or the date coverage would otherwise end under this policy. If an employee becomes disabled due to a pre-existing condition, benefits may be payable under our policy if the employee was insured for Voluntary LTD with the prior carrier, and was insured at the time coverage changed to our policy, and remained insured under this policy. For benefits to be payable, the employee must satisfy the pre-existing condition exclusion under either our policy, or the prior policy if benefits would have been payable had the prior plan remained in place. The benefit payable will be the lesser of the monthly benefit payable under the prior plan or the monthly benefit under our plan. Mental and Nervous Disorder Limitation Disabilities due to Mental and/or Nervous disorders are limited to the number of months shown in the Plan Design Summary unless the disabled employee is confined to a facility licensed for the treatment of Mental and Nervous disorders. Special Conditions Limitation Disabilities due to condition identified as a Special Condition are limited to the number of months shown in the Plan Design Summary, unless the disabled employee is confined to a licensed medical facility licensed to provide treatment for the disabled employee's condition. Special Conditions include but are not limited to muscoskeletal and connective tissue disorders of the neck and back including any disease or disorder of the cervical, thoracic and lumbosacral back and its surrounding soft tissue including sprains and strains of joints and adjacent muscles. The lifetime cumulative maximum period payable for all disabilities due to a mental disorder, substance abuse or special conditions is indicated in the Plan Design Summary. Only that period of benefits will be paid for any combination of such disabilities even if the disabilities are not continuous or not related. Worksite Modification Benefit This benefit assists in covering the cost of modifying the disabled employee's worksite to allow that employee to return to work. Once all parties agree on the modification to be performed, We will reimburse the employer the actual cost of the modification, up to the amount shown in the Plan Design Summary. Survivor Income Benefit If a disabled employee dies after having been disabled for a minimum of 90 or more consecutive days and was receiving benefits under the policy, we will pay a lump sum benefit equal to the number of months of benefit as indicated in the Plan Design Summary. Day Care Expense Benefit To assist employees taking advantage of our Rehabilitative Incentive Income feature, we offer Day Care Expense Benefits. This benefit reimburses claimants for any day care Quote ID: 46495 47of49 Dearborn National Prepared for: City of Lubbock, Texas expenses they may incur for children under age 13 while participating in the rehabilitation program. The benefit pays up to the amount indicated in the Plan Design Summary, to an overall monthly maximum of $1,000. Rehabilitation Benefit If the disabled employee is participating in a formal rehabilitation plan while receiving benefits, we will pay an additional monthly benefit equal to the percentage of their benefit indicated in the Plan Design Summary, up to the amount indicated. This additional benefit is payable for a maximum of the number of months indicated in the Plan Design Summary. Extension of Coverage for FMLA Leave If an insured employee is eligible for and received approval for leave under the Family and Medical Leave Act of 1993 (FMLA) or any applicable state family and medical leave law, insurance will continue (provided premium continues to be paid) for a period up to the later of: • The leave period permitted by FMLA and any amendments; or • The leave period permitted by applicable state law. EXCLUSIONS The policy does not cover any loss or Disability caused by, resulting from, arising out of or substantially contributed, directly or indirectly, to by any one or more of the following: • A Pre -Existing Condition • Commission of, participation in, or an attempt to commit an assault or felony; • Intentionally Self -Inflicted Injuries; • Participation in a war, declared or undeclared; • Active military duty; • Active Participation in a Riot; • Commission of a Felony for which the insured has been convicted. Quote ID: 46495 48 of 49 Dearborn Nation(:.1F Prepared for: City of Lubbock, Texas Enhanced Product Services Included with Voluntary Long Term Disability Insurance Disability Resource Services - Telephonic and Face -to -Face Support for Behavioral Health Issues Provided to all groups with Long -Term Disability coverage: • 24 Hour telephonic support (for all Long -Term Disability insureds) for behavioral health issues. A staff of master degree clinicians is available to provide each caller with assessment, counseling and referral advice for face-to-face counseling. Offered at no additional charge, these services enhance the value of an employee benefit program while helping to manage employee productivity and minimize absences. • Face-to-face counseling. Up to 3 face-to-face counseling sessions per year to address appropriate behavioral health issues. • Guidance Resources ® Online is a secure, password -protected interactive Web site that contains self -assessments, search tools, extensive content on personal health and powerful tools to help with personal, relational, legal, health and financial concerns. This service is free of charge to you, your insured employees and their families. Assistance through Guidance Resources ® Online is available 24 hours a day, 7 days a week. Enhanced Employee Assistance Programs (EAPs) are available. Contact your Dearborn National representative for more information. Guidance Resources ® Online and Employee Assistance Programs (EAPs) are made available through ComPsych ® , a worldwide leader in EAPs, managed behavioral health, work -life services, crisis intervention and Human Resources support services. Quote ID: 46495 49 of 49 CITY OF LUBBOCK, TX RFP 14-11842-DT Ancillary Benefits Plan for City Employees Checklist Please ensure that you complete and return the following documents and information to the City of Lubbock Purchasing and Contract Management Department before the deadline. Any corrections must be initialed by person making the correction. Late submittals will not be accepted. x The Request for Proposal Form MUST be completed x Clearly mark the RFP number, title, due date and time, and your company name and address on the outside of the sealed envelope or container. x Submit original and three (3) copies of the proposal. x Completed and signed the Insurance Affidavit. x Completed and signed SUSPENSION AND DEBARMENT CERTIFICATION. Please include Company Federal TAX ID number or Social Security number. x Completed and signed the Non -Collusion Affidavit. FAILURE TO PROVIDE ANY OF THE ABOVE MAY RESULT IN YOUR PROPOSAL BEING DEEMED NON -RESPONSIVE. Dearborn National Life Insurance Company Printed Name of Company eff Jay 972-766-9337 Contact Person Name and Phone Number PLEASE INCLUDE THIS COMPLETED PAGE AS THE FIRST PAGE OF YOUR SUBMITTAL. 0 A Dearborn ` National Strength. Independence. Solutions. GROUP BENEFITS PROPOSAL Prepared for City of Lubbock, Texas Proposal valid for two months following October 01, 2014 DEARBORN NATIONAL SALES REPRESENTATIVE: Jeff Jay 214.33/1,6918 Jeff jay@bcbstx.com Visit us at: www.dearbornnational.com Underwritten by Dearborn National', Life Insurance Company Dearborn NationOt Prepared for: City of Lubbock, Texas Group Life and Accidental Death and Dismemberment Insurance Group Life and Accidental Death and Dismemberment Insurance plans provide security to those families that have suffered the loss of a loved one. Basic Life Rate and Cost summary Proposed Effective Date*: October 01, 2014 Current Plan Basic Life • All Eligible Active Employees # of Lives Estimated Volume Rates Per Estimated $1,000 Monthly Monthly Premium 2,107 $21,070,000 $0.035 $737.45 • All Retireed Employees who retireed on or after January 1, 1974 but before April 1, 1988 # of Lives Estimated Volume Rates Per Estimated $1,000 Monthly Monthly Premium 46 $45,000 $0.600 $27.00 • All Retireed Employees who retireed on or after December 1, 1995 • All Retireed Employees who retireed on or after April 1, 1988 but before December 1, 1995 # of Lives Estimated Volume Rates Per Estimated $1,000 Monthly Monthly Premium 486 $1,936,000 $3.060 $5,924.16 Basic AD&D # of Lives Estimated Volume Rates Per Estimated $1,000 Monthly 2,107 $20,902,500 Monthly$0.015 Premium $313.54 Rate Guarantee Period: 36 months *Quote valid for two months following the proposed effective date Enhanced Product Services Offered with Group Term Life Insurance • Travel Assistance Services (Available to groups with 50 or more lives; Not available in all states) • Beneficiary Resource Services Important Notes: The above rates and premium estimates are based on the employee data submitted by you. Final rates and premiums will be based on the plan and employee data provided by you at inception. This proposal is subject to exclusions and limitations in the policy issued by us. In addition, if coverage was inforce prior to the effective date of coverage, the rates quoted are subject to revisions based on acceptance and review of the inforce carrier's policy. Changes in risk that may impact the rates quoted include, but are not limited to: • The composition of the group, employees or dependents, changes by more than 10% • The employer contribution changes • Any of the plan designs are changed • A change in applicable law requires a change in the insurance provided by the policy or the classes of persons eligible for insurance under the policy. Quote ID: 46495 2 of 49 Dearborn - National Prepared for: City of Lubbock, Texas Group Life Insurance Plan Design Summary Basic Term Life - Employee Eligibility All Retireed Employees who retireed on or after January All Eligible Active 1, 1974 but before April 1, Employees 1988 Number of Employees 2,107 46 Basic Life Benefit $10,000 $2,000 or $5,000 Guarantee Issue $10,000 $5,000 Waiver of Premium Included Not Included Elimination Period 6 Months Waiver Duration To Age 65 Portability To Age 65 To Age 65 Portability Maximum $10,000 $5,000 Conversion Included Included Accelerated Death Benefit* 75% of Benefit Amount Not Included Maximum $500,000 Age Reduction Schedule** 35% at age 65 None 50% at age 70 35% at age 75 Policyholder Contribution 100% 100% Participation Minimum 100% 100% *For groups with Basic and Supplemental or Voluntary Life coverage, the Accelerated Death Benefit maximum applies to all coverages **Benefits are reduced by the percentage indicated and are calculated from the original amount at the attainment of the age shown. Quote ID: 46495 3 of 49 nea cborn Nationo Basic Term Life - Employee Eligibility Number of Employees Basic Life Benefit Guarantee Issue Portability Portability Maximum Conversion Age Reduction Schedule** Policyholder Contribution Participation Minimum Prepared for: City of Lubbock, Texas All Retireed Employees who retireed on or after December 1, 1995 399 $2,000 or $5,000 $5,000 To Age 65 $5,000 Included None 100% 100% All Retireed Employees who retireed on or after April 1, 1988 but before December 1, 1995 87 $2,000 $2,000 To Age 65 $2,000 Included None 100% 100% "Benefits are reduced by the percentage indicated and are calculated from the original amount at the attainment of the age shown. Quote ID: 46495 4 of 49 Dearborn National Prepared for: City of Lubbock, Texas Basic AD&D - Employee Eligibility All Eligible Active Employees Basic AD&D Benefit Same as Basic Life Seat Belt Included Percentage 10% Maximum $25,000 Air Bag Included Percentage 5% Maximum $5,000 Education Benefit Included Percentage 3% Annual Maximum $3,000 Duration 4 Years Repatriation Benefit Actual costs to $5,000. Day Care Benefit Included Percentage 3% Annual Maximum $5,000 Duration 5 Years Spouse Training Benefit $5,000 Coma Benefit Included Percentage 1% Maximum $1,000 Duration 11 Months Quote ID: 46495 5 of 49 Dearborn National* Prepared for: City of Lubbock, Texas Underwriting Considerations for Group Life Coverage Considerations • Voluntary AD&D Employee rate is $0.025 • Voluntary AD&D Family rate is $0.038 Underwriting Conditions • Employees must be legally working in the United States in order to be eligible for coverage. • Insured Persons enrolling more than 31 days after their initial eligibility date must submit satisfactory Evidence of Insurability for all benefit amounts. • Coverage for amounts in excess of the Guarantee Issue amount is not effective until the date we approve the application. • This proposal provides only basic information on the features of the policy. It is not intended to be a complete representation of all terms and conditions of the contract. A complete listing of the terms, conditions, limitations, exclusions and reduction of benefits is available upon request. In the event of conflict between this proposal and the policy, the terms of the policy will govern. • Product features and provisions may be slightly different due to state requirements. When sold, the actual policy for the state in which the policy is issued will reflect the state's requirements. • This proposal illustrates the cost of the insurance program and is based upon the information submitted by you. Actual cost will be determined after an application has been accepted and will depend upon data obtained when the program becomes effective. • The Supplemental Life guarantee issue amount shown in this proposal are offered to employees whose initial eligibility date (new hires) is on or after the effective date of coverage. • If the Supplemental Life Participation Minimum stated in the Plan Design Summary is met, all current amounts in force will be grandfathered, subject to the plan design maximums and the grandfathering limits stated in the Plan Design Summary. The Guarantee Issue amount shown in this proposal will only be offered to employees whose initial eligibility date (new hires) is on or after the effective date of coverage. Employees not previously covered, or those who have selected to increase their coverage, will need to provide satisfactory Evidence of Insurability. • Should the Supplemental Life Participation Minimum not be met, grandfathering will not apply and satisfactory Evidence of Insurability will be required for all amounts by all applicants, including those participating in the prior carrier's plan. Participation is measured based on the participation level achieved at initial enrollment with Dearborn National. A spouse application does not count toward the Participation Requirement. Transition of Coverage from Previous Carrier Most group life carriers have standardized provisions in their contracts that address issues concerning transition from one carrier to another. Each carrier has specific responsibilities to ensure that employees who are not actively at work at the time of the transition do not lose their coverage. The terminating carrier should retain responsibility for any employee who is disabled on the date of termination, regardless of whether or not the individual is on Waiver of Premium. It is recommended that this issue be discussed with the terminating carrier to verify how persons disabled on the effective date of our policy will be handled. Actively at Work Actively at work requirements will be waived, provided premiums are paid when due, for employees who: • Are covered on the day immediately preceding our policy effective date; and • Were on lay-off, non -medical leave of absence or sabbatical leave; and who are being provided an extension of benefits with their prior carrier Coverage will continue for the balance of the time provided for under the prior carrier's policy, but not to exceed 12 months. We do not agree to waive the actively at work provision on other employees. Quote ID: 46495 6 of 49 Dearborn 14 Nationale Prepared for: City of Lubbock, Texas Voluntary Life and Accidental Death and Dismemberment Insurance Voluntary Life and Accidental Death and Dismemberment Insurance plans provide security to those families that have suffered the loss of a loved one. Voluntary Life Rate and Cost Summary Proposed Effective Date*: October 01, 2014 Current Plan Voluntary Life • All Eligible Active Employees Age Band Employee Rates Per 1 000 Monthly Below 20 $0.050 20-24 $0.050 25-29 $0.050 30-34 $0.070 35-39 $0.080 40-44 $0.130 45-49 $0.180 50-54 $0.300 55-59 $0.530 60-64 $0.860 65-69 $1.360 70-74 $2.410 75-79 $4,450 80-84 $7.560 85-89 $7.560 90-94 $7.560 95-99 $7.560 100 and above $7.560 Quote ID: 46495 7of49 Dearborn National • All Retireed Employees Voluntary AD&D Prepared for: City of Lubbock, Texas Age Band Employee Rates Per 1 000 Monthly Below 20 $0.110 20-24 $0.110 25-29 $0.110 30-34 $0.120 35-39 $0.170 40-44 $0.260 45-49 $0.440 50-54 $0.780 55-59 $1.270 60-64 $1.440 65-69 $2.380 70-74 $4.120 75-79 $6.200 80-84 $9.750 85-89 $9.750 90-94 $9.750 95-99 $9.750 100 and above $9.750 Employee Age Band Rates Per 1 000 Monthly Employee $0.025 Voluntary Dependent Life • All Eligible Active Employees Spouse Age Band Rates Per 5 000 Monthly Composite $0.800 Dependent Child ren Rates per unit Life 0.500 • All Retired Employees who Retired on or after January 1, 1974 but before December 1, 1995 Spouse Age Band Rates Per unit Monthly Composite $1.250 Quote ID: 46495 8of49 Dearborn Nat>Conal` Prepared for: City of Lubbock, Texas • All Retired Employees who Retired on or after December 1, 1995 Spouse Age Band Rates Per unit Monthly Composite $1.250 Dependent Child ren Rates per unit Life 1.250 Rate Guarantee Period: 36 Months *Quote valid for two months following the proposed effective date Enhanced Product Services Offered with Group Term Life Insurance • Travel Assistance Services (Available to groups with 50 or more lives; Not available in all states) • Beneficiary Resource Services Important Notes: The above rates and premium estimates are based on the employee data submitted by you. Final rates and premiums will be based on the plan and employee data provided by you at inception. This proposal is subject to exclusions and limitations in the policy issued by us. In addition, if coverage was in force prior to the effective date of coverage, the rates quoted are subject to revisions based on acceptance and review of the inforce carrier's policy. Changes in risk that may impact the rates quoted include, but are not limited to: • The composition of the group, employees or dependents, changes by more than 10% • The employer contribution changes • Any of the plan designs are changed • A change in applicable law requires a change in the insurance provided by the policy or the classes of persons eligible for insurance under the policy. Quote ID: 46495 9 of 49 Dearborn National' Prepared for: City of Lubbock, Texas Group Life Insurance Plan Design Summary Voluntary Life - Employee Eligibility Number of Employees Voluntary Life Benefit Minimum Maximum Benefit Rounding Definition of Earnings Average Period Guarantee Issue Waiver of Premium Elimination Period Waiver Duration Portability Portability Maximum Conversion Accelerated Death Benefit* Maximum Age Reduction Schedule** Policyholder Contribution Participation Minimum All Eligible Active Employees All Retireed Employees 1,678 363 Amounts from 1 to 3 times Amounts from $10,000 to salary in increments of 1 times $10,000 in increments of salary $10,000 $1,000 $500,000 To Next Higher $1,000 Not Applicable Earnings w/Comm 12 Months $250,000 $250,000 Included Not Included 6 Months To Age 65 To Age 65 To Age 65 $500,000 $10,000 Included Included 75% of Benefit Amount Not Included $500,000 35% at age 65 35% at age 65 50% at age 70 50% at age 70 35% at age 75 35% at age 75 0% 0% 25% 25% * For groups with Basic and Supplemental or Voluntary Life coverage, the Accelerated Death Benefit maximum applies to all coverages **Benefits are reduced by the percentage indicated and are calculated from the original amount at the attainment of the age shown. Quote ID: 46495 10of49 Dearborn NC1tIon l Prepared for: City of Lubbock, Texas Voluntary AD&D - Employee Eligibility All Full Time Active Employees that work a minimum of 40 hours per week Voluntary AD&D Benefit Same as Voluntary Life Seat Belt Included Percentage 10% Maximum $25,000 Air Bag Included Percentage 5% Maximum $5,000 Education Benefit Included Percentage 3% Annual Maximum $3,000 Duration 4 Years Repatriation Benefit Actual costs to $5,000 Day Care Benefit Included Percentage 3% Annual Maximum $5,000 Duration 5 Years Spouse Training Benefit $5,000 Common Disaster Benefit Increases spouse amount to equal employee amount. Maximum $150,000 Coma Benefit Included Percentage 1% Maximum $1,000 Duration it Months Quote ID: 46495 11 of 49 Dearborn National Voluntary Dependent Life Eligibility Spouse Benefit Not to Exceed Spouse Guarantee Issue Child Benefit Birth - 14 days 15 Days - 6 months 6 Months - Maximum Child Maximum Age Student Maximum Age Child Guarantee Issue Dependent Portability Dependent Conversion Age Reduction Schedule Prepared for: City of Lubbock, Texas All Eligible Active Employees Amounts from $5,000 to $50,000 in increments of $ 5, 000 Includes Domestic Partners 100% of Employee Amount $50,000 $0 $100 Amounts from $2,500 to $10,000 in increments of $2,500 26 26 $10,000 Included Included Same As Employee All Retired Employees who Retired on or after 3anuary 1, 1974 but before December 1, 1995 Amounts from $2,000 to $2,000 in increments of $2,000 Includes Domestic Partners 100% of Employee Amount $50,000 Not Included Included Included Same As Employee Quote ID: 46495 12of49 Dearborn WttIonal Voluntary Dependent Life Eligibility Spouse Benefit Not to Exceed Spouse Guarantee Issue Child Benefit Birth - 14 days 15 Days - 6 months 6 Months - Maximum Child Maximum Age Student Maximum Age Child Guarantee Issue Dependent Portability Dependent Conversion Age Reduction Schedule Prepared for: City of Lubbock, Texas All Retired Employees who Retired on or after December 1, 1995 Amounts from $2,500 to $2,500 in increments of $2,500 Includes Domestic Partners 100% of Employee Amount $50,000 $0 $0 Amounts from $1,000 to $1,000 in increments of $1,000 26 26 $10,000 Included Included Same As Employee Quote ID: 46495 13of49 vea.cbOfn NO-tiOnCa.11 Prepared for: City of Lubbock, Texas Underwriting Considerations for Group Life Coverage Underwriting Conditions • Employees must be legally working in the United States in order to be eligible for coverage. • Insured Persons enrolling more than 31 days after their initial eligibility date must submit satisfactory Evidence of Insurability for all benefit amounts. • Coverage for amounts in excess of the Guarantee Issue amount is not effective until the date we approve the application. • This proposal provides only basic information on the features of the policy. It is not intended to be a complete representation of all terms and conditions of the contract. A complete listing of the terms, conditions, limitations, exclusions and reduction of benefits is available upon request. In the event of conflict between this proposal and the policy, the terms of the policy will govern. • Product features and provisions may be slightly different due to state requirements. When sold, the actual policy for the state in which the policy is issued will reflect the state's requirements. • This proposal illustrates the cost of the insurance program and is based upon the information submitted by you. Actual cost will be determined after an application has been accepted and will depend upon data obtained when the program becomes effective. • The Voluntary Life guarantee issue amount shown in this proposal are offered to employees whose initial eligibility date (new hires) is on or after the effective date of coverage. • If the Voluntary Life Participation Minimum stated in the Plan Design Summary is met, all current amounts in force will be grandfathered, subject to the plan design maximums and the grandfathering limits stated in the Plan Design Summary. The Guarantee Issue amount shown in this proposal will only be offered to employees whose initial eligibility date (new hires) is on or after the effective date of coverage. Employees not previously covered, or those who have selected to increase their coverage, will need to provide satisfactory Evidence of Insurability. • Should the Voluntary Life Participation Minimum not be met, grandfathering will not apply and satisfactory Evidence of Insurability will be required for all amounts by all applicants, including those participating in the prior carrier's plan. Participation is measured based on the participation level achieved at initial enrollment with Dearborn National. A spouse application does not count toward the Participation Requirement. Transition of Coverage from Previous Carrier Most group life carriers have standardized provisions in their contracts that address issues concerning transition from one carrier to another. Each carrier has specific responsibilities to ensure that employees who are not actively at work at the time of the transition do not lose their coverage. The terminating carrier should retain responsibility for any employee who is disabled on the date of termination, regardless of whether or not the individual is on Waiver of Premium. It is recommended that this issue be discussed with the terminating carrier to verify how persons disabled on the effective date of our policy will be handled. Actively at Work • Actively at work requirements will be waived, provided premiums are paid when due, for employees who: • Are covered on the day immediately preceding our policy effective date; and • Were on lay-off, non -medical leave of absence or sabbatical leave; and who are being provided an extension of benefits with their prior carrier Coverage will continue for the balance of the time provided for under the prior carrier's policy, but not to exceed 12 months. We do not agree to waive the actively at work provision on other employees. Quote ID: 46495 14 of 49 De, arbOfn >vatiOnat Prepared for: City of Lubbock, Texas Voluntary Short Term Disability Dearborn National's Group Voluntary Short Term Disability plans help replace lost income should an insured employee become disabled due to an accident or sickness, including pregnancy or complications from pregnancy. Voluntary Short Term Disability Rate and Cost Summary Proposed Effective Date*: October 01, 2014 Current Plan • All Full Time Active Employees Option 2 Age Band Rates Per $10 Weekly Benefit Monthly Below 20 0. 20-24 0. TTT- 2S-29 $0.229 0-34 $0.217 3 -39 $0.209 40-44 0.22 45-49 0.24 50-54 $0.309 55-59 $0.414 60-64 $0.522 65-69 $0.534 70-74 $0.604 7 -79 $0.604 0-84 $0.604 85-89 $0.604 90-94 $0.604 95-99 $0.604 100 and above $0.04 Quote ID: 46495 15 of 49 nenrborn Nntionar Prepared for: City of Lubbock, Texas • All Full Time Active Employees Option 1 Age Band Rates Per $10 Weekly Benefit Monthly Below 20 $0.286 20-24 $0.287 25-29 VO.30-34 . 1 35-39 . 70 40-44 $0.290 45-49 $0.313 50-54 0. 55-59 $0.518 60-64 0.6 3 -69 $0.667 70-74 $0.754 75-79 $0.754 80-84 $0.754 8 -89 $0.754 90-94 $0.754 95-99 $0.754 100 an a ove 0.754 Rate Guarantee Period: 36 Months *Quote valid for two months following the proposed effective date Important Notes: The above rates and premium estimates are based on the employee data submitted by you. Final rates and premiums will be based on the plan and employee data provided by you at inception. This proposal is subject to exclusions and limitations in the policy issued by us. In addition, if coverage was inforce prior to the effective date of coverage, the rates quoted are subject to revisions based on acceptance and review of the inforce carrier's policy. Changes in risk that may impact the rates quoted include, but are not limited to: • The composition of the group, employees or dependents, changes by more than 10% • The employer contribution changes • Any of the plan designs are changed • A change in applicable law requires a change in the insurance provided by the policy or the classes of persons eligible for insurance under the policy. Quote ID: 46495 16 of 49 MCI Orn National Prepared for: City of Lubbock, Texas Voluntary Short Term Disability Plan Design Summary Eligibility Number of Employees VSTD Weekly Benefit Definition of Earnings Average Period Maximum Weekly Benefit Minimum Weekly Benefit Elimination Period Injury Sickness Benefits Begin Injury Sickness Maximum Period Payable Benefit Paid Survivor Benefit Worksite Modification Benefit Pre -Existing Condition Exclusion Occupational injury/Sickness Definition of Disability Partial Disability Earnings Test Work Incentive Benefit Policyholder Contribution Employee Contribution Basis Participation Requirement Tax Services All Full Time Active Employees - 2 1,906 66.67% of weekly earnings Earnings w/Comm 12 Months $1,150 $25 7 Days 7 Days 8th Day 8th Day 13 weeks Until LTD Benefits Begin 3 weeks Included 12/12 Not Covered Total or Partial Disability 80% Included 0% Post -tax 25% W-2 Printing All Full Time Active Employees -1 201 60% of weekly earnings Earnings w/Comm 12 Months $1,150 $25 7 Days 7 Days 8th Day 8th Day 25 weeks Until LTD Benefits Begin 3 weeks Included 12/12 Not Covered Total or Partial Disability 80% Included 0% Post -tax 25% W-2 Printing Enhanced Product Services Offered with Voluntary Short Term Disability • W-2 Reporting for Claimants • Telephonic Claim Intake Underwriting Considerations for Voluntary Short Term Disability Underwriting Conditions • Employees must be legally working in the United States in order to be eligible for coverage. • Unless otherwise requested, Short Term Disability benefit payments will not begin until the employee's compensation payments from the employer, including but not limited to vacation pay, salary continuation or sick leave benefit payments, have ceased. • This proposal provides only basic information on the features of the policy. It is not intended to be a complete representation of all terms and conditions of the contract. A complete listing of the terms, conditions, limitations, exclusions and reduction of benefits is available upon request. In the event of conflict between this proposal and the policy, the terms of the policy will govern. • Product features and provisions may be slightly different due to state requirements. When sold, the actual policy for the state in which the policy is issued will reflect the state's requirements. • This proposal illustrates the cost of the insurance program and is based upon the information submitted by you. Actual cost will be determined after an application has been accepted and will depend upon data obtained when the program becomes effective. Quote ID: 46495 17 of 49 De,,afbOfn National Prepared for: City of Lubbock, Texas Voluntary Long Term Disability Dearborn National's Group Voluntary Long Term Disability plans provide long term income replacement security. Programs feature return to work claim management programs focused on personalized claim service. Voluntary Long Term Disability Rate and Cost Summary Proposed Effective Date*: October 01, 2014 Current Plan • All Active Full Time Employees Option 1 Age Band Rates Per $100 Monthly Covered Payroll Monthly Below 20 $0.140 20-24 $0.140 25-29 $0.160 30-34 $0.170 35-39 $0.180 40-44 $0.250 45-49 $0.310 50-54 $0.420 55-59 $0.640 60-64 $0.790 65-69 $0.790 70-74 $0.790 75-79 $0.790 80-84 $0.790 85-89 $0.790 90-94 $0.790 95-99 $0.790 100 and above $0.790 Quote ID: 46495 18 of 49 Dearborn National Prepared for: City of Lubbock, Texas • All Active Full Time Employees Option 2 Age Band Rates Per $100 Monthly Covered Payroll Monthly Below 20 $0.160 20-24 $0.160 25-29 $0.180 30-34 $0.200 35-39 $0.210 40-44 $0.280 45-49 $0.360 50-54 $0.490 55-59 $0.740 60-64 $0.910 65-69 $0.910 70-74 $0.910 75-79 $0.910 80-84 $0.910 85-89 $0.910 90-94 $0.910 95-99 $0.910 100 and above $0.910 Rate Guarantee Period: 36 Months *Quote valid for two months following the proposed effective date Important Notes: The above rates and premium estimates are based on the employee data submitted by you. Final rates and premiums will be based on the plan and employee data provided by you at inception. This proposal