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Resolution - 2022-R0414 - Contract 16869 with Davis Vision 10.11.22
Resolution No. 2022-RO414 Item No. 6.7 October 11, 2022 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, Contract No. 16869 for a voluntary vision plan for full-time employees per RFP 22-16694-TF, by and between the City of Lubbock and Davis Vision, in substantially the same form as the exemplar attached hereto as Exhibit "A", and related documents. Said Contract is attached hereto and incorporated in this resolution as if fully set forth herein and shall be included in the minutes of the City Council. Passed by the City Council on October 11, 2022 TRAY PANE, MAYOR ATTEST: '0' &"' zlX------ Rebec a Garza, City Secre Ali APPRO ED O CONTENT: Clifton Beck, Director of Human Resources APPROVED ASS FORM: City Attorney ccdocs/RES.Contract-Davis Vision September 21, 2022 Resolution No. 2022-RO414 l)i MetLife Metropolitan Life Insurance Company 200 Park Avenue, New York, New York 10166 CERTIFICATE OF INSURANCE Metropolitan Life Insurance Company ("MetLife"), a stock company, certifies that You and Your Dependents are insured for the benefits described in this certificate, subject to the provisions of this certificate. This certificate is issued to You under the Group Policy and it includes the terms and provisions of the Group Policy that describe Your insurance. PLEASE READ THIS CERTIFICATE CAREFULLY. This certificate is part of the Group Policy. The Group Policy is a legal contract between MetLife and the Policyholder and may be changed or ended without Your consent or notice to You. Policyholder: CUSTOMER NAME Group Policy Number: VHXXXXXX-B-1-G. Type of Insurance: Vision Insurance MetLffe Toll Free Number(s): For Claim Information FOR VISION CLAIMS: 1-833-EYE-LIFE (1-833-393-5433) THIS CERTIFICATE ONLY DESCRIBES VISION INSURANCE. FOR CALIFORNIA RESIDENTS: REVIEW THIS CERTIFICATE CAREFULLY. IF YOU ARE 65 OR OLDER ON YOUR EFFECTIVE DATE OF THIS CERTIFICATE, YOU MAY RETURN IT TO US WITHIN 30 DAYS FROM THE DATE YOU RECEIVE IT AND WE WILL REFUND ANY PREMIUM YOU PAID. IN THIS CASE, THIS CERTIFICATE WILL BE CONSIDERED TO NEVER HAVE BEEN ISSUED. • •WO I IN-.• For Idaho Residents: TEN DAY RIGHT TO EXAMINE CERTIFICATE: You may return the certificate to Us within 10 days from the date You receive it. If You return it within the 10 day period, the certificate will be considered never to have been issued. We will refund any premium paid after We receive Your notice of cancellation. THIS CERTIFICATE IS SUBJECT TO THE LAWS OF NEW JERSEY. THE GROUP INSURANCE POLICY PROVIDING COVERAGE UNDER THIS CERTIFICATE WAS ISSUED IN A JURISDICTION OTHER THAN MARYLAND AND MAY NOT PROVIDE ALL THE BENEFITS REQUIRED BY MARYLAND LAW. For Residents of North Dakota: If You are not satisfied with Your Certificate, You may return it to Us within 20 days after You receive it, unless a claim has previously been received by Us under Your Certificate. We will refund within 30 days of Our receipt of the returned Certificate any Premium that has been paid and the Certificate will then be considered to have never been issued. You should be aware that, if You elect to return the Certificate for a refund of premiums, losses which otherwise would have been covered under Your Certificate will not be covered. GCERT2000 SAMPLE as amended by GEND16-NM-DSC EXHIBIT A Commented [KE2):...st%Jn:ize to remove the "-G" Commented [WA3R2]: Removed -G and added -, For New Mexico Residents: This type of plan is NOT considered "minimum essential coverage" under the Affordable Care Act and therefore does NOT satisfy the individual mandate that You have health insurance coverage. If You do not have other health insurance coverage, You may be subject to a federal tax penalty. For New Hampshire Residents: 30 Day Right to Examine Certificate. Please read this Certificate. You may return the Certificate to Us within 30 days from the date You receive it. If you return it within the 30 day period, the Certificate will be considered never to have been issued and We will refund any premium paid for insurance under this Certificate. WE ARE REQUIRED BY STATE LAW TO INCLUDE THE NOTICE(S) WHICH APPEAR ON THIS PAGE AND IN THE NOTICE(S) SECTION WHICH FOLLOWS THIS PAGE. PLEASE READ THE(SE) NOTICE(S) CAREFULLY. GCERT2000 SAMPLE as amended by GEND16-NM-DSC NOTICE FOR RESIDENTS OF TEXAS Have a complaint or need help? If you have a problem with a claim or your premium, call your insurance company or HMO first. If you can't work out the issue, the Texas Department of Insurance may be able to help. Even if you file a complaint with the Texas Department of Insurance, you should also file a complaint or appeal through your insurance company or HMO. If you don't, you may lose your right to appeal. Metropolitan Life Insurance Company To get information or file a complaint with your insurance company or HMO: Call: Corporate Consumer Relations Department at 1-800-438-6388 Toll -free: 1-800-438-6388 Email: RTQA@versanthealth.com Mail: Davis Vision Attention: Complaints and Appeals P.O. Box 791 Latham, NY 12110 The Texas Department of Insurance To get help with an insurance question or file a complaint with the state: Call with a question: 1-800-252-3439 File a complaint: www.tdi.texas.gov Email: ConsumerProtection@tdi.texas.gov Mail: MC 111-1A, P.O. Box 149091, Austin, TX 78714-9091 LTiene una queja o necesita ayuda? Si tiene un problema con una reclamaci6n o con su prima de seguro, (lame primero a su compania de seguros o HMO. Si no puede resolver el problema, es posible que el Departamento de Seguros de Texas (Texas Department of Insurance, por su nombre en ingl6s) pueda ayudar. Aun si usted presenta una queja ante el Departamento de Seguros de Texas, tambi6n debe presentar una queja a trav6s del proceso de quejas o de apelaciones de su compania de seguros o HMO. Si no to hace, podria perder su derecho para apelar. Metropolitan Life Insurance Company Para obtener informacion o para presentar una queja ante su compania de seguros o HMO: Llame a: Departamento de Relaciones Corporativas del Consumidor al 1-800-438-6388 GCERT-TX-NOTICE 2020 Teldifono gratuito: 1-800438-6388 Correo electr6nico: RTQA@versanthealth.com Direcci6n postal: Davis Vision Attention: Complaints and Appeals P.O. Box 791 Latham, NY 12110 El Departamento de Seguros de Texas Para obtener ayuda con una pregunta relacionada con los seguros o para presenter una queja ante el estado: Llame con sus preguntas al: 1-800-252-3439 Presente una queja en: www.tdi.texas.gov Correo electr6nico: ConsumerProtection@tdi.texas.gov Direcci6n postal: MC 111-1A, P.O. Box 149091, Austin, TX 78714-9091 GCERT-TX-NOTICE 2020 NOTICE FOR RESIDENTS OF ALASKA, LOUISIANA, MINNESOTA, MONTANA, NEW HAMPSHIRE, NEW MEXICO, TEXAS, UTAH AND WASHINGTON The Definition Of Child Is Modified For The Coverages Listed Below: For Alaska Residents (Vision Insurance): The term also includes newborns. For Louisiana Residents (Vision Insurance): The term also includes Your grandchildren residing with You. The age limit for children and grandchildren will not be less than 21, regardless of the child's or grandchild's student status or full-time employment status. In addition, the age limit for students will not be less than 24. Your natural child, adopted child, stepchild or grandchild under age 21 will not need to be supported by You to qualify as a Child under this insurance. For Minnesota Residents (Vision Insurance): The term also includes: • Your grandchildren who are financially dependent upon You and reside with You continuously from birth; • children for whom You or Your Spouse is the legally appointed guardian; and • children for whom You have initiated an application for adoption. The age limit for children and grandchildren will not be less than 25 regardless of the child's or grandchild's student status or full-time employment status. Your natural child, adopted child stepchild or children for whom You or Your Spouse is the legally appointed guardian under age 25 will not need to be supported by You to qualify as a Child under this insurance. For Montana Residents (Vision Insurance): The term also includes newborn infants of any person insured under this certificate. The age limit for children will not be less than 25, regardless of the child's student status or full-time employment status. Your natural child, adopted child or stepchild under age 25 will not need to be supported by You to qualify as a child under this insurance. For New Hampshire Residents (Vision Insurance): The age limit for children will not be less than 26, regardless of the child's marital status, student status or full- time employment status. Your natural child, adopted child or stepchild under age 26 will not need to be supported by You to qualify as a Child under this insurance. For New Mexico Residents (Vision Insurance): The age limit for children will not be less than 25, regardless of the child's student status or full-time employment status. Your natural child, adopted child or stepchild will not be denied vision insurance coverage under this certificate because: • that child was born out of wedlock; • that child is not claimed as Your dependent on Your federal income tax return; or • that child does not reside with You. For Texas Residents (Vision Insurance): The term also includes Your grandchildren. The age limit for children and grandchildren will not be less than 25, regardless of the child's or grandchild's student status, full-time employment status or military service status. Your natural child, adopted child or stepchild under age 25 will not need to be supported by You to qualify as a Child under this insurance. In addition, grandchildren must be able to be claimed by You as a dependent for Federal Income Tax purposes at the time You applied for Insurance. GCERT2000 notice/childdef NOTICE FOR RESIDENTS OF ALASKA, LOUISIANA, MINNESOTA, MONTANA, NEW HAMPSHIRE, NEW MEXICO, TEXAS, UTAH AND WASHINGTON (continued) For Utah Residents (Vision Insurance): The age limit for children will not be less than 26 regardless of the child's student status or full-time employment status. Your natural child, adopted child or stepchild under age 26 will not need to be supported by You to qualify as a Child under this insurance. The term includes an unmarried child who is incapable of self-sustaining employment because of a mental or physical handicap as defined by applicable law and who has been continuously covered under a Vision plan since reaching age 26, with no break in coverage of more than 63 days, and who otherwise qualifies as a Child except for the age limit. Proof of such handicap must be sent to Us within 31 days after: • the date the Child attains the limiting age in order to continue coverage; or • You enroll a Child to be covered under this provision; and at reasonable intervals after such date, but no more often than annually after the two-year period immediately following the date the Child qualifies for coverage under this provision. For Washington Residents (Vision Insurance): The age limit for children will not be less than 26. regardless of the child's marital status, student status, or full-time employment status. Your natural child, adopted child or stepchild under age 26 will not need to be supported by You to qualify as a Child under this insurance. GCERT2000 notice/childdef 6 NOTICE FOR RESIDENTS OF ALL STATES WHO ARE INSURED FOR VISION INSURANCE Notice Regarding Your Rights and Responsibilities Rights: • We will treat communications, financial records and records pertaining to Your care in accordance with all applicable laws relating to privacy. • Decisions with respect to vision treatment are the responsibility of You and the Vision Provider. We neither require nor prohibit any specified treatment. However, only certain specified services are covered for benefits. Please see the Vision Insurance sections of this certificate for more details. • You may request a written response from Metl-ife to any written concern or complaint. Responsibilities: • You are responsible for the prompt payment of any charges for services performed by the Vision Provider not fully covered by your Vision Insurance. • You should consult with the Vision Provider about treatment options, proposed and potential procedures, anticipated outcomes, potential risks, anticipated benefits and altematives. You should share with the Vision Provider the most current, complete and accurate information about Your medical and vision history and current conditions and medications. • You should follow the treatment plans and health care recommendations agreed upon by You and the Vision Provider. GCERT2000 notice/visrights NOTICE FOR RESIDENTS OF ARKANSAS If You have a question concerning Your coverage or a claim, first contact the Policyholder or group account administrator. If, after doing so, You still have a concern, You may call the toll free telephone number shown on the Certificate Face Page. Policyholders have the right to file a complaint with the Arkansas Insurance Department (AID). You may call AID to request a complaint form at (800) 852-5494 or (501) 371-2640 or write the Department at: Arkansas Insurance Department Consumer Services Division 1 Commerce Way, Suite 102 Little Rock, Arkansas 72202 GCERT2000 noticelar NOTICE FOR RESIDENTS OF CALIFORNIA IMPORTANT NOTICE TO OBTAIN ADDITIONAL INFORMATION, OR TO MAKE A COMPLAINT, CONTACT THE POLICYHOLDER OR METLIFE AT: DAVIS VISION ATTENTION: COMPLAINTS AND APPEALS P.O. BOX 791 LATHAM, NY 12110 1-800-438-6388 IF, AFTER CONTACTING THE POLICYHOLDER AND/OR METLIFE, YOU FEEL THAT A SATISFACTORY SOLUTION HAS NOT BEEN REACHED, YOU MAY FILE A COMPLAINT WITH THE CALIFORNIA DEPARTMENT OF INSURANCE DEPARTMENT AT: DEPARTMENT OF INSURANCE CONSUMER SERVICES 300 SOUTH SPRING STREET LOS ANGELES, CA 90013 WEBSITE: http://www.insurance.ca.gov/ 1-800-927-4357 (within California) 1-213-897-8921 (outside California) GCERT2000 notice/ca NOTICE FOR RESIDENTS OF THE STATE OF CALIFORNIA California law provides that for vision insurance, domestic partners of California's residents must be treated the same as spouses. If the certificate does not already have a definition of domestic partner, then the following definition applies: "Domestic Partner means each of two people, one of whom is an employee of the Policyholder, a resident of California and who have registered as domestic partners or members of a civil union with the California government or another government recognized by California as having similar requirements." If the certificate already has a definition of domestic partner, that definition will apply to California residents, as long as it recognizes as a domestic partner any person registered as the employee's domestic partner with the California government or another government recognized by California as having similar requirements. Wherever the term "Spouse" appears in this certificate it shall, unless otherwise specified, be read to include Your Domestic Partner. Wherever the term step -child appears, it is replaced by step -child or child of Your Domestic Partner. GCERT2000 ] 0 notice/dp/ca NOTICE FOR RESIDENTS OF GEORGIA IMPORTANT NOTICE The laws of the state of Georgia prohibit insurers from unfairly discriminating against any person based upon his or her status as a victim of family violence. GCERT2000 notice/ga NOTICE FOR RESIDENTS OF IDAHO If You have a question concerning Your coverage or a claim, first contact the Policyholder. If, after doing so, You still have a concern, You may call the toll free telephone number shown on the Certificate Face Page. If You are still concerned after contacting both the Policyholder and MetLife, You should feel free to contact: Idaho Department of Insurance Consumer Affairs 700 West State Street, 3111 Floor PO Box 83720 Boise, Idaho 83720-0043 1-800-721-3272 (for calls placed within Idaho) or 208-334-4250 or