is subject to exclusions and limitations in the policy issued by us. In addition, if coverage was inforce prior to the effective date of coverage, the rates quoted are subject to revisions based on acceptance and review of the inforce carrier's policy. Changes in risk that may impact the rates quoted include, but are not limited to: • The composition of the group, employees or dependents, changes by more than 10% • The employer contribution changes • Any of the plan designs are changed • A change in applicable law requires a change in the insurance provided by the policy or the classes of persons eligible for insurance under the policy. Quote ID: 46495 19of49 Dearborn NO-tional Prepared for: City of Lubbock, Texas Voluntary Long Term Disability Plan Design Summary Eligibility LTD Benefit Definition of Earnings Average Period Maximum Monthly Benefit Minimum Monthly Benefit Elimination Period Accumulation of Elimination Period Maximum Period Payable Benefit Integration Own Occupation Period Partial Disability Income Earnings Test During Own Occ Period After Own Occ Period Pre -Disability Salary Indexing Work Incentive Benefit Offset Method Rehabilitative Incentive Income Offset Method Includes Day Care Benefit Expenses Per Child Months Mental Disorder Limitation Substance Abuse Limitation Special Conditions Limitation Limitation Basis Pre -Existing Condition Exclusion Survivor Benefit Worksite Modification Benefit Rehabilitation Benefit Maximum Duration Policyholder Contribution Employee Contribution Basis Participation Requirement All Active Full Time Employees 60% of monthly earnings Earnings w/Comm - 1 12 $5,000 $100 180 Days Up to 1/2 the Elimination Period SSNRA Primary and Family 24 Months with loss of duties and earnings Included 80% 60% Greater of 3% or average annual change in CPI-W 12 Months Proportionate Loss of Income 12 Months Proportionate Loss of Income $350 12 24 Months No Limitation 12 Months Per Lifetime 3/12 3 Months Greater of 2 times benefit amount or $1,500 5% $500 6 Months 0% Post -tax 57% All Active Full Time Employees 66.67% of monthly earnings Earnings w/Comm - 2 12 $5,000 $100 90 Days Up to 1/2 the Elimination Period SSNRA Primary and Family 24 Months with loss of duties and earnings Included 80% 60% Greater of 3% or average annual change in CPI-W 12 Months Proportionate Loss of Income 12 Months Proportionate Loss of Income $350 12 24 Months No Limitation No Limitation Per Lifetime 3/ 12 3 Months Greater of 2 times benefit amount or $1,500 5% $500 6 Months 0% Post -tax 57% Enhanced Product Services Offered with Voluntary Long Term Disability • Disability Resource Services • W-2 Reporting for Claimants Underwriting Considerations for Voluntary Long Term Disability Underwriting Conditions • Employees must be legally working in the United States in order to be eligible for coverage. • This proposal provides only basic information on the features of the policy. It is not intended to be a complete representation of all terms and conditions of the contract. A Quote ID: 46495 20 of 49 Dearborn National:� Prepared for: City of Lubbock, Texas complete listing of the terms, conditions, limitations, exclusions and reduction of benefits is available upon request. In the event of conflict between this proposal and the policy, the terms of the policy will govern. Product features and provisions may be slightly different due to state requirements. When sold, the actual policy for the state in which the policy is issued will reflect the state's requirements. This proposal illustrates the cost of the insurance program and is based upon the information submitted by you. Actual cost will be determined after an application has been accepted and will depend upon data obtained when the program becomes effective. Quote ID: 46495 21 of 49 t Dearborn*Nationod "It, . w.dear; Mr;;r;at.or,ai,cvrt; Strength. Indeoendence. Solutions. VOLUNTARY INSURANCE BENEFITS COMMUNICATION AND ENROLLMENT STRATEGY Employers want to provide comprehensive benefit programs to attract and retain valuable employees. Dearborn National has developed a flexible program of Voluntary, employee -funded benefits. By offering a valuable Voluntary program, an employer can significantly enhance its benefit portfolio at no additional cost. Offering Voluntary benefits I d EMPLOYER ANNOUNCEMENT LETTER to your employees The group agrees to distribute a letter on its letterhead (paper empowers them to select or electronic) infon•ning employees that the Voluntary benefits the coverage that meets will be offered. This correspondence should be distributed three their needs and the needs to four weeks before the enrollment. of their families. It is important that employees d POSTERS TO RAISE AWARENESS are aware of these benefits understand their The group agrees to display awareness posters in gatheringand areas, cafeterias, break roorns or elevator banks. These posters value. This is accomplished will create awareness of the upcoming benefit(s) being offered with a well -planned and inform employees where and when they can get more Communication and information and attend an enrollment meeting. The posters Enrollment strategy. Proper should be on display two 4,seeks before the enrollment meeting communication of benefits is held. is important to the success of any Group Insurance HOLD ENROLLMENT MEETINGS Plan. It is essential that all Many employees need additional infromation to make a insureds have a thorough sound benefits selection. An enrollment meeting provides an understanding of exactly opportunity for employees to ask questions and receive answers what the coverage provides. from a benefit specialist. The group agrees to allow the broker; enroller to conduct informational enrollment meetings. Offering of voluntary coverage, also includes d DISTRIBUTE BENEFIT SUMMARIES the Communication and Enrollment Strategy as Group -specific Benefit Summaries provide detailed information outlined here, on available plans, empowering employees to make the best. decision for their individual needs. The broker !enrollerand group agree to distribute Benefit Summaries to all employees during the enrollment inesetings ;'c:fi(lt:i5 a9 la SCi ... ?J•.:!; 1, elY ;i i1i, . ;•I" tie r'.,Ji rh ..!!if J'7 'i JC? .St -Y, fcg 0f.•+h° ' dr.•YS:+!(u;? : ' I`; ::y•sl• '? (: • .7d,ti ;•�=•i ^i ' - ,: i 01 d%i .3iCJ iQt�:l: r!17,7l.d:'. f=•�+'�:, ... ;2:ii;i {,i (�.'.�tl '!''-!A, is ii:;11�;i Z:fi:,}5 .fir- il';!�. ?''- s, Lati�ir! !0d 'r'u !W • r,tT. Quote ID: 46495 22 of 49 Dearborn National Prepared for: City of Lubbock, Texas We Are Dearborn National Dearborn Nationale offers a broad selection of insurance and financial products that cover many markets - Voluntary and Employer Paid Group Benefits, Worksite, Individual and a wide array of enhanced product services. We serve groups and individuals, including some of the largest companies and most recognized names in the United States. A Strong Parent Company Our parent company, Health Care Service Corporation (HCSC), a Mutual Legal Reserve Company, is the largest non -investor owned health care insurance provider in the United States and the 41h largest overall. To learn more about our family of companies that make up HCSC, please visit www.hcsc.com. Strong Ratings The ratings of the Dearborn National companies speak to our commitment to managing our business well and remaining financially strong. Benefit programs in this proposal are underwritten by Dearborn Nationale Life Insurance Company. Dearborn Nationale Life Insurance Company is rated A+ (Superior), by A.M. Best Company and A+ (Strong)Z by Standard & Poor's for financial strength in it's most recent report. A National Presence Through the underwriting companies of Dearborn Nationale Life Insurance Company, Dearborn Nationale Life Insurance Company of New York, and Colorado Bankers Life Insurance Company °, we are licensed in all 50 states as well as the District of Columbia. Affirmed December 19, 2013. A.M. Best Company rates the overall financial results of a company using a scale of A++ (Superior) to F (In Liquidation). 2 Affirmed November 13, 2013. Standard & Poor's Insurer Financial Strength Rating uses a scale ranging from AAA (Extremely Strong) to R (Experienced Regulatory Action). Products and services marketed under the Dearborn Nationale brand and the star logo are underwritten and/or provided by Dearborn Nationale Life Insurance Company (Downers Grove, IL) in all states (excluding New York), the District of Columbia, the United States Virgin Islands, the British Virgin Islands and Puerto Rico. Quote ID: 46495 23of49 Dearborn National Prepared for: City of Lubbock, Texas Benefit Highlights Basic Life Eligibility Eligibility is as indicated in the Plan Design Summary. To be eligible, employees must be legally working in the United States and meet the eligibility requirements indicated in the Plan Design Summary. Insured Persons may have to complete a Waiting Period. Seasonal, part-time and temporary employees are not eligible. Effective Date If an insured person is absent from work due to injury or sickness on the last day of work prior to their effective date, the effective date of coverage will be delayed until 12:01 a.m. on the day coinciding with or next following their return to active work for a period of one day. Guarantee Issue Life Insurance Amounts up to the Guarantee Issue amount stated in the Plan Design Summary are offered with no need for Evidence of Insurability. Amounts in excess of the Guarantee Issue amount are subject to underwriting approval before becoming effective. Conversion Insureds who terminate employment, or lose a portion of their life coverage, may be able to convert their Life coverage to individual policies. Upon coverage termination administrators have 31 days after coverage ends to inform the insureds of their right to convert to an individual policy without evidence of insurability. Conversion does not apply to AD&D or Waiver of Premium amounts. Portability - Basic Life If Life coverage ceases for reasons other than retirement, sickness, injury or termination of the policy, eligible insured persons can purchase portable term life insurance without Evidence of Insurability. As long as premiums are paid, portable coverage continues until the insured reaches the maximum age indicated in the plan design summary. Accelerated Benefits Insureds who are diagnosed as being terminally ill can access a portion of their life insurance benefits while they are alive. The insured can accelerate a percentage of their life insurance amount, up to the maximum amount, as indicated in the Plan Design Summary. If life insurance benefits are subject to age reductions within 12 months of receiving proof of terminal illness, the accelerated death benefit will reduce accordingly. The minimum amount that can be accelerated and the definition of Terminally III are shown in the Additional Plan Features. Waiver of Premium We will continue coverage for insureds who become totally disabled and complete the Elimination Period shown on the Plan Design Summary. Life Insurance will be extended to the age as indicated in the Plan Design Summary, with no premium charge. The onset of the disability must occur before the insured reaches the age indicated in the Additional Plan Features and they must meet the definition of disability for the entire elimination period. The amount of insurance extended will be the amount of Life Insurance in force immediately prior to the date of the Total Disability. This amount is subject to any reductions under the policy. Quote ID: 46495 24 of 49 Dearborn Natior1Q1 Prepared for: City of Lubbock, Texas Limitations and Exclusions Supplemental Life benefits, including Waiver of Premium, are not payable for a loss which is caused by a suicide or attempted suicide within one year of the effective date of coverage. Termination of Coverage The insured's life insurance will terminate on the earliest of the following dates: • The date the policy is terminated; • The date the insured stops making any required contribution toward payment of premiums; • The date the insured is no longer a member of an eligible class; • The date the insured requests termination of coverage. • The date the insured is no longer covered as a result of a disability, layoff, leave of absence, sabbatical or military leave. Extension of Coverage If an employee is no longer Actively at Work as a result of a disability, layoff, leave of absence, sabbatical or military duty, they may be able to continue to be eligible for group Life insurance coverage as follows: Disability - Until the end of the month following the period indicated in the Additional Plan Features after which the disability began, provided all premiums have been paid and the policy is still in force and has not been replaced with a new carrier. Layoff - Until the end of the month following the period indicated in the Additional Plan Features after which the layoff began, provided all premiums have been paid and the policy is still in force and has not been replaced with a new carrier. Leave of Absence - Until the end of the month following the period indicated in the Additional Plan Features after which the leave of absence began or the period of time in accordance with FMLA, provided all premiums have been paid and the policy is still in force and has not been replaced with a new carrier. Sabbatical - Until the end of the month following the period indicated in the Additional Plan Features after which the sabbatical began, provided all premiums have been paid and the policy is still in force and has not been replaced with a new carrier. Military Leave - Until the end of the month following the period indicated in the Additional Plan Features after which the disability began, provided all premiums have been paid and the policy is still in force and has not been replaced with a new carrier. Extension of Coverage for FMLA Leave If an insured is eligible for and receives approval for leave under the Family and Medical Leave Act of 1993 (FMLA) or any applicable state, family and medical leave law, insurance will continue (provided premium continues to be paid) for a period up to the later of: • The leave period permitted by FMLA and any amendments; or • The leave period permitted by applicable state law. Transition of Coverage from a Previous Carrier As an established group life insurance carrier, it has been our experience that most carriers have standardized procedures when it comes to determining responsibility for employee transition situations. Our position has been that the terminating carrier is responsible for anyone who was insured under their contract, but is disabled and does not meet the requirements of becoming Quote ID: 46495 25 of 49 Dearborn Nationcd Prepared for: City of Lubbock, Texas insured under our contract. This person may or may not be eligible for Waiver of Premium under the prior policy. It is our recommendation that this issue be discussed with the terminating carrier to identify any insured's who may not be eligible for coverage on the effective date of our policy. While awaiting the decision of the terminating carrier, it is recommended that the impacted employee apply for conversion. We will cover any eligible insureds who may be on vacation, leave of absence, observing a holiday, etc. on the effective date of our policy. Quote ID: 46495 26 of 49 Dearborn National Prepared for: City of Lubbock, Texas Basic Accidental Death and Dismemberment Accidental Death and Dismemberment (AD&D) plan pays an additional benefit when a covered insured loses their life, or a limb due to an accident. Benefits are paid based on the following schedule. D&D SCHEDULE OF LOSSES BENEFIT AMOUNT Loss of Life 100% Loss of Both Hands or Both Feet 100% Loss of One Hand and One Foot 100% Loss of Speech and Hearing 100% Loss of Sight of Both Eyes 1000/0 Loss of One hand and the Sight of One Eye 100% Loss of One Foot and the Sight of One Eye 100% Quadriplegia 100% Paraplegia 75% Hemiplegia 50% Loss of Sight of One Eye 50% Loss of One Hand or One Foot 50% Loss of Speech or Hearing 50% Loss of Thumb and Index Finger of Same Hand 25% Uniplegia 25% The following additional benefits are included with our Accidental Death & Dismemberment plan. For amount and availability of benefits, please refer to the Plan Design Summary. Seat Belt Benefit Pays an additional benefit, up to the percentage and maximum amounts indicated in the Plan Design Summary, if the covered insured dies in an automobile accident while wearing a properly worn seat belt. Air Bag Benefit Pays an additional benefit, up to the percentage and maximum amounts indicated in the Plan Design Summary, if the covered insured dies in an automobile accident while seated in a seat containing a factory installed air bag. Education Benefit Pays an additional benefit, up to the percentage and annual maximum indicated in the Plan Design Summary, if a covered insured dies in an accident and has qualified dependent children attending a school of higher learning. The benefit is payable for each insured child and up to four annual payments. Repatriation If a covered insured dies as a result of an accident more than 75 miles from their principal place of residence, the benefit pays the actual costs, up to the maximum amount indicated in the Plan Design Summary, for the preparation and transportation of the insured employee's body back to their home. Day Care Benefit If a covered insured dies as the result of an accident, a day care benefit, up to the percentage and annual maximum indicated in the Plan Design Summary, is payable for Quote ID: 46495 27 of 49 Dearborn National Prepared for: City of Lubbock, Texas reimbursement of eligible day care expenses for each qualified dependent enrolled in a licensed day care facility. The benefit is payable each year up a maximum five years. Spouse Training Benefit If a covered insured dies as the result of an accident, a benefit is payable to the insured's spouse to cover their cost of education, up to the maximum amount indicated in the Plan Design Summary, if they enroll in a school of higher learning within one year of the insured's death. Coma Benefit If a covered insured is injured in an accident, becomes comatose within 31 days of the accident, and remains comatose for a period of at least 60 days, we will pay a percentage of the insured's benefit amount, on a monthly basis. The percentage, monthly maximum and number of months are as indicated in the Plan Design Summary. Reduction Schedule Benefits reduce according to the schedule indicated in the Plan Design Summary. All reduction percentages are from the original amount. Exclusions Unless specifically covered in the policy, or required by state law, we will not pay any AD&D benefit for any loss that, directly or indirectly, results in any way from or is contributed to by: • Disease of the mind or body, or any treatment thereof; • Infections, except those from an accidental cut or wound; • Suicide or attempted suicide; • Intentionally self-inflicted injury; • War or act of war; • Travel or flight in any aircraft while a member of the crew; • Commission of or participation in a felony; • Under the influence certain drugs, narcotics or hallucinogens unless properly used as prescribed by a physician; • Intoxication as defined in the jurisdiction where the accident occurred; • Participation in a riot. Quote ID: 46495 28 of 49 neacborn National Prepared for: City of Lubbock, Texas Enhanced Product Services Included with Group Term Life Beneficiary Resource Services TM: A Wellness Plan for Life When a loved one dies, families often face complex issues ranging from estate planning, legal questions, funeral planning, coping with grief and financial uncertainties. That's why Dearborn National offers Beneficiary Resource Services, a program that combines family wellness and security at the most difficult of times. Services include grief and financial counseling, funeral planning, legal support as well as online will preparation. Beneficiary Resource Services is provided by Bensinger, DuPont & Associates (BDA). Services for insureds and their families. Online Will Preparation- A will is one of the most important documents every adult should have, and creating one has never been easier. Insureds and their families will have access to a full legal library with many estate planning documents, including an online will. Insureds can create their own wills online in a safe and secure way, right from their homes. The will can be saved and updated as family situations change. Creating a will provides security and peace of mind for several reasons: • Appoints a guardian for children • Controls where property and assets go • Provides family security • Without one, the state can make these decisions Funeral Planning - Insureds and beneficiaries have access to an online funeral planning site that features a variety of helpful tools and information, such as: • A downloadable funeral planning guide for insureds to document vital information their loved ones will need when making final arrangements • Calculators to estimate and compare expenses for various types of funeral arrangements • Information on funeral requirements and various religious customs • Directories to locate funeral homes and cemeteries in the insured's area Services for beneficiaries (and their families) after a death claim or for those that qualify for an accelerated death benefit Unlimited Phone Contact - Available for up to one year with a grief counselor, legal advisor or financial planner. Face -to -Face Working Sessions* - Five face-to-face working sessions are available to the insured person or beneficiary. All five sessions may be used with one grief counselor or legal advisor, or they may be split among the two types of counselors or advisors in geographically accessible locations. A one -hour financial consultation on the phone is also available. *May include face-to-face sessions, over -the -phone sessions or time taken for research or document preparation. Referrals and Support Services - BDA maintains a comprehensive directory of qualified and accessible grief counselors and legal and financial consultants. Follow Up - Counselors will initiate follow-up calls when necessary for up to one full year from the date of initial contact. Quote ID: 46495 29of49 EXHIBIT Cl SAMPLE BASIC AND VOLUNTARY LIFE POLICIES FORT DEARBORN LIFE Insurance Company' Administrative Office: 1020 3151 Street Downers Grove IL 60515-5591 (A stock life insurance company, herein called the "We" "Us" or "Our") Policyholder: CITY OF LUBBOCK Policy Number: GFZ03192-0001 Policy Effective Date: January 1, 2011 Anniversary Date: January I We agree with the Policyholder to insure certain eligible Employees of the Policyholder. We promise to pay benefits for loss covered by the Policy in accordance with its provisions. The Policyholder should read this Policy carefully and contact Fort Dearborn Life Insurance Company© promptly with any questions. Policjpho/(ler means the Employer to whom the Policy is issued and who sponsored the coverage for its Employees. Employer means the Policyholder and includes any division, subsidiary, or affiliated company named in the Policy. POLICY EFFECTIVE DATE AND TERM The Polic) takes effect on the Policy Effective Date stated above subject to any participation requirement stated in the Policy. All insurance periods will be computed from that date. The Policy remains in force for the period for which premium has been paid. It may be renewed for further successive periods by payment of premium as stated in the Policy. All periods of insurance begin and end at 12:01 A.M., Standard Time, at the Policyholder's address as stated in the Policy, and on the Application. Signed for Fort Dearborn Life Insurance Company,�— Secretary President Basic Group Term Life Insurance Policy with Accidental Death & Dismemberment Benefits Non -Participating FDLI-504-707 TX TABLE OF CONTENTS PRO VISION PAGE Premium 3 Premium Rate Guarantee 3 Policy Termination 4 Additional Provisions 4 Rate Addendum S Application Attached ATTACHMENTS: • Master Application • Certificate of Insurance FDLI-504-707 TX PREMIUM How is the initial premium calculated? Initial life, AD&D insurance premium is calculated in accordance with the rates set forth on the attached Rate Addendum. When is premium paid? The Policy is issued in consideration of the payment in advance of premium on the premium due date indicated on the Application. Payment must be made by the premium due date as shown on the Application. If an addition, termination or change in insurance takes place other than on a regular due date, any premium adjustment will take effect on the next due date. Is premium payahle while an Insured receives benefits? We will waive premium for an insured Employee in accordance with the Waiver of Premium provision of the Policy. Is there a grace period for premium payment? We will allow a grace period of 31 days for the payment of any premiums due except the first. Insurance coverage shall continue in force during the grace period unless the Policyholder• has given Us advance written notice of cancellation in accordance with the terms of this Policy. If premium is not received by the end of the grace period, this Policy will terminate as of the last date for which premium was paid. The Policyholder is liable for premium due on coverage provided during the grace period. If We receive written notice during the grace period that the Policy is to be canceled, We will cancel it as of the later of: 1. the date requested in the cancellation notice; or 2. the date We receive such notice. The Policvholder must pay a pro rata premium for any coverage provided during the grace period. PREMIUM RATE GUARANTEE What is the initial premium rate guarantee? A change in premium rates will not take effect before January 1, 2015. However, We may change premium rates if the risk assumed changes. Premium rates may change if the following occurs: 1. a change in the Policy design; 2. a change in the terms of the Policy; 3. addition or deletion of a division, subsidiary or affiliated company; 4. a change in the number of Insurecls by 10% or more from the number of Insureds on the initial Effective Date; 5. a change in the laws or regulations or other government action which applies to the Policy; 6. for reasons other than 1-5 above such as but not limited to a change in factors bearing on the risk assumed. The Policyholder must furnish notice and documentation satisfactory to Us within 31 days of the occurrence of any event which would cause a change in rates as described above. If the Policyholder fails to provide such timely notice, we will apply new rates retroactively to the date of the event. We will notify the Policvholder in writing at least 31 days in advance of any premium rate changes. A change may take effect on an earlier date if both the Policyholder and We agree. FDL 1-504-707 TIC POLICY TERMINA TION Who nu{v cancel the Policy or a plan uncler the Policv? The Policy or a plan under the Policy can be canceled by the Policyholder with 31 days written notice delivered to Us. This Policy will terminate for any of the following reasons: 1. if the Policyholcer fails to pay any premium within the 31-day Grace Period, this Policy will terminate in accordance with the terms set forth in the Grace Period provision. 2. We may terminate this Policy on any premium due date if: a. coverage is Noncontribulwy and less than 100% of the eligible Employees participate; or b. the Policyholder fails to perform any of its obligations that relate to the Policy; or c. the Policyholder does not promptly provide Us with information that is reasonably required; or d. fewer than 2 Employees are insured under the Policy. If We cancel the Policy, for reasons other than the Policyholder's failure to pay premium, a written notice will be delivered to the Policyholder at least 31 days prior to the cancellation date. ADDITIONAL PROVISIONS What happens if an inadvertent error occurs? Clerical error or omission by Us to the Policyholder will not: 1. Prevent an Employee from receiving coverage, if he is entitled to coverage under the terms of the Policy; or 2. Cause coverage to begin or coverage to continue for an Employee when the coverage would not otherwise be effective. If the Policyholder gives Us information about an Employee that is incorrect, We will: 1. Use the facts to decide whether the Employee has coverage under the Policy and in what amounts; and 2. Make a fair adjustment of the premium. Will certificates be issued? We will deliver certificates of insurance to the Policyholder for issuance to each insured Employee. The certificates will describe the benefits, to whom they are payable, the Policy limitations and where the Policy may be inspected. What is consiclered to be the entire contract? This entire Policy consists of. 1. all Policy provisions and any amendments and/or attachments issued; 2. the Certificate of Coverage; and 3. the Policyholder's signed Application. FDL 1-504-707 TX 4 RATE ADDENDUM (All Rates Per $1,000 Per Month unless otheiivise staled) Class 01 Term Life: $0.035 Class 01 Accidental Death & Dismemberment: $0.02 Class 02 Term Life: $4.06 Class 03 Term Life: $4.06 Class 04 Term Life: $4.06 Class 05 Term Life: $.60 PDL 1-504-707 TX STA TE SUPPLEMENT The following policies apply only to those individuals in your group insurance program who reside in the referenced states. Arizona and Maine Except as otherwise permitted by law, we will not disclose collected personal information about an individual to a nonaffiliated third party with whom we jointly offer products without giving the individual an opportunity to tell us that he or she does not want us to share his or her personal information. Minnesota and Montana Except as otherwise permitted by law, we will not disclose collected personal information about an individual to a nonaffiliated third party with whom we jointly offer products without obtaining the individual's written authorization. Montana Upon written request, an individual who has authorized the collection of health information is entitled to receive a record of Fort Dearborn's disclosures of any of his medical record information made within the preceding 3 years. Oregon An individual has the right to authorize disclosure of his or her personal information to an insurance company. An Oregon resident can exercise this right by requesting an authorization form in writing. Our address is: Fort Dearborn Life Insurance Company@ 1020 31" Street Downers Grove, Illinois 60515 FDL 1-504-707 TX FORT DEARBORN LIFE Insurance Company' Administrative Office: 1020 3 1 " Street Downers Grove IL 60515-5591 (A stock life insurance company, herein called the "We" "Us" or "Our") Policyholder: CITY OF LUBBOCK Policy Number: GFZ03192-0001 Policy Effective Date: January 1, 2011 Anniversary Date: January 1 We agree with the Policyholder to insure certain eligible Employees of the Policyholder. We promise to pay benefits for loss covered by the Policy in accordance with its provisions. The Policyholder should read this Policy carefully and contact Fort Dearborn Life Insurance Company@ promptly with any questions. Policyholder means the Employer to whom the Policy is issued and who sponsored the coverage for its Employees. Emplr�yer means the Policyholder and includes any division, subsidiary, or affiliated company named in the Policy. POLICY EFFECTIVE DA TE AND TERM The Policy takes effect on the Policy Effective Date stated above subject to any participation requirement stated in the Policy. All insurance periods will be computed from that date. The Policy remains in force for the period for which premium has been paid. It may be renewed for further successive periods by payment of premium as stated in the Policy. All periods of insurance begin and end at 12:01 A.M., Standard Time, at the Policyholder's address as stated in the Policy, and on the Application. Signed for Fort Dearborn Life Insurance Company ,�— Secretary President Voluntary Group Term Life Insurance Policy with Accidental Death & Dismemberment and Dependent Life Insurance with Dependent Accidental Death and Dismemberment Benefits Non -Participating FDL 1-504-707 TX TABLE OF CONTENTS PROVISION PAGE Premium 3 Premium Rote Guarantee 3 Policy Termination 4 Additional Provisions 4 Rote Addendum S Application Attached ATTACHMENTS: • Master Application • Certificate of Insurance FDL 1-504-707 TX PREMIUM How is the initial prentiunt calculated? Initial life, AD&D and Dependent Life insurance premium is calculated in accordance with the rates set forth on the attached Rate Addendum. When is prentiunt pairl? The Policy is issued in consideration of the payment in advance of premium on the premium due date indicated on the Application. Payment must be made by the premium due date as shown on the Application. If an addition, termination or change in insurance takes place other than on a regular due date, any premium adjustment will take effect on the next due date. Is premium payable while an Insttred receives benefits? We will waive premium for an insured Employee in accordance with the Waiver of Premium provision of the Policy. Is there a grace period for prentiunt paynzent? We will allow a grace period of 31 days for the payment of any premiums due except the first. Insurance coverage shall continue in force during the grace period unless the Policyholder has given Us advance written notice of cancellation in accordance with the terms of this Policy. if premium is not received by the end of the grace period, this Policy will terminate as of the last date for which premium was paid. The Policyholder is liable for premium due on coverage provided during the grace period. If Give receive written notice during the grace period that the Policy is to be canceled, We will cancel it as of the later of: 1. the date requested in the cancellation notice; or 2. the date We receive such notice. The Policyholder must pay a pro rata premium for any coverage provided during the grace period. PREMIUM RA TE G UARANTEE What is the initial prentium rate guarantee? A change in premium rates will not take effect before January 1, 2015. However, We may change premium rates if the risk assumed changes. Premium rates may change if the following occurs: I. a change in the Policy design; 2. a change in the terms of the Policy; 3. addition or deletion of a division, subsidiary or affiliated company; 4. a change in the number of Insureds by 10% or more from the number of Insureds on the initial Effective Date; 5. a change in the laws or regulations or other government action which applies to the Policy; 6. for reasons other than 1-5 above such as but not limited to a change in factors bearing on the risk assumed. The Policyholder must furnish notice and documentation satisfactory to Us within 31 days of the occurrence of any event which would cause a change in rates as described above. if the Policyholder fails to provide such timely notice, we will apply new rates retroactively to the date of the event. We will notify the Policyholder in writing at least 31 days in advance of any premium rate changes. A change may take effect on an earlier date if both the Policyholder and We agree. FDLi-504-707 TX POLICY TERMINATION Who nary cancel the Policv or a plan under the Policy? The Policy or a plan under the Policy can be canceled by the Policyholder with 31 days written notice delivered to Us. This Policy will terminate for any of the following reasons: 1. If the Policyholder fails to pay any premium within the 31-day Grace Period, this Policy will terminate in accordance with the terms set forth in the Grace Period provision. 