www.DOI.Idaho.gov GCERT2000 noticerd 12 NOTICE FOR RESIDENTS OF ILLINOIS IMPORTANT NOTICE To make a complaint to MetLife, You may write to: Davis Vision Attention: Complaints and Appeals P.O. Box 791 Latham, NY 12110 The address of the Illinois Department of Insurance is: Illinois Department of Insurance Public Services Division Springfield, Illinois 62767 GCERT2000 noticefil 13 NOTICE FOR RESIDENTS OF INDIANA Questions regarding your policy or coverage should be directed to: Metropolitan Life Insurance Company 1-833-EYE-LIFE (1-833-393-5433) If you (a) need the assistance of the government agency that regulates insurance; or (b) have a complaint you have been unable to resolve with your insurer you may contact the Department of Insurance by mail, telephone or email: State of Indiana Department of Insurance Consumer Services Division 311 West Washington Street, Suite 300 Indianapolis, Indiana 46204 Consumer Hotline: (800) 622-4461; (317) 232-2395 Complaint can be filed electronically at www.in.govAdoi GCERT2000 noticern 14 NOTICE FOR RESIDENTS OF MAINE You have the right to designate a third party to receive notice if Your insurance is in danger of lapsing due to a default on Your part, such as for nonpayment of a contribution that is due. The intent is to allow reinstatements where the default is due to the insured person's suffering from cognitive impairment or functional incapacity. You may make this designation by completing a "Third -Party Notice Request Form" and sending it to MetLife. Once You have made a designation, You may cancel or change it by filling out a new Third -Party Notice Request Form and sending it to MetLife. The designation will be effective as of the date MetLife receives the form. Call MetLife at the toll -free telephone number shown on the face page of this certificate to obtain a Third -Party Notice Request Form. Within 90 days after cancellation of coverage for nonpayment of premium, You, any person authorized to act on Your behalf, or any covered Dependent may request reinstatement of the certificate on the basis that You suffered from cognitive impairment or functional incapacity at the time of cancellation. GCERT2000 notice/me 15 NOTICE FOR MASSACHUSETTS RESIDENTS CONTINUATION OF VISION INSURANCE 1. If Your Vision Insurance ends due to a Plant Closing or Covered Partial Closing, such insurance will be continued for 90 days after the date it ends. 2. If Your Vision Insurance ends because: • You cease to be in an Eligible Class; or • Your employment terminates; for any reason other than a Plant Closing or Covered Partial Closing, such insurance will continue for 31 days after the date it ends. Continuation of Your Vision Insurance under the CONTINUATION OF INSURANCE WITH PREMIUM PAYMENT subsection will end before the end of continuation periods shown above if You become covered for similar benefits under another plan. Plant Closing and Covered Partial Closing have the meaning set forth in Massachusetts Annotated Laws, Chapter 151A, Section 71A. CONTINUATION OF VISION INSURANCE FOR YOUR FORMER SPOUSE If the judgment of divorce dissolving Your marriage provides for continuation of insurance for Your former Spouse when You remarry, Vision Insurance for Your former Spouse that would otherwise end may be continued. To continue Vision insurance under this provision: 1. You must make a written request to the employer to continue such insurance; 2. You must make any required premium to the employer for the cost of such insurance. The request form will be furnished by the Employer. Such insurance may be continued from the date Your marriage is dissolved until the earliest of the following: • the date Your former Spouse remarries; • the date of expiration of the period of time specified in the divorce judgment during which You are required to provide Vision Insurance for Your former Spouse; • the date coverage is provided under any other group health plan; • the date Your former Spouse becomes entitled to Medicare; • the date Vision Insurance under the policy ends for all active employees, or for the class of active employees to which You belonged before Your employment terminated; • the date of expiration of the last period for which the required premium payment was made; or • the date such insurance would otherwise terminate under the policy. If Your former Spouse is eligible to continue Vision Insurance under this provision and any other provision of this Policy, all such continuation periods will be deemed to run concurrently with each other and shall not be deemed to run consecutively. GCERT2000 notice/ma 16 NOTICE FOR RESIDENTS OF MISSISSIPPI CLAIMS FOR VISION INSURANCE Routine Questions on Vision Insurance Claims If there is any question about a claim payment, an explanation may be requested from MetLife by dialing 1-833-EYE-LIFE (1-833-393-5433). Initial Determination If Your claim for Vision Insurance benefits is a Clean Claim and it is approved, benefits will be paid within 25 days after We receive Proof in an electronic form of a covered loss, or within 35 days after receipt of Proof in paper form of a covered loss. Proof includes, but is not limited to, information essential for Us to administer coordination of benefits. "Clean Claim" means a claim that: • does not require further information, adjustment or alteration by You or the provider of the services in order to process and pay it; • does not have any defects; • does not have any impropriety, including any lack of supporting documentation; and • does not involve a particular circumstance required special treatment that substantially prevents timely payments from being made on the claim. A Clean Claim does not include a claim submitted by a provider more than 30 days after the date of service, or if the provider does not submit the claim on Your behalf, a claim submitted more than 30 days after the date the provider bills You. Errors, such as system errors, attributable to the insurer, do not change the clean claim status. If We do not deny payment of such benefits to You by the end of the 25 day period for clean claims submitted in electronic form, or 35 day period for Clean Claims submitted in paper form, and such benefits remain due and payable to You, interest will accrue on the amount of such benefits at the rate of 3 percent per month until such benefits are finally settled. If We do not pay benefits to You when due and payable, You may bring action to recover such benefits, any interest which has accrued with respect to such benefits and any other damages which may be allowed by law. We will pay benefits when We receive satisfactory Proof of Your claim. If We are unable to pay a claim for Vision Insurance benefits because additional information or documentation is required, or there is a particular circumstance requiring special treatment, within 25 days after the date We receive the claim if it is submitted in electronic form, or within 35 days after the date MetLife receives the claim if it is submitted in paper form, We will send You notice of what supporting documentation or information is needed. Any claim or portion of a claim for Vision Insurance benefits that is resubmitted with all of the supporting documentation requested in Our notice and becomes payable will be paid to You within 20 days after it is received. GCERT2000 notice/ms/vis 17 NOTICE FOR RESIDENTS OF MISSISSIPPI Claim Denial Appeals If a claim is denied in whole or in part, under the terms of this certificate, a request may be submitted to Us by a Covered Person or a Covered Person's authorized representative for a full review of the denial. A Covered Person may designate any person, including their provider, as their authorized representative. References in this section to "Covered Person" include the Covered Person's authorized representative. where applicable. Initial Appeal. All requests for review must be made within one hundred eighty (180) calendar days following denial of a claim. A Covered Person may review, during normal business hours, any documents used by Us pertinent to the denial. A Covered Person may also submit Written comments or supporting documentation concerning the claim to assist in Our review. Our response to the initial appeal, including specific reasons for the decision, shall be communicated to the Covered Person within thirty (30) calendar days after receipt of the request for the appeal. Second Level Appeal. If a Covered Person disagrees with the response to the initial appeal of the denied claim, the Covered Person has the right to a second level appeal. A request for a second level appeal must be submitted to Us within sixty (60) calendar days after receipt of Our response to the initial appeal. We shall communicate Our final determination to the Covered Person within thirty (30) calendar days from receipt of the request, or as required by any applicable state or federal laws or regulations. Our communication to the Covered Person shall include the specific reasons for the determination. Other Remedies. When a Covered Person has completed the appeals stated herein, additional voluntary alternative dispute resolution options may be available, including mediation or arbitration. Additional information is available from the U.S. Department of Labor or the insurance regulatory agency for the Covered Persons' state of residency. Additionally, under the provisions of ERISA (Section 502(a)(1)(B) 29 U.S.C. 1132(a)(1)(13)), the Covered Person has the right to bring a civil action when all available levels of reviews, including the appeal process, have been completed. ERISA remedies may apply in those instances where the claims were not approved in whole or in part as the result of appeals under this Policy and the Covered Person disagrees with the outcome of such appeals. Time of Action. No action in law or in equity shall be brought to recover on this Policy prior to the Covered Person exhausting his/her rights under this Policy and/or prior to the expiration of sixty (60) calendar days after the claim and any applicable documentation has been filed with Us. No such action shall be brought after the expiration of any applicable statute of limitations, in accordance with the terms of this Policy. No such action shall be brought after the expiration of three (3) years from the last date that the claim and any applicable invoices were submitted to Us, and no such action shall be brought at all unless brought within three (3) years from the expiration of the time within which such materials are required to be submitted in accordance with the terms of this Policy. If it is determined in such action that We acted in bad faith as evidenced by a repeated or deliberate pattern of failing to pay benefits and/or claims when due, You (or the provider, if You assigned the benefits to the provider) shall be entitled to recover any interest which may accrue plus damages in an amount up to three (3) times the amount of the benefits that remain unpaid until the claim is finally settled or adjudicated. Insurance Fraud: Any Covered Person who intends to defraud, knowingly facilitates a fraud, submits a claim containing false or deceptive information, or who commits any other similar act as defined by applicable state or federal law, is guilty of insurance fraud. Such an act is grounds for immediate termination of the coverage under this Policy of the Covered Person committing such fraud. GCERT2000 notice/ms/vis 18 NOTICE FOR NEW HAMPSHIRE RESIDENTS CONTINUATION OF YOUR VISION INSURANCE If You are a resident of New Hampshire, Your Vision Insurance may be continued if it ends because Your employment ends unless: • Your employment ends due to Your gross misconduct; • this Vision Insurance ends for all employees; • this Vision Insurance is changed to end Vision Insurance for the class of employees to which You belong; • You are entitled to enroll in Medicare; or • Your Vision Insurance ends because You failed to pay the required premium. The Employer must give You written notice of: • Your right to continue Your Vision Insurance; • the amount of premium payment that is required to continue Your Vision Insurance; • the manner in which You must request to continue Your Vision Insurance and pay premiums; and • the date by which premium payments will be due. The premium that You must pay for Your continued Vision Insurance may include: • any amount that You contributed for Your Vision Insurance before it ended; • any amount the Employer paid; and • an administrative charge which will not to exceed two percent of the rest of the premium. To continue Your Vision Insurance, You must: • send a written request to continue Your Vision Insurance; and • pay the first premium within 30 days after the date Your employment ends. The maximum continuation period will be the longest of: • 36 months if Your employment ends because You retire, and within 12 months of retirement You have a substantial loss of coverage because the employer files for bankruptcy protection under Title 11 of the United States Code; • 29 months if You become entitled to disability benefits under Social Security within 60 days of the date Your Employment ends; or • 18 months. Your continued Vision Insurance will end on the earliest of the following to occur: • the end of the maximum continuation period; • the date this Vision Insurance ends; • the date this Vision Insurance is changed to end Vision Insurance for the class of employees to which You belong; • the date You are entitled to enroll for Medicare; • if You do not pay the required premium to continue Your Vision Insurance; or • the date You become eligible for coverage under any other group Vision coverage. GCERT2000 is notice/coilnh NOTICE FOR NEW HAMPSHIRE RESIDENTS (continued) CONTINUATION OF YOUR DEPENDENT'S VISION INSURANCE If You are a resident of New Hampshire, Your Vision Insurance for Your Dependents may be continued if it ends because Your employment ends, Your marriage ends in divorce or separation, or You die, unless: • Your employment ends due to Your gross misconduct; • this Vision Insurance ends for all Dependents; • this Vision Insurance is changed, for the class of employees to which You belong, to end Vision Insurance for Dependents; • the Dependent is entitled to enroll in Medicare; or • Your Vision Insurance for Your Dependents ends because You fail to pay a required premium. If Vision Insurance for Your Dependents ends because Your marriage ends in divorce or separation, the party responsible under the divorce decree or separation agreement for payment of premium for continued Vision Insurance must notify the employer, in writing, within 30 days of the date of the divorce decree or separation agreement that the divorce or separation has occurred. If You and Your divorced or separated Spouse share responsibility for payment of the premium for continued Vision Insurance, both You and Your divorced or separated Spouse must provide the notification. The Employer must give You, or Your former Spouse if You have died or Your marriage has ended, written notice of: • Your right to continue Your Vision Insurance for Your Dependents; • the amount of premium payment that is required to continue Your Vision Insurance for Your Dependents; • the manner in which You or Your former Spouse must request to continue Your Vision Insurance for Your Dependents and pay premiums; and • the date by which premium payments will be due. The premium that You or Your former Spouse must pay for continued Vision Insurance for Your Dependents may include: • any amount that You contributed for Your Vision Insurance before it ended; and • any amount the Employer paid. To continue Vision Insurance for Your Dependents, You or Your former Spouse must: • send a written request to continue Vision Insurance for Your Dependents; and • must pay the first premium within 30 days of the date Vision Insurance for Your Dependents ends. If You, and Your former