2. We may terminate this Policy on any premium due date if. a. coverage is Contributory and less than 25% of the eligible Employees participate; or b. the Policyholder fails to perform any of its obligations that relate to the Policy; or c. the Policyholder does not promptly provide Us with information that is reasonably required; or d. fewer than 2 Employees are insured under the Policy. If We cancel the Policy, for reasons other than the Policyholcler's failure to pay premium, a written notice will be delivered to the Policyholder at least 31 days prior to the cancellation date. ADDITIONAL PROVISIONS What happens if an inadvertent error occurs? Clerical error or omission by Us to the Policyholder will not: 1. Prevent an Employee from receiving coverage, if he is entitled to coverage under the terms of the Policy; or 2. Cause coverage to begin or coverage to continue for an Employee when the coverage would not otherwise be effective. If the Policyholder gives Us information about an Employee that is incorrect, We will: 1. Use the facts to decide whether the Employee has coverage under the Policy and in what amounts; and 2. Make a fair adjustment of the premium. Will certificates be issued? PVe will deliver certificates of insurance to the Policyholder for issuance to each insured Employee. The certificates will describe the benefits, to whom they are payable, the Policy limitations and where the Policy may be inspected. What is considered to be the entire contract? This entire Policy consists of: l . all Policy provisions and any amendments and/or attachments issued; 2. the Certificate of Coverage; and 3. the Policyholder's signed Application; and 4. the Employee's signed enrollment forms. FDL1-504-707 TX 4 RATE ADDENDUM (All Rates Per S1,000 Per Month unless otherivise staled) Class 01 Voluntary Spouse Life: $.80 per $5,000 Class 01 Voluntary Child Life: $ 2,500 benefit $0.50 per family unit $ 5,000 benefit $1.00 per family unit $ 7,500 benefit $1.50 per family unit $10,000 benefit $2.00 per family unit Class 01 Voluntary Accidental Death and Dismemberment: Individual Plan: $0.025 Family Plan: $0.038 Class 01 Voluntary Tenn Life: Age Range UNDER to 30 30 to 34 35 to 39 40 to 44 45 to 49 50 to 54 55 to 59 60 to 64 65 to 69 70 to 74 75 to 79 80 to 84 Rate $.06 $.08 $.09 $.14 $.20 $.33 $.59 $.96 $1.51 $2.68 $4.94 $8.40 FDLI-504-707 TX 5 Class 02, 03 &04 Voluntary Dependent Life (Spouse & Child(ren): $1.25 per family unit Class 02,03 &04 Voluntary Term Life: Age Range Rate UNDER to 30 $.11 30 to 34 $.12 35 to 39 $.17 40 to 44 $.26 45 to 49 $.44 50 to 54 $.78 55 to 59 $1.27 60to 64 $1.44 65to 69 $2.38 70 to 74 $4.12 75 to 79 $6.20 80 to 84 $9.75 FDLI-504-707 TX 6 STATE SUPPLEMENT The following policies apply only to those individuals in your group insurance program who reside in the referenced states. Arizona and Maine Except as otherwise permitted by law, we will not disclose collected personal information about an individual to a nonaffiliated third party with whom we jointly offer products without giving the individual an opportunity to tell us that he or she does not want us to share his or her personal information. Minnesota and Montana Except as otherwise permitted by law, we will not disclose collected personal information about an individual to a nonaffiliated third party with whom we jointly offer products without obtaining the individual's written authorization. Montana Upon written request, an individual who has authorized the collection of health information is entitled to receive a record of Fort Dearborn's disclosures of any of his medical record information made within the preceding 3 years. Oregon An individual has the right to authorize disclosure of his or her personal information to an insurance company. An Oregon resident can exercise this right by requesting an authorization form in writing. Our address is: Fort Dearborn Life Insurance Company@ 1020 3 1 " Street Downers Grove, Illinois 60515 FDL1-504-707 TX Dearborn ' N(Aional' Strength. Independence. Solutions. 3. QUESTIONS Please type your responses underneath each question. The parenthetical numbers (letters) are provided as a courtesy so that the Scope of Work paragraph, if applicable, can be referenced. RA) Carrier Ouestions 1. Provide a brief overview of your Carrier/Provider (furnish your business philosophy, mission statement, management structure, organizational chart, etc. Dearborn National was founded and incorporated in the state of Illinois in 1966 to provide ancillary insurance products and services to the customers of our parent company, Flealth Care Service Corporation (HCSC). HCSC, a mutual legal reserve company conducts business as Blue Cross and Blue Shield of Illinois, Montana, New Mexico, Oklahoma and Texas. HCSC is the largest health care insurance provider in the state of Illinois and is the 4t" largest medical carrier nationally. HCSC is a wholly -owned, not -for -profit, Mutual Legal Reserve Company established and licensed to sell insurance in 1936, under the statutes of the State of Illinois. Dearborn National provides employer groups with a comprehensive portfolio of insurance products and services including group and voluntary term life insurance, accidental death & dismemberment (AD&D), critical illness, and short and long term disability and dental plans. We are licensed in all 50 states, (Dearborn National Life Insurance Company of New York is licensed in New York), as well as the District of Columbia, the U.S. Virgin Islands, the British Virgin Islands, Guam and Puerto Rico. Dearborn National has been providing Life and AD&D insurance for over 44 years, and Disability insurance coverage for over 33 years. We continually re-evaluate our products and services to make sure we are meeting the needs of our clients and offering the solutions that work best in an ever changing industry and culture. Dearborn National demonstrates a commitment to service by offering outstanding account management and customer service teams. The account management team will interact with the City of Lubbock as necessary to ensure the ongoing maintenance of your benefits program. We will work together with the City of Lubbock to develop procedures, policies, and reports to ensure a smooth transition and flawless implementation. 49 RPP 14-1 1842-DT Ancillary Benefits Plan Large company resources combined with the flexibility and quick response time of a small company are key to Dearborn National's success. Our primary focus is to service the needs of our customers through continued investment in quality employees and enhanced technology. This ensures we provide innovative products and superior service meeting the expectations of our client base. 2. Please list the services provided from your office. • Implementation and installation of the City of Lubbock account including ongoing meetings and status reports • Plan design and contract review and delivery • Training on administrative procedures with ongoing support • Report delivery and review • Follow LIP, issue resolution and ongoing evaluations • Supplying accurate and useful reports • Providing printed materials for all presentations at no charge. 3. Please provide the number of client support and a brief description of the staff that will be dedicated to the City of Lubbock. Please list the number of staff current!)) serviced for public clients and other clients. We have an experienced Customer Service staff trained to handle administrative, billing and claims (life and disability) inquiries for our employer groups. Our Customer Service toll -free number is 1-800-348-4512, and hours of operation are Monday through Friday, 7:00 a.m. to 7:00 p.m. Central Standard Time. Inquiries can be made by telephone, email or in writing. 4. State the type of ownership of your Carrier/Provider. Give the State and date of your incorporation if applicable. List headquarters and regional/full service office locations, and website address. Dearborn National was founded and incorporated in the state of Illinois in 1966 to provide ancillary insurance products and services to the customers of our parent company, Health Care Service Corporation (HCSC). HCSC, a mutual legal reserve company conducts business as Blue Cross and Blue Shield of Illinois, Montana, New Mexico, Oklahoma and Texas. HCSC is the largest health care insurance provider in the state of Illinois and is the 4t" largest medical carrier nationally. HCSC is a wholly -owned, not -for -profit, Mutual Legal Reserve Company established and licensed to sell insurance in 1936, under the statutes of the State of Illinois. Headquarters: Home Office: Administrative Office: Dearborn National Dearborn National 1001 East Lookout Drive RPP 14-1 1842-DT Ancillary Benefits Plan 300 East Randolph Street 1020 31 st Street Richardson, TX 75082 Chicago, IL 60601 Downers Grove, IL 60515 Phone: 800-331-0512 Fax: 630-824-5413 Dearborn National's Website: www.dearbornnational.com S. Please provide the primary and secondary contact name, title and resume including any professional certifications or designations. Please list the number of participants ciirrently serviced for public clients and other clients. Jeff Jay Sales Executive Dearborn National 1001 East Lookout Drive Richardson, TX 75082 Phone: (972) 996-8597 E-mail: jelTJavndearbornnational.com Jeff Jay joined the Dearborn National sales team in January of 2014, and currently covers central and southern Texas. An expert in the industry, Jeff has over fourteen years' experience in the sales of ancillary insurance products and services. Jeff's comprehensive background includes expertise in life and disability products, training and underwriting. He is client focused and solution oriented, meeting the highest standards of excellence in customer service. Jeff's experience prior to joining Dearborn National includes sales of ancillary business for Cigna and Mutual of Omaha. Jeff received a Bachelor Degree in Economics from University of Oklahoma and holds a Texas General Lines insurance license. Tonja Shastid Accorrnt Manager Dearborn National 1001 East Lookout Drive Richardson, Texas 75082 Phone: 972-996-9352 Fax: 972-231-5964 E-mail: tonja_shastid@dearbornnational.com Tonja Shastid has been with the company since 1982. She has worked in various departments including Group & Individual Life, Marketing, and Policy Issue. Ms. Shastid's current position is Regional Account Manager for Dearborn National. Her responsibilities include being a liaison between Group Administration and Marketing, 3 RFP 14-1 1842-DT Ancillary Benefits Plan and providing solution oriented service for primarily large accounts. Ms. Shastid holds a Group 1 Insurance License for the State of Texas. 6. Please list any complaints filed with the Texas Department of Insurance on arty person ill your organization from five years ago to today. Dearborn National does not currently have any claims field against it which are unresolved and presently pending before any State of Texas Administrative agency. Litigation or claims fled against Dearborn National have largely been beneficiary disputes or cases where various parties contested the right to benefits. None of this litigation has been material. 7. Please provide status of ally current or pending litigation against your Carrier/Provider that might affect your ability to deliver the services that you offer. Past and pending litigation or clairns filed against us have largely been beneficiary disputes (cases where various parties contested the right to benefits). None of this litigation has been material, nor would it adversely impact our performance under an agreement with City of Lubbock. 8. Do you anticipate that your Carrier/Provider will be acquired in the foreseeable future? Is your Carrier/Provider planning to acquire ally other companies? If yes, please provide the names of the companies and the nature of the business. Dearborn National currently has no plans for future mergers or acquisitions. There are no projected or pending agreements to sell out• company. 9. Include the names of three (3) current customers (title and phone numbers) that have used your Carrier/Provider for the same or ❑similar products described in this RFP. We recognize the importance of providing City of Lubbock with current and former client references in choosing Dearborn National as your new Life/Disability carrier. To meet your request for references and to remain considerate of our existing clients, we will furnish references when we are selected as a finalist. We look forward to providing City of Lubbock with references and associated details during the finalist process. 4 RFP I4-11842-DT Ancillary Benefits Plan 10. Describe any other value-added services your Carrier/Provider is capable of provide. At Dearborn National, we have put together a range of enhanced product services to complement our existing product lines. These services include Beneficiary Resource Services, Travel Resource Services, Online Will Preparation, an Employee Assistance Program (EAP), Disability Resource Services and Disability Claim Management. Beneficiary Resource Sen-ices Included at no additional cost, Beneficiary Resource Services combines grief, legal and financial counseling to support beneficiaries during their time of loss. Beneficiary Resource Services is provided by Bensinger, DuPont & Associates (BDA) and is available to the beneficiary for LIP to one year from the date BDA is contacted. Services are also available to insured individuals who qualify for an accelerated benefit from the group life insurance plan. When the insured person or beneficiary contacts BDA, a counselor will assess their needs to develop a plan and provide access to grief counseling, financial counseling and/or legal services. Counselors coordinate the services while maintaining confidentiality. Services include: • Unlimited phone contact • Up to 5 face to face working sessions • Referrals and support services • Follow LIP Travel ResourceServices Dearborn National's proposal includes Travel Resource Services at no additional cost. Travel Resource Services provides employees (and families) traveling more than 100 miles from home the protection they need when medical care or other services are required while away from home. Some of the services included in this program are: • Referral to a local qualified doctor through a network of providers • Evacuation to the closest adequate medical facility • Repatriation from a place of hospitalization to the insured's home • Return of a travel companion to their home • Return of dependent children of the insured to their home RPP 14-1 1842-D'r Ancillary Benefits Plan Pre -Trip information on the destination including weather, inoculation requirements and travel advisories • Additional benefits and services Will Preparation Dearborn National's proposal includes Will Preparation Services at no additional cost. Online will preparation gives employees access to a web site where they can create, Update and maintain a will. To make the will preparation process simple and convenient, the web site provides resources such as a "Frequently Asked Questions" page and a "Dictionary of Important Terms". Disability Resource Services Disability Resource Services provides the extra support needed for those on long-term disability claim. Web -based services assist employees with personal, relational, health and financial concerns. Offered at no additional cost to all long-term disability claimants, Disability Resource Services provides easy access to professionals through a toll -free dedicated phone line 24 hours a day, seven days a week. Claimants can use the telephonic assistance available, or they choose face-to-face counseling sessions for emotional issues. Disability Resource Services includes two components: Guidance Resources® Online and employee counseling services. 3(B) SCOPE QUESTIONS 1. Are you willing to participate in open enrollment to make your product(s) available to the City of Lubbock employees? We are willing to offer open enrollment during annual enrollment where employees and spouses currently enrolled can increase their benefit by 1 level up to the guarantee issue amount. 2. Are you willing to participate at new employee orientation to make your product(s) available? Representatives from Dearborn National will be available to attend enrollment meetings, benefit fairs and general employee communication meetings. RFP 14-11342-1)1- Ancillary Benefits Plan 3. Do you have a local office where City employees and family members can meet to discuss yore• prodrrct(s)? We have an office in Richardson, Texas. 4. Do you offer Plan portability ender similar terms if a City employee terminates his or her employment with the City? Yes, portability is available to employees that terminate their employment. S. Are you capable of providing website access to your plans so that the City employees can utilize the proposed services by using your website? Dearborn National's website, located at ++++w.dearbornnational.com, can be used by employees to: Download administrative forms Contact our customer service area Locate information about Dearborn National In addition, our administrative section for employers offers secure access to: The Benefits Manager web portal Online administrative guides Product descriptions 3 (C) S UMMA R Y Explain in one page or less how your sohttion will differentiate yorr front other Carriers/Providers and why we should choose you as our successful Carrier/Provider. List the unique features that give your Carrier/Provider a competitive edge in the industry. With more than 43 years of experience, Dearborn National is among the nation's leading providers of group life insurance programs. We believe that we are best qualified to perform the services detailed within the RFP request due to our strong financial standing, competitive rates offered, and commitment to service. We offer outstanding account management and customer service teams along with an established, trained administrative staff with proven ability to provide excellent service. We are committed to responding to your needs with prompt and courteous service at all times and settling all eligible claims as quickly and accurately as possible. RFP 14-11842-DT Ancillary Benefits Plan ('n.ctn,ner .Suticfnctinn: Dearborn National demonstrates a commitment to service by offering outstanding account management and customer service teams. The account management team will interact with the City of Lubbock as necessary to ensure the ongoing maintenance of your benefits program. We will work together with the City of Lubbock to develop procedures, policies, and reports to ensure a smooth transition and flawless implementation. Financial Stuhiiit),: Dearborn National prides itself on strong capital position and commitment to excellent customer service. With the relationship to our parent company, Health Care Service Corporation, Dearborn National has the backing of a premier health insurance company. This allows us to expand our capabilities and keep up-to-date with changes in the industry. k7e.vihilih!: Large company resources combined with the flexibility and quick response time of a small company are key to Dearborn National's success. Our primary focus is to service the needs of our customers through continued investment in quality employees and enhanced technology. This ensures we provide innovative products and superior service meeting the expectations of our client base. RFP 14-1 I8d2-D'r Ancillary Benefits Plan Dearborn Na1-YMOX Strength, Independence, Solutions. 4. PRODUCTS AND PRICING SCHEDULE 4(A) Group Employer -Paid Group Life/AD&D Insurance Basic Life and AD&D Employer -Paid Group Life Insurance Vendor Answer Guaranteed Issue $10,000 Policy portability under similar terms and conditions es Length of time with carrier 1/1/1 1 Minimum participation 100% A M Best Rating of carrier (A VIII min) + (Superior) Life insurance waiver of premium notifications No Limitations and exclusions Offer current limitations and exclusions Accelerated Death Benefit Yes Line of Duty Benefit No Benefit Reduction Schedule similar es Seat Belt Benefit Yes Air Bag Benefit Yes Career Adjustment Benefit Yes listed as Spouse Training benefit Child Care Benefit Yes Higher Education Benefit Yes Enrollment Guidelines Similar Same as current Multi -year quotes are preferred and will be considered first. Please complete the pricing form below and attach your premium schedule. The Bi-weekly costs will be determined from a random sample of 100 below: Item Employer -Paid Group Life Vendor Answer 1 Multi -year Rate Quote 3 Years 2 Please attach a five year rate history Rates will be guaranteed for 3 years 3 Cost per $1000 $0.035 for Basic Life Actives 44 RFP 14-11842-DT Ancillary Benefits Plan 4 (c) Voluntary Short-term Disabilities Minimum requirements: Voluntary Short-term disability insurance — policy should include an "own occupation" definition of disability and waiver of premium for disability. The policy must cover on duty and off duty disability. The waiting period for benefits cannot be longer than 30 days. The benefit payout period must be at least 13 weeks. The benefit must be at least 50% of usual pay offset from other sources of income such as social security or workers compensation. However, the minimum benefit must be at least 40% of usual pay without any offsets. Please include other features of your policy in the evaluation below. The policy must have guaranteed issue for new hires and initial open enrollment period. The carrier/provider must have an A M Best rating of A VIII or better. Please include examples of any promotions or promotional materials. You can propose more than one product for each product line. Please complete the product evaluation form below for each product you are proposing. Short term Disability Vendor Answer Guaranteed Issue No OWN OCCUPATION Definition of Yes Portable under similar terms and conditions No WAIVER OF PREMIUM for disability o On duty and Off duty coverage Yes Length of time with carrier on -applicable Minimum participation 5% A M Best Rating of carrier (A VIII min) +(Superior) Waiting period for illness (30 days maximum days Waiting period for injury (30 days maximum days Coverage period (13 week minimum) 25 weeks for option l & 13 for option 2 Percent of usual pay (50% minimum) 60% for option 1 & 66 2/3% for option 2 Minimum Percent of usual pay with Social Security, Worker's Comp or other i n c o m e offset (40% minimum) 25 minimum benefit '12/12 pre -ex _ _J Other features: Please list other features of your policy. Minimum participation — greater consideration will be given for lower number of minimum participation. Page 1 Understood A M Best Rating — greater consideration will be assigned for higher A M Best rating. The minimum rating is A VIII. The A.M. Best Company affirmed an A+ (Superior) rating for Dearborn National Life Insurance Company. in its December 19, 2013 report, for financial condition, operating performance and market profile. The outlook is positive. Effective October 10, 2011, Dearborn National's financial size category is IX ($250 Million to $500 Million). Waiting Periods — greater consideration will be assigned for shorter waiting periods. Understood Coverage Periods — greater consideration will be assigned for longer coverage periods. Understood Percent of usual pay — greater consideration will be assigned for higher percentages of usual pay. Understood Pricin Item Voluntary Short -Term Disability Insurance Vendor Answer 1 Multi -year Rate Quote (5 points per 13 Years year. F 2 Please attach a five year rate history'Rates will be guaranteed for 2 years L 3 Bi Weekly Cost per Sample of 100 Rates are age banded listed in the proposal Multi -year quotes are preferred and will be considered first. Please complete the pricing form below and attach your premium schedule. The Bi-weekly costs will be determined from a random sample of 100 below: 4(D) Long-term Disability Minimum requirements: Long-term disability insurance — policy should include an "any occupation" definition of disability and waiver of premium for disability. We would prefer a policy that has an Page 2 own occupation test for disability for 2 years and any occupation test thereafter. The policy must cover on duty and off duty disability. The waiting period for benefits cannot be longer than 180 days. The benefit payout period must be at least 5 years, but would prefer until age 65. The benefit must be at least 50% of usual pay offset from other sources of income such as social security or workers compensation. However, the minimum benefit must be at least 40% of usual pay without any offsets. Please include other features of your policy in the evaluation below. The policy must have guaranteed issue for new hires and initial open enrollment period. The carrier/provider must have an A M Best rating of A VIII or better. Please include examples of any promotions or promotional materials. You can propose more than one product for each product line. Please complete the product evaluation form below for each product you are proposing. 5. SCHEDULE OF BENEFITS Disability Income Insurance — Monthly Income Benefits Long term Disability Vendor Answer Yes Yes Guaranteed Issue WAIVER OF PREMIUM for disability Portable under similar terms and No conditions Yes Non -applicable On duty and Off duty coverage Length of time with carrier (1 point per Minimum participation 5% A M Best Rating of carrier (A + (Superior) VIII min) Yes, 24 months Own Occupation test for wait period? 180 days for option 1 and 90 days for option 2 Waiting period for illness (180 days maximum) Waiting period for injury (180 180 days for option 1 and 90 days for option 2 days maximum) Coverage period (5 year minimum) years rate guarantee Percent of usual pay (50% 0% for option 1 and 66 2/3% for option 2 minimum Minimum Percent of usual pay with Social Security, Worker's Minimum benefit is $100 Comp or other income offset (40% minimum) Page 3 Other features: Please list other Day Care Benefit, Rehabilitation Benefit, Worksite features of your policy, modification Minimum participation — greater consideration will be given for lower number of minimum participation. Understood A M Best Rating — greater consideration will be assigned for higher A M Best rating. The minimum rating is A VIII. The A.M. Best Company affirmed an A+ (Superior) rating for Dearborn National life Insurance Company in its December 19, 2013 report, for financial condition, operating performance and market profile. The outlook is positive. Effective October 10, 2011, Dearborn National's financial size category is IX ($250 Million to $500 Million). Waiting Periods — greater consideration will be assigned for shorter waiting periods. Understood Coverage Periods — greater consideration will be assigned for longer coverage periods. Understood Percent of usual pay — greater consideration will be assigned for higher percentages of usual pay. Understood Pricina Item Long term Disability Insurance 1 Multi -year Rate Quote (5 points per year. 3 Years 2 Please attach a five year rate history Rates are guaranteed for 3 years 3 Bi Weekly Cost per Sample of 100 IRates are included in the proposal Multi-vear quotes are preferred and will be considered first. Please complete the pricing form below and attach your premium schedule. The Bi-weekly costs will be determined from a random sample of 100 below: Page 4 Dearborn Natlonctf Prepared for: City of Lubbock, Texas BDA's nationwide network of experienced professionals can offer counseling for individuals facing difficult emotional, financial or legal issues. RDA's counselors are available 24 hours a day, 365 days a year. All calls are completely confidential. Travel Resource Services' In today's global economy, the need for world travel is now greater than ever. However, a trip, whether for business or pleasure, can be disrupted by the unexpected. A medical emergency, a lost prescription or even emergencies involving a spouse, child or traveling companion can jeopardize a trip. To provide the support people need while traveling on business or pleasure, we provide Travel Resource Servicesz, a program that assists travelers if the unexpected happens. Services are available to insureds and their families traveling 100 or more miles from their primary residence, and include: 6 Medical Search and Referral 6 Medical Evacuation/Return Home 6 Dependent Children Assistance 6 Return of Mortal Remains 6 Emergency Message Relay 6 Emergency Cash 6 Legal Assistance/Bail 6 Pre -Trip Information 6 Medical Monitoring 6 Traveling Companion Assistance 6 Visit by Family Member/Friend 6 Replacement of Medication and Eyeglasses 6 Emergency Travel Arrangements 6 Locating Lost or Stolen Items 6 Interpretation/Translation 1 Travel Assistance Services are provided to groups with 50 or more employees; Not available in all states. z We contract with Europ Assistance USA, Inc. to provide the Travel Resource Services. We do not provide any part of the Travel Resource Services, Quote ID: 46495 41 !pd5: Dearborn National` Prepared for: City of Lubbock, Texas Additional Plan Features Basic Life All Retireed All Retireed All Retireed Employees Employees All Eligible Employees who retireed who retireed Active who retireed on or after on or after Employees on or after April 1, 1988 January 1, December but before 1974 but 1, 1995 December before April 1, 1995 1, 1988 Option Current Plan Current Plan Current Plan Current Plan Waiver of Premium - Definition of Any Occupation Not Applicable Not Applicable Not Applicable Disability Waiver of Premium - Maximum Qualifying 60 Not Applicable Not Applicable Not Applicable Age Waiver of Premium - Specific Conditions Not Applicable Not Applicable Not Applicable Not Applicable Benefit Extended Insurance Benefit - Definition of Not Applicable Not Applicable Not Applicable Not Applicable Disability Extended Insurance Benefit - Maximum Not Applicable Not Applicable Not Applicable Not Applicable Qualifying Age Extended Insurance Not Applicable Not Applicable Not Applicable Not Applicable Benefit - Duration FMLA Extension Included Included Included Included Extension Disability 12th Month 12th Month 12th Month 12th Month Layoff Next month Next month Next month Next month Leave Next month Next month Next month Next month Sabbatical 6th Month 6th Month 6th Month 6th Month Military Leave 12th Month 12th Month 12th Month 12th Month Accelerated Death $15,000 Not Applicable Not Applicable Not Applicable - Minimum Accelerated Death Benefit - Definition of 12 Months Not Applicable Not Applicable Not Applicable Terminal Illness Quote ID: 46495 42!pd5: Dearborn National Prepared for: City of Lubbock, Texas Benefit Highlights Voluntary Life Eligibility Eligibility is as indicated in the Plan Design Summary. To be eligible, employees must be legally working in the United States and meet the eligibility requirements indicated in the Plan Design Summary. Insured Persons may have to complete a Waiting Period. Seasonal, part-time and temporary employees are not eligible. Effective Date If an insured person is absent from work due to injury or sickness on the last day of work prior to their effective date, the effective date of coverage will be delayed until 12:01 a.m. on the day coinciding with or next following their return to active work for a period of one day. Guarantee Issue Voluntary Life Insurance Amounts up to the Guarantee Issue amount stated in the Plan Design Summary are offered with no need for Evidence of Insurability. Amounts in excess of the Guarantee Issue amount are subject to underwriting approval before becoming effective. Conversion Insureds who terminate employment, or lose all or a portion of their coverage for other reasons may be able to convert all or a portion of their Life coverage to individual policies. Upon coverage termination administrators have 31 days after coverage ends to inform the insureds of their right to convert to an individual policy without evidence of insurability. Conversion does not apply to AD&D or Waiver of Premium amounts. Portability If Voluntary Life coverage ceases for reasons other than retirement, sickness, injury or termination of the policy, eligible insured persons can purchase portable term life insurance without Evidence of Insurability. As long as premiums are paid, portable coverage continues until the insured reaches the maximum age indicated in the plan design summary. Accelerated Benefits Insureds who are diagnosed as being terminally ill can access a portion of their life insurance benefits while they are alive. The insured can accelerate a percentage of their life insurance amount, up to the maximum amount, as indicated in the Plan Design Summary. If life insurance benefits are subject to age reductions within 12 months of receiving proof of terminal illness, the accelerated death benefit will reduce accordingly. The minimum amount that can be accelerated and the definition of Terminally III are shown in the Additional Plan Features. Waiver of Premium We will continue coverage for insureds who become totally disabled and complete the Elimination Period shown on the Plan Design Summary. Voluntary Life Insurance will be extended to the age as indicated in the Plan Design Summary, with no premium charge. The onset of the disability must occur before the insured reaches the age indicated in the Additional Plan Features and they must meet the definition of disability for the entire elimination period. The amount of insurance extended will be the amount of Life Insurance Quote ID: 46495 43!pcj5: Dearborn NO-tioncd Prepared for: City of Lubbock, Texas in force immediately prior to the date of the Total Disability. This amount is subject to any reductions under the policy. Consolidated Claim Management for Life and Long Term Disability For those insured under our Life and Long Term Disability programs, we have a seamless claim process for filing claims for Waiver of Premium and Long Term Disability. The claimant simply completes one claim form, and we handle the rest. Reduction of Benefits The Insured's Voluntary life insurance amount will reduce upon reaching the ages as indicated in the Plan Design Summary. All reduction percentages are calculated from the original amount. Limitations and Exclusions Voluntary Life benefits, including Waiver of Premium, are not payable for a loss which is caused by a suicide or attempted suicide within one year of the effective date of coverage. Termination of Coverage The insured's Voluntary life insurance will terminate on the earliest of the following dates: o The date the policy is terminated; o The date the insured stops making any required contribution toward payment of premiums; o The date the insured is no longer a member of an eligible class, requests termination of coverage. o The date the insured is no longer covered as a result of a disability, layoff, leave of absence, sabbatical or military leave. Extension of Coverage If an employee is no longer Actively at Work as a result of a disability, layoff, leave of absence, sabbatical or military duty, they may be able to continue to be eligible for Voluntary Life insurance coverage as follows: Disability - Until the end of the month following the period indicated in the Additional Plan Features after which the disability began, provided all premiums have been paid and the policy is still in force and has not been replaced with a new carrier. Layoff - Until the end of the month following the period indicated in the Additional Plan Features after the layoff began, provided all premiums have been paid and the policy is still in force and has not been replaced with a new carrier. Leave of Absence - Until the end of the month following the period indicated in the Additional Plan Features after which the leave of absence began or the period of time in accordance with FMLA, provided all premiums have been paid and the policy is still in force and has not been replaced with a new carrier. Sabbatical - Until the end of the month following the period indicated in the Additional Plan Features after the sabbatical began, provided all premiums have been paid and the policy is still in force and has not been replaced with a new carrier. Military Leave - Until the end of the month following period indicated in the Additional Plan Features after which the disability began, provided all premiums have been paid and the policy is still in force and has not been replaced with a new carrier. Quote ID: 46495 44!pg5: Dearborn National Prepared for: City of Lubbock, Texas Extension of Coverage for FMLA Leave If an insured is eligible for and receives approval for leave under the Family and Medical Leave Act of 1993 (FMLA) or any applicable state, family and medical leave law, insurance will continue (provided premium continues to be paid) for a period up to the later of: o The leave period permitted by FMLA and any amendments; or o The leave period permitted by applicable state law. Transition of Coverage from a Previous Carrier As an established group life insurance carrier, it has been our experience that most carriers have standardized procedures when it comes to determining responsibility on employee transition situations. Our position has been that the terminating carrier is responsible for anyone who was insured under their contract, but is disabled and does not meet the requirements of becoming insured under our contract. This person may or may not be eligible for Waiver of Premium under the prior policy. It is our recommendation that this issue be discussed with the terminating carrier to identify any insured's who may not be eligible for coverage on the effective date of our policy. While awaiting the decision of the terminating carrier, it is recommended that the impacted employee apply for conversion. We will cover any eligible insureds who may be on vacation, leave of absence, observing a holiday, etc. on the effective date of our policy. Quote ID: 46495 45!pd5: MCIL Of National} Prepared for: City of Lubbock, Texas Voluntary Accidental Death and Dismemberment Our Voluntary Accidental Death and Dismemberment (AD&D) plan pays an additional benefit when a covered insured loses their life, or a limb due to an accident. Benefits are paid based on the following schedule. AD&D SCHEDULE OF LOSSES BENEFIT AMOUNT Loss of Life 100% Loss of Both Hands or Both Feet 100% Loss of One Hand and One Foot 100% Loss of Speech and Hearing 100% Loss of Sight of Both Eyes 100% Loss of One Hand and the Sight of One Eye 100% Loss of One Foot and the Sight of One Eye 100% Quadriplegia 100% Paraplegia 75% Hemiplegia 50% Loss of Sight of One Eye 50% Loss of One Hand or One Foot 50% Loss of Speech or Hearing 50% Loss of Thumb and Index Finger of Same Hand 25% Uniplegia 25% The following additional benefits are included with our Accidental Death & Dismemberment plan. For amount and availability of benefits, please refer to the Plan Design Summary. Seat Belt Benefit Pays an additional benefit, up to the percentage and maximum amounts indicated in the Plan Design Summary, if the covered insured dies in an automobile accident while wearing a properly worn seat belt. Air Bag Benefit Pays an additional benefit, up to the percentage and maximum amounts indicated in the Plan Design Summary, if the covered insured dies in an automobile accident while seated in a seat containing a factory installed air bag. Education Benefit Pays an additional benefit, up to the percentage and annual maximum indicated in the Plan Design Summary, if a covered insured dies in an accident and has qualified dependent children attending a school of higher learning. The benefit is payable for each insured child and up to four annual payments. Repatriation If a covered insured dies as a result of an accident more than 75 miles from their principal place of residence, the benefit pays the actual costs, up to the maximum amount indicated in the Plan Design Summary, for the preparation and transportation of the insured employee's body back to their home. Day Care Benefit If a covered insured dies as the result of an accident, a day care benefit, up to the percentage and annual maximum indicated in the Plan Design Summary, is payable for Quote ID: 46495 46!pd5: Dearborn National Prepared for: City of Lubbock, Texas reimbursement of eligible day care expenses for each qualified dependent enrolled in a licensed day care facility. The benefit is payable each year up a maximum five years. Spouse Training Benefit If a covered insured dies as the result of an accident, a benefit is payable to the insured's spouse to cover their cost of education, up to the maximum amount indicated in the Plan Design Summary, if they enroll in a school of higher learning within one year of the insured's death. Common Disaster Benefit If a covered insured dies as the result of an accident, and their insured spouse dies in the same accident, or separate accidents occurring within 24 hours of each other, we will increase the insured spouse's benefit to equal the benefit of the insured, up to the maximum amount shown in the Plan Design Summary. Coma Benefit If a covered insured is injured in an accident, becomes comatose within 31 days of the accident, and remains comatose for a period of at least 60 days, we will pay a percentage of the insured's benefit amount, on a monthly basis. The percentage, monthly maximum and number of months are as indicated in the Plan Design Summary. Reduction Schedule Benefits reduce according to the schedule indicated in the Plan Design Summary. All reduction percentages are from the original amount. Exclusions Unless specifically covered in the policy, or required by state law, we will not pay any AD&D benefit for any loss that, directly or indirectly, results in any way from or is contributed to by: 6 Disease of the mind or body, or any treatment thereof; 6 Infections, except those from an accidental cut or wound; 6 Suicide or attempted suicide; 6 Intentionally self-inflicted injury; 6 War or act of war; 6 Travel or flight in any aircraft while a member of the crew; 6 Commission of or participation in a felony; 6 Under the influence certain drugs, narcotics or hallucinogens unless properly used as prescribed by a physician; 6 Intoxication as defined in the jurisdiction where the accident occurred; 6 Participation in a riot. Quote ID: 46495 47!pcj5: Dearborn National Prepared for: City of Lubbock, Texas Voluntary Dependent Life Insurance Dependent Effective Date of Coverage If the insured meets the effective date requirements, then the dependents are eligible for coverage unless confined to a hospital. If hospitalized dependent coverage will become effective on the date the eligible dependent is no longer hospital confined. Spouse Coverage A covered spouse , which includes Domestic Partners where permitted, will be covered for the amount indicated in the Plan Design Summary. In order for a spouse to be covered, the eligible insured person must also be covered. A spouse cannot be insured for more than 100% of the amount the insured person is eligible for. Spouse Guarantee Issue Spouse amounts up to the Guarantee Issue amount stated in the Plan Design Summary are offered with no need for Evidence of Insurability. Amounts in excess of the Guarantee Issue amount are subject to underwriting approval before becoming effective. Dependent Child Coverage Eligible Dependent Children will be covered for the amounts as indicated in the Plan Design Summary. Dependent children are covered until reaching the ages indicated in the Plan Design Summary. Portability If Voluntary Life coverage ceases for reasons other than the employees retirement or termination of the policy, eligible insured dependents can purchase portable term life insurance without Evidence of Insurability. As long as premiums are paid, portable coverage continues until the spouse reaches the maximum age indicated in the plan design summary. Conversion Dependents whose coverage terminates may be able to convert their Voluntary Life coverage to individual policies. Upon coverage termination administrators have 31 days after coverage ends to inform the dependents of their right to convert to an individual policy without evidence of insurability. Conversion does not apply to amounts. Termination of Dependent Life Insurance Dependent Life insurance will end on the earliest of the following: o The date the insured person is no longer covered under the policy; o The date the Policy is terminated; o The date any required premiums cease to be paid; or o The date the dependent is no longer an eligible dependent under the policy. Quote ID: 46495 48!pd5: Dearborn National Prepared for: City of Lubbock, Texas Enhanced Product Services Included with Group Term Life Beneficiary Resource Services TM: A Wellness Plan for Life When a loved one dies, families often face complex issues ranging from estate planning, legal questions, funeral planning, coping with grief and financial uncertainties. That's why Dearborn National offers Beneficiary Resource Services, a program that combines family wellness and security at the most difficult of times. Services include grief and financial counseling, funeral planning, legal support as well as online will preparation. Beneficiary Resource Services is provided by Bensinger, DuPont & Associates (BDA). Services for insureds and their families. Online Will Preparation- A will is one of the most important documents every adult should have, and creating one has never been easier. Insureds and their families will have access to a full legal library with many estate planning documents, including an online will. Insureds can create their own wills online in a safe and secure way, right from their homes. The will can be saved and updated as family situations change. Creating a will provides security and peace of mind for several reasons: o Appoints a guardian for children o Controls where property and assets go o Provides family security o Without one, the state can make these decisions Funeral Planning - Insureds and beneficiaries have access to an online funeral planning site that features a variety of helpful tools and information, such as: o A downloadable funeral planning guide for insureds to document vital information their loved ones will need when making final arrangements o Calculators to estimate and compare expenses for various types of funeral arrangements 6 Information on funeral requirements and various religious customs 6 Directories to locate funeral homes and cemeteries in the insured's area Services for beneficiaries (and their families) after a death claim or for those that qualify for an accelerated death benefit Unlimited Phone Contact - Available for up to one year with a grief counselor, legal advisor or financial planner. Face -to -Face Working Sessions* - Five face-to-face working sessions are available to the insured person or beneficiary. All five sessions may be used with one grief counselor or legal advisor, or they may be split among the two types of counselors or advisors in geographically accessible locations. A one -hour financial consultation on the phone is also available. *May include face-to-face sessions, over -the -phone sessions or time taken for research or document preparation. Referrals and Support Services - BDA maintains a comprehensive directory of qualified and accessible grief counselors and legal and financial consultants. Follow Up - Counselors will initiate follow-up calls when necessary for up to one full year from the date of initial contact. Quote ID: 46495 49!pg5: 6 Medical Monitoring 6 Traveling Companion Assistance 6 Visit by Family Member/Friend 6 Replacement of Medication and Eyeglasses 6 Emergency Message Relay 6 Emergency Travel Arrangements 6 Emergency Cash 6 Locating Lost or Stolen Items 6 Legal Assistance/Bail 6 Interpretation/Translation 6 Pre -Trip Information 1 Travel Assistance Services are provided to groups with 50 or more employees; Not available in all states. z We contract with Europ Assistance USA, Inc. to provide the Travel Resource Services. We do not provide any part of the Travel Resource Services. Travel Resource Services' In today's global economy, the need for world travel is now greater than ever. However, a trip, whether for business or pleasure, can be disrupted by the unexpected. A medical emergency, a lost prescription or even emergencies involving a spouse, child or traveling companion can jeopardize a trip. To provide the support people need while traveling on business or pleasure, we provide Travel Resource Service52, a program that assists travelers if the unexpected happens. Services are available to insureds and their families traveling 100 or more miles from their primary residence, and include: 6 Medical Search and Referral 6 Medical Evacuation/Return Home 6 Dependent Children Assistance 6 Return of Mortal Remains Dearborn NCLtionaY Prepared for: City of Lubbock, Texas BDA's nationwide network of experienced professionals can offer counseling for individuals facing difficult emotional, financial or legal issues. BDA's counselors are available 24 hours a day, 365 days a year. All calls are completely confidential. Travel Resource Services' In today's global economy, the need for world travel is now greater than ever. However, a trip, whether for business or pleasure, can be disrupted by the unexpected. A medical emergency, a lost prescription or even emergencies involving a spouse, child or traveling companion can jeopardize a trip. To provide the support people need while traveling on business or pleasure, we provide Travel Resource ServiceS2, a program that assists travelers if the unexpected happens. Services are available to insureds and their families traveling 100 or more miles from their primary residence, and include: 6 Medical Search and Referral 6 Medical Evacuation/Return Home 6 Dependent Children Assistance 6 Return of Mortal Remains 6 Medical Monitoring 6 Traveling Companion Assistance 6 Visit by Family Member/Friend 6 Replacement of Medication and Eyeglasses 6 Emergency Message Relay 6 Emergency Travel Arrangements 6 Emergency Cash 6 Locating Lost or Stolen Items 6 Legal Assistance/Bail 6 Interpretation/Translation 6 Pre -Trip Information 1 Travel Assistance Services are provided to groups with 50 or more employees; Not available in all states. z We contract with Europ Assistance USA, Inc. to provide the Travel Resource Services. We do not provide any part of the Travel Resource Services. Quote ID: 46495 4: !PAS: nea cbOf NQtIOCIa Prepared for: City of Lubbock, Texas Quote ID: 46495 51iPJ 5: Dearborn NO-tionol Prepared for: City of Lubbock, Texas Additional Plan Features Voluntary Life All Eligible All Retireed Active Employees Employees Option Current Plan Current Plan Waiver of Premium - Definition of Disability Any Occupation Not Applicable Waiver of Premium - Maximum Qualifying 60 Not Applicable Age Waiver of Premium - Specific Conditions Not Applicable Not Applicable Benefit Extended Insurance Benefit - Definition of Not Applicable Not Applicable Disability Extended Insurance Benefit - Maximum Not Applicable Not Applicable Qualifying Age Extended Insurance Benefit - Duration Not Applicable Not Applicable FMLA Extension Included Included Extension Disability 12th Month 12th Month Layoff Next month Next month Leave Next month Next month Sabbatical 6th Month 6th Month Military Leave 12th Month 12th Month Accelerated Death - Minimum $15,000 Not Applicable Accelerated Death Benefit - Definition of 12 Months Not Applicable Terminal Illness Quote ID: 46495 52!pg5: Denrborn National Prepared for: City of Lubbock, Texas Benefit Highlights Voluntary Short Term Disability Insurance Eligibility Eligibility is as indicated in the Plan Design Summary. To be eligible, employees must be legally working in the United States and regularly working the minimum number of hours as agreed. Employees may have to complete a Waiting Period. Seasonal, part-time and temporary employees are not eligible. Elimination Period Elimination Period is the period of time from the onset of disability until benefits begin. The elimination period is indicated in the Plan Design Summary. Unless otherwise indicated, benefits begin upon exhaustion of all other sick leave, vacation, PTO or other salary continuation plans. Total Disability is not required during the elimination period and can be satisfied with days of Partial or Total Disability. Additionally, there is no earnings loss requirement during the elimination period. Trial Work Day Period To encourage employees to return to work, employees may attempt to return to work full-time during their elimination period, without being required to restart the elimination period. Employees can temporarily return to work for a period of up to 1/2 the elimination period, maximum 14 days, and not have to begin their elimination period again if they stop working due to the same condition. Maximum Period Payable Voluntary STD benefits are payable for the complete number of weeks indicated on the Plan Design Summary, or until LTD benefits are payable, whichever occurs first. The Maximum Period shown does not include the elimination period. Survivor Benefit If a disabled employee dies after receiving disability benefits for more than three consecutive weeks, we will pay the beneficiary of the disabled employee a lump sum benefit equal to the amount shown in the Plan Design Summary. Worksite Modification Benefit This benefit assists in covering the cost of modifying the disabled employee's worksite to allow that employee to return to work. Once all parties agree on the modification to be performed, we will reimburse the employer the actual cost of the modification, up to the greater of two times the employee's weekly benefit, or $1,500, unless otherwise indicated. Pre -Existing Condition Limitation Benefits are not payable for disability caused by conditions that existed on the employee's effective date as indicated below: o A sickness or injury for which the employee received medical treatment, or advice was rendered, prescribed or recommended whether or not the sickness was diagnosed at all or within the number of months shown in the Plan Design Summary prior to the employee's effective date, and o Begins within the number of months shown in the Plan Design Summary of the employee's effective date. Definition of Disability Disabled means that the employee is Totally Disabled or Partially Disabled due to an injury or sickness. The employee must be under the regular care of a doctor who is appropriate for the disabling condition. Loss of professional license or certification does not in and of itself mean the employee is Disabled. Total Disability To be considered Totally Disabled, the insured must be unable to perform the material and substantial duties of their regular occupation and have a loss of income. Quote ID: 46495 53!pJ5: Dearborn Ntlti0fIC Prepared for: City of Lubbock, Texas Partial Disability To be considered Partially Disabled, the insured must have suffered an injury or sickness, is able to perform some but not all of the material and substantial duties of their regular occupation, and as a result is earning between 20% and the percentage of their pre - disability income indicated in the Plan Design Summary. Work Incentive Benefit If the employee meets the definition of Partial Disability, they are eligible to receive a Work Incentive Benefit. To encourage disabled employees to return to work in some capacity, we standardly offer a Work Incentive Benefit on all Voluntary STD contracts. The Work Incentive Benefit pays the full monthly benefit as long as the combination of the benefit plus earnings does not exceed 100% of their pre -disability income. If benefits are due for a period of less than one week, payments will be made at a daily rate of 1/7th of the weekly benefit. Extension of Coverage for FMLA Leave If an insured employee is eligible for and received approval for leave under the Family and Medical Leave Act of 1993 (FMLA) or any applicable state family and medical leave law, insurance will continue (provided premium continues to be paid) for a period up to the later of: 6 The leave period permitted by FMLA and any amendments; or o The leave period permitted by applicable state law. Exclusions o Loss of professional license, occupational license or certification; o Pre -Existing condition; o Commission of, participation in, or an attempt to commit an assault or felony; o Intentionally self-inflicted injuries; o Attempted suicide, regardless of mental capacity; o Cosmetic surgery, except when required due to injury or sickness o Occupational injury or sickness o Participation in a war, declared or undeclared, or any act of war Quote ID: 46495 54!pg5: Dearborn NO-tI0n(Al Prepared for: City of Lubbock, Texas Enhanced Product Services Included with Voluntary Short Term Disability Insurance Telephonic Claim Reporting To streamline Voluntary STD claim intake, we offer a telephonic claim intake process. To initiate the claim, the employee calls us toll -free and answers a few simple questions. After the claim number is assigned and medical record release authorization is obtained, we contact the employer and physician as needed. Online Claim Status Through our Benefits Manager web portal, employers have online access to Voluntary STD claim information. Two reports are available - Pending Disability Claim Report includes new claims awaiting evaluation, claims awaiting payment, and claims in the appeal process. Experience Disability Claim Report includes claims on which payments have been made and are still open, closed, or in the appeal process. W-2 Reporting Upon request, we will prepare and mail W-2 Wage and Tax Statements to employees at no additional charge to the employer. If we have agreed to pay the employer's share of FICA taxes, we will prepare and mail W-2 Wage and Tax Statements. We prepare W-2 Wage and Tax Statements using the applicable insuring company's federal tax identification number. A signed FICA Match / W2 Tax Agreement is required on all disability cases. Quote ID: 46495 55!pg5: Dearborn Wktionol Prepared for: City of Lubbock, Texas Benefit Highlights Voluntary Long Term Disability Insurance Eligibility Eligibility is as indicated in the Plan Design Summary. To be eligible, employees must be legally working in the United States and regularly working the minimum number of hours as agreed. Employees may have to complete a Waiting Period. Seasonal, part-time and temporary employees are not eligible. Elimination Period Elimination Period is the period of time from the onset of disability until benefits begin. The elimination period is indicated in the Plan Design Summary. Total Disability is not required during the elimination period and can be satisfied with days of Partial or Total Disability. Additionally, there is no earnings loss requirement during the elimination period Trial Work Day Period To encourage employees to return to work, employees may attempt to return to work full- time during their elimination period, without being required to restart the elimination period. Employees can temporarily return to work for a period up to 1/2 the elimination period and do not have to begin their elimination period again if they stop working due to the same condition. Maximum Period Payable Voluntary Long Term Disability Benefits are payable based on the following schedule. Social Security Normal Retirement Age (SSNRA) The maximum period of payment will be determined according to the following table: Age When Disability Begins Maximum Period Payable Less than age 60 To Social Security Normal Retirement Age (SSNRA) Age 60 60 months or to SSNRA, whichever is greater Age 61 48 months or to SSNRA, whichever is greater Age 62 42 months or to SSNRA, whichever is greater Age 63 36 months or to SSNRA, whichever is greater Age 64 30 months or to SSNRA, whichever is greater Age 65 24 months Age 66 21 months Age 67 18 months Age 68 15 months Age 69 and over 12 months Definition of Disability Disabled means that the employee is Totally Disabled or Partially Disabled due to an injury or sickness. The employee must be under the regular care of a doctor who is appropriate for the disabling condition. Loss of professional license or certification does not in and of itself mean the employee is Disabled. Total Disability During the Own Occupation Period as indicated in the Plan Design Summary, Totally Disabled means the insured must be unable to perform the material and substantial duties of their regular occupation and/or* have disability earnings less than 20% of their pre - disability income. Quote ID: 46495 56!pd5: Dearborn Nationale Prepared for: City of Lubbock, Texas After the own occ period, Totally Disabled means the insured must be unable to engage in any gainful occupation and/or* have disability earnings less than 20% of their pre -disability income. * See Plan Design Summary for class