Spouse, if applicable, fail to provide any required notification, or fail to request to continue Vision Insurance for Your Dependents and pay the first premium within the time limits stated in this section, Your right to continue Vision Insurance for Your Dependents will end. GCERT2000 20 notice/coi/nh NOTICE FOR NEW HAMPSHIRE RESIDENTS (continued) CONTINUATION OF YOUR DEPENDENT'S VISION INSURANCE (Continued) The maximum continuation period will be the longest of the following that applies: • 36 months if Vision Insurance for Your Dependents ends because Your marriage ends in divorce or separation, except that with respect to a Spouse who is age 55 or older when your marriage ends in divorce or separation the maximum continuation period will end when the divorced or separated Spouse becomes eligible for Medicare or eligible for participation in another employer's group plan; • 36 months if Vision Insurance for Your Dependents ends because You die, except that with respect to a Spouse who is age 55 or older when You die, the maximum continuation period will end when Your surviving Spouse becomes eligible for Medicare or eligible for participation in another employer's group vision coverage; • 36 months if Vision Insurance for Your Dependents ends because You become entitled to benefits under Title XVIII of Social Security, except that with respect to a Spouse who is age 55 or older when You become entitled to benefits under Title XVIII of Social Security, the maximum continuation period will end when the divorced or separated Spouse becomes eligible for Medicare or eligible for participation in another employer's group vision coverage; • 36 months if You become entitled to benefits under Title XVIII of Social Security while You are already receiving continued benefits under this section, except that with respect to a Spouse who is age 55 or older when You first become entitled to continue Your Vision Insurance the maximum continuation period will end when the divorced or separated Spouse becomes eligible for Medicare or eligible for participation in another employer's group vision coverage; • 36 months with respect to a Dependent Child if Vision Insurance ends because the Child ceases to be a Dependent Child; • 36 months if Your employment ends because You retire, and within 12 months of retirement You have a substantial loss of coverage because the employer files for bankruptcy protection under Title 11 of the United States Code; • 29 months if Vision Insurance for Your Dependents ends because Your employment ends, and within 60 days of the date Your employment ends you become entitled to disability benefits under Social Security; • 18 months if Vision Insurance for Your Dependents ends because Your employment ends. A Dependent's continued Vision Insurance will end on the earliest of the following to occur: • the end of the maximum continuation period; • the date this Vision Insurance ends; • the date this Vision Insurance is changed to end Vision Insurance for Dependents for the class of employees to which You belong; • the date the Dependent becomes entitled to enroll for Medicare; • if You do not pay a required premium to continue Vision Insurance for Your Dependents; or • the date the Dependent becomes eligible for coverage under any other group vision coverage. GCERT2000 21 notice/coi/nh NOTICE FOR RESIDENTS OF NEW MEXICO Consumer Complaint Notice If You are a resident of New Mexico, Your coverage will be administered in accordance with the minimum applicable standards of New Mexico law. If You have concerns regarding a claim, premium, or other matters relating to this coverage, You may file a complaint with the New Mexico Office of Superintendent of Insurance (OSI) using the complaint form available on the OSI website and found at: https://www.osi.state.nm.us/ConsumerAssistance/index.aspx. GCERT2000 notice/nm-cm 22 NOTICE FOR RESIDENTS OF ALL STATES CIVIL UNIONS AND DOMESTIC PARTNERS The New Jersey Civil Union Act grants Civil Union partners the same benefits, protections and responsibilities that flow from marriage under New Jersey state law. The New Jersey Domestic Partnership Act grants Domestic Partners some of the benefits, protections and responsibilities that flow from marriage under New Jersey state law. However, some or all of the benefits, protections and responsibilities related to health insurance that are available to married persons under federal law may not be available to Civil Union Partners or to Domestic Partners. As a result, Civil Union Partners, Domestic Partners and their families may or may not have access to certain benefits under this notice and the certificate to which it is attached that derive from federal law. You are advised to seek expert advice to determine Your rights under this notice and the certificate to which it is attached. GCERT2000 notice/cu/nj 23 NOTICE FOR RESIDENTS OF PENNSYLVANIA Vision Insurance for a Dependent Child may be continued past the age limit if that Child is a full-time student and insurance ends due to the Child being ordered to active duty (other than active duty for training) for 30 or more consecutive days as a member of the Pennsylvania National Guard or a Reserve Component of the Armed Forces of the United States. Insurance will continue if such Child: • re -enrolls as a full-time student at an accredited school, college or university that is licensed in the jurisdiction where it is located; • re -enrolls for the first term or semester, beginning 60 or more days from the child's release from active duty. • continues to qualify as a Child, except for the age limit; and • submits the required Proof of the child's active duty in the National Guard or a Reserve Component of the United States Armed Forces. Subject to the Date Insurance For Your Dependents Ends subsection of the section entitled ELIGIBILITY PROVISIONS: INSURANCE FOR YOUR DEPENDENTS, this continuation will continue until the earliest of the date: the insurance has been continued for a period of time equal to the duration of the child's service on active duty; or the child is no longer a full-time student. GCERT2000 notice/pa 24 NOTICE FOR RESIDENTS OF TEXAS 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. GCERT2000 noticetb(twc 25 VISION INSURANCE: PROCEDURES FOR VISION CLAIMS NOTICE FOR RESIDENTS OF TEXAS If You reside in Texas, note the following Procedures for Vision Claims will be followed Routine Questions on Vision Insurance Claims If there is any question about a claim payment, an explanation may be requested from Metl-ife by dialing 1-833-EYE-LIFE (1-833-393-5433). Claim Denial Appeals If a claim is denied in whole or in part, under the terms of this certificate, a request may be submitted to Us by a Covered Person or a Covered Person's authorized representative for a full review of the denial. A Covered Person may designate any person, including their provider, as their authorized representative. References in this section to "Covered Person" include the Covered Person's authorized representative, where applicable. Initial Appeal. All requests for review must be made within one hundred eighty (180) calendar days following denial of a claim. A Covered Person may review, during normal business hours, any documents used by Us pertinent to the denial. A Covered Person may also submit Written comments or supporting documentation concerning the claim to assist in Our review. Our response to the initial appeal, including specific reasons for the decision, shall be communicated to the Covered Person within thirty (30) calendar days after receipt of the request for the appeal. Second Level Appeal. If a Covered Person disagrees with the response to the initial appeal of the denied claim, the Covered Person has the right to a second level appeal. A request for a second level appeal must be submitted to Us within sixty (60) calendar days after receipt of Our response to the initial appeal. We shall communicate Our final determination to the Covered Person within thirty (30) calendar days from receipt of the request, or as required by any applicable state or federal laws or regulations. Our communication to the Covered Person shall include the specific reasons for the determination. Other Remedies. When a Covered Person has completed the appeals stated herein, additional voluntary alternative dispute resolution options may be available, including mediation or arbitration. Additional information is available from the U.S. Department of Labor or the insurance regulatory agency for the Covered Persons' state of residency. Additionally, under the provisions of ERISA (Section 502(a)(1)(B) 29 U.S.C. 1132(a)(1)(13)), the Covered Person has the right to bring a civil action when all available levels of reviews, including the appeal process, have been completed. ERISA remedies may apply in those instances where the claims were not approved in whole or in part as the result of appeals under this Policy and the Covered Person disagrees with the outcome of such appeals. Time of Action. No action in law or in equity shall be brought to recover on this Policy prior to the Covered Person exhausting his/her rights under this Policy and/or prior to the expiration of sixty (60) calendar days after the claim and any applicable documentation has been filed with Us. No such action shall be brought after the expiration of any applicable statute of limitations, in accordance with the terms of this Policy. No such action shall be brought after the expiration of three (3) years from the last date that the claim and any applicable invoices were submitted to Us, and no such action shall be brought at all unless brought within three (3) years from the expiration of the time within which such materials are required to be submitted in accordance with the terms of this Policy. Insurance Fraud: Any Covered Person who intends to defraud, knowingly facilitates a fraud, submits a claim containing false or deceptive information, or who commits any other similar act as defined by applicable state or federal law, is guilty of insurance fraud. Such an act is grounds for immediate termination of the coverage under this Policy of the Covered Person committing such fraud. GCERT2000 26 notice/visionttx NOTICE FOR RESIDENTS OF UTAH Notice of Protection Provided by Utah Life and Health Insurance Guaranty Association This notice provides a brief summary of the Utah Life and Health Insurance Guaranty Association ("the Association") and the protection it provides for policyholders. This safety net was created under Utah law, which determines who and what is covered and the amounts of coverage. The Association was established to provide protection in the unlikely event that your life, health, or annuity insurance company becomes financially unable to meet its obligations and is taken over by its insurance regulatory agency. If this should happen, the Association will typically arrange to continue coverage and pay claims, in accordance with Utah law, with funding from assessments paid by other insurance companies. The basic protections provided by the Association are: • Life Insurance o $500,000 in death benefits o $200,000 in cash surrender or withdrawal values • Health Insurance o $500,000 in hospital, medical and surgical insurance benefits o $500,000 in long-term care insurance benefits o $500,000 in disability income insurance benefits o $500,000 in other types of health insurance benefits • Annuities o $250,000 in withdrawal and cash values The maximum amount of protection for each individual, regardless of the number of policies or contracts, is $500,000. Special rules may apply with regard to hospital, medical and surgical insurance benefits. Note: Certain policies and contracts may not be covered or fully covered. For example, coverage does not extend to any portion of a policy or contract that the insurer does not guarantee, such as certain investment additions to the account value of a variable life insurance policy or a variable annuity contract. Coverage is conditioned on residency in this state and there are substantial limitations and exclusions. For a complete description of coverage, consult Utah Code, Title 3 IA, Chapter 28. Insurance companies and agents are prohibited by Utah law to use the existence of the Association or its coverage to encourage you to purchase insurance. When selecting an insurance company, you should not rely on Association coverage. If there is any inconsistency between Utah law and this notice, Utah law will control. To learn more about the above protections, as well as protections relating to group contracts or retirement plans, please visit the Association's website at www.utifega.org or contact: Utah Life and Health Insurance Guaranty Assoc. Utah Insurance Department 60 East South Temple, Suite 500 3110 State Office Building Salt Lake City UT 84111 Salt Lake City UT 84114-6901 (801)320-9955 (801)538-3800 A written complaint about misuse of this Notice or the improper use of the existence of the Association may be filed with the Utah Insurance Department at the above address. GTY-NOTICE-UT-0710 27 NOTICE TO RESIDENTS OF VIRGINIA IMPORTANT INFORMATION REGARDING YOUR INSURANCE In the event You need to contact someone about this insurance for any reason please contact Your agent. If no agent was involved in the sale of this insurance, or if You have additional questions You may contact the insurance company issuing this insurance at the following address and telephone number. Davis Vision Attention: Complaints and Appeals P.O. Box 791 Latham, NY 12110 To phone in a claim related question, You may call Claims Customer Service at: 1-833-EYE-LIFE (1-833-393-5433) If You have any questions regarding an appeal or grievance concerning the vision services that You have been provided that have not been satisfactorily addressed by this Vision Insurance, You may contact the Virginia Office of the Managed Care Ombudsman for assistance. The Office of the Managed Care Ombudsman Bureau of Insurance P.O. Box 1157 Richmond, VA 23218-1157 1-804-371-9691 - phone 1-877-310-6560 - toll -free 1-804-371-9944 - fax www.scc.yirainia.goy - web address ombudsman(ascc.virginia.00v - email Or. Office of Licensure and Certification Division of Acute Care Services Virginia Department of Health 9960 Mayland Drive Suite 401 Henrico, Virginia 23233-1463 Phone number: 1-800-955-1819/ local: 804-367-2106 Fax: (804) 527-4503 MCHIP@vdh.virginia.gov Written correspondence is preferable so that a record of Your inquiry is maintained. When contacting Your agent, company or the Bureau of Insurance, have Your policy number available. GCERT2000 28 notice/va1 NOTICE TO RESIDENTS OF VIRGINIA (continued) VISION INSURANCE: PROCEDURES FOR VISION CLAIMS Routine Questions on Vision Insurance Claims If there is any question about a claim payment, an explanation may be requested from MetLife by dialing 1-833-EYE-LIFE (1-833-393-5433). Claim Denial Appeals If a claim is denied in whole or in part, under the terms of this certificate, a request may be submitted to Us by a Covered Person or a Covered Person's authorized representative for a full review of the denial. A Covered Person may designate any person, including their provider, as their authorized representative. References in this section to "Covered Person" include the Covered Person's authorized representative, where applicable. Initial Appeal. All requests for review must be made within one hundred eighty (180) calendar days following denial of a claim. A Covered Person may review, during normal business hours, any documents used by Us pertinent to the denial. A Covered Person may also submit Written comments or supporting documentation concerning the claim to assist in Our review. Our response to the initial appeal, including specific reasons for the decision, shall be communicated to the Covered Person within thirty (30) calendar days after receipt of the request for the appeal. Second Level Appeal. If a Covered Person disagrees with the response to the initial appeal of the denied claim, the Covered Person has the right to a second level appeal. A request for a second level appeal must be submitted to Us within sixty (60) calendar days after receipt of Our response to the initial appeal. We shall communicate Our final determination to the Covered Person within thirty (30) calendar days from receipt of the request, or as required by any applicable state or federal laws or regulations. Our communication to the Covered Person shall include the specific reasons for the determination. Other Remedies. When a Covered Person has completed the appeals stated herein, additional voluntary alternative dispute resolution options may be available, including mediation or arbitration. Additional information is available from the U.S. Department of Labor or the insurance regulatory agency for the Covered Persons' state of residency. Additionally, under the provisions of ERISA (Section 502(ax1 XB) 29 U.S.C. 1132(a)(1)(13)), the Covered Person has the right to bring a civil action when all available levels of reviews, including the appeal process, have been completed. ERISA remedies may apply in those instances where the claims were not approved in whole or in part as the result of appeals under this Policy and the Covered Person disagrees with the outcome of such appeals. Time of Action. No action in law or in equity shall be brought to recover on this Policy prior to the Covered Person exhausting his/her rights under this Policy and/or prior to the expiration of sixty (60) calendar days after the claim and any applicable documentation has been filed with Us. No such action shall be brought after the expiration of any applicable statute of limitations, in accordance with the terms of this Policy. No such action shall be brought after the expiration of three (3) years from the last date that the claim and any applicable invoices were submitted to Us, and no such action shall be brought at all unless brought within three (3) years from the expiration of the time within which such materials are required to be submitted in accordance with the terms of this Policy. Insurance Fraud: Any Covered Person who intends to defraud, knowingly facilitates a fraud, submits a claim containing false or deceptive information, or who commits any other similar act as defined by applicable state or federal law, is guilty of insurance fraud. Such an act is grounds for immediate termination of the coverage under this Policy of the Covered Person committing such fraud. GCERT2000 29 notice/va1 NOTICE FOR RESIDENTS OF WISCONSIN KEEP THIS NOTICE WITH YOUR INSURANCE PAPERS PROBLEMS WITH YOUR INSURANCE? - If You are having problems with Your insurance company or agent, do not hesitate to contact the insurance company or agent to resolve Your problem. Davis Vision Attention: Complaints and Appeals P.O. Box 791 Latham, NY 12110 1-833-EYE-LIFE (1-833-393-5433) You can also contact the OFFICE OF THE COMMISSIONER OF INSURANCE, a state agency which enforces Wisconsin's insurance laws, and file a complaint. You can contact the OFFICE OF THE COMMISSIONER OF INSURANCE by contacting: Office of the Commissioner of Insurance Complaints Department P.O. Box 7873 Madison, WI 53707-7873 1-800-236-8517 outside of Madison or 608-266-0103 in Madison. GCERT2000 noticetwi 30 TABLE OF CONTENTS Section Page CERTIFICATE FACE PAGE........................................................................................................................I.......1 NOTICES.............................................................................................................................................................3 SCHEDULEOF BENEFITS.............................................................................................................................. 33 DEFINITIONS................................................................................................................................................... 38 ELIGIBILITY PROVISIONS: INSURANCE FOR YOU...................................................................................... 42 EligibleClasses.......................................................................................................................................... 42 Date You Are Eligible for Insurance........................................................................................................... 42 Enrollment Process For Vision Insurance.................................................................................................. 42 Date Your Insurance Takes Effect.............................................................................................................. 42 CateYour Insurance Ends......................................................................................................................... 43 ELIGIBILITY PROVISIONS: INSURANCE FOR YOUR DEPENDENTS......................................................... 44 Eligible Classes For Dependent Insurance................................................................................................ 44 Date You Are Eitiglble For Dependent Insurance....................................................................................... 44 Enrollment Process For Dependent Vision Insurance................................................................................ 44 Cate Vision Insurance Takes Effect For Your Dependents........................................................................ 44 Cate Your Insurance For Your Dependents Ends...................................................................................... 46 CONTINUATION OF INSURANCE WITH PREMIUM PAYMENT.................................................................... 47 For Mentalty or PhysiCalty Handicapped Children...................................................................................... 47 ForFamily And Medical Leave................................................................................................................... 47 COBRA Continuation For Vision Insura nos ............................................................................................... 47 AtThe Polk:yholdor s Option...................................................................................................................... 47 VISION INSURANCE.. .................................. — .... - . ................................... ...... ...... ......................... ....... I ... 1.48 VLSI N INSURANCE: DESCRIPTION OF COVERED SERVICES AND MATERIALS ................................... 51 GCERT2000 31 toe TABLE OF CONTENTS (continued) Section VISION: INSURANCE' EXCLUSIONS Pape VISION INSURANCE: COORDINATION OF BENEFITS................................................................................. 53 VISION INSURANCE: FILING A CLAIM ...........................•..................................................................... 58 VISION INSURANCE: PROCEDURES FOR VISION CLAIMS............................................................. I.......... 59 GENERAL PROVISIONS ... ....... ._.....................................................................................................................60 Assignment................................................................................................................................................. 60 Vision Insurance: Who We Will Pay........................................................................................................... 60 EntireContract............................................................................................................................................60 Incontestability: Statements Made by You.................................................................................................60 Conformity with Law GCERT2000 32 toc ... 60 SCHEDULE OF BENEFITS This schedule shows the benefits that are available under the Group Policy. You and Your Dependents are only covered for insurance: • for which You become and remain eligible; • which You elect, if subject to election; and • which are in effect. In addition, You are eligible for Dependent Insurance only while You have Dependents who qualify BENEFIT Provider Network: Vision Insurance For You and Your Dependents BENEFIT AMOUNTS AND HIGHLIGHTS Davis Vision National Network Exam Lenses Frame Contacts Service Interval 1, 12 months 12 months 12 months 12 months In -Network Out -of -Network Exam Co -Payment $0 $0 Z to Retinal imaging Co P ent shall not pigpi Materials Co -Payment $0 $0 yment shall not awly to Contact Lenses QcLPa EXAMINATION (one per frequency) Low Vision Services means the evaluation, diagnosis and prescription of Low Vision devices by an eyecare professional who specializes in low vision rehabilitation. Low Vision evaluation does not include orthoptics or vision training. It includes the initial Low Vision evaluation and follow-up visits In -Network Cover (Using an In -Network Covered in full after any applicable Co -Payment (Using an Out -of -Network $40 allowance after any Payment Comprehensive examination of visual Comprehensive examination of visual functions and prescription of corrective functions and prescription of corrective t.omprenensive tvawanon 1 t%omprenensrve tvaluation $300 Allowance once every 60 months $300 Allowance once every 60 months Follow-up Evaluation I Follow-up Evaluation $100 Allowance for each follow-up $100 Allowance for each follow-up visit visit up to four times every 60 months up to four times every 60 months Low Vision Aids Low Vision Aids $600 Allowance per aid, $1,200 $600 Allowance per aid, $1,200 lifetime maximum lifetime maximum GCERT2000 33 sch SCHEDULE OF BENEFITS (continued) In -Network Coverage Out -of -Network Coverage (Using an In -Network Vision (Using an Out -of -Network Vision Provider) Provider RETINAL Covered in full with a Co -Payment not Applied to the allowance for the eye IMAGING to exceed $39. examination Coverage for retinal imaging is an enhancement to eye examination. Retinal imaging is not available at all provider locations — contact your In - Network Vision Provider to see if this technology (or equipment or service) is available. STANDARD Covered in full after any applicable Single Vision $40 allowance CORRECTIVE LENSES Co -Payment Lenses (Single, Lined Bifocal, Lined Lined Bifocal $60 allowance Lined Trifocal $80 allowance Lenticular $100 allowance Trifocal or Lenticular) GCERT2000 34 sch SCHEDULE OF BENEFITS (continued) In -Network Coverage Out -of -Network Coverage (Using an In -Network Vision (Using an Out -of -Network Vision Provider) Provider STANDARD LENS Standard Covered in full Applied to the allowance for the OPTIONS Polycarbonate (Placeholder for applicable corrective lens (child up to age 18) co -pay waived) These lens options Tints/Dyes — Solid Covered in full Applied to the allowance for the are available with a applicable corrective lens Tints/Dyes — Covered in full ..not to exceed" pricing/maximum Gradient member out of pocket amount.' Progressive — $50 $60 allowance Standard Progressive — $90 Premium Progressive — Ultra $140 Progressive — $175 Ultimate Ultra Violet Coating $12 Applied to the allowance for the applicable corrective lens Standard $30 (Placeholder Polycarbonate for co -pay waived) (adult) Scratch Resistant Covered in full Coating Anti -Reflective Tier 1 - $35 Coating Tier 2 - $48 Tier 3 - $60 Tier 4 - $85 Photochromic $65 Blue Light Filtering $15 Digital Single $30 Vision Polarized $75 High Index $55. $120 1.67/1.74 FRAMES DAVIS VISION NETWORK COLLECTION Not Applicable Fashion: Covered in full Designer: Covered in full Premier: Covered in full after $25 Co -Payment NON -COLLECTION Covered up to a $130 allowance after $50 allowance after any applicable Co - any applicable Co -Payment Payment CONTACT LENSES GCERT2000 35 sch SCHEDULE OF BENEFITS (continued) FITTING AND Standard and Premium Fit: EVALUATION COLLECTION Covered in full Not Applicable ONLY LECTIVE COLLECTION Covered in full Not Applicable Planned Replacement: 2 boxes Disposable: 4 boxes Contact lenses are provided in place of lens and frame benefits available herein. NON -COLLECTION $130 allowance $105 allowance Additional $50 allowance at JContact lenses are provided in place of I isionworks lens and frame benefits available herein; 1Contact lenses are provided in place of lens and frame benefits available hereint NECESSARY Covered in full $225 allowance Necessary contact lenses are a Plan Necessary contact lenses are a Plan Benefit when specific benefit criteria are Benefit when specific benefit criteria are satisfied and when prescribed by satisfied and when prescribed by Covered Person's In -Network Vision Covered Person's In -Network Vision Provider. Provider. Contact lenses are provided in place of Contact lenses are provided in place of lens and frame benefits available herein. lens and frame benefits available herein. ' Not all providers participate in vision program discounts, including the member out-of-pocket features. Call your provider prior to scheduling an appointment to confirm if the discount and member out-of-pocket features are offered at that location. Discounts and member out-of-pocket are not insurance and subject to change without notice. GCERT2000 36 sch Commented [WA4]: Spreadsheets says CIF but I didn't see this in in HMIG cent. Do we need to make reference to CIF here or just the number of boxes for Planned vs. Commented [BMSR4]: The original cert has a column for Collection Contacts, which are CIF for the 2 boxes / 4 boxes. These are not covered CON, which looks correct here. Commented [WA611t4]: I added Covered in full at the top in the Collection section before we indicate number of boxes. Is that how we want it to read? Commented [KE7]: Elective contact lens section needs to be customized to match HMIG certificate Commented [WA75]: Should this language stay or be removed? Commented [BM16R751: Frankly, I'd rather see it in the ( far left column once rather than in both the INN and DON columns. (Same with Elective above and Necessary below). Commented [KE17]: Elective contact lens section needs to be customized to match HMIG certificate Commented [WAS]: HMIG cert and spreadsheet say visionworks is $180 allowance. Using the language that we drafted for additional $50 visionworks for frames. Commented [BM9RB]: Looks good Commented [WA10]: Should this language stay or be removed? Commented IBM 11R10]: What do our current VSP certs do? Commented [WA12R10]: We don't have Collection/Non-Collection language in our VSP certs. I will leave it in so it mimics the Collection language. Commented [BM13R70]: OK, sounds good Commented [KE14]: Elective contact lens section needs to be customized to match HMIG certificate SCHEDULE OF BENEFITS (continued) Value -Added Features Available At In -Network Vision Providers (These features are not insurance.) REFRACTIVE SURGERY DISCOUNT Savings of 40% - 50% off the national average price of Refractive Surgery are available at over 1,000 locations across our nationwide network of laser vision correction providers. ADDITIONAL PAIR DISCOUNTS Members may receive 50% off of additional complete pairs of eyeglasses and sunglasses at Visionworks and 30% off at other participating providers on the same transaction. Otherwise, a 20% discount off the providers usual and customary rate may be available. Contact lenses may be available at a 10% discount. ADDITIONAL SAVINGS ON LENS Average 20-25% savings on all lens enhancements not otherwise ENHANCEMENTS covered under the Meti-ife Vision Insurance program. 2 ADDITIONAL SAVINGS ON 20% off any amount over your frames allowance.2 FRAMES BREAKAGE WARRANTY All eyeglasses come with a breakage warranty for repair or replacement of the frame and/or lenses for a period of one year from the date of delivery. The one-year breakage warranty applies to all plan -covered eyeglasses (i.e., all spectacle lenses, Davis Vision Exclusive Collection frames and national retailer frames, where our Exclusive Collection is not displayed). Warranty does not apply to Glasses.com ADDITIONAL SAVINGS ON 15% off any amount over your contact lens allowance. 