specifics Partial Disability During the Own Occupation Period as indicated in the Plan Design Summary, Partially Disabled means the insured must have suffered an injury or sickness and as a result is earning between 20% and the percentage of their pre -disability income as indicated in the Plan Design Summary. Following the own occupation period, Partially Disabled means the insured is gainfully employed and earning between 20% and the percentage of their pre - disability income indicated in the Plan Design Summary. During the elimination period, there does not need to be a loss of income to be considered either Partially or Totally Disabled. Recurrent Disability If disability for which benefits were payable ends but recurs due to the same or related causes less than 6 months after the end of a prior disability, it will be considered a resumption of the prior disability. Such recurrent disability shall be subject to the provisions of the policy that were in effect at the time the prior disability began. Disability which recurs more than 6 months after the end of a prior disability is subject to: 6 A new Elimination Period; 6 A new Maximum Period Payable; and 6 The other provisions of the policy that are in effect on the date the disability recurs. Disability must recur while the employee's coverage is in force under the policy. Voluntary LTD Monthly Benefit If the employee meets the definition of Total Disability, they are eligible to receive a Voluntary LTD Monthly Benefit. Work Incentive Benefit If the employee meets the definition of Partial Disability, they are eligible to receive a Work Incentive Benefit. To encourage disabled employees to return to work in some capacity, a Work Incentive Benefit is offered to all Partially Disabled employees. For the number of months indicated in the Plan Design Summary, we will pay the full monthly benefit as long as the combination of the benefit plus earnings does not exceed 100% of their indexed pre -disability income. After this period, our benefit will be calculated by multiplying the benefit times the adjusted loss of salary ratio. Rehabilitative Incentive Income A unique standard feature of the Voluntary LTD contract is the Rehabilitation Incentive Income feature. If we identify a partially disabled employee as a candidate for a rehabilitation program, we will work with them to structure a voluntary rehabilitation plan that assists the employee in returning to employment. The Plan details the vocational rehabilitation services available to the employee. While the employee is participating in a voluntary rehabilitation plan, and continues to meet the obligations of the program, we will allow the employee to retain a combination of benefits and disability income in excess of 100% of their indexed pre -disability income, for 12 months. After 12 months, we will offset the Voluntary LTD benefit by multiplying the benefit times the adjusted loss of salary ratio. Quote ID: 46495 57i pd5: Dearborn NC1tIonaf Prepared for: City of Lubbock, Texas Pre -Existing Condition Exclusion Benefits are not payable for a disability caused by a condition that existed on the employee's effective date as indicated below: o A sickness or injury for which the employee received medical treatment, or advice was rendered, prescribed or recommended whether or not the sickness was diagnosed at all or misdiagnosed within the number of months prior to the employee's effective date as indicated in the Plan Design Summary, and o The condition results in a Disability that begins within the number of months after the employee's effective date as indicated in the Plan Design Summary . Continuity of Coverage (No Loss/No Gain) If an employee was insured under the prior policy on the day before this policy's effective date due to a continuance or extension of coverage, the employee may have limited coverage under this policy even if they do not satisfy the actively at work requirement. Coverage will be extended to the earlier of the end of the month the employee becomes actively at work, end of any extension period under the prior policy, or the date coverage would otherwise end under this policy. If an employee becomes disabled due to a pre-existing condition, benefits may be payable under our policy if the employee was insured for Voluntary LTD with the prior carrier, and was insured at the time coverage changed to our policy, and remained insured under this policy. For benefits to be payable, the employee must satisfy the pre-existing condition exclusion under either our policy, or the prior policy if benefits would have been payable had the prior plan remained in place. The benefit payable will be the lesser of the monthly benefit payable under the prior plan or the monthly benefit under our plan. Mental and Nervous Disorder Limitation Disabilities due to Mental and/or Nervous disorders are limited to the number of months shown in the Plan Design Summary unless the disabled employee is confined to a facility licensed for the treatment of Mental and Nervous disorders. Special Conditions Limitation Disabilities due to condition identified as a Special Condition are limited to the number of months shown in the Plan Design Summary, unless the disabled employee is confined to a licensed medical facility licensed to provide treatment for the disabled employee's condition. Special Conditions include but are not limited to muscoskeletal and connective tissue disorders of the neck and back including any disease or disorder of the cervical, thoracic and lumbosacral back and its surrounding soft tissue including sprains and strains of joints and adjacent muscles. The lifetime cumulative maximum period payable for all disabilities due to a mental disorder, substance abuse or special conditions is indicated in the Plan Design Summary. Only that period of benefits will be paid for any combination of such disabilities even if the disabilities are not continuous or not related. Worksite Modification Benefit This benefit assists in covering the cost of modifying the disabled employee's worksite to allow that employee to return to work. Once all parties agree on the modification to be performed, We will reimburse the employer the actual cost of the modification, up to the amount shown in the Plan Design Summary. Survivor Income Benefit If a disabled employee dies after having been disabled for a minimum of 90 or more consecutive days and was receiving benefits under the policy, we will pay a lump sum benefit equal to the number of months of benefit as indicated in the Plan Design Summary. Day Care Expense Benefit To assist employees taking advantage of our Rehabilitative Incentive Income feature, we offer Day Care Expense Benefits. This benefit reimburses claimants for any day care Quote ID: 46495 58!pd5: Dearborn National Prepared for: City of Lubbock, Texas Enhanced Product Services Included with Voluntary Long Term Disability Insurance Disability Resource Services - Telephonic and Face -to -Face Support for Behavioral Health Issues Provided to all groups with Long -Term Disability coverage: 6 24 Hour telephonic support (for all Long -Term Disability insureds) for behavioral health issues. A staff of master degree clinicians is available to provide each caller with assessment counseling and referral advice for face-to-face counseling. Offered at no additional charge, these services enhance the value of an employee benefit program while helping to manage employee productivity and minimize absences. o Face-to-face counseling. Up to 3 face-to-face counseling sessions per year to address appropriate behavioral health issues. o Guidance Resources ® Online is a secure, password -protected interactive Web site that contains self -assessments, search tools, extensive content on personal health and powerful tools to help with personal, relational, legal, health and financial concerns. This service is free of charge to you, your insured employees and their families. Assistance through Guidance Resources ® Online is available 24 hours a day, 7 days a week. Enhanced Employee Assistance Programs (EAPs) are available. Contact your Dearborn National representative for more information. Guidance Resources @ Online and Employee Assistance Programs (EAPs) are made available through ComPsych @ , a worldwide leader in EAPs, managed behavioral health, work -life services, crisis intervention and Human Resources support services. Quote ID: 46495 5: !pg5: Dearborn NQtiof1al Prepared for: City of Lubbock, Texas expenses they may incur for children under age 13 while participating in the rehabilitation program. The benefit pays up to the amount indicated in the Plan Design Summary, to an overall monthly maximum of $1,000. Rehabilitation Benefit If the disabled employee is participating in a formal rehabilitation plan while receiving benefits, we will pay an additional monthly benefit equal to the percentage of their benefit indicated in the Plan Design Summary, up to the amount indicated. This additional benefit is payable for a maximum of the number of months indicated in the Plan Design Summary. Extension of Coverage for FMLA Leave If an insured employee is eligible for and received approval for leave under the Family and Medical Leave Act of 1993 (FMLA) or any applicable state family and medical leave law, insurance will continue (provided premium continues to be paid) for a period up to the later of: 6 The leave period permitted by FMLA and any amendments; or 6 The leave period permitted by applicable state law. EXCLUSIONS The policy does not cover any loss or Disability caused by, resulting from, arising out of or substantially contributed, directly or indirectly, to by any one or more of the following: 6 A Pre -Existing Condition 6 Commission of, participation in, or an attempt to commit an assault or felony; 6 Intentionally Self -Inflicted Injuries; 6 Participation in a war, declared or undeclared; 6 Active military duty; 6 Active Participation in a Riot; 6 Commission of a Felony for which the insured has been convicted. Quote ID: 46495 59!pg5: EXHIBIT C2 SAMPLE LONG TERM DISABILITY POLICY Group Long Term Disability Insurance Employee Benefit Booklet DearbornNaflOfi(11'� SAMPLE TX SANIPLETX-0001 Class 1-01 1 Products and services marketed under the Dearborn National"' brand and the star logo are underwritten and or provided by Dearborn National " Life Insurance Company (Downers Grove, IL) in all states (excluding New York), the District of Columbia, the United States Virgin Islands, the British Virgin Islands, Guam and Puerto Rico. 09/07/2012 Dearborn National® Life Insurance Company Group Certificate Dearborn National Life Insurance Company Chicago, Illinois Administrative Office: 1020 31st Street • Downers Grove, IL 60515 Having issued Group Policy No. SAMPLETX-0001 (herein called the Policy or this Plan) to SAMPLE TX (herein called the Policyholder) CERTIFIES that You are insured, provided that You qualify under the ELIGIBILITY AND EFFECTIVE DATES provision, become insured and remain insured in accordance with the terms of the Policy. Your insurance is subject to all the definitions, limitations and conditions of the Policy. It takes effect on the effective date stated in the ELIGIBILITY AND EFFECTIVE DATES provision. This certificate describes Your eligibility for benefits and the terms and provisions of the Policy. It replaces and cancels any other certificate previously issued to You under the Policy. If the terms and provisions of the Certificate of Coverage (issued to You) are different from the policy (issued to the Policvholder), the Policy will govern. Your coverage may be canceled or changed in whole or in part under the terms and provisions of the Policy. READ YOUR CERTIFICATE CAREFULLY Signed for Dearborn National Life Insurance Company Secretary President THE INSURANCE POLICY UNDER WHICH THIS CERTIFICATE IS ISSUED IS NOT A POLICY OF WORKERS' COMPENSATION INSURANCE. YOU SHOULD CONSULT YOUR EMPLOYER TO DETERMINE WHETHER YOUR EMPLOYER IS A SUBSCRIBER TO THE WORKERS' COMPENSATION SYSTEM. Group Long Term Disability Certificate Non -Participating THIS IS NOT A WORKERS' COMPENSATION CERTIFICATE 2-LTDC-412 IMPORTANT NOTICE To obtain information or make a complaint: You may contact your (title) at (telephone number) You may call Dearborn National Life Insurance Company's toll -free telephone number for infor- mation or to make a complaint at: 1-800-348-4512 You may also write to Dearborn National Life Insurance Company at: 1020 30 Street, Downers Grove, IL 60515-5591 You may contact the Texas Department of Insurance to obtain information on companies, coverages, rights or complaints at: 1-800-252-3439 You may write the Texas Department of Insurance: P. O. Box 149104 Austin, TX 78714-9104 FAX #(512) 475-1771 Web: http://www.tdi.state.tx.us E-mail: ConsumerProtection@tdi.state.tx.us PREMIUM OR CLAIM 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 become a part or condition of the attached document. 9-632-895 AVISO IMPORTANTE Para informacion o para someter una queja: Peude communicarse con su (title) at (telephone number). Usted puede llamar at numero de telefono gratis de Dearborn National Life Insurance Company para informacion o para someter una queja at: 1-800-348-4512 Usted tambien escribir a Dearborn National Life Insurance Company at: 1020 30 Street, Downers Grove, IL 60515-5591 Puede comunicarse con el Departamento de Seguros de Texas para conseguir informacion acerca de companias, coberturas, derechos o quejas at: 1-800-252-3439 Puede escribir al Departamento de Seguros de Texas: P. O. Box 149104 Austin, TX 78714-9104 FAX #(512) 475-1771 Web: http://www.tdi.state.tx.us E-mail: ConsumerProtection@tdi.state.tx.us DISPUTAS SOBRE PRIMAS 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 at Departamento de Seguros de Texas. UNA ESTE AVISO A SU POLIZA: Este aviso es solo para proposito de informacion y no se convierte en parte o condicion del documento adjunto. TABLE OF CONTENTS SCHEDULE OF BENEFITS ELIGIBILITYAND EFFECTIVE DATES LONG TERM DISABILITY BENEFITS EXCL USIONS AND LIMITATIONS TERMINATION OF COVERAGE S UPPLEMENTAL BENEFITS AND SERVICES DA Y CARE EXPENSE BENEFIT SURVIVOR INCOME BENEFIT TERMINAL ILLNESS BENEFIT WORKSITE MODIFICATION BENEFIT CLAIM SER VICES FILING A CLAIM UNIFORM PROVISIONS DEFINITIONS Note: All terms in Italics are listed and defined in the Definitions section or within the certificate itself. 2-LTDC-412 SCHEDULE OF BENEFITS Policvholdei•: SAMPLE TX Policy Number: SAMPLETX-0001 Effective Date: January 1, 2013 Eligibility: The following are eligible: All active full-time employees. A full-time employee is one who regularly works a minimum of 30 hours per week for the Policyholder. Part-time, seasonal and temporary employees of the Policvholdei• are not eligible. Waiting Period: If You are in a class eligible for insurance on or before the Policy Effective Date: First of the month following 30 Days of continuous, full-time active work If You enter a class eligible for insurance after the Policy Effective Date: First of the month following 30 Days of continuous, full-time active work Rehire Provision: If Your coverage ends due to termination of employment and you return to Active GVork in an eligible class within 6 months, you will not have to satisfy a new PVaiting Pei•i od. Elimination Period: 90 Days LTD Monthly Benefit: 60% of Monthly Earnings to a Mnxinnim Gross Monthly Benefit of $5,000.00 per month subject to reduction by deductible sources of income or Disabilitv Earnings Social Security Offset Method: Primary & Family Minimum Monthly Benefit: $100.00 or 10% of Your Gross LTD Monthiv Benefit, whichever is greater Policyholder Contribution: 100% of remium 2-LTDC-412 Maximum Period Payable: on Date Disability Commences Maximum Period Payable —Age Less than 60 To SSNRA* 60 60 months or to SSNRA*, whichever is greater 61 48 months or to SSNRA*, whichever is greater 62 42 months or to SSNRA*, whichever is greater 63 36 months or to SSNRA*, whichever is greater 64 30 months or to SSNRA*, whichever is greater 65 24 months 66 21 months 67 18 months 68 15 months 69 or over 12 months * Social Security Normal Retirement Ages Based on the 1983 amendment to the Social Security Act, the following are normal retirement ages by date of birth. Year of Birth Social Security Normal Retirement Age 1937 or earlier 65 years 1938 65 years, 2 months 1939 65 years, 4 months 1940 65 years, 6 months 1941 65 years, 8 months 1942 65 years, 10 months 1943-1954 66 years 1955 66 years, 2 months 1956 66 years, 4 months 1957 66 years, 6 months 1958 66 years, 8 months 1959 66 years, 10 months 1960 or later 67 years 2-LTDC-412 OTHER FEATURES The following other features are included: • Waiver of Premium • Work Incentive Benefit • Rehabilitation Incentive Income • Recurrent Disability • FMLA Coverage Extension • Survivor Benefit • Day Care Benefit • Worksite Modification Benefit • Vocational Rehabilitation Service • Social Security Assistance • Continuity of Coverage THIS SCHEDULE OF BENEFITS CANCELS AND REPLACES ALL OTHER SCHEDULES PREVIOUSLY ISSUED TO YOU UNDER THE POLICY. IT OUTLINES THE POLICY FEATURES. THE FOLLOWING PAGES PROVIDE A COMPLETE DESCRIPTION OF THE PROVISIONS OF YOUR CERTIFICATE. 2-LTDC-412 7 ELIGIBILITY AND EFFECTIVE DATES Who is eligible for this insurance? The following people are eligible: All active full-time employees. The Waiting Period is shown in the Schedule of Benefits. 00001 When does Your Noncontributory insurance become effective? If You are an eligible Employee, Your Noncontribihtay coverage under the Policy will become effective on the day following completion of the Waiting Period, if any, shown in the Schedule of Benefits, provided you are Actively at Work on that day. If You waive all or a portion of Your Noncontributory coverage and choose to enroll at a later date, You are considered a late applicant and must furnish Evidence of Insurability satisfactory to Us before coverage can become effective. Coverage will become effective on the date We determine that the Evidence of Insurability is satisfactory and We provide written notice of approval. You must be Actively at Work for coverage under the Policy to become effective. If, because of I jury or Sickness, You are not Actively at Work on the date the insurance would otherwise take effect, it will take effect on the day You return to Active Work. Noncontributory means the Policyholder pays 100% of the premium for this insurance. 00002 Who pays for Your coverage? The Policyholder pays the entire cost of Your coverage. 00008 Do You have to pay premium while You receive benefits? We will waive premium for You during a period of Disability for which the LTD Monthly Benefit is payable under the Policy. Premium payment is required during Your Elimination Period or any other period when the LTD Monthly Benefit is not payable under the Policy. 00009 What /happens if We are replacing an existing Policy? Effect on Actively at Work requirement If You were insured under the Prior Policy on the day before the Policy Effective Date, You may be covered by the Policy even if You do not satisfy the Actively at Work requirement as stated in the When does insurance become effective? provision and You would otherwise be eligible to become insured under the Policy, We will provide limited coverage under this Plan. Coverage under this provision will begin on the Policy effective date and will continue until the earliest of: i . The end of the month following the date You become Activelv at Work; 2. The end of any period of continuance or extension provided under the Prior Policy; or 3. The date coverage would otherwise end, according to the provisions of the Policy. Your coverage under this provision is subject to payment of premium. Effect on Benefits If You do not satisfy the Activelv at Work requirement, 1ou may still be eligible for benefits under the Policy as follows: 2-LTDC-412 The benefits payable under the Policy will be the benefits which would have been payable under the terms of the Prior Policy if it had remained in force; and the benefits payable under the Policy will be reduced by any benefits payable under the Prior Policy for the same Disability for which the prior carrier is liable. The Prior Policy is the group disability insurance policy issued to the Policyholder by ABC Carrier whose coverage terminated immediately prior to the Policy Effective Date. Effect on Pre-existing Conditions If You have a Disability due to a Pre -Existing Condition after the Prior Policy has been replaced by this Plan, Benefits may be payable if: 1. You were insured under the Prior- Policy at the time the Policyholder changed coverage from the Prior Policy to the Policy; and 2. You have been continuously insured under this Plan from the effective date of this Plan until the date Yom- Disability began. In order for benefits to be paid, You must satisfy the Pr-e-Existing Condition exclusion under: 1. this Plan; or 2. the Prior- Policy, if benefits would have been paid had the Prior Policy remained in force. If You satisfy the Pre -Existing Condition exclusion of this Plan, We will determine Yom- payments according to this Plan's provision. If You do not satisfy the Pr•e-Existing Condition exclusion of this Plan, but You do satisfy the Pre -Existing Condition provision under the Prior- Policy: 1. Your Monthly Benefit will be the lesser of: a. The Monthly Benefit that would have been payable under the terms of the Prior -Policy if it had remained in force; or b. The Monthly Benefit under this Plan. 2. Benefits will end on the earlier of: a. The date benefits end under the Policy, as described under the Maximum Period Payable; or b. The date benefits would have ended under the Prior- Policy if it had remained in force. If You do not satisfy the Pr•e-Existing Condition exclusion under either this Plan or the Prior- Policy, We will not make any payments. We will require proof that You were insured under the Prior Policy. 00010 2-LTDC-412 LONG TERM DISABILITY BENEFITS How do We define Total Disability? Total Disability or Totally Disabled means that due to Sickness or I jury; 1. You are continuously unable to perform the Material and Substantial Duties of Your Regular Occupation, and 2. Your Disability Earnings, if any, are less than 20% of Your pre -disability Indexed Monthly Earnings. 00011 How do We define Partial Disability? Partial Disability or Partially Disabled means that: l . During the Elimination Period You are unable to perform all of the Material and Substantial Duties of Your Regular Occupation. 2. Due to I jury or Sickness You are unable to perform all of the Material and Substantial Duties of Your Regular Occupation, and Your Disability Earnings, if any, are at least 20% but less than or equal to 80% of Your pre - disability Indexed Monthly Earnings. 00014 Loss of Professional License or Certification If You require a professional license or certification for Your occupation, loss of that professional license or certification does not in and of itself constitute Disability. 00017 What is the Elimination Period and hoiv is it satisfied? The Elimination Period is a period of continuous Disability which must be satisfied before You are eligible to receive benefits from Us. It is shown in the Schedule of Benefits and begins on Your Date of Disabilitv. If You temporarily recover and return to work, We will treat Your Disability as continuous if You return to work for a period of less than or equal to one-half the Elimination Period rounded up to the next whole number, not to exceed 90 days. The days that You are not Disabled will not count toward Your Elimination Period. If You return to work for a period greater than one-half the Elimination Period, or 90 days, whichever is less, and become Disabled again, You will have to begin a new Elimination Period. 00018 Can You satisfy Your Elimination Period if You are working? You can satisfy Yow• Elimination Period if You are working, provided You meet the definition of Disability. 00019 What Disability Benefit are You eligible to receive? If You are Disabled, You are eligible to receive one of the following at any given time: 1. an LTD Monthly Benefit; 2. a Work Incentive Benefit; or 3. Rehabilitation Incentive Income. While You are Disabled, You might be eligible to receive one or the other of the above, but You cannot receive more than one of these benefits at the same time. 00020 2-LTDC-412 10 What is Your LTD Monthly Benefit and how is it calculated? Your LTD Monthly Benefit will be based on Yom- Monthly Earnings as reported to Us by the Policyholder and for which premium has been paid. An LTD Monthly Bennefit will be payable after the end of the Elimination Period if You are Disabled. We will calculate Yaw- Gn-oss LTD Monthly Benefit amount as follows: 1. Multiply Your Monthly Earnings by 60%. 2. The maximum Gross LTD Monthly Benefit is $5,000.00. 3. Compare the answers from Item 1 and Item 2. The lesser of these two amounts is Your Gross LTD Monthly Benefit. 4. Subtract the Deductible Sources of Income f oni You- Gross LTD Monthly Benefit. The resulting figure is Yaw - Net LTD Monthly Benefit. 5. Compare the answer from item 3 and 4. The lesser amount figured in item 5 is Yoi-Monthly Benefit. If a benefit is payable for less than one month, it will be paid on the basis of 1/301h of the Net LTD Monthly Benefit for each day of Disability. 00021-A How do We define Mmithly Earnings? Monthly Earnings means Yoir gross monthly income from Yom- Employee- in effect just prior to Your Date of Disability. It includes You- total income before taxes and any deductions made for pre-tax contributions to a qualified deferred compensation plan, Section 125 plan, or flexible spending account. It includes income actually received from commissions, but does not include bonuses, overtime pay, or any other extra compensation, or income received from sources other than Yon-Ennployer. Commissions will be averaged for the lesser of: a. the 12 full calendar month period of Your employment with Your Employee- just prior to the date Disability begins; or b. the period of actual employment with Your Employer. Earnings, whether for a full year or partial year, will be converted to a monthly amount for the purpose of calculating the Monthly Benefit. 00022 What are the Deductible Sources of Income? 1. Disability benefits paid, payable, or for which You are eligible under: a. The Social Security Act, including any amounts for which Yom- dependents may qualify because of Youn- Disability; b. Any Workers' Compensation or Occupational Disease Act or Law, or any other law which provides compensation for an occupational Injury or Sickness; c. Occupational accident coverage provided by or through the Policvholdee-; d. Any Statutory Disability Benefit Law; e. The Railroad Retirement Act; f. The Canada Pension Plan, Quebec Pension Plan, or any other similar disability or pension plan or act; g. The Canada Old Age Security Act; h. Any Public Employee Retirement System Plan, or any State Teachers' Retirement System Plan, or any plan provided as an alternative to any of the above acts or plans; 2-LTDC-412 I i i. Title 46, United States Code Section 688 et seq (The Jones Act); j. Title 33, United States Code Section 901 et seq (Longshore and Harbor Workers' Compensation Act). 2. Disability benefits paid, payable, or for which You are eligible under: a. Any group insurance plan provided by or through the Policyholder , and b. Any sick leave or salary continuance plan provided by or through the Policyholder which causes the Net Monthly Benefit, plus Deductible Sources of Income and any salary continuation to exceed 100% of Your pre -disability Indexed Monthly Earnings. The amount in excess of 100% of Yow• pre -disability Indexed Monthly Earnings will be used to reduce Your Net Monthly Benefit. 3. Retirement benefits paid under the Social Security Act including any amounts for which Your dependents may qualify because of Your retirement; 4. Retirement and Disability benefits paid under a Retirement Plan provided by the Policyholder except for amounts attributable to Your contributions; 5. Disability benefits paid under any No Fault Auto Motor Vehicle coverage; 6. Amounts received from a third party after subtracting attorney's fees by judgment, settlement or otherwise, not to exceed 50% of the net settlement. Proration of Lump Sum Awards If any Deductible Source of Income described above is paid in a single sum through compromise settlement or as an advance on future liability, We will determine the amount of reduction to Your Gross LTD Monthly Benefit as follows: 1. 6Ve will divide the amount paid by the number of months for which the settlement or advance was provided; or 2. If the number of months for which the settlement or advance is made is not known, We will divide the amount of the settlement or advance by the expected remaining number of months for which 6Ve will provide benefits for Your Disability based on the Proof of Disability which 6Ve have, subject to a maximum of 60 months. What other sources of income are not deductible? 6Ve will not reduce Your Gross LTD Monthly Benefit by any of the following: 1. deferred compensation arrangements such as 401(k), 403(b) or 457 plans; 2. credit disability insurance; 3. pension plans for partners; 4. military pension and disability income plans; 5. franchise disability income plans; 6. individual disability income plans; 7. a Retirement Plan from another Policyholder; 8. profit sharing plans; 9. thrift or savings plans; 10. individual retirement account (IRA); 11. tax sheltered annuity (TSA); 12. stock ownership plan. i0023 Can You ►vork and still receive benefits? While Disabled, You may qualify for the Work Incentive Benefit or Rehabilitation Incentive Income, but not both. 2-LTDC-412 12 Work Incentive Benefit A Work Incentive Benefit will be payable if You are Disabled and Gainfully Employed after the end of the Elimination Period, or after a period during which You received LTD Monthly Benefits. The Work Incentive Benefit will be calculated while You are Gainfully Employed as follows: 1. We will add together the Gross Monthly Benefit and Disability Earnings and compare to pre -disability Indexed Monthly Earnings. 2. If the total amount in Item 1 exceeds 100% of pre -disability Indexed Monthly Earnings, the Work Incentive Benefit will be equal to the LTD Monthly Benefit reduced by the amount of the excess. 3. If the total amount in Item 1 does not exceed 100% of pre -disability Indexed Monthly Earnings, the Work Incentive Benefit will be equal to the LTD Monthly Benefit amount. After the first 24 months of disability payments while You are Disabled and Gainfully Employed, the Work Incentive Benefit will be equal to the Net Monthly Benefit multiplied by the Adjusted Loss of Salary Ratio. The Work Incentive Benefit will cease on the earliest of the following: 1. the date You are no longer Disabled; or 2. the end of the Maximum Period Payable. Adjusted Loss of Salary Ratio is equal to: A divided by B A Your pre -disability Indexed Monthly Earnings minus Your Disability Earnings B= Your• pre -disability Indexed Monthly Earriirrgs Rehabilitation Incentive Income Rehabilitation Incentive Income will be payable after the end of the Elimination Period, or after a period during which You received LTD Monthly Benefits. This benefit is payable if You are Disabled and Gainfully Employed in an occupation that has been approved as part of a Rehabilitation Plan. Rehabilitation Incentive Income will be calculated during the first 24 months of Gainful Employment as follows: 1. If Disability Earnings exceed 100% of pre -disability Indexed Monthly Earnings, Rehabilitation Incentive Income will be equal to the Net Monthly Benefit reduced by the amount of the excess. 2. If DisabilityEarnings do not exceed 100% of pre -disability Indexed Monthly Earnings, Rehabilitation Incentive Income will be equal to the Monthly Benefit. After the first 24 months of Gainful Employment, Rehabilitation Incentive Income will be equal to the LTD Monthly Benefit multiplied by the Adjusted Loss of Salary Ratio. Rehabilitation Incentive Income will cease on the earliest of the following: 1. as stated in the Rehabilitation Plan; 2. the date You fail to comply with the requirements of the Rehabilitation Plan; 3. the date You are no longer Gainfidlv Employed; or 4. the end of the Maxinmim Period Payable. Adjusted Loss of Salary Ratio is equal to: A divided by B A= Your pre -disability Indexed Monthly Earnings minus Your Disability Earnings B= Your pre -disability Indexed Monthly Earnings Oo024-A 2-LTDC-412 13 What is the minimum Net LTD Monthly Benefit payable under the Policy? The Net LTD Monthly Benefit payable for Disability will not be less than $100.00 or 10% of Your Gross LTD Monthly Benefit, whichever is greater. The minimum Net LTD Monthly Benefit does not apply if You are Gainfully Employed 00025 What happens if Your Deductible Sources of Income increase? The Net LTD Monthly Benefit will not be further reduced for subsequent cost -of -living increases which are paid, payable, or for which You or Your dependents are eligible under any Deductible Source of Income shown above. 00026 How long will You receive benefits under the Policy? We will send You a payment for each month of Disability up to the Maximum Period Payable as shown in the Schedule oJBenefits. Payment of benefits is also subject to any benefit duration limitation pertaining to Your Disability. 00027 What happens if Your Disability recurs? If Disability for which benefits were payable ends but recurs due to the same or related causes less than 6 months after the end of a prior Disability, it will be considered a resumption of the prior Disability. Such recurrent Disability shall be subject to the provisions of the Policy that were in effect at the time the prior Disability began. Disability which recurs more than 6 months after the end of a prior Disability is subject to: 1. a new Elimination Period; 2. a new Maximum Period Payable; and 3. the other provisions of the Policy that are in effect on the date the Disability recurs. Disability must recur while Your coverage is in force under the Policy. 00028 2-LTDC-412 14 EXCLUSIONS AND LIMITATIONS What are the exclusions and limitations tinder the Policy? The Policy does not cover any loss or Disability caused by, resulting from, arising out of or substantially contributed, directly or indirectly, to by any one or more of the following: • a Pre -Existing Condition; • commission of, participation in, or an attempt to commit an assault or felony; • Intentionally self-inflicted injuries; • attempted suicide, regardless of mental capacity; • participation in a war, declared or undeclared, or any act of war; • active military duty; • active Participation in a Riot; The Policy has limitations on: • Mental Disorder - Disability beyond 24 months after the Elimination Period if it is due to a Mental Disorder- of any type. Confinement in a Hospital or institution licensed to provide care and treatment for mental illness will not be counted as part of the 24-month limit. • Substance Abuse — A Substance Abuse (drug or alcohol) related Disability unless You are participating in a Substance Abuse treatment program approved by the State where the treatment program is provided. The cost of the treatment program must be borne by You or another group plan of the Policyholder (such as a group health plan or Employee Assistance Program) if one is available and covers this type of treatment. Except as specifically stated above, in no event will LTD Monthly Benefits for a Mental Disorder or Substance Abuse be paid beyond the earliest of the date: l . 24 LTD Monthly Benefit payments have been made; or 2. the Maximum Period Payable is reached; or 3. You refuse to participate in an appropriate, available treatment program, or You leave the treatment program prior to completion; or 4. You are no longer following the requirements of Yom- treatment plan under the program; or 5. You complete the initial treatment plan, exclusive of any aftercare or follow-up services. The lifetime cumulative Maximum Period Payable for all disabilities due to a Mental Disorder and Substance Abuse is 24 months. Only 24 months of benefits will be paid for any combination of such disabilities even if the disabilities: 1. are not continuous; and/or 2. are not related. Furthermore: • Benefits are not payable for any period during which You are confined to a penal or correctional institution if the period of confinement exceeds 30 days. • Benefits are not payable when You are able to return to work in Your Regular Occupation on a part-time basis but You do not. 00029 2-LTDC-412 15 TERMINATION OF COVERAGE When will Your insurance terminate? Your coverage will terminate on the earliest of the following dates: 1. the date on which the Policy is terminated; 2. the date You stop making any required contribution toward payment of premiums; 3. the date on which the Employer's participation under the Policy is terminated; or 4. the date You: a. are no longer a member of a class eligible for this insurance, b. request termination of coverage under the Policy, c. are retired or pensioned, or d. cease work because of a leave of absence, furlough, layoff, or temporary work stoppage due to a labor dispute, unless We and the Policyholder have agreed in writing in advance of the leave to continue insurance during such period. Termination will not affect a covered loss which began while the coverage was in force. 00030 Will coverage be continued if You are eligible for leave under FMLA? In the event You are eligible for and the Policyholder approves a leave under the Family and Medical Leave Act of 1993 (FMLA), or any applicable state family and medical leave law (State FML), provided the required premium continues to be paid, Your insurance will continue for a period of up to the later of: 1. the leave period permitted by the federal Family and Medical Leave Act of 1993 and any amendments; or 2. the leave period permitted by applicable state law. While granted a Family or Medical Leave of Absence: l . The Policyholder must remit the required premium according to the terms of the Policy; and 2. coverage will terminate if You do not return to work as scheduled according to the terms of Your agreement with the Policyholder. 00031 Will coverage be continued if You are eligible for leave under USERRA? If You are on a leave of absence for active military service as described under the Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA) and applicable state law, Your coverage may be continued until the end of the later of: 1. the length of time the coverage may be continued under the Certificate for an FMLA or State FML leave of absence; or 2. the length of time the coverage may be continued under the Certificate of Coverage for a leave of absence other than an FMLA or State FML leave of absence. 00032 Will coverage be continued for other leaves of absence? If You are on an approved leave of absence other than an FMLA or State FML leave of absence, and if premium is paid, Your coverage will be continued through the end of the month that immediately follows the month in which Your leave of absence begins. 2-LTDC-412 16 If the Policyholder has approved more than one type of leave of absence for You during any one period that You are not Actively at Work We will consider such leaves to be concurrent for the purpose of determining how long Your coverage may continue under the Policy. If Your coverage is not continued during an FMLA or State FML leave of absence, and You become Actively at Work immediately following the end of Your FMLA or State FML leave of absence, Your coverage will be reinstated. We will not apply a new Waiting Period, require Evidence Of Insurability, or apply a new Pre-existing Condition limitation. If Your coverage is not continued during a leave of absence for active military service, and You return to active employment, You• coverage may be reinstated in accordance with USERRA and applicable state law. In no event will Your coverage under the policy be continued beyond the date Your coverage would otherwise end according to the terms of the When will Your insurance terminate? provision. 00033 2-LTDC-412 17 DAY CARE EXPENSE BENEFIT Are Day Care E-xpense Benefits available while You are Disabled? While Disabled and receiving Rehabilitation Incentive Income, You will be reimbursed for Day Care Expenses for each Eligible Child. You must supply satisfactory proof to Us that You incurred such charges. Day Care Expenses mean monthly expenses, up to $350.00 per child per month, to a maximum total benefit of $1,000.00 per month, charged by a licensed day care provider who is not a member of Your immediate family or living in Your residence. Eligible Child means Your Dependent Child under age 13 who lives with You. Dependent Child(ren) means any unmarried child of Yours, whether natural, step, foster or adopted, who is primarily dependent on You for financial support and maintenance. The Day Care Expense Benefit payments will end the earliest of the following to occur: 1. the date You are no longer incurring Dav Care Expenses for your Eligible Child; 2. the date You are no longer receiving Rehabilitation Incentive Income; 3. after 24 monthly Day Care Expense Benefit payments have been made for each Eligible Child 00034 2-LTDC-412 18 EDUCATION BENEFIT What is the Education Benefit? If You continue to be Disabled after 6 months of receiving the LTD Monthly Benefit under the Policy, and You are not Gainfully Employed, We will also pay a monthly Education Benefit for each of Your Dependent Child(ren) who is an Eligible Student as defined below. Dependent Child(ren) means any unmarried child of Yours, whether natural, step, foster or adopted who is primarily dependent on You for financial support and maintenance. An Eligible Student means the child(ren) is (are): 1. Your Dependent Child(ren), and is(are) less than 23 years of age; and 2. attending a School for Higher Learning on a full-time basis. School for Higher Learning means an institution which 1. is legally authorized by the State in which it is located; and 2. provides either a program for: a. Bachelor's degrees or not less than a two year program with full credit towards a Bachelor's degree; or b. gainful employment as long as such program is at least one year of training; and 3. is accredited by an Agency or association recognized by the U.S. Department of Education under the Higher Education Assistance Act as may be amended from time to time The Education Benefit is $1,500.00 per month, paid in addition to Your LTD Monthly Benefit. It is payable to You, and will not be reduced by Deductible Sources of Income. The Education Benefit will be paid to You upon Our receipt of satisfactory proof that the above requirements have been met. The Education Benefit will be payable between school semesters or terms, if the Eligible Student is enrolled or registered for the next scheduled semester or term. The Education Benefit payments will end the earliest of the following to occur: 1. the date You are no longer Disabled, 2. the date Your Dependent Child(ren) is (are) no longer an Eligible Student as defined above, or 3. the date You die. 00035 2-LTDC-412 19 SURVIVOR INCOME BENEFIT What happens if You die while receiving benefits? We will pay a Survivor Income Benefit to an Eligible Survivor when proof is received that You died: 1. After the Disability had continued for 6 or more consecutive months; and 2. While receiving an LTD Monthly Benefit The Survivor Income Benefit shall be payable on a lump sum basis immediately after We receive written proof of Yom- death. The benefit will be equal to 3 times Yow-Last Monthly Benefit. The benefit shall accrue from Your date of death. Eligible Survivor means Yom- Spouse, if living, or if Yom- Spouse dies before the final monthly benefit is paid, then Your children who are under age 23. If payment becomes due to Yow- children, payment will be made to: 1. the children; or 2. a person named by Us to receive payments on the children's behalf. This payment will be valid and effective against all claims by others representing or claiming to represent the children. Last Monthly Benefit means the Monthly Benefit paid to You immediately prior to Your- death, but not including any reductions for Deductible Sources of Income. The Survivor Income Benefit cannot be paid if benefits are paid under the Terminal Illness Benefit. If there is no Eligible Survivor-, We will pay the Survivor Income Benefit to Your estate. 00036 2-LTDC-412 20 FAMILY INCOME BENEFIT What is the Family Intone Benefit? We will pay a Family Income Benefit to an Eligible Survivor when proof is received that You died: 1. after the Disability had continued for 6 or more consecutive months; and 2. while receiving an LTD Monthly Benefit This benefit will be paid monthly for 12 months from the date of death. The benefit amount will be equal to 100% of Your Last Monthly Benefit. Eligible Survivor means Your Spouse, if living, or if Your Spouse dies before the final monthly benefit is paid, then Your children who are under age 23. If payment becomes due to Your children, payment will be made to: 1. the children; or 2. a person named by Us to receive payments on the children's behalf. This payment will be valid and effective against all claims by others representing or claiming to represent the children. Last Monthly Benefit means the monthly benefit paid to You immediately prior to Your death, but not including any reductions for Deductible Soin-ces of Income. The Family Income Benefit cannot be paid if benefits are paid under the Survivor Income Benefit or the Terminal Illness Benefit. If there is no Eligible Survivor, GVe will pay the Family Income Benefit to your estate. 00037 2-LTDC-412 21 TERMINAL ILLNESS BENEFIT What happens if You are diagnosed as being Terminally Ill? We will pay a Terminal Illness Benefit to You when proof is received that You are Terminally Ill. The Terminal Illness Benefit will be paid: 1. after You or Your legal representative has filed proof acceptable to Us ; and 2. after Total Disability has continued for at least 6 consecutive months; and 3. while You are receiving, or are eligible to receive an LTD Monthly Benefit under the Policy. The Terminal Illness Benefit amount will be 3 times Your Last Monthly Benefit. The Terminal Illness Benefit is payable once in a lump sum to Yon while You are alive, and is in lieu of a Survivor Income Benefit. The Terminal Illness Benefit paid under this provision may be taxable. If so, You or Your beneficiary may incur a tax obligation. As with all tax matters, You or Your Beneficiary should consult a personal tax advisor to assess the impact of this Terminal Illness Benefit. Last Monthly Benefit means the Monthly Benefit paid to You immediately prior to Your request for benefits under the Terminal Illness Benefits provision, but not including any reductions for Deductible Sources of Income. Terminally Ill means You have been examined and diagnosed by Your Doctor as having a medically determined condition which is expected to result in death within 6 months from the date that a claim for benefit under this provision is received by Us. We have the sole right to determine if such proof is acceptable. 00038 2-LTDC-412 22 REHABILITATION BENEFIT What is the Rehabilitation Benefit? If You are receiving a Monthly Benefit and You are participating in a Rehabilitation Plait approved by Us , You will receive a monthly Rehabilitation Benefit. The Rehabilitation Benefit pays 35% of Your Gross LTD Monthly Benefit to a maximum of $1,400.00 per month subject to the maximum Monthly Benefit as shown in the Schedule of Benefits. Eligibility for a Rehabilitation Plan is based upon You- education, training, work experience and physical and/or mental capacity. To be considered for a Rehabilitation Plait: 1. Your Disability must prevent You from performing Your Regular Occupation: 2. You must have the physical and/or mental capacities necessary for successful completion of a Rehabilitation Plait; and 3. there must be a reasonable expectation that the Rehabilitation Plait will help You return to Gainful Employment. The Rehabilitation Benefit is not subject to policy provisions which would otherwise increase or reduce the Monthly Benefit. Rehabilitation Benefit payments will end on the earliest of the following dates: 1. after 24 monthly Rehabilitation Benefit payments have been made; 2. on the date We determine that You are no longer eligible to participate in a Rehabilitation Plait; 3. on the date You are no longer participating in the Rehabilitation Plan; or 4. on any other date monthly payments would cease in accordance with the Policy. 00039 2-LTDC-412 23 COST OF LIVING ADJUSTMENT What is the Cost -of -Living Adjustment? We will make a Cost -of -Living Adjustment (COLA) after You have received one year of Monthly Benefit payments. Your payment will increase by the lesser of 1. 35% of Your Gross Monthly LTD Benefit, or 2. the percentage change in the CPI-YV for the calendar month that falls 90 days prior to the date the annual adjustment is to be made compared to the same calendar month for the previous year. The COLA adjustment will be made on the first anniversary of payments and each following anniversary not to exceed 10 anniversary adjustment periods while You continue to receive payments for Yow- disability. Each month GVe will add the COLA to Your monthly payment. When YVe add the adjustment to Yow• payment, the increase may cause Your payment to exceed the Maximum Benefit. Compounding will continue up to the maximum number of adjustments. CPI-W means the Consumer Price Index for all urban wage earners and clerical workers in the United States as published by the Bureau of Labor Statistics of the United States Department of Labor or its successors. If the CPI- W is discontinued or changed, We may use another index that most closely reflects the cost of living in the United States. 00040 2-LTDC-412 24 ACCIDENTAL DISMEMBERMENT BENEFIT What is the Accidental Dismemberment Benefit? If, while insured under the Policy, You suffer an Injury in an Accident, 6Ve will pay an Accidental Dismemberment Benefit for the Specific Losses listed below. The Accidental Dismemberment Benefit is equal to the Net LTD Monthly Benefit and is payable for the length of time stated below, or until You• date of death, whichever first occurs. This benefit is paid in lieu of the LTD Monthly Benefit, the Work Incentive Benefit or Rehabilitation Incentive Income. The loss must: 1. Occur within 365 days of the Accident; and 2. Be the direct and sole result of the Accident; and 3. Be independent of all other causes. Specific Loss Months Payable Quadriplegia 60 months Paraplegia 55 months Hemiplegia 50 months Loss of both hands 46 months Loss of both feet 46 months Loss of the entire sight of both eyes 46 months Loss of one hand and one foot 46 months Loss of one hand and the entire sight of one eye 46 months Loss of one foot and the entire sight of one eye 46 months Loss of one hand 23 months Loss of one foot 23 months Loss of the entire sight of one eye 15 months Loss of the thumb and index finger of either hand 12 months After payment of the Accidental Dismemberment Benefit, benefits may continue subject to the other provisions of the Policy. If more than one loss results from any one hywy, YVe will pay only for that loss with the greatest number of months payable. Specific Loss means, with respect to hand or foot, the actual, complete and permanent severance through or above the wrist or ankle joint; with respect to eye, the irrecoverable loss of the entire sight thereof; and with respect to thumb and index finger, the actual, complete and permanent severance through or above the metacarpophalangeal joints. Quadriplegia means complete paralysis of both arms and both legs as a result of an hywy to the Spinal Cord. The paralysis must be determined by a Doctor to be permanent, complete and irreversible. Paraplegia means complete paralysis of either both arms or both legs as a result of an hywy to the Spinal Cord. The paralysis must be determined by a Doctor to be permanent, complete and irreversible. Hemiplegia means the complete paralysis of one arm and one leg on the same side of the body as a result of an hywy to the Spinal Cord. The paralysis must be determined by a Doctor to be permanent, complete and irreversible. 2-LTDC-412 25 We may require proof of total paralysis on a periodic basis. 00041 2-LTDC-412 26 CATASTROPHIC DISABILITY BENEFIT What is a Catastrophic Disability Benefit? We will pay a monthly Catastrophic Disability Benefit to You if You are receiving LTD Monthly Benefits (or Accidental Dismemberment Benefits) and We receive proof that You are Catastrophically Disabled. Catastrophic Disability Benefit payments will begin at the end of the Catastrophic Disability Elimination Period shown in the Schedule of Benefits. You are Catastrophically Disabled when We determine that, due to Sickness or Injmy: 1. You are unable to perform, without human assistance or regular supervision from another person, at least 2 of the 6 Activities of Daily Living; or 2. You become Cognitively Impaired; and 3. You are not Gainfully Employed. When will Your coverage become effective? You will become insured for Catastrophic Disability Benefit coverage on Your effective date under the LTD plan. However, the Catastrophic Disability Benefit coverage will be delayed if, on Your effective date, You cannot safely and completely perform one or more of the Activities of Daily Living without another person's assistance, or verbal cueing, or You are Cognitively Impaired. Coverage will begin on the date You can safely and completely perform all of the Activities of Daily Living without another person's assistance or verbal cueing, or no longer are Cognitively Impaired. How etch ivill We pay if You are Disabled? The Catastrophic Disability Benefit is 35% of pre -disability Indexed 1fondh1y Earnings to a maximum Catastrophic Disability Benefit of the lesser of the maximum LTD Mantlely Benefit or $1,400.00. This benefit is not subject to Policy provisions which would otherwise increase or reduce the benefit amount such as Deductible Sources of Income. When will Your Catastrophic Disability Benefit payments end? Catastrophic Disabilitv Benefit payments will end on the earliest of the following dates: 1. the date You are no longer Catastrophically Disabled; 2. the date You become ineligible for LTD Monthly Benefit payments; 3. the end of the Catastrophic Disability Maximum Period Payable shown in the Schedule ofBenefits; or 4. the date You die. What claim infornnatiou is needed for Catastrophic Disability Benefits? The Filing a Claim section under the Policy applies to Catastrophic Disability Benefit coverage. We may also require an interview with You. 2-LTDC-412 27 CAREGIVER RESPITE BENEFIT We will pay You a Caregiver Respite Benefit for each day of a Respite Interval, subject to the conditions below: 1. You must be receiving a Catastrophic Disability Benefit or a Spousal Catastrophic Disability Benefit; 2. The benefit is payable if Informal Home Care has been provided for at least 6 continuous months for You or Your Spouse beginning with Your or Your Spouse's Date of Disability; 3. The benefit is payable for Companion Care received by You or Your Spouse in Your home or a private residence during a Respite Interval; 4. The benefit is equal to the daily Companion Care cost incurred, not to exceed $100 per day; and 5. The benefit is payable to You following submission of proof of Your incurred costs for Companion Care during the Respite Interval, Contpatnion Care means medically necessary custodial care furnished during a Respite Interval for a minimum of 8 hours per day by a Home Health Care Provider accredited by either the Joint Commission on Accreditation of Health Care Organizations or Community Health Accreditation Program. Itforntal Caregiver means the person who has primary responsibility of providing Informal Home Care for You. A person who is paid for caring for You or Your Spouse cannot be an Informal Caregiver. Ittforntal Honte Care means medically necessary custodial care provided at Your home or a private residence by an Informal Caregiver. Such care is provided in lieu of confinement in a nursing home, or care received at Your home from a paid provider. Respite Interval means a period of one or more consecutive days during which the Informal Caregiver is temporarily relieved of the Informal Home Care duties. Two Respite Intervals are permitted per calendar year, subject to a cumulative total of 14 days per calendar year. Unused days expire on December 31 and cannot be carried over into any future calendar year. 2-LTDC-412 28 CAREGIVER TRAINING BENEFIT We will pay You a Caregiver Training Benefit if an Informal Caregiver incurs an expense to be trained to provide Informal Home Care for You, subject to the conditions below: 1. You must be receiving a Catastrophic Disability Benefit or a Spousal Catastrophic Disability Benefit; 2. Caregiver Training must be provided by a Home Health Care Provider accredited by either the Joint Commission on Accreditation of Health Care Organizations or Community Health Accreditation Program, by a Nursing Home or by a Hospital while You or Your Spouse are receiving the Catastrophic Disability Benefit. If You or Your Spouse are in a Nursing Home or in a Hospital, the Caregiver Training Benefit will only be payable if the training will make it possible for You or Your Spouse to return to You• residence where You or Your Spouse can be cared for by the Infornial Caregiver; 3. The amount of the benefit is the cost incurred for the Caregiver Training, subject to $500 maximum per period of Disability; 4. The benefit is payable to You following submission to Us of proof of Your or Your Spouse's costs incurred for Caregiver Training. Caregiver Training means training received by the Informal Caregiver to care for You or You- Spouse in Your residence. Informal Caregiver means the person who has primary responsibility of providing bifaMnal Home Care for You or Your Spouse. A person who is paid for caring for You or Your Spouse cannot be an Informal Caregiver. Informal Home Care means medically necessary custodial care provided at Your home or a private residence by an Informal Caregiver. Such care is provided in lieu of confinement in a nursing home, or care received at Your home from a paid provider. 2-LTDC-412 29 EMERGENCY ALERT SYSTEM BENEFIT We will pay You an Emergency Alert System Benefit for the cost to rent or lease an Emergency Alert System which will allow You or Your Spouse to remain in Your residence alone, subject to the conditions below: 1. You must be receiving a Catastrophic Disability Benefit or a Spousal Catastrophic Disability Benefit; 2. The benefit is payable for a medically necessary Emergency Alert System; 3. Your or Your Spouse's condition must be such that You or You• Spouse could not be left alone were it not for the presence of the Emergency Alert System; 4. The benefit is the lesser of $25 per month or the actual cost to rent or lease the Emergency Alert System; 5. The benefit is payable to You, in arrears, after every 6 months, following submission of proof of Your incurred costs for the Emergency Alert System; and 6. We will not pay for any charges incurred as a result of installing, servicing or maintaining the Emergency Alert System. This includes, but is not limited to, any charges for normal telephone service while the system is installed or for a home security system. Emergency Alert System means a communication system located in Your residence, that is used to summon medical attention in case of a medical emergency. 0004? 2-LTDC-412 30 SPOUSAL CATASTROPHIC DISABILITY BENEFIT What is the Spousal Catastrophic Disability Bettefit? Spousal Catastrophic Disability pays a benefit of $1,300.00 per month for 12 months after YourSpoitse has been Catastrophically Disabled for 35 days. Catastrophically Disabled means that due to Sickness or I jtrty YVe determine that: 1. Yow• Spouse is unable to perform, without human assistance or regular supervision from another person, at least 2 of the 6 Activities of Daily Living; or 2. Your Spouse becomes Cognitively Impaired; and 3. Your Spouse is not working for wages at any occupation. When ivill Your Spouse's coverage become effective? Your Spouse will become insured for the Spousal Catastrophic Disability Benefit on Your effective date under the Policy, or on the date of Yow• marriage, if later. However, the Spousal Catastrophic Disability coverage will be delayed for Your Spouse if, on Your Spouse's effective date, Your Spouse cannot safely and completely perform one or more of the Activities of Daily Living without another person's assistance or verbal cueing, or Your Spouse becomes Cognitively Impaired. Coverage will begin on the date Your Spouse can safely and completely perform all of the Activities of Daily Living without another person's assistance or verbal cueing or no longer is Cognitively Impaired. Spousal Catastrophic Disability coverage will continue as long as the benefit is in effect and You are insured under the Policy. How much will We pay if Your Spouse is Disabled? The Spousal Catastrophic Disability Benefit is $1,300.00 per month. The benefit is payable to You. This benefit is not subject to Policy provisions which would otherwise increase or reduce the benefit amount such as Deductible Sources of Income. When ►vill You be eligible to receive Spousal Catastrophic Disability Benefits? We will pay a monthly Spousal Catastrophic Disability Benefit when We receive proof that Your Spouse is Catastrophically Disabled under this benefit. Spousal Catastrophic Disability Benefits will begin at the end of the Elimination Period for the Spousal Catastrophic Disability Benefit shown above. What is the Spousal Catastrophic Disability Benefit Elimination Period? The Spousal Catastrophic Disability Benefit Elimination Period is 35 days. This is the number of calendar days at the beginning of a continuous period of Catastrophic Disability for which no benefits are payable. What erclusions and limitations apply to Spousal Catastrophic Disability? Catastrophic Disability caused by, contributed to or resulting from a Pre -Existing Condition (as defined directly below) is excluded from the Spousal Catastrophic Disability Benefit. Other Policy provisions that exclude or limit coverage will apply to this Spousal Catastrophic Disability Benefit. For Spousal Catastrophic Disability coverage, Your Spouse will be considered to have a Pre -Existing Condition if Your Spouse's Catastrophically Disabling condition was caused by, contributed to by, or resulted from a condition for which medical treatment or advice was rendered, prescribed or recommended within 6 months prior to Yow• Spouse's effective date of insurance. A condition shall no longer be considered pre-existing if it causes loss which begins after Your Spouse has been insured under the Policy for a period of 12 months. R`heu will Spousal Catastrophic Disability Benefit payments end? Benefit payments will end on the earliest of the following dates: 1. the date Your Spouse is no longer Catastrophically Disabled under the benefit; or 2-LTDC-412 31 2. 12 months following the satisfaction of the Elimination Period; or 3. the date Your Spouse dies. What claim information is needed for Spousal Catastrophic Disability Benefit? The Filing a Claim section under the Policy applies to Spousal Catastrophic Disability Benefit coverage. We may also require an interview with Your Spouse. 00043 2-LTDC-412 32 WORKSITE MODIFICATION BENEFIT What is the Worksite Modification Benefit? GVe will assist You and the Policyholder in identifying modifications GVe agree are likely to help You remain at work or return to work. This agreement will be in writing and must be signed by You, the Policyholder and Us. When this occurs, YVe will reimburse the Policyholder for the cost of the modification, up to the greater of: 1. $1,500.00; or 2. 2 times Your Last Monthly Benefit. We will reimburse the Policyholder upon completion of the following: 1. agreed upon modifications made on Your behalf are completed; 2. written proof of expenses incurred by Yoiu- Policyholder have been provided to Us; and 3. You have returned to work and are an Actively at YVork Employee. Last Monthly Benefit means the monthly benefit paid to You immediately prior to Your request for benefits under the Worksite Modification Benefit provision, but not including any reductions for Deductible Sources of Income. 