2 CONTACTS 15% discount on additional contacts. 2 2 These features may not be available in all states and with all In -Network Vision Providers. Please check with Your In -Network Vision Provider. GCERT2000 37 sch DEFINITIONS As used in this certificate, the terms listed below will have the meanings set forth below. When defined terms are used in this certificate, they will appear with initial capitalization. The plural use of a term defined in the singular will share the same meaning. Terms that mean or refer to a marital relationship, or that may be construed to mean or refer to a marital relationship, such as "marriage", "spouse", "husband", "wife", "dependent", "relative," "survivor", "immediate family", and any other such terms include the relationship created by a Civil Union as described under the New Jersey Civil Union Act and also include a Domestic Partnership. Terms that mean or refer to the inception or dissolution of a marriage, such as "date of marriage", "divorce decree", "termination of marriage", and any other such terms include the inception or dissolution of a Civil Union or Domestic Partnership. Terms that mean or refer to family relationships arising from a marriage, such as "family", "immediate family", "dependent", "children", "relative", "survivor", and any other such terms include family relationships created by a Civil Union or Domestic Partnership. For example, the term "stepchild" includes the child of a Civil Union Partner or the child of a Domestic Partner. Actively at Work or Active Work means that You are performing all of the usual and customary duties of Your job on a Full -Time basis. This must be done at: • the Policyholder's place of business; • an alternate place approved by the Policyholder, or • a place to which the Policyholder's business requires You to travel. You will be deemed to be Actively at Work during weekends or Policyholder approved vacations, holidays or business closures if You were Actively at Work on the last scheduled work day preceding such time off. Anisometropia means a condition of unequal refractive state of the two eyes, one eye requiring a different lens correction than the other. Child means the following: (for residents of Alaska, Louisiana, Minnesota, Montana, New Hampshire, New Mexico, Texas, Utah and Washington, the Child Definition is modified as explained in the notice pages of this certificate - please consult the Notice) Your natural or adopted child; Your stepchild (including the child of a Civil Union Partner or a Domestic Partner); or a child who resides with and is fully supported by You; and who, in each case, is under age 26 and unmarried. The definition of Child includes newborns. An adopted child includes a child placed in Your physical custody for purpose of adoption. If prior to completion of the legal adoption the child is removed from Your custody, the child's status as an adopted child will end. If You provide Us notice, a Child also includes a child for whom You must provide Vision Insurance due to a Qualified Medical Child Support Order as defined in the United States Employee Retirement Income Security Act of 1974 as amended. The term includes an Employee's Child who is incapable of self-sustaining employment because of a mental or physical disability as defined by applicable law, and has been so disabled continuously since a date before the Child reached the limiting age and who otherwise qualifies as a Child except for the age limit. For the purposes of determining who may become covered for insurance, the term does not include any person who: • is on active duty in the military of any country or international authority; however, active duty for this purpose does not include weekend or summer training for the reserve forces of the United States, including the National Guard; or • is insured under the Group Policy as an employee. GCERT2000 38 def as amended by GCR07-13 dp and GCR09-07 dip DEFINITIONS (continued) Civil Union means the legally recognized union of two individuals of the same sex entered into in New Jersey pursuant to the New Jersey Civil Union Act. It also includes a same -sex relationship entered into outside of New Jersey which is valid under the laws of the jurisdiction under which the same -sex relationship is created. Contributory Insurance means insurance for which the Policyholder requires You to pay any part of the premium. Contributory Insurance includes: Vision Insurance for You and Vision Insurance for Your Dependents Co -Payment or Co -Pay means a fixed dollar amount for which We are not responsible, as shown in the Schedule of Benefits. You must pay Your Co -Payment at the time services are rendered or materials ordered. Covered Person(s) means an Employee and/or a Dependent covered under this Certificate. Covered Services and Materials mean a vision service or materials used to treat Your or Your Dependent's vision condition which is: • prescribed or performed by a Vision Provider while such person is insured for Vision Insurance; • Necessary to treat the condition; and • described in the SCHEDULE OF BENEFITS or VISION INSURANCE: DESCRIPTION OF COVERED SERVICES AND MATERIALS sections of this certificate. Dependent(s) means Your Spouse, Civil Union Partner or Domestic Partner and/or Child. Domestic Partner means each of two people, one of whom is an employee of the Policyholder, who: • have registered as each other's domestic partner or reciprocal beneficiary with a government agency where such registration is available or who are in a same -sex relationship from another jurisdiction which provides some, but not all of the rights and obligations of marriage; or • are of the same or opposite sex and have a mutually dependent relationship so that each has an insurable interest in the Iffe of the other. Each person must be: 1. 18 years of age or older, 2. unmarried; 3. the sole domestic partner of the other; 4. sharing a primary residence with the other, and 5. not related to the other in a manner that would bar their marriage in the jurisdiction in which they reside. A Domestic Partner declaration attesting to the existence of an insurable interest in one another's lives must be completed and Signed by the employee. Full -Time means Active Work of at least 00 hours per week on the Policyholder's regular work schedule for the eligible class of employees to which You belong. In -Network Vision Provider means an optometrist, ophthalmologist, or optician licensed and otherwise qualified to practice vision care and/or provide vision care materials who is contracted to provide Plan Benefits to Covered Persons of MetLife and accepts reimbursement at the negotiated rate. Keratoconus means a development or dystrophic deformity of the cornea in which it becomes cone shaped due to a thinning and stretching of the tissue in its central area. Maximum Benefit Allowance means the maximum amount We will allow for Covered Services and Materials provided by a Vision Provider. GCERT2000 39 def as amended by GCR07-13 dp and GCR09-07 dp Commented (WA181: Changed to 30 hours to go out with this as default/standard DEFINITIONS (continued) Necessary means Covered Services and Materials that are necessary and meet with professionally recognized standards of practice. The fact that a Vision Provider may prescribe, order, recommend or approve a service or material does not, in itself, make it medically necessary, or make it a Covered Service and Material even though it is listed in the Group Policy or the Benefit Schedule as Covered Service and Material. Out -of -Network Vision Provider/Non-Network Vision Provider means any optometrist, optician, ophthalmologist or other licensed and qualified vision care provider who has not contracted to provide vision care services and/or vision care materials to Covered Persons of MetLife. Plan or Plan Benefits means the vision care services and vision care materials which a Covered Person is entitled to receive by virtue of coverage under this Certificate. Progressive Lens means a multifocal lens that makes the transition from distance to near vision by a gradual, progressive addition of power. The result is a lens with a seamless appearance. Proof means Written evidence satisfactory to Us that a person has satisfied the conditions and requirements for any benefit described in this certificate. When a claim is made for any benefit described in this certificate, Proof must establish: • the nature and extent of the loss or condition; • Our obligation to pay the claim; and • the claimant's right to receive payment. Proof must be provided at the claimant's expense Service Interval or Frequency means a period of consecutive months, as shown in the SCHEDULE OF BENEFITS, in which You or Your Dependent may receive Covered Services and Materials. This period starts on Your or Your Dependent's effective date of coverage. A subsequent service interval starts after vision services or materials are received. Once Covered Services and Materials are received during any service interval, additional services are not covered during the same service interval and are subject to an additional charge. Signed means any symbol or method executed or adopted by a person with the present intention to authenticate a record, which is on or transmitted by paper or electronic media which is acceptable to Us and consistent with applicable law. Spouse means Your lawful spouse or, Civil Union Partner, or Domestic Partner. For the purposes of determining who may become covered for insurance, the term does not include any person who: • is on active duty in the military of any country or international authority; however, active duty for this purpose does not include weekend or summer training for the reserve forces of the United States, including the National Guard; or • is insured under the Group Policy as an employee. For Texas residents Spouse means the following: Spouse means Your lawful spouse. Wherever the term "Spouse" appears in the certificate it shall, unless otherwise specified, be read to include Your Domestic Partner. Vision Provider means an eye care professional who is an optometrist, ophthalmologist, or registered dispensing optician, who: • Is licensed as such by the proper authorities in the jurisdiction where such services are performed; • Is acting within the scope of such license. GCERT2000 40 def as amended by GCR07-13 dp and GCR09-07 dp DEFINITIONS (continued) We, Us and Our mean MetLife. Written or Writing means a record which is on or transmitted by paper or electronic media which is acceptable to Us and consistent with applicable law. Year or Yearly, for Vision Insurance, means the 12 month period that begins January 1. You and Your mean an employee who is insured under the Group Policy for the insurance described in this certificate. GCERT2000 41 def as amended by GCR07-13 dp and GCR09-07 dip ELIGIBILITY PROVISIONS: INSURANCE FOR YOU ELIGIBLE CLASS(ES) All Full -Time employees of the Policyholder. DATE YOU ARE ELIGIBLE FOR INSURANCE You may only become eligible for the insurance available for Your eligible class as shown in the SCHEDULE OF BENEFITS. If You are in an eligible class on May 1, 2022, You will be eligible for the insurance described in this certificate on that date. If You enter an eligible class after May 1, 2022, You will be eligible for insurance on the date You enter that class. ENROLLMENT PROCESS FOR VISION INSURANCE If You are eligible for insurance, You may enroll for such insurance by completing the required form in Writing. If You enroll for Contributory Insurance, You must also give the Policyholder Written permission to deduct premiums from Your pay for such insurance. You will be notified by the Policyholder how much You will be required to contribute. The Vision Insurance has a regular enrollment period established by the Policyholder. Subject to the rules of the Group Policy, You may enroll for Vision Insurance only when You are first eligible, during an annual enrollment period or if You have a Qualifying Event. You should contact the Policyholder for more information regarding the flexible benefits plan. DATE YOUR INSURANCE TAKES EFFECT Enrollment When First Eligible If You complete the enrollment process within 31 days of becoming eligible for insurance, such insurance will take effect on the date You become eligible, provided You are Actively at Work on that date. If You are not Actively at Work on the date the insurance would otherwise take effect, the Insurance will take effect on the day You resume Active Work. If You Do Not Enroll When First Eligible If You do not complete the enrollment process within 31 days of becoming eligible, You will not be able to enroll for insurance until the next enrollment period for Vision Insurance, as determined by the Policyholder, following the date You first become eligible. At that time You will be able to enroll for insurance for which You are then eligible. Enrollment During An Annual Enrollment Period During any annual enrollment period as determined by the Policyholder, You may enroll for insurance for which You are eligible. The changes to Your insurance made during an enrollment period will take effect on the first day of the month following the enrollment period, if You are Actively at Work on that date. If You are not Actively at Work on the date the insurance would otherwise take effect, insurance will take effect on the date You resume Active Work. Commented [KE19]: Customize GCERT2000 42 e/ee ELIGIBILITY PROVISIONS: INSURANCE FOR YOU (continued) Enrollment Due to a Qualifying Event You may enroll for insurance for which You are eligible between annual enrollment periods only if You have a Qualifying Event. If You have a Qualifying Event, You will have 31 days from the date of that change to make a request. This request must be consistent with the nature of the Qualifying Event. The insurance enrolled for, or changes to Your insurance made as a result of a Qualifying Event, will take effect on the first day of the month following the date of Your request, if You are Actively at Work on that date. If You are not Actively at Work on the date the insurance would otherwise take effect, insurance will take effect on the day You resume Active Work. Qualifying Event includes: • marriage; or • the birth, adoption or placement for adoption of a dependent child; or • divorce, legal separation or annulment; or • the death of a dependent; or a change in Your or Your dependent's employment status, such as beginning or ending employment, strike, lockout, taking or ending a leave of absence, changes in worksite or work schedule, if it causes You or Your dependent to gain or lose eligibility for group coverage. DATE YOUR INSURANCE ENDS Your insurance will end on the earliest of: 1. the date the Group Policy ends; 2. the date insurance ends for Your class; 3. the last day of the calendar month in which You cease to be in an eligible class; 4. the end of the period for which the last premium has been paid for You; 5. the last day of the calendar month in which Your employment ends, Your employment will end if You cease to be Actively at Work in any eligible class, except as stated in the section entitled CONTINUATION OF INSURANCE WITH PREMIUM PAYMENT; or 6. the last day of the calendar month in which You retire in accordance with the Policyholder's retirement plan. In certain cases insurance may be continued as stated in the section entitled CONTINUATION OF INSURANCE WITH PREMIUM PAYMENT. GCERT2000 43 e/ee ELIGIBILITY PROVISIONS: INSURANCE FOR YOUR DEPENDENTS ELIGIBLE CLASS(ES) FOR DEPENDENT INSURANCE All Full -Time employees of the Policyholder. DATE YOU ARE ELIGIBLE FOR DEPENDENT INSURANCE You may only become eligible for the Dependent insurance available for Your eligible class as shown in the SCHEDULE OF BENEFITS. If You are in an eligible class on May 1, 2022, You will be eligible for Dependent insurance on the later of: 1. May 1, 2022; and 2. the date You obtain a Dependent. If You enter an eligible class after May 1, 2022, You will be eligible for Dependent insurance on the later of: 1. the date You enter a class eligible for insurance; and 2. the date You obtain a Dependent. No person may be insured as a Dependent of more than one employee. ENROLLMENT PROCESS FOR DEPENDENT VISION INSURANCE If You are eligible for Dependent Insurance, You may enroll for such insurance by completing the required form in Writing for each Dependent to be insured. If You enroll for Contributory Insurance, You must also give the Policyholder Written permission to deduct premiums from Your pay for such insurance. You will be notified by the Policyholder how much You will be required to contribute. In order to enroll for Vision Insurance for Your Dependents, You must either (a) already be enrolled for Vision Insurance for You or (b) enroll at the same time for Vision Insurance for You. The Vision Insurance has a regular enrollment period established by the Policyholder. Subject to the rules of the Group Policy, You may enroll for Dependent Vision Insurance only when You are first eligible, during an enrollment period or if You have a Qualifying Event. You should contact the Policyholder for more information regarding the flexible benefits plan. DATE VISION INSURANCE TAKES EFFECT FOR YOUR DEPENDENTS Enrollment When First Eligible If You complete the enrollment process within 31 days of becoming eligible for Dependent Insurance, such insurance will take effect on the date You become eligible, provided You are Actively at Work on that date. If You are not Actively at Work on the date the insurance would otherwise take effect, the insurance will take effect on the day You resume Active Work. If You Do Not Enroll When First Eligible If You do not complete the enrollment process within 31 days of becoming eligible, You will not be able to enroll for Dependent Insurance until the next enrollment period for Vision Insurance, as determined by the Policyholder, following the date You first become eligible. At that time You will be able to enroll for insurance for which You are then eligible. GCERT2000 44 e/dep ELIGIBILITY PROVISIONS: INSURANCE FOR YOUR DEPENDENTS (continued) Enrollment During An Annual Enrollment Period During any enrollment period as determined by the Policyholder, You may enroll for Dependent Insurance for which You are eligible. The changes to Your Dependent Insurance made during an enrollment period will take effect on the first day of the month following the enrollment period, if You are Actively at Work on that date. If You are not Actively at Work on the date the insurance would otherwise take effect, insurance will take effect on the date You resume Active Work. Enrollment Due to a Qualifying Event You may enroll for Dependent Insurance for which You are eligible between annual enrollment periods only if You have a Qualifying Event. If You have a Qualifying Event, You will have 31 days from the date of that change to make a request. This request must be consistent with the nature of the Qualifying Event. The insurance enrolled for or changes to Your insurance made as a result of a Qualifying Event will take effect on the first day of the month following the date of Your request, if You are Actively at Work on that date. If You are not Actively at Work on the date the insurance would otherwise take effect, insurance will take effect on the day You resume Active Work. Qualifying Event includes: • marriage; • the birth, adoption or placement for adoption of a dependent child; • divorce, legal separation or annulment; • the death of a dependent; • a change in Your or Your dependent's employment status, such as beginning or ending employment, strike, lockout, taking or ending a leave of absence, changes in worksite or work schedule, if it causes You or Your dependent to gam or lose eligibility for group coverage; Once You have enrolled one Child for Dependent Insurance, each succeeding Child will automatically be insured for such insurance on the date the Child qualifies as a Dependent. GCERT2000 45 e/dep ELIGIBILITY PROVISIONS: INSURANCE FOR YOUR DEPENDENTS (continued) DATE YOUR INSURANCE FOR YOUR DEPENDENTS ENDS A Dependent's insurance will end on the earliest of: 1. the date You die; 2. the date Vision Insurance for You ends; 3. the date the Group Policy ends; 4. the last day of the calendar month in which You cease to be in an eligible class; 5. the date insurance for Your Dependents ends under the Group Policy; 6. the date insurance for Your Dependents ends for Your class; 7. the last day of the calendar month in which Your employment ends; Your employment will end if You cease to be Actively at Work in any eligible class, except as stated in the section entitled CONTINUATION OF INSURANCE WITH PREMIUM PAYMENT; 8. the end of the period for which the last premium has been paid; 9. the last day of the calendar month the person ceases to be a Dependent; or 10. the last day of the calendar month in which You retire in accordance with the Policyholder's retirement plan. In certain cases insurance may be continued as stated in the section entitled CONTINUATION OF INSURANCE WITH PREMIUM PAYMENT. GCERT2000 46 e/dep FOR MENTALLY OR PHYSICALLY HANDICAPPED CHILDREN Insurance for a Dependent Child may be continued past the age limit if the child is incapable of self-sustaining employment because of a mental or physical handicap as defined by applicable law. Proof of such handicap must be sent to Us within 31 days after the date the Child attains the age limit and at reasonable intervals after such date. Subject to the DATE YOUR INSURANCE FOR YOUR DEPENDENTS ENDS subsection of the section entitled ELIGIBILITY PROVISIONS: INSURANCE FOR YOUR DEPENDENTS, insurance will continue while such Child: • remains incapable of self-sustaining employment because of a mental or physical handicap; and • continues to qualify as a Child, except for the age limit. FOR FAMILY AND MEDICAL LEAVE Certain leaves of absence may qualify for continuation of insurance under the Family and Medical Leave Act of 1993 (FMLA), or other legally mandated leave of absence or similar laws. Please contact the Policyholder for information regarding such legally mandated leave of absence laws. COBRA CONTINUATION FOR VISION INSURANCE If Vision Insurance for You or a Dependent ends, You or Your Dependent may qualify for continuation of such insurance under the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended (COBRA). Please refer to the COBRA section of Your summary plan description or contact the Policyholder for information regarding continuation of insurance under COBRA. AT THE POLICYHOLDER'S OPTION The Policyholder has elected to continue insurance by paying premiums for employees who cease Active Work in an eligible class for any of the reasons specified below. If Your insurance is continued, insurance for Your Dependents may also be continued. Insurance will continue for the following periods: 1. for the period You cease Active Work in an eligible class due to layoff, up to 3 months; 2. for the period You cease Active Work in an eligible class due to any other Policyholder approved leave of absence, up to 3 months; 3. for the period You cease Active Work in an eligible class due to injury or sickness, up to � months. At the end of any of the continuation periods listed above, Your insurance will be affected as follows: • if You resume Active Work in an eligible class at this time, You will continue to be insured under the Group Policy; • if You do not resume Active Work in an eligible class at this time, Your employment will be considered to end and Your insurance will end in accordance with the DATE YOUR INSURANCE ENDS subsection of the section entitled ELIGIBILITY PROVISIONS: INSURANCE FOR YOU. If Your insurance ends, Your Dependents' insurance will also end in accordance with the DATE YOUR INSURANCE FOR YOUR DEPENDENTS ENDS subsection of the section entitled ELIGIBILITY PROVISIONS: INSURANCE FOR YOUR DEPENDENTS. GCERT2000 47 coi-eport Commented [WA20j: Updated m 3 monchs per Liz'i e- maii comment chac change was made to default to th;s as stendard VISION INSURANCE Benefits are available for Covered Services and Materials provided by either In -Network Vision Providers or Out -of -Network Vision Providers. However, You may be able to reduce Your out-of-pocket costs by using In - Network Vision Providers because Out -of -Network Vision Providers have not entered into an agreement to limit their charges. You are always free to receive services from any Vision Provider. You do not need any authorization from Us before seeing a Vision Provider. In -Network Vision Providers have agreed to provide Covered Services and Materials as listed in the SCHEDULE OF BENEFITS. If You or a Dependent incur a charge for Covered Services and Materials from an Out -of -Network Vision Provider, Proof of such service must be sent to Us. When We receive such Proof, We will review the claim and if We approve it, will pay the insurance in effect on the date that service was completed. The benefits available under this Vision Insurance are set forth on the SCHEDULE OF BENEFITS. In addition to the Co -Payment, if applicable, You may be responsible for: • the cost of any services or materials that are not Covered Services and Materials; and • the cost of any service or material that is in excess of the Maximum Benefit Allowance listed on the SCHEDULE OF BENEFITS. We do not provide vision services. Whether or not benefits are available for a particular service does not mean You should or should not receive the service. You and Your Vision Provider have the right and are responsible at all times for choosing the course of treatment and services to be performed. When requesting Covered Services and Materials from an In -Network Vision Provider, We recommend that You confirm that the Vision Provider is currently an In -Network Vision Provider at the time that the Covered Services and Materials are provided. You can obtain a customized listing of MetLife's In -Network Vision Providers either by calling 1-833-EYE-LIFE (1-833-393-5433) or by visiting Our website at www.metlife.com/mybenefits. PLAN BENEFITS We will pay benefits for charges incurred by You or a Dependent for Covered Services and Materials as shown in the SCHEDULE OF BENEFITS, subject to the conditions set forth in this certificate. If You receive Covered Services and Materials from an In -Network Vision Provider, We will pay the provider directly for all covered benefits. If You or Your Dependent receive Covered Services and Materials from an Out -of -Network Vision Provider, and You assign payment of Vision Insurance benefits to Your or Your Dependent's Vision Provider, We will pay benefits directly to the Vision Provider. Otherwise, We will pay Vision Insurance benefits to You. In -Network If Covered Services and Materials are provided by an In -Network Vision Provider, We will base the benefit on the Plan Benefits listed on the SCHEDULE OF BENEFITS. If an In -Network Vision Provider provides Covered Services and Materials, You will be responsible for paying: • the Co -Payment, if applicable; and • the cost of any service or material that is in excess of the Plan Benefits listed on the SCHEDULE OF BENEFITS. GCERT2000 vision 48 VISION INSURANCE (continued) Out -of -Network If Covered Services and Materials are provided by an Out -of -Network Vision Provider, We will base the benefit on the Plan Benefits listed on the SCHEDULE OF BENEFITS, subject to the Maximum Benefit Allowance. Out -of -Network Vision Providers may charge You more than the Maximum Benefit Allowance. If an Out -of - Network Vision Provider provides Covered Services and Materials, You will be responsible for paying any amount in excess of the Maximum Benefit Allowance charged by the Out -of -Network Vision Provider. Emergency Vision Care Emergency vision care means vision screening, examination, and evaluation by a Vision Provider, or, to the extent permitted by applicable law, by appropriate personnel under the supervision of a Vision Provider to determine if an emergency vision condition exists, and, if it does, the care and treatment necessary to relieve or eliminate the Emergency Vision Condition. The cost sharing applied to You for emergency care shall be the same regardless of whether the services were rendered by an In -Network Vision Provider or Out -of -Network Vision Provider. Necessary Contact Lenses Necessary contact lenses are a Plan Benefit when specific benefit criteria are satisfied and when prescribed by Covered Person's In -Network Vision Provider. Generally, coverage will be authorized for the following reasons: • Aphakia-379.31 or 743.35. • Nystagmus-379.50 through 379.56, 386.11, 386.12 or 386.2. • Keratoconus-371.60, 371.61, 371.62, 743.41, or 743.42. • Corneal transplant—V42.5. • Corneal dystrophies-371.50 through 371.58. • Anisometropia greater than or equal to 2.00 diopters difference in any meridian based on the spectacle prescription. • High ametropia greater than or equal to ±10.00 diopters in either eye in any meridian based on the spectacle prescription. • Irregular astigmatism-367.22. The codes listed above are from the International Classification of Diseases, Ninth Revision, Clinical Modification and are used to describe diseases, injuries, symptoms and conditions. If You have questions about the diagnoses listed above or the codes included with the diagnoses, please contact Your Vision Provider. We will pay benefits for a 90 day period after Your insurance ends if: • the Covered Service was performed by a Vision Provider while You are insured for Vision Insurance; and • the Covered Service requires more than one visit to complete. If You are Fully Disabled on the date Your Vision Insurance ends because the Group Policy ends, We will pay benefits for Covered Services if: • the Covered Service was recommended in Writing by a Vision Provider or Physician; • the Covered Service was begun prior to the date Your Vision Insurance ended; • the Covered Service was performed within 90 days after this Vision Insurance ends. GCERT2000 vision 49 VISION INSURANCE (continued) "Fully Disabled" for purposes of Vision Insurance means that because of a sickness or injury: You cannot do Your job; or a Dependent cannot do his or her usual activities. GCERT2000 vision 50 VISION INSURANCE: DESCRIPTION OF COVERED SERVICES AND MATERIALS Subject to the Service Intervals and Plan Benefits indicated in the SCHEDULE OF BENEFITS, the following will be Covered Services and Materials: 1. One complete visual examination, if indicated as a Covered Service on the SCHEDULE OF BENEFITS. Dilation is included as a Covered Service when provided by an In -Network Vision Provider. 2. Standard corrective lenses. We will cover a pair of standard single vision, lined bifocal, lined trifocal or lenticular lenses that are necessary to correct vision. Standard corrective lenses are as follows: • eyesizes up to and including 60mm; • multi -focal lenses in all segment widths; • prism and slab off; • base curves (regardless of curve); • lenses with the combined power in any meridian is +/- .50 diopters or greater in at least one eye; and • plastic or glass lenses. 3. The following lens options described in the SCHEDULE OF BENEFITS: tint (solid and gradient), standard plastic scratch coating, standard polycarbonate (if you are less than 18 years of age), standard anti - reflective coating, plastic photochromic, blue light filtering, digital single vision, polarized, high Index (1.67/1.74). 