00044 2-LTDC-412 33 RETIREMENT PLAN PROTECTION BENEFIT What is the Retirement Plan Protection Benefit? If You are Disabled, a Retirement Plan Protection Benefit is payable to the Policyholder on Your behalf. While receiving the Long Term Disability Monthly Benefit If You are Disabled and are receiving a Monthly Benefit under the Policy, the Retirement Plan Protection Benefit is calculated as the lesser of the following: 1. 35% of Your average Monthly Earnings as calculated over the last 12 months of employment prior to Your Date of Disability (or You• period of employment with Your Policyholder i f less than 12 months), 2. $1,400.00 per month; or 3. the average monthly contribution made by the Policyholder to Your pension plan over the last 12 months of employment prior to Your Date of Disability (or Your period of employment with the Policyholder if less than 12 months). While Receiving a Work Incentive Benefit or Rehabilitation Incentive Income If You are Disabled and are receiving a Work Incentive Benefit or Rehabilitation Incentive Income, the Retirement Plan Protection Benefit is calculated by multiplying the amount of Retirement Plan Protection Benefit otherwise payable as stated above by the Adjusted Loss of Salary Ratio. Adjusted Loss of Salary Ratio is equal to: A divided by B A Your pre -disability Indexed Monthly Earnings minus You- Disability Earnings B= Your pre -disability Indexed Monthly Earnings Payment of the Retirement Plan Protection Benefit is made directly to the Policyholder on Your behalf. The Policyholder may deposit such payments into the Policyholder -sponsored pension plan if the Policyholder determines that such contributions may be accepted by the plan. We do not act as plan administrator or trustee of the Policyholder's sponsored pension plan, therefore We cannot make the above determination. If the Policyholder or the trustee of Your plan determines that the benefits payable under this provision cannot legally be accepted by the pension plan, We will, upon written request from the Policyholder, make the Retirement Plan Protection Benefit payable to You. Such payments may constitute taxable income to You. Retirement Plan Protection Benefit payments will end on the earliest of the following: l . the date You are no longer Disabled under the contract; or 2. the date You are no longer eligible to participate in the Policyholder's defined contribution or defined benefit plan; or 3. the end of the Alfaxinuni Period Payable; or 4. the date of You• death. 00045 2-LTDC-412 34 CONVERSION PRIVILEGE What are Your conversion options if You end employment? If You end employment with the Policyholder, Your coverage under the Policy will end. You may be eligible to purchase insurance under the group conversion policy. To be eligible, You must have been insured for at least 12 consecutive months under the Policyholder's group plan on the date You end employment. We will consider the amount of time You were insured under this Plan and the plan it replaced, if any. You must apply for insurance under the conversion policy, and pay the first (annual/semi-annual) premium within 31 days after the date Your employment ends. The conversion policy will be at the premium rate and on the form then being made available by Us for conversion. You are not eligible to apply for coverage under the group conversion policy if: 1. You are or become insured under another group long term disability plan within 31 days after Your employment ends; 2. You are Disabled under the terms of the Policy; 3. You recover from a Disability and do not return to work or with the Policyholder; 4. You are on a leave of absence; or 5. Your coverage under the Policy ends for any of the following reasons: a. The Policy is canceled; b. The Policy is changed to exclude the class of employees to which You belong; c. You are no longer in an eligible class; d. You end Your working career or retire and receive payment form the Policyholder's Retirement Plan; or e. You fail to pay the required premium under the Policy. 00046 2-LTDC-412 35 CLAIM SERVICES What other services are available to You while You are Disabled? If You are Disabled and eligible to receive Disability benefits under the Policy, We will evaluate You for eligibility to receive any of the following. We will make the final determination for any of the following benefits or services. Vocational Rehabilitation Service Rehabilitation services are available when We determine that these services are reasonably required to assist in returning You to Gainful n/ Employment. Vocational rehabilitation services might include but are not limited to one or more of the following: 1. job modification; 2. job retraining; 3. job placement; 4. other activities. Eligibility for vocational rehabilitation services is based upon Your education, training, work experience and physical and/or mental capacity. To be considered for rehabilitation services: 1. Your Disability must prevent You from performing Your Regular Occupation; 2. You must have the physical and/or mental capacities necessary for successful completion of a rehabilitation program, and 3. there must be a reasonable expectation that rehabilitation services will help You return to Gainful Employment. Social Security Disability Assistance When necessary, We will provide an advocate for You in applying for and securing Social Security Disability awards. When TVc determine that Social Security Assistance is appropriate for You, it is provided at no additional cost to You. 00047 2-LTDC-412 36 FILING A CLAIM What are the Claim Filing Requirements? Initial Notice of Claim We ask that You notify Us of Your claim as soon as possible, so that We may make a timely decision on Your claim. The Policyholder can assist You with the appropriate telephone number and address of Our Claim Department. You must send Us written notice of Your Disability within 30 days of the Date of Disability, or as soon as reasonably possible. Notice may be sent to Our Claim Department at the address shown on the claim form or given to Our Agent. Written Proof of Loss Within 15 days of Our being notified in writing of Your claim, We will supply You with the necessary claim forms. The claim form is to be completed and signed by You, the Policyholder and Your Doctor. If You do not receive the appropriate claim forms within 15 days, then You will be considered to have met the requirements for written proof of loss if We receive written proof, which describes the occurrence, extent and nature of loss as stated in the Proof of Disability provision. Time Limit for Filing Yottr Claim You must furnish Us with written proof of loss within 91 days after the end of Your Elimination Period. The length of the Elimination Period is shown in the Schedule of Benefits. If it is not possible to give Us written proof within 91 days, the claim is not affected if the proof is given as soon as possible. However, unless You are legally incapacitated, written proof of loss must be given no later than 1 year after the time proof is otherwise due. No benefits are payable for claims submitted more than 1 year after the time proof is due. However, You can request that benefits be paid for late claims if You can show that: 1. It was not reasonably possible to give written proof during the 1 year period, and 2. Proof of loss satisfactory to Us was given as soon as was reasonably possible. Proof of Disability The following items, supplied at Your expense, must be a part of Your proof of loss. Failure to provide complete proof of loss may delay, suspend or terminate Your benefits. 1. The date Your Disability began; 2. The cause of Your Disability; 3. The prognosis of Your Disability; 4. Proof that You are receiving Appropriate and Regular Care for Your condition from a Doctor, who is someone other than You or a member of Your immediate family, whose specialty or expertise is the most appropriate for Your disabling condition(s) according to Generallv Accepted Medical Practice. 5. Objective medical findings which support Your Disability. Objective medical findings include but are not limited to tests, procedures, or clinical examinations standardly accepted in the practice of medicine, for Your disabling condition(s). 6. The extent of Your Disabilitv, including restrictions and limitations which are preventing You from performing Your Regular Occupation. 7. Appropriate documentation of Your Month(v Earnings. If applicable, regular monthly documentation of Your Disability Earnings. 8. If You were contributing to the premium cost, the Policyholder must supply proof of Your appropriate payroll deductions. 9. The name and address of any Hospital or Health Care Facility where You have been treated for Your Disabilitv. 10. If applicable, proof of incurred costs covered under other benefit provisions in the Policy. 2-LTDC-412 37 Continuing Proof of Disability You may be asked to submit proof that You continue to be Disabled and are continuing to receive Appropriate and Regular Care of a Doctor. Requests of this nature will only be made as often as reasonably necessary, but not more frequently than once every 3 months. If required, this will be at Your expense and must be received within 45 days of Our request. Failure to comply with such a request may delay, suspend or terminate Your benefits. Examination At Our expense, 6Ve have the right to have You examined as often as reasonably necessary while the claim continues. Failure to comply with this examination may result in denial, suspension or termination of benefits, unless We agree You have a valid and acceptable reason for not complying. Authorization and Documentation You will be asked to supply 1. You will be required to provide signed authorization for Us to obtain and release all reasonably necessary medical, financial or other non -medical information in support of Your Disability claim. Failure to submit this information may deny, suspend or terminate Your benefits. 2. You will be required to supply proof that You have applied for other Deductible Sources of Income such as Workers' Compensation or Social Security Disability benefits, when applicable. 3. You will be required to notify Us when You receive or are awarded other Deductible Sources of Income. You must tell Us the nature of the Deductible Source of Income, the amount received, the period to which the benefit applies, and the duration of the benefit if it is being paid in installments. 00048-TX Time of Payntent of Claim As soon as We have all necessary substantiating documentation for Your Disability claim, We will pay Your benefit on a monthly basis, so long as You continue to qualify for it. We will pay benefits to You unless otherwise indicated. If You die while Your claim is open, any due and unpaid Disability benefit will be paid, at Our option, to the surviving person or persons in the first of the following classes of successive preference beneficiaries: Your: 1) Spouse; 2) children including legally adopted children; 3) parents; or 4) Your estate. If any benefit is payable to an estate, a minor or a person not competent to give a valid release, 6Ve may pay up to $1,000 to any relative or beneficiary of Yowl whom We deem to be entitled to this amount. We will be discharged to the extent of such payment made by Us in good faith. 00049 Can You assign Your benefits? Your benefits are not assignable, which means that You may not transfer Your benefits to anyone else. What will happen if a claim is overpaid? A claim overpayment can occur when You receive a retroactive payment from a Deductible Source of Income when 6Ve inadvertently make an error in the calculation of Your claim; or if fraud occurs. The overpayment amount equals the amount 6Ve paid in excess of the amount We should have paid under the Policy. We have the right to recover from You any amount that is an overpayment of benefits under the Policy. You must refund to us the overpaid amount. We may also, without forfeiting our right to collect an overpayment through any means legally available to Us, recover all or any portion of an overpayment by reducing or withholding future benefit payments, including the Minimum lblonthly Benefit. In an overpayment situation, We will determine the method by which the repayment is made. You will be required to sign an agreement with Us which details the source of the overpayment, the total amount We will recover and the method of recovery. If LTD Monthly Benefits are suspended while recovery of the overpayment is being made, suspension will also apply to the minimum LTD Alonthh, Benefits payable under the Policy. 2-LTDC-412 38 Subrogation —Right of Reimbursement When any claim payment is made, We reserve any and all rights to subrogation and/or reimbursement to the fullest extent allowed by statute and customary practice. Any party to this contract shall not perform any act that will prejudice such rights without prior agreement with Us. We will bear any expenses associated with Our pursuit of subrogation or recovery. 00050 2-LTDC-412 39 UNIFORM PROVISIONS Entire Contract, Changes The Policy, the Policyholder's application, the employee's certificate of coverage, and Your application, if any, and any other attached papers, form the entire contract between the parties. Coverage under the Policy can be amended by mutual consent between the Policyholder and Us. No change in the Policy is valid unless approved in writing by one of Our officers. No agent has the right to change the Policy or to waive any of its provisions. Statements on the Application In the absence of fraud, all statements made in any signed application are considered representations and not warranties (absolute guarantees). No representation by: 1. the Policyholder in applying for the Policy will make it void unless the representation is contained in the signed application; or 2. any Entplovee in applying for insurance under the Policy will be used in defense to a claim under the Policy unless it is contained in a written application signed by the Insured and a copy of such application is or has been given to him or to his personal representative. Legal Actions Unless otherwise provided by federal law, no legal action of any kind may be filed against Us: 1. until 60 days after proof of claim has been given; or 2. more than 3 years after proof of Disability must be filed, unless the law in the state where You live allows a longer period of time. Clerical Error Clerical error or omission by Us to the Policyholder will not: 1. Prevent You from receiving coverage, if You are entitled to coverage under the terms of the Policy; or 2. Cause coverage to begin or coverage to continue for You when the coverage would not otherwise be effective. If the Policyholder gives Us information about You that is incorrect, We will: 1. Use the facts to decide whether You have coverage under the Policy and in what amounts; and 2. Make a fair adjustment of the premium. Misstatement of Age If Your age has been misstated, an equitable adjustment will be made in the premium. If the amount of the benefit is dependent upon Your age, as shown in the Benefit Duration Schedule, the amount of the benefit will be the amount You would have been entitled to if Your correct age were known. Note: A refund of premium will not be made for a period more than twelve months before the date the Company is advised of the error. Incontestability The validity of the Policy shall not be contested, except for non-payment of premiums, after it has been in force for two years from the date of issue. The validity of the Policy shall not be contested on the basis of a statement made relating to insurability by any person covered under the Policy after such insurance has been in force for two years during such person's lifetime, and shall not be contested unless the statement is contained in a written instrument signed by the person making such statement. Conformity ivith State Statutes and Regulations If any provision of the Policy conflicts with the statutes and regulations of the state in which the Policy was issued or delivered, it is automatically changed to meet the minimum requirements of the statute. 2-LTDC-412 40 Workers' Compensation or State Disability Insurance The Policy is not in place of, and does not affect the requirements for coverage by any workers' compensation or state disability insurance. Agency Neither the Policyholder, any employer, any associated company, nor any administrator appointed by the foregoing is Our agent. General Provisions We have the right to inspect all of the Policyholder's records on the Policy at any reasonable time. This right will extend until: 1. 2 years after termination of the Policy; or 2. all claims under the Policy have been settled, whichever is later. The Policy is in the Policyholder's possession and may be inspected by You at any time during normal business hours at the Policyholder's office. 00051-TX 2-LTDC-412 41 DEFINITIONS The following are key words and phrases used in this certificate. When these words and phrases, or forms of them, are used, they are capitalized and italicized in the text. As You read this certificate, refer back to these definitions. Accident or Accidental means a sudden, unexpected event that was not reasonably foreseeable. 00052 Actively at Work or Active Work means that You must be: 1. working for the Policyholder on a full-time active basis; or 2. working at least the minimum number of hours shown in the Schedule of Benefits: and either: a. working at the Policyholder's usual place of business; or b. working at a location to which the Policyholder's business requires You to travel; 3. a legal citizen or resident of the United States of America; 4. are paid regular earnings by the Policyholder, and 5. not a temporary or seasonal Employee. You will be considered Actively at 6Vork if You were actually at work on the day immediately preceding: 1. a weekend (except for one or both of these days if they are scheduled days of work); 2. holidays (except when such holiday is a scheduled work day); 3. paid vacations; 4. any non-scheduled work day; 5. excused leave of absence (except medical leave and lay-off); and 6. emergency leave of absence (except emergency medical leave). 0005.3 Appropriate and Regular Care means that You are regularly visiting a Doctor as frequently as medically required to meet Your basic health needs. The effect of the care should be of demonstrable medical value for Your disabling condition(s) to effectively attain and/or maintain maximum medical improvement. 00055 Date of Disability is the date 6Ve determine that You are Disabled. 00057 Disability or Disabled means that You satisfy the definition of either Total Disability or Partial Disability. 00058 Disability Earnings is the wage or salary You earn from Gainful Ennplovmennt after a Disability begins. It includes any earnings You could receive if You were working to Your Maximum Capacity. Any lump sum payment will be prorated, based on the time over which it accrued or the period for which it was paid. If You• Disability Earnings routinely fluctuate widely from month to month, 6Ve may average Your Disability Earnings over the most recent three months to determine if Your claim should continue. If 6Ve average Your Disability Earnings, 6Ve will not terminate Your claim unless the average of Your Disability Earnings from the last three months exceeds 80% of Your Indexed Monthly Earnings. 00059 2-LTDC- 705 42 Domestic Partner means an adult of the same or opposite gender who has an emotional, physical and financial relationship to You, similar to that of a Spouse, as evidenced by the following: 1. You and Your Domestic Partner share financial responsibility for a joint household and intend to continue an exclusive relationship indefinitely; 2. You and Your Domestic Partner each are at least eighteen (18) years of age; 3. You and Your Domestic Partner are both mentally competent to enter into a binding contract; 4. You and Your Domestic Partner share a residence and have done so for at least 12 months; 5. Neither You nor Your Domestic Partner- are married to or legally separated from anyone else; 6. You and Your Domestic Partner are not related to one another by blood closer than would bar marriage; and Neither You nor Your Domestic Partner is a Domestic Partner of anyone else. Where the laws of the governing jurisdiction mandate a definition of Domestic Partner other than shown above, that definition will be used in the Policy. 00060 Doctor means a person legally licensed to practice medicine, psychiatry, psychology or psychotherapy, who is neither Yon nor a member of Your immediate family. A licensed medical practitioner is a Doctor if applicable state law requires that such practitioners be recognized for purposes of certification of Disability, and the treatment provided by the practitioner is within the scope of his or her license. 00061 Elimination Period means the number of calendar days at the beginning of a continuous period of Disability for which no benefits are payable. The Elimination Period is shown in the Schedule of Benefits. 00062 Employee means an Actively at YVork full-time Employee whose principal employment is with the Policyholder, at the Policyhholder's usual place of business or such place(s) that the Policvholder's normal course of business may require, who is Actively at YVork for at least the number of hours per week as stated in the Application and is reported on the Policyholder's records for Social Security and withholding tax purposes. 00069 Gainful Occupation, Gainful Employment or Gainfully Employed means the performance of any occupation for wages, remuneration or profit, for which You are qualified by education, training or experience on a full-time or part-time basis. 00063 Generally Accepted Medical Practice or Generally Accepted in the Practice of Medicine means care and treatment which is consistent with relevant guidelines of national medical, research and health care coverage organizations and governmental agencies. 00064 Gross LTD Monthly Benefit means that benefit shown in the Schedule ofBenefhts which applies to You. 00065 Hospital or Health Care Facility is a legally operated, accredited facility licensed to provide full-time care and treatment for the condition(s) causing Your Disability. It is operated by a full-time staff of licensed physicians and registered nurses. It does not include facilities which primarily provide custodial, educational or rehabilitative care. 00066 htdeved Monthly Earnings means Your Monthly Earnings adjusted on each anniversary of benefit payment by the lesser of 3% or the current annual percentage increase in the Consumer Price Index. You• Indexed Monthly Earnings may increase or remain the same, but will never decrease. 2-LTDC- 705 43 Consumer Price Index (CPI-W) means the Consumer Price Index for all urban wage earners and clerical workers in the United States as published by the Bureau of Labor Statistics of the United States Department of Labor or its successors. If the CPI-W is discontinued or changed, We may use another index that most closely reflects the cost of living in the United States. Indexing is only used as a factor in the determination of the percentage of lost earnings while You are Disabled and working in a Gainful Occupation. 00067 Injury means bodily injury that is the direct result of an Accident and not related to any other cause. The It jury must occur, and Disability resulting from the It flay must begin while You are covered under the Policy. It jury that occurs before You are covered under the Policy will be treated as a Sickness. 00068 LTD means Long Term Disability. 00070 Male pronoun, whenever used, includes the female. 00071 Material and Substantial Duties means duties that: 1. are normally required for the performance of Your Regular Occupation; and 2. cannot be reasonably omitted or modified, except that if You are required to work on average in excess of 40 hours per week, We will consider You able to perform that requirement if You have the capacity to work 40 hours. 00072 Marinium Capacity means, based on You• restrictions and limitations: 1. The greatest extent of work You are able to do in Your Regular Occupation. 0007.3 Macimri» i Medical Improvement is the level at which, based on reasonable medical probability, further material recovery from, or lasting improvement to, an It jiuy or Sickness can no longer be reasonably anticipated. 00074 Maximum Period Payable, as shown in the Schedule of Benefits, means the longest period of time that We will make payments to You for any one period of Disability. 00075 Mental Disorder means a disorder found in the current diagnostic standards of the American Psychiatric Association. 00076 Monthly Benefit means the LTD Monthly Benefit shown in the Schedule of Benefits which applies to You. 00077 2-LTDC- 705 44 Monthly Earnings means Your gross monthly income from Your Eniployei- in effect just prior to Your Date of Disability. It includes Yow- total income before taxes and any deductions made for pre-tax contributions to a qualified deferred compensation plan, Section 125 plan, or flexible spending account. It includes income actually received from commissions, but does not include bonuses, overtime pay, or any other extra compensation, or income received from sources other than Your- Employer. Commissions will be averaged for the lesser of: a. the 12 full calendar month period of Your- employment with Your Employer just prior to the date Disability begins; or b. the period of actual employment with Yow-Enployer. 00078 Net LTD Monthly Benefit means the Gross LTD Monthly Benefit less the Deductible Sources of Income. 00079 Participation in: a Riot shall include promoting, inciting, conspiring to promote or incite, aiding, abetting, and all forms of taking part in, but shall not include actions taken in defense of public or private property, or actions taken in defense of the person of the insured, if such actions of defense are not taken against persons seeking to maintain or restore law and order including but not limited to police officers and firemen. 00080 Pre-existing Condition means a condition which; 1. was caused by, or results from a Sickness or b jury for which You received medical treatment, or advice was rendered, prescribed or recommended whether or not the Sickness was diagnosed at all or was misdiagnosed within 3 months prior to Your- effective date; and 2. results in a Disability which begins in the first 12 months after Your effective date. 00081 Regular Occupation means the occupation that You are routinely performing when Your Disability begins. We will look at Yaw- occupation as it is normally performed in the national economy, instead of how the work tasks are performed for a specific Policyholder- or at a specific location. 00082 Rehabilitation Plan: means a written agreement between You and Us. Its purpose is to assist You in returning to Gainful it Employment. The Rehabilitation Plan will outline the time and dates of the vocational rehabilitation services, Our responsibilities, Yow- responsibilities and the responsibilities of any third party which might be involved. The Rehabilitation Plan will be at Oin- expense, at the expense of the third party, or a shared expense of Oiirs and a third party. The Rehabilitation Plan may include the Day Care Expense Benefit. 0008.3 Riot shall include all forms of public violence, disorder or disturbance of the public peace, by three or more persons assembled together, whether or not acting with common intent and whether or not damage to persons or property or unlawful act or acts is the intent or the consequence of such disorder. 00085 Schedule of Benefits means the schedule which is a part of this certificate. 00086 Sickness means sickness or disease causing Disability which begins while You are covered under the Policy. 00087 Spouse means lawful spouse in the jurisdiction in which You reside. Spouse will include Your Domestic Partner. 00091 2-LTDC- 705 45 Substance Abuse means a pattern of pathological use of alcohol or other psychoactive drugs resulting in impairment of social and or occupational functioning, debilitating physical condition, inability to abstain from or reduce consumption of the substance, or the need for daily substance use for adequate functioning. 00092 Waiting Period as shown in the Schedule of benefit means the continuous length of time immediately before Your - Effective Date during which You must be in an Eligible Class. Any period of time prior to the Policy Effective Date You were Actively at Work for Your Employer will count towards completion of the Waiting Period. 00093 We, Ottr and Us mean the Dearborn National Life Insurance Company, Chicago, Illinois. 00094 You, Your and Yours means the employee to whom this certificate is issued and whose insurance is in force under the terms of the Policy. 