4. Contact lenses. • A standard fitting and 1 follow-up visit by a Vision Provider. • The following contact lenses options, as described in the SCHEDULE OF BENEFITS: conventional, disposable, and Necessary. 5. Necessary low vision aids and evaluations. 6. We do not cover costs above the Maximum Benefit Allowance shown in the SCHEDULE OF BENEFITS for frames. If frames are selected that are more expensive than that amount, You will be charged the difference between the Maximum Benefit Allowance and the Vision Provider's charge for the more expensive frame. 7. Necessary contact lenses in lieu of all benefits for vision materials. GCERT2000 vis/covsery 51 VISION INSURANCE: EXCLUSIONS We will not pay Vision Insurance benefits for charges incurred for: 1. Services and/or materials not specifically included in the SCHEDULE OF BENEFITS as covered Plan Benefits. 2. Any portion of a charge in excess of the Maximum Benefit Allowance or reimbursement indicated in the SCHEDULE OF BENEFITS. 3. Plano lenses (lenses with refractive correction of less than t .50 diopter). 4. Two pairs of glasses instead of bifocals. 5. Replacement of lenses, frames and/or contact lenses furnished under this Plan which are lost, stolen or damaged, except at the normal intervals when Plan Benefits are otherwise available. 6. Orthoptics or vision training and any associated supplemental testing. 7. Medical surgical treatment of the eye. 8. Prescription or non-prescription medications. 9. Contact lens insurance policies and service agreements. 10. Refitting of contact lenses after the initial (90-day) fitting period. 11. Contact lens modification, polishing and cleaning. 12. Any eye examination or any corrective eyewear required as a condition of employment. 13. Services or supplies received by You or Your Dependent before the Vision Insurance starts for that person. 14. Missed appointments. 15. Services or materials resulting from or in the course of a Covered Person's regular occupation for pay or profit for which the Covered Person is entitled to benefits under any Workers' Compensation Law, Employer's Liability Law or similar law. You must promptly claim and notify the Company of all such benefits. 16. Local, state and/or federal taxes, except where MetLife is required by law to pay. 17. Services: • for which the employer of the person receiving such services is required to pay by law; or • received at a facility maintained by the Employer, labor union, mutual benefit association, or VA hospital. 18. Services or materials received as a result of disease, defect, or injury due to war or an act of war (declared or undeclared), taking part in a riot or insurrection, or committing or attempting to commit a felony. 19. Services and materials obtained while outside the United States, except for emergency vision care. 20. Services, procedures, or materials for which a charge would not have been made in the absence of insurance. GCERT2000 vis/exclusions 52 VISION INSURANCE: COORDINATION OF BENEFITS You or Your Dependent may be covered for health benefits or services by more than one Plan. For instance, You may be covered by this Policy as an employee and by another Plan as a Dependent of Your spouse, civil union partner or domestic partner. If You or Your Dependent are, this provision allows Us to coordinate what We pay with what another Plan pays or provides. This provision sets forth the rules for determining which is the Primary Plan and which is the Secondary Plan. Coordination of benefits is intended to avoid duplication of benefits while at the same time preserving certain rights to coverage under all Plans under which the covered person is covered. Definitions The words shown below have special meanings when used in this provision. Please read these definitions carefully. "Allowable Expense" means the charge for any vision service, supply or other item of expense for which the covered person is liable when the vision service, supply or other item of expense is covered at least in part under any of the Plans involved, except where a statute requires another definition, or as otherwise stated below. "Claim Determination Period" means a Calendar Year, or portion of a Calendar Year, during which You or Your Dependent are covered by this Policy and at least one other Plan and incurs one or more Allowable Expense(s) under such Plans. "Plan" means coverage with which coordination of benefits is allowed. Plan includes: • group insurance and group subscriber contracts, including insurance continued pursuant to a Federal or State continuation law; • self -funded arrangements of group or group -type coverage, including insurance continued pursuant to a Federal or State continuation law; • group or group -type coverage through a health maintenance organization (HMO) or other prepayment, group practice and individual practice Plans, including insurance continued pursuant to a Federal or State continuation law; • Medicare or other governmental benefits, except when, pursuant to law, the benefits must be treated as in excess of those of any private insurance Plan or nongovernmental Plan. Plan does not include: • individual or family insurance contracts or subscriber contracts; • individual or family coverage through a health maintenance organization or under any other prepayment, group practice and individual practice Plans; • group or group -type coverage where the cost of coverage is paid solely by the covered person except when coverage is being continued pursuant to a Federal or State continuation law; • school accident — type coverage • a State Plan under Medicaid "Primary Plan" means a Plan whose benefits for a covered person's vision coverage must be determined without taking into consideration the existence of any other Plan. There may be more than one Primary Plan. A Plan will be the Primary Plan if either "1" or "2" below exist: 1. the Plan has no order of benefit determination rules, or it has rules that differ from those contained in this Coordination of Benefits provision; or 2. all Plans which cover the covered person use order of benefit determination rules consistent with those contained in the Coordination of Benefits provision and under those rules, the Plan determines its benefits first. GCERT2000 vis/cob 53 VISION INSURANCE: COORDINATION OF BENEFITS (continued) "Reasonable and Customary" means, for the purposes of this Coordination of Benefits provision only, an amount that is not more than the usual or customary charge for the service or supply as determined by the Plan, based on a standard which is most often charged for a given service by a Vision Provider within the same geographic area. "Secondary Plan" means a Plan which is not a Primary Plan. If a covered person is covered by more than one Secondary Plan, the order of benefit determination rules of this Coordination of Benefits and Services provision shall be used to determine the order in which the benefits payable under the multiple Secondary Plans are paid in relation to each other. The benefits of each Secondary Plan may take into consideration the benefits of the Primary Plan or Plans and the benefits of any other Plan which, under this Coordination of Benefits and Services provision, has its benefits determined before those of that Secondary Plan. Primary And Secondary Plan We consider each Plan separately when coordinating payments. The Primary Plan pays or provides services or supplies first, without taking into consideration the existence of a Secondary Plan. If a Plan has no coordination of benefits provision, or if the order of benefit determination rules differ from those set forth in these provisions, it is the Primary Plan. A Secondary Plan takes into consideration the benefits provided by a Primary Plan when, according to the rules set forth below, the Plan is the Secondary Plan. If there is more than one Secondary Plan, the order of benefit determination rules determine the order among the Secondary Plans. The Secondary Plan (s) will pay up to the remaining unpaid allowable expenses, but no Secondary Plan will pay more than it would have paid if it had been the Primary Plan. The method the Secondary Plan uses to determine the amount to pay is set forth below in the Procedures to be Followed by the Secondary Plan to Calculate Benefits section of this provision. As is always true, we will not reduce Allowable Expenses for necessary and appropriate services and supplies on the basis that precertification, preapproval, notification or second surgical opinion procedures were not followed. Rules For The Order Of Benefit Determination The benefits of the Plan that covers the covered person as an employee, member, subscriber or retiree shall be determined before those of the Plan that covers the covered person as a dependent. The coverage as an employee, member, subscriber or retiree is the Primary Plan. 1. The benefits of the Plan that covers the covered person as an employee who is neither laid off nor retired, or as a dependent of such person, shall be determined before those for the Plan that covers the covered person as a laid off or retired employee, or as such a person's dependent. If the other Plan does not contain this rule, and as a result the Plans do not agree on the order of benefit determination, this portion of this provision shall be ignored. 2. The benefits of the Plan that covers the covered person as an employee, member, subscriber or retiree, or dependent of such person, shall be determined before those of the Plan that covers the covered person under a right of continuation pursuant to Federal or State law. If the other Plan does not contain this rule, and as a result the Plans do not agree on the order of benefit determination, this portion of this provision shall be ignored. 3. If a child is covered as a dependent under Plans through both parents, and the parents are neither separated nor divorced, the following rules apply: a. The benefits of the Plan of the parent whose birthday falls earlier in the Calendar Year shall be determined before those of the parent whose birthday falls later in the Calendar year. b. If both parents have the same birthday, the benefits of the Plan which covered the parent for a longer period of time shall be determined before those of the parent for a shorter period of time. GCERT2000 vis/cob 54 VISION INSURANCE: COORDINATION OF BENEFITS (continued) c. Birthday, as used above, refers only to month and day in a calendar year, not the year in which the parent was born. d. If the other Plan contains a provision that determines the order of benefits based on the gender of the parent, the birthday rule in this provision shall be ignored. 4. If a child is covered as a Dependent under Plans through both parents, and the parents are separated or divorced, the following rules apply: a. The benefits of the Plan of the parent with custody of the child shall be determined first. b. The benefits of the Plan of the spouse, civil union partner or domestic partner of the parent with custody shall be determined second. c. The benefits of the Plan of the parent without custody shall be determined last. d. If the terms of a court decree state that one of the parents is responsible for the vision expenses for the child, and if the entity providing coverage under that Plan has knowledge of the terms of the court decree, then the benefits of that Plan shall be determined first. The benefits of the Plan of the other parent shall be considered as secondary. Until the entity providing coverage under the Plan has knowledge of the terms of the court decree regarding vision expenses, this portion of this provision shall be ignored. 5. If the above order of benefits does not establish which Plan is the Primary Plan, the benefits of the Plan that covers the employee, member or subscriber for a longer period of time shall be determined before the benefits of the Plan(s) that covered the person for a shorter period of time. Procedures to be Followed by the Secondary Plan to Calculate Benefits In order to determine which procedure to follow, it is necessary to consider: • the basis on which the Primary Plan and the Secondary Plan pay benefits; and • whether the Vision Provider who provides or arranges the services and supplies is in the network of either the Primary Plan or the Secondary Plan. For the purpose of applying the following provisions, if the Plan does not have a network, the Vision Provider will be considered on the same basis as an in -network Vision Provider. Benefits may be based on the Reasonable and Customary Charge (R&C), or some similar term. This means that the Vision Provider bills a charge and the covered person may be held liable for the full amount of the billed charge. In this section, a Plan that bases benefits on a reasonable and customary charge is called an "R&C Plan." Benefits may be based on a contractual fee schedule, sometimes called a negotiated fee schedule, or some similar term. This means that although a Vision Provider, called an In -Network Vision Provider, bills a charge, the covered person may be held liable only for an amount up to the negotiated fee. In this section, a Plan that bases benefits on a negotiated fee schedule is called a "Fee Schedule Plan." If the covered person uses the services of a Non -Network Vision Provider, the Plan will be treated as an R&C Plan even though the Plan under which he or she is covered allows for a fee schedule. Payment to the Vision Provider may be based on a capitation. This means that the health maintenance organization (HMO) pays the Vision Provider a fixed amount per covered person. The covered person is liable only for the applicable deductible, coinsurance or copayment. If the covered person uses the services of a non -network Vision Provider, the HMO will only pay benefits in the event of emergency care or urgent care. In this section, a Plan that pays Vision Providers based upon capitation is called a "Capitation Plan." In the rules below, "Vision Provider" refers to the Vision Provider who provides or arranges the services or supplies and HMO refers to a health maintenance organization Plan. GCERT2000 vis/cob 55 VISION INSURANCE: COORDINATION OF BENEFITS (continued) The Primary Plan is an R&C Plan and the Secondary Plan is an R&C Plan: The Secondary Plan shall pay the lesser of: • the difference between the amount of the billed charges and the amount paid by the Primary Plan; and • the amount the Secondary Plan would have paid if it had been the Primary Plan. When the benefits of the Secondary Plan are reduced as a result of this calculation, each benefit shall be reduced in proportion, and the amount paid shall be charged against any applicable benefit limit of the Plan The Primary Plan is a Fee Schedule Plan and the Secondary Plan is a Fee Schedule Plan: If the Vision Provider is an In -Network Vision Provider in both the Primary Plan and the Secondary Plan, the Allowable Expense shall be the fee schedule of the Primary Plan. The Secondary Plan shall pay the lesser of: • the amount of any deductible, coinsurance or copayment required by the Primary Plan; or • the amount the Secondary Plan would have paid if it had been the Primary Plan. The total amount the Vision Provider receives from the Primary Plan, the Secondary Plan and the covered person shall not exceed the fee schedule of the Primary Plan. In no event shall the covered person be responsible for any payment in excess of the copayment, coinsurance or deductible of the Secondary Plan. The Primary Plan is an R&C Plan and the Secondary Plan is a Fee Schedule Plan: If the Vision Provider is an In -Network Vision Provider in the Secondary Plan, the Secondary Plan shall pay the lesser of: • the difference between the amount of the billed charges for the Allowable Charges and the amount paid by the Primary Plan; or • the amount the Secondary Plan would have paid if it had been the Primary Plan. The covered person shall only be liable for the copayment, deductible or coinsurance under the Secondary Plan if the covered person has no liability for copayment, deductible or coinsurance under the Primary Plan and the total payments by both the Primary and Secondary Plans are less than the Vision Provider's billed charges. In no event shall the covered person be responsible for any payment in excess of the copayment, coinsurance or deductible of the Secondary Plan. The Primary Plan is a Fee Schedule Plan and the Secondary Plan is an R&C Plan: If the Vision Provider is a network Vision Provider in the Primary Plan, the Allowable Expense considered by the Secondary Plan shall be the fee schedule of the Primary Plan. The Secondary Plan shall pay the lesser of: • the amount of any deductible, coinsurance or copayment required by the Primary Plan; or • the amount the Secondary Plan would have paid if it had been the Primary Plan. The Primary Plan is a Fee Schedule Plan and the Secondary Plan is an R&C Plan or Fee Schedule Plan: If the Primary Plan is an HMO Plan that does not allow for the use of Non -Network Vision Providers except in the event of urgent care or emergency care and the service or supply the covered person receives from a non -network Vision Provider is not considered as urgent care or emergency care, the Secondary Plan shall pay benefits as if it were the Primary Plan. The Primary Plan is a Capitation Plan and the Secondary Plan is a Fee Schedule Plan or R&C Plan: If the covered person receives services or supplies from a Vision Provider who is in the network of both the Primary Plan and the Secondary Plan, the Secondary Plan shall pay the lesser of: a) the amount of any deductible, coinsurance or copayment required by the Primary Plan; or b) the amount the Secondary Plan would have paid if it had been the Primary Plan. GCERT2000 vis/cob 56 VISION INSURANCE: COORDINATION OF BENEFITS (continued) Right To Receive And Release Needed Information Certain facts are needed to apply these COB rules. We have the right to decide which facts We need. We may get needed facts from or give them to any other organization or person. We need not tell, or get the consent of, any person to do this. Each person claiming benefits under This Plan must give Us any facts We need to pay the claim. Facility Of Payment A payment made under another Plan may include an amount which should have been paid under This Plan If it does, We may pay that amount to the organization which made that payment. That amount will then be treated as though it were a benefit paid under This Plan. We will not have to pay that amount again. The term "payment made" includes providing benefits in the form of services, in which case "payment made" means reasonable monetary value of the benefits provided in the form of services. Right Of Recovery If the amount of the payments made by Us is more than it should have paid under this COB provision, We may recover the excess from one or more of: • the persons We have paid or for whom We have paid; • insurance companies; or • other organizations. The "amount of the payments made" includes the reasonable monetary value of any benefits provided in the form of services. GCERT2000 vis/cob 57 VISION INSURANCE: FILING A CLAIM CLAIMS FOR VISION INSURANCE If you select an In Network Vision Provider, You do not need to file a claim If you select an Out -of -Network Vision Provider, You may provide full payment to the Out -of -Network Vision Provider at the time of service and submit the invoice including an itemized statement of charges with Your claim form, or You may be able to assign the claim to the Out -of -Network Vision Provider. If the Out -of - Network Vision Provider accepts the assignment, the provider will submit the claim on your behalf. You will be responsible for any charges not covered by the Plan. Out of network claim forms needed to file for benefits under the group insurance program can be obtained by calling MetLife at 1-833-EYE-LIFE (1-833-393-5433). If You do not receive the claim form before the expiration of 15 days after We receive notice of any claim under the policy, You shall be deemed to have complied with the requirements of the Group Policy. Vision claim forms can also be downloaded from www.metife.com/mybenefits. The instructions on the claim form should be followed carefully. This will expedite the processing of the claim. When We receive the claim form and Proof, Your claim will be paid subject to the terms and provisions of this certificate and the Group Policy. CLAIMS FOR VISION INSURANCE BENEFITS When a claimant files a claim for Vision Insurance benefits described in this certificate, both the notice of claim and the required Proof should be sent to Us within 90 days from the date of service. Failure to give notice within such time shall not invalidate nor reduce any claim if it shall be shown not to have been reasonably possible to give such notice and that notice was given as soon as was reasonably possible. Claim and Proof may be given to Us by following the steps set forth below: Step 1 A claimant can request a claim form by downloading it from www.metlife.com/mybenefits. Step 2 Complete the claim form as instructed and return it with the invoice. Step 3 The claimant must give Us Proof not later than 180 days from the date of service. GCERT2000 58 vis/claim VISION INSURANCE: PROCEDURES FOR VISION CLAIMS Routine Questions on Vision Insurance Claims If there is any question about a claim payment, an explanation may be requested from MetLife by dialing 1-833-EYE-LIFE (1-833-393-5433). Claim Denial Appeals If a claim is denied in whole or in part, under the terms of this certificate, a request may be submitted to Us by a Covered Person or a Covered Person's authorized representative for a full review of the denial. A Covered Person may designate any person, including their provider, as their authorized representative. References in this section to "Covered Person" include the Covered Person's authorized representative, where applicable. Initial Appeal. All requests for review must be made within one hundred eighty (180) calendar days following denial of a claim. A Covered Person may review, during normal business hours, any documents used by Us pertinent to the denial. A Covered Person may also submit Written comments or supporting documentation concerning the claim to assist in Our review. Our response to the initial appeal, including specific reasons for the decision, shall be communicated to the Covered Person within thirty (30) calendar days after receipt of the request for the appeal. Second Level Appeal. If a Covered Person disagrees with the response to the initial appeal of the denied claim, the Covered Person has the right to a second level appeal. A request for a second level appeal must be submitted to Us within sixty (60) calendar days after receipt of Our response to the initial appeal. We shall communicate Our final determination to the Covered Person within thirty (30) calendar days from receipt of the request, or as required by any applicable state or federal laws or regulations. Our communication to the Covered Person shall include the speck reasons for the determination. Other Remedies. When a Covered Person has completed the appeals stated herein, additional voluntary alternative dispute resolution options may be available, including mediation or arbitration. Additional information is available from the U.S. Department of Labor or the insurance regulatory agency for the Covered Persons' state of residency. Additionally, under the provisions of ERISA (Section 502(a)(1)(B) 29 U.S.C. 1132(a)(1)(B)), the Covered Person has the right to bring a civil action when all available levels of reviews, including the appeal process, have been completed. ERISA remedies may apply in those instances where the claims were not approved in whole or in part as the result of appeals under this Policy and the Covered Person disagrees with the outcome of such appeals. Time of Action. No action in law or in equity shall be brought to recover on this Policy prior to the expiration of sixty (60) calendar days after Written Proof of loss has been furnished in accordance with the requirements of this policy. No such action shall be brought after the expiration of three (3) years after the time Written Proof of loss is required to be furnished. Time of Action. No action in law or in equity shall be brought to recover on this Policy prior to the expiration of sixty (60) calendar days after Proof of Loss and any applicable documentation has been filed with Us. No such action shall be brought unless brought within three (3) years from expiration of the time within which Proof of loss is required under this Policy. Insurance Fraud: Any Person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Insurance Fraud. Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties. GCERT2000 vislclaimrev 59 GENERAL PROVISIONS Assignment The rights and benefits under the Group Policy are not assignable prior to a claim for benefits, except as required by law. We are not responsible for the validity of an assignment. Upon receipt of a Covered Service, You may assign Vision Insurance benefits to the Vision Provider providing such service. Vision Insurance: Who We Will Pay If You assign payment of Vision Insurance benefits to Your or Your Dependent's Vision Provider, We will pay benefits directly to the Vision Provider. Otherwise, We will pay Vision Insurance benefits to You. Entire Contract Your insurance is provided under a contract of group insurance with the Policyholder. The entire contract with the Policyholder is made up of the following: 1. the Group Policy and its Exhibits, which include the certificate(s); 2. the Policyholder's application, attached to the Group Policy; and 3. any amendments and/or endorsements to the Group Policy. Incontestability: Statements Made by You Any statement made by You will be considered a representation and not a warranty. Evidence of insurability will not be required nor will any statement made by You, which relates to insurability, be used: 1. to contest the validity of the insurance benefits; or 2. to reduce the insurance benefits. Conformity with Law If the terms and provisions of this certificate do not conform to any applicable law, this certificate shall be interpreted to so conform. GCERT2000 gp 10104 60 THE PRECEDING PAGE IS THE END OF THE CERTIFICATE. THE FOLLOWING IS ADDITIONAL INFORMATION. MetLife Delaware American Life Insurance Company MetLife Health Plans, Inc. MetLife Legal Plans, Inc. MetLife Legal Plans of Florida, Inc. Metropolitan General Insurance Company Metropolitan Life Insurance Company Metropolitan Tower Life Insurance Company SafeGuard Health Plans, Inc. SafeHealth Life Insurance Company Our Privacy Notice We know that you buy our products and services because you trust us. This notice explains how we protect your privacy and treat your personal information. It applies to current and former customers. "Personal information" as used here means anything we know about you personally. SECTION 1: Plan Sponsors and Group Insurance Contract Holders This privacy notice is for individuals who apply for or obtain our products and services under an employee benefit plan, group insurance or annuity contract, or as an executive benefit. In this notice, "you" refers to these individuals. SECTION 2: Protecting Your Information We take important steps to protect your personal information. We treat it as confidential. We tell our employees to take care in handling it. We limit access to those who need it to perform their jobs. Our outside service providers must also protect it, and use it only to meet our business needs. We also take steps to protect our systems from unauthorized access. We comply with all laws that apply to us. SECTION 3: Collecting Your Information We typically collect your name, address, age, and other relevant information. We may also collect information about any business you have with us, our affiliates, or other companies. Our affiliates include life insurers, a legal plans company and a securities broker -dealer. In the future, we may also have affiliates in other businesses. SECTION 4: How We Get Your Information We get your personal information mostly from you. We may also use outside sources to help ensure our records are correct and complete. These sources may include consumer reporting agencies, employers, other financial institutions, adult relatives, and others. These sources may give us reports or share what they know with others. We don't control the accuracy of information outside sources give us. If you want to make any changes to information we receive from others about you, you must contact those sources. We may ask for medical information. The Authorization that you sign when you request insurance permits these sources to tell us about you. We may also, at our expense: • Ask for a medical exam • Ask for blood and urine tests • Ask health care providers to give us health data, including information about alcohol or drug abuse We may also ask a consumer reporting agency for a "consumer report" about you (or anyone else to be insured). Consumer reports may tell us about a lot of things, including information about: • Reputation Driving record • Finances • Work and work history Hobbies and dangerous activities The information may be kept by the consumer reporting agency and later given to others as permitted by law. The agency will give you a copy of the report it provides to us, if you ask the agency and can provide adequate identification. If you write to us and we have asked for a consumer report about you, we will tell you so and give you the name, address and phone number of the consumer reporting agency. Another source of information is MIB, Inc. ("MIB"). It is a not -for -profit membership organization of insurance companies which operates an information exchange on behalf of its Members. We, or our reinsurers, may make a brief report to MIB. If you apply to another MIB Member company for life or health insurance coverage, or a claim for benefits is submitted, MIB, upon request, will supply such company with the information in its file. Upon receipt of a request from you MIB will arrange disclosure of any information it may have in your file. Please contact MIB at 866-692-6901. If you question the accuracy of information in MIB's CPN-Initial Enr/SOH and SBR (08/21) Page 1 file, you may contact MIB and seek a correction in accordance with the procedures set forth in the federal Fair Credit Reporting Act. You may do so by writing to MIB, Inc., 50 Braintree Hill, Suite 400, Braintree, MA 02184- 8734 or go to MIB website at www. mib.com. SECTION 5: Using Your Information We collect your personal information to help us decide if you're eligible for our products or services. We may also need it to verify identities to help deter fraud, money laundering, or other crimes. How we use this information depends on what products and services you have or want from us. It also depends on what laws apply to those products and services. For example, we may also use your information to: • administer your products and services • perform business research • market new products to you • comply with applicable laws • process claims and other transactions • confirm or correct your information • help us run our business SECTION 6: Sharing Your Information With Others We may share your personal information with others with your consent, by agreement, or as permitted or required by law. We may share your personal information without your consent if permitted or required by law. For example, we may share your information with businesses hired to carry out services for us. We may also share it with our affiliated or unaffiliated business partners through joint marketing agreements. In those situations, we share your information .to jointly offer you products and services or have others offer you products and services we endorse or