00095 2-LTDC- 705 46 Administrative Office:1020 31" Street Downers Grove, Illinois 60515 DEARBORN NATIONAL® LIFE INSURANCE COMPANY Chicago, Illinois RIDER This Rider is made a part of the Policy or Certificate (hereafter "the Policy") to which it is attached. It takes effect and ends at the same time as the Policy. All provisions of the Policy, including any other Riders or Amendatory Endorsements will apply to this Rider, except that in the event of a conflict, the specific provisions of this Rider will govern. Disability Resource Services f1khat is Disability Resource Services? Disability Resource Services is a noninsurance benefit made available to You which provides access at no additional cost to the following services: • Access to Guidance Resources" Online, a secure, password -protected interactive website that contains self -assessments, search tools, extensive content on personal health, relational, legal, health and financial concerns for You. • Access to unlimited telephonic counseling service. This service provides access to experts to provide You with assessment, counseling and referral advice. • Up to three face-to-face counseling sessions. Ho►v Do You Access Disability Resource Services? Guidance Resources is accessed online. Your employer will provide You with a password to use on the website. The website URL is www.GuidanceResources.com. Telephonic and face to face counseling is available if you qualify as stated above. To contact a counselor, please call 1-866-899-1363. Guidance Resources and telephonic counseling is provided by ComPsychr'' Corporation. We do not underwrite or administer this program. Mien do Disability Resource Services Terminate? • Disability Resource Services terminate if Your coverage is terminated under the section on Mien does Your coverage under- the Policy end? located in the Termination Provision of the contract; or, • When you are no longer qualify for Total Disability or Partial Disability benefits under the Policy. President Nothing contained in this Rider shall be held to alter or affect any provision or condition of the Policy other th�as stated above. FDL2-NIB-DRS (5 2012) NOTICE to the Policyholder and Certificate bolder Insured under the Group Long Term Disability Insurance Policy Provided by Dearborn National Life Insurance Company Regarding the Disability Resource Services Noninsurance Benefit This notice is to advise you that Your Group Disability Insurance program also provides a non - insurance benefit: Disability Resource Semites. Noninsurance Benefit Description and How the Benefit May Be Obtained Disability Resource Services is a noninsurance benefit that provides you with a link to Guidance Resources" Online, a secure, password -protected interactive website that contains self -assessments, search tools, and extensive content on personal health, relational, legal, health and financial concerns for insured persons and their family. In addition You have access to telephonic counseling by calling 1-866-899-1363, and up to three face-to- face counseling sessions. This noninsurance benefit is available at the option of the Policyholder without any action required on the part of an insured person to either accept or decline the service. There is no charge for this noninsurance benefit. The service is currently administered and provided by ComPsych') Corporation. Dearborn National Life Insurance Company (sometimes referred to as "We" or "Our") makes this program available, but it does not underwrite or administer the Disability Resource Services program. Why This Service is Being Made Available We are making this service available to provide support and assistance to insureds who have suffered a loss that is covered by the group disability insurance policy. Living with a disability can be difficult, and this program provides counseling, and assistance with locating services to support the insured and their family members. Termination of the Noninsurance Benefit This noninsurance benefit is provided free of charge It is subject to tennination at our option or at the option of the program administrator. If We discontinue this service We will notify the Policyholder not less than thirty (30) days in advance of the discontinuance of this service. If the current program administrator discontinues the program and we are unable to find a replacement, we will notify the Policyholder as soon as is reasonable under the circumstances. If discontinued, the services available under this noninsurance benefit will no longer be available. Unless tenninated by Us or by the Program administrator, the Disability Resource Services noninsurance benefit is available following a covered loss for as long as you remain covered under the group disability insurance policy and such policy remains in effect. NIB-DRS-Notice (5/2012) ERISA INFORMATION STATEMENT* The benefits described in your certificate are insured by a Policy issued by Dearborn National Life Insurance Company ("Dearborn National"), pursuant to an Employee Welfare Benefit Plan (" the Plan") established by your employer ("the Company"). This ERISA Information Statement ("EIS") describes some of the key provisions of the Plan in effect as of the Effective Date of the Policy. It is not the intention of the EIS to cover all situations that may arise, but to provide you with a general understanding of your benefits. In the case of any item not covered by the EIS or in the event of any conflict between the EIS and the Policy, the Plan will always control. You should not rely on any oral explanation, description, or interpretation of the Plan because the written terms of the Plan will govern. Your right to any benefit depends on the actual facts and terms and conditions of the particular Plan; no rights accrue by reason of or arising out of any statement shown in or omitted from this EIS. A. ADMINISTRATION OF THE PLAN The Plan Administrator is responsible for the administration of the Plan. The Plan Administrator has full discretionary authority and control over the Plan. This authority provides the Plan Administrator with the power necessary to operate, manage and administer the Plan. This authority includes, but is not limited to, the power to interpret the Plan and determine who is eligible to participate, to determine the amount of benefits that may be paid to a participant or his or her beneficiary, and the status and rights of participants and beneficiaries. The Plan Administrator also has the authority to prescribe the rules and procedures under which the Plan shall operate, to request information, and to employ or appoint persons to aid the Plan Administrator in the administration of the Plan. Failure by the Plan or the Plan Administrator to insist upon compliance with any provisions of the Plan at any time or under any set of circumstances shall not operate to waive or modify the provision or in any manner render it unenforceable as to any other time or as to any other occurrence, whether the circumstances are or are not the same. No waiver of any term or condition of the Plan shall be valid unless contained in a written memorandum expressing the waiver and signed by the person authorized by the Plan Administrator to sign the waiver. The Plan may be amended, terminated or suspended in whole or in part, at any time without the consent of the employees or beneficiaries. Any amendment, termination or suspension shall be in writing, and attached to the Plan. Any amendment, termination or suspension shall be executed according to the Employer's authorized procedures. Any such authorization may be specific to the Plan or persons authorized to act on behalf of the Employer or may be general as to duties of such person. Except for termination or suspensions, any amendments affecting the Policy and/or Certificate must also be approved in writing by an officer of Dearborn National and shall be effective as of the date agreed to, in writing by the Plan Sponsor and Dearborn National. Notwithstanding anything to the contrary in this document, the Policy shall terminate according to the provisions in the Policy. The Plan has other fiduciaries, advisors and service providers. The Plan Administrator may allocate fiduciary responsibility among the Plan's fiduciaries and may delegate responsibilities to others. Any allocation or delegation must be done in writing and kept with the records of the Plan. The Plan's life benefits are provided pursuant to an insurance policy issued to the Company. Dearborn National's (the Insurer's) services shall be limited to, and the Plan Administrator has the full discretionary and final authority to: resolve all matters when a review pursuant to the claims procedures has been requested; interpret, establish and enforce rules and procedures for the administration of the Policy and any claim under it; and determine eligibility of Employees and Dependents for benefits and their entitlement to and the amount of benefits. Each fiduciary is solely responsible for its own improper acts or omissions. Except to the extent required by ERISA, no fiduciary has the duty to question whether any other fiduciary is fulfilling all of the responsibilities imposed upon the other fiduciary by law. Nor is a fiduciary liable for a breach of fiduciary duty committed before it became, or after it stopped being, a fiduciary. However, a fiduciary may be liable for a breach of fiduciary responsibility of any Plan fiduciary, to the extent provided in ERISA Section 405(a). The Employer makes no promise to continue these * If this Plan is an ERISA plan, these ERISA provisions apply. However, your employer may issue a Summary Plan Description ("SPD"). If it does, and if there are any conflicts between the SPD and the EIS in regards to your ERISA rights, the SPD provisions will always control. FDL EIS Standard 4 2009 rev'd. C. submit written comments, documents, records and other information relating to your claim, without regard to whether such information was submitted or considered in the initial benefit determination. Dearborn National will make a decision no more than 45 days after we receive your appeal. The time for decision may be extended for one additional 45 day period provided that, prior to the extension, Dearborn National notifies you in writing that an extension is necessary due to special circumstances, identifies those circumstances and gives the date by which it expects to render its decision. If your claim is extended due to your failure to submit information necessary to decide your claim on appeal, the time for your decision shall be tolled from the date on which the notification of the extension is sent to you until the date we receive your response to the request. The written decision will include specific references to the Plan provisions on which the decision is based and any other notice(s), statement(s) or information required by applicable law. 2. Life Insurance Plans Dearborn National will give you a decision no more than 90 days after receipt of due proof of loss, except in special circumstances (such as the need to obtain further information), but in no case more than 180 days after the due proof of loss is received. The written decision will include specific reasons for the decision and specific references to the Plan provisions on which the decision is based. If the claim is denied, in whole or in part, the claimant will receive a written notice giving the following: - the reason for the denial; - the Policy provisions on which the denial is based; - an explanation of what other information, if any, may be needed to process the claim and why it is needed; and - the steps that have to be followed to have the claim reviewed. Any denied claim may be appealed to the Insurer for a full and fair review. The claimant may: a) request a review upon written application within 60 days of receipt of claim denial; b) upon request and free of charge, review pertinent documents, records and other information relevant to the claim and receive copies of same; and c) submit issues, comments, records, and other information in writing. A decision will be made by the Insurer no more than 60 days after receipt of the request for review, except in special circumstances (such as the need to obtain additional evidence), but in no case more than 120 days after the request for review is received. The written decision will include specific reasons for the decision and specific references to the Plan provisions on which the decision is based. The decision will advise you of any other appeal rights you have under the Plan, as well as your right to bring an action under Section 502(a) of ERISA. C. ERISA NOTICE OF YOUR RIGHTS As a participant in the Plan you are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974 ("ERISA"). ERISA provides that all Plan participants shall be entitled to: Examine, without charge, at the Plan Administrator's office and at other locations, such as work sites and union halls, all Plan documents, including insurance contracts, collective bargaining agreements and copies of all documents filed with the U.S. Department of Labor, such as detailed annual reports and Plan descriptions. Obtain copies of all Plan documents and other Plan information upon written request to the Plan Administrator. The Plan Administrator may make a reasonable charge for the copies. Receive a summary of the Plan's annual financial report. The Plan Administrator is required to furnish each participant with a copy of this summary annual report. In addition to creating rights for the Plan participants, ERISA imposes duties upon the people who are responsible for the operation of the employee benefit Plan. The people who operate your Plan, called "fiduciaries" of the Plan, have a duty to do so prudently and in the interest of you and other Plan participants and beneficiaries. No one, including your employers, your union, or any other persons, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a welfare benefit or exercising your rights under ERISA. If your claim for a welfare benefit is denied in whole or in part you must receive a written explanation of the reason for the * If this Plan is an ERISA plan, these ERISA provisions apply. However, your employer may issue a Summary Plan Description ("SPD"). If it does, and if there are any conflicts between the SPD and the EIS in regards to your ERISA rights, the SPD provisions will always control. FDL EIS Standard 4 2009 rev'd. benefits in the future and rights to future benefits will never vest. Retirement does not give any retiree any vested right to continue to participate or receive Plan benefits. B. CLAIMS PROCEDURE: When you or your Beneficiary are eligible to receive benefits, you or your Beneficiary, or your authorized representative (collectively, "you") must notify the Plan Administrator by submitting the proper form in writing. You may do this by sending notice of your claim to the Plan Administrator who has been appointed to assist Dearborn National in the claims processing for this Plan or by contacting Dearborn National directly at: Claims Department Dearborn National Life Insurance Company 1020 31 st Street Downers Grove, IL. 60515-5591 1-800-348-4512 For the purpose of this Section, including Subsections 1 and 2 below, the terms "written" and "in writing" include "electronic." Any action required to be "written" or "in writing," may be done electronically, where available. If Dearborn National uses electronic notices, it will do so in accordance with 29 CFR 2520.104b- 1C(i), (iii) and (iv). 1. Disability Insurance Plans Dearborn National will give you a written response to your claim, usually within 45 days. The time for decision may be extended for two additional 30 day periods provided that, prior to any extension period, Dearborn National notifies you in writing that an extension is necessary due to matters beyond the control of the Plan, identifies those matters and gives the date by which it expects to render its decision. If the extension is due to your failure to submit information necessary to decide your claim, the time for decision shall be tolled from the date on which we send you notice of the extension until the date we receive your response to our request. This period will be no longer than 45 days after we have requested the information. At that time we will decide your claim based on the information we have at that time. If the claim is denied, in whole or in part, you will receive a written notice giving the following: - the reason for the denial; - the Policy provisions on which the denial is based; - an explanation of what other information, if any, may be needed to process the claim and why it is needed; - the steps that you have to follow to have the claim reviewed; - a statement that you have the right to bring a civil action under section 502(a) of ERISA after you appeal - our decision and after you receive a written denial on appeal; and - if an internal rule, guideline, protocol, or other similar criterion was relied upon in making the denial, either (i) the specific rule, guideline, protocol or other similar criterion; or (ii) a statement that such a rule, guideline, protocol or other similar criterion was relied upon in making the denial and that a copy will be provided free of charge to you upon request; and if denial is based on medical judgment, either (i) an explanation of the scientific or clinical judgment for the determination, applying the terms of the Plan to your medical circumstances, or (ii) a statement that such explanation will be provided to you free of charge upon request. If the claim has been denied, in whole or in part, you can appeal the denial to us for a full and fair review. You have at least 180 days to appeal from the claim denial. You may: a. request a review upon written application within 180 days of the claim denial; b. request, free of charge, copies of all documents, records and other information relevant to your claim; and * If this Plan is an ERISA plan, these ERISA provisions apply. However, your employer may issue a Summary Plan Description ("SPD"). If it does, and if there are any conflicts between the SPD and the EIS in regards to your ERISA rights, the SPD provisions will always control. FDL EIS Standard 4 2009 rev'd. denial. You have the right to have the Plan review and reconsider your claim. Under ERISA, there are steps you can take to enforce your rights. For instance, if you request materials from the plan and do not receive them within 30 days, you may file a suit in federal court. In such a case, the court may require the Plan Administrator to provide the materials and pay you up to $I 10 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the Plan Administrator. If you have a claim for benefits which is denied or ignored, in whole or in part, you may file suit in a state or federal court. If it should happen that Plan fiduciaries misuse the Plan's money, or if you are discriminated against for asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in federal court. The court will decide who should pay costs and legal fees. If you are successful the court may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees, for example, if it finds your claim is frivolous. If you have any questions about this statement or about your rights under ERISA, you should contact the nearest office of the Pension and Welfare Benefits Administration, United States Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries, Employee Benefit Security Administration, United States Department of Labor, 200 Constitution Avenue, NW Washington DC 20210. D. PARTICIPANT'S RIGHTS This Plan shall not be deemed to constitute a contract between the Company and any participant or to be consideration or an inducement for the employment of any participant or employee. Nothing contained in this Plan shall be deemed to give any participant or employee the right to be retained in the service of the Company or to interfere with the right of the Company to discharge any participant or employee at any time regardless of the effect which such discharge shall have upon him or her as a participant of this Plan. * 1 f this Plan is an ERISA plan, these ERISA provisions apply. However, your employer may issue a Summary Plan Description ("SPD"). If it does, and if there are any conflicts between the SPD and the EIS in regards to your ERISA rights, the SPD provisions will always control. FDL EIS Standard 4 2009 redd. Dearborn W National@' Administrative Office: 1020 31st Street • Downers Grove, IL 60515-5591 Products and services marketed under the Dearborn National"` brand and the star logo are underwritten and/or provided by Dearborn National '�Life Insurance Company (Downers Grove, IL) in all states (excluding New York), the District of Columbia, the United States Virgin Islands, the British Virgin Islands, Guam and Puerto Rico. ACORN® CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 07/08/2014 �. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME` MARSH USA INC. PHONE FAX 540 W MADISON lg(C• No,RAI( C, No): E-MAIL ADDRESS: CHICAGO, IL 60661 Attn: Healthcare.AccountsCSS@marsh com/FAX 212-948.1307 INSURERS AFFORDING COVERAGE NAIC If INSURER A: Travelers Casualty And Surety Company Of America 31194 J05515-PL-PL-14-15 INSURED HEALTH CARE SERVICE CORP. INSURER B : INSURER C : AND ITS SUBSIDIARIES INSURER D : 300 EAST RANDOLPH STREET CHICAGO, IL 60601-5655 INSURER E: INSURER F : COVERAGES CERTIFICATE NUMBER: CHI-00496331E-01 REVISION NUMBER:1 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPE OF INSURANCE ADDL SUER WVD POLICY NUMBER POLICY EFF MMIDD/YYYY POLICY EXP MM/DD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAG ( RENTED PREMISESS Ea occurrence) S CLAIMS -MADE F OCCUR MED EXP (Any one person) $ PERSONAL & ADV INJURY 5 GENERAL AGGREGATE S GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS -COMP/OP AGG S POLICY PRO- n LOC _ SJECT v AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) S ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) S Pe aPER cidentDAMAGE $ NON -OWNED HIREDAUTOS AUTOS $ UMBRELLA LIAB I OCCUR EACH OCCURRENCE S AGGREGATE S EXCESS LIAB CLAIMS -MADE DIED I I RETENTION $ $ WORKERS COMPENSATION WC STATU- OTH- EEL AND EMPLOYERS' LIABILITY Y / N E L EACH ACCIDENT $ ANY PROPRIETOR,PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? ❑ NIA E L DISEASE - EA EMPLOYE 5 (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E L DISEASE -POLICY LIMIT 1 5 A PROFESSIONAL LIABILITY/E&O 103996357 01/01/2014 01101120117LIMIT OF LIAB LITY $5,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required) RE RFP 14.11580-DT 1..CR I Irlt A 1 C. 1`1ULUCK L ANt r_LLA I IUN CITY OF LUBBOCK 162513TH STREET LUBBOCK, TX 79401 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjee —3VtoL1'-01e>" @ 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD ACOR" CERTIFICATE OF LIABILITY INSURANCE DATE (MM1DD/YYYY) 07I08I2014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: MARSH USA INC PHCNE 540 W. MADISON A/C No): E-MAIL ADDRESS: CHICAGO, IL 60661 Attn: Healthcare AccounlsCSS@marsh com/FAX: 212-948-1307 INSURERS AFFORDING COVERAGE NAIC # INSURER A : Zurich American Insurance Company 16535 J05515-ALL-GAXW-13.14 INSURED HEALTH CARE SERVICE CORPORATION INSURER B NIA N/A INSURER C : American Zurich Insurance Company 40142 AND ITS SUBSIDIARIES INSURER D : 300 EAST RANDOLPH STREET CHICAGO, IL 60601 INSURER E INSURER F : COVERAGES CERTIFICATE NUMBER: CHI-004963315-01 REVISION NUMBER: I THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT 1MTH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INS LTRPOLICY TYPE OF INSURANCE ADDL SUBR NUMBER POLICY EFF MMIDDIYYYY POLICY EXP MMIDDIYYYY LIMITS A GENERAL LIABILITY GLO 937712710 (AOS) 11101/2013 11/01/2014 EACH OCCURRENCE $ 2,000,000 X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE F OCCUR DAMAGE TO NTED PREMISES Ea occurrence S 1,000,000 MED EXP (Any one person) S 10,000 PERSONAL & ADV INJURY $ 2,000,000 GENERAL AGGREGATE S 2,000,000 GEML AGGREGATE LIMIT AP�PL�IES PER PRODUCTS - COMP/OP AGG 5 2,000,000 X POLICY � JECTPRO- I I LOC s A AUTOMOBILE LIABILITY BAP 9377126 10 11/01/2013 11/01/2014 (CEO, acMBINED INGLE LIMITcident $ 1.000,000 X BODILY INJURY (Per person) S ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS AUTO PHYSICAL DAMAGE BODILY INJURY (Per accident) S PROPERTY DAMAGE Per accident S NON -OWNED HIRED AUTOS AUTOS $1,000 COMP/$1,000 COLL S UMBRELLA LIAB OCCUR EACH OCCURRENCE S AGGREGATE S EXCESS LIAB CLAIMS -MADE DED I I RETENTIONS S C WORKERS COMPENSATION WC 937712810 (AOS) 11/01/2013 11/01/2014 X wC STATU- OTH- A AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORIPARTNERIEXECUTIVE OFFICERIMEMBER EXCLUDED? (Mandatory In NH) N / A WC 937712910 (RETRO) 11101I2013 11I0112014 E.L. EACH ACCIDENT 1,000,000 S E.L. DISEASE - EA EMPLOYE $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space Is required) RE RFP RFP 14-11580-DT CITY OF LUBBOCK AND ITS OFFICERS, EMPLOYEES, AND ELECTED REPRESENTATIVES AS ADDITIONAL INSURED, AS TO COMMERCIAL GENERAL LIABILITY INSURANCE WHEN REQUIRED BY WRITTEN AGREEMENT. WAIVER OF SUBROGATION WHEN REQUIRED BY WRITTEN AGREEMENT. CERTIFICATE HOLDER CANCELLATION CITY OF LUBBOCK SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 162513TH STREET THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN LUBBOCK, TX 79401 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. ManashiMukherjee �trauoca� @ 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD 0 Additional Insured - Automatic - Owners, Lessees Or ZURICHO Contractors Policy No. Eff. Date of Pol. Exp. Date of Pol. Eff. Date of End. Producer No. AddT Prem Return Prem. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. Named Insured: HEALTH CARE SERVICE C RPORATION Address (including ZIP Code): =00 E. RANDOLPH ST. FLOOR 14,CHICAGO, IL 60601-5099 This endorsement modifies insurance provided under the: Commercial General Liability Coverage Part A. Section II —Who Is An Insured is amended to include as an insured any person or organization who you are required to add as an additional insured on this policy under a written contract or written agreement. However, if you have entered into a construction contract or construction agreement with an additional insured person or organization, the insurance afforded to such additional insured only applies to the extent permitted by law. B. The insurance provided to the additional insured person or organization applies only to "bodily injury", "property damage" or "personal and advertising injury" covered under Section I — Coverage A — Bodily Injury And Property Damage Liability and Section I — Coverage B — Personal And Advertising Injury liability, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf, and resulting directly from your ongoing operations or 'Your work" as included in the "products -completed operations hazard", which is the subject of the written contract or written agreement. C. However, regardless of the provisions of Paragraphs A. and B. above: 1. We will not extend any insurance coverage to any additional insured person or organization: a. That is not provided to you in this policy; or b. That is any broader coverage than you are required to provide to the additional insured person or organization in the written contract or written agreement; and 2. We will not provide Limits of Insurance to any additional insured person or organization that exceed the lower of: a. The Limits of Insurance provided to you in this policy; or b. The Limits of Insurance you are required to provide in the written contract or written agreement. D. The insurance provided to the additional insured person or organization does not apply to: "Bodily injury", "property damage" or "personal and advertising injury" arising out of the rendering or failure to render any professional architectural, engineering or surveying services including: 1. The preparing, approving or failing to prepare or approve maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifications; and 2. Supervisory, inspection, architectural or engineering activities. U-GL-1175-E CW (04/ 12) Page 1 of 2 Includes copyrighted material of Insurance Services Office, Inc., with its permission. E. The following is added to Paragraph 2. Duties In The Event Of Occurrence, Offense, Claim Or Suit of Section IV — Commercial General Liability Conditions: The additional insured must see to it that: 1. We are notified as soon as practicable of an 'occurrence" or offense that may result in a claim; 2. We receive written notice of a claim or "suit' as soon as practicable; and 3. A request for defense and indemnity of the claim or "suit' will promptly be brought against any policy issued by another insurer under which the additional insured may be an insured in any capacity. This provision does not apply to insurance on which the additional insured is a Named Insured, if the written contract or written agreement requires that this coverage be primary and non-contributory. F. For the coverage provided by this endorsement: 1. The following paragraph is added to Paragraph 4.a. of the Other Insurance Condition of Section W—Commercial General Liability Conditions: This insurance is primary insurance as respects our coverage to the additional insured person or organization, where the written contract or written agreement requires that this insurance be primary and non-contributory with respect to any other policy upon which the additional insured is a Named Insured. In that event, we will not seek contribution from any other such insurance policy available to the additional insured on which the additional insured person or organization is a Named Insured. 2. The following paragraph is added to Paragraph 4.b. of the Other Insurance Condition of Section IV —Commercial General Liability Conditions: This insurance is excess over: Any of the other insurance, whether primary, excess, contingent or on any other basis, available to an additional insured, in which the additional insured on our policy is also covered as an additional insured on another policy providing coverage for the same 'occurrence", offense, claim or "suit'. This provision does not apply to any policy in which the additional insured is a Named Insured on such other policy and where our policy is required by written contract or written agreement to provide coverage to the additional insured on a primary and non- contributory basis. G. This endorsement does not apply to an additional insured which has been added to this policy by an endorsement showing the additional insured in a Schedule of additional insureds, and which endorsement applies specifically to that identified additional insured. All other terms and conditions of this policy remain unchanged. U-GL-1175-E CW (04/ 12) Page 2 of 2 Includes copyrighted material of Insurance Services Office, Inc., with its permission. TYPE 1. Worker's Compensation and Employers Liability City of Lubbock, TX RFP 14-11842-DT Ancillary Benefits Insurance Requirement AMOUNT Statutory $500,000 EXHIBIT D 2. Commercial General (public) Liability insurance including coverage for the following: a. Premises operations Combined single limit for b. Products/completed operations bodily injury and property c. Personal injury damage of $500,000 per d. Advertising injury occurrence or its equivalent. e. Contractual liability 3. Errors and Omissions 4. Comprehensive Automobile Liability a. Any auto $1,000,000 Combined single limit for bodily injury and property damage of $300,000 per occurrence or its equivalent The City shall be entitled, upon request, and without expense, to receive copies of the policies and all endorsements thereto and may make any reasonable request for deletion, revision, or modification of particular policy terms, conditions, limitations, or exclusions (except where policy provisions are established by law or regulation binding upon either of the parties hereto or the underwriter of any of such policies). Upon such request by the City, the Carrier/Provider shall exercise reasonable efforts to accomplish such changes in policy coverages, and shall pay the cost thereof. The Carrier/Provider agrees that with respect to the above required insurance, insurance contracts and certificate(s) of insurance will contain and state, in writing, on the certificate or its attachment, the following required provisions: a. Name the City of Lubbock and its officers, employees, and elected representatives as additional insured, (as the interest of each insured may appear) as to commercial general liability insurance; b. Provide for 30 days notice to the City for cancellation, nonrenewal, or material change (except in the instance of non-payment); c. Provide for notice to the City at the address shown below by registered mail; d. The Carrier/Provider agrees to waive subrogation against the City of Lubbock, its officers, employees, and elected representatives for injuries, including death, property damage, or any other loss to the extent same may be covered by the proceeds of insurance; e. Provide that all provisions of this contract concerning liability, duty, and standard of care together with the indemnification provision, shall be underwritten by contractual liability coverage sufficient to include such obligations within applicable policies. f. All copies of the Certificates of Insurance shall reference the project name or bid number for which the insurance is being supplied. The Carrier/Provider shall notify the City in the event of any change in coverage and shall give such notices not less than 30 days prior the change, which notice must be accompanied by a replacement CERTIFICATE OF INSURANCE. All notices shall be given to the City at the following address: Marta Alvarez — Director of Purchasing and Contract Management City of Lubbock 1625 13th Street Lubbock, Texas 79401 Approval, disapproval, or failure to act by the City regarding any insurance supplied by the Carrier/Provider shall not relieve the Carrier/Provider of hill responsibility or liability for damages and accidents as set forth in the contract documents. Neither shall the bankruptcy, insolvency, or denial of liability by the insurance Carrier/Provider exonerate the Carrier/Provider from liability. POLICY NUMBER:GLO 9377127-10 COMMERCIAL GENERAL LIABILITY CG 20 26 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Persons Or Or anization s WHERE REQUIRED BY WRITTEN CONTRACT PRIOR TO LOSS Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Section II — Who Is An Insured is amended to include as an additional insured the person(s) or organiza- tion(s) shown in the Schedule, but only with respect to liability for "bodily injury", 'property damage" or "personal and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or omis- sions of those acting on your behalf: A. In the performance of your ongoing operations; or B. In connection with your premises owned by or rented to you. CG 20 26 07 04 © ISO Properties, Inc., 2004 Page 1 of 1 0 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 13 (Ed. 4-84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule. Schedule ALL PERSONS OR ORGANIZATIONS. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective Policy No. Endorsement No. Insured Insurance Company WC 00 03 13 (Ed. 4-84) Countersigned By Premium $ Copyright 1983 National Council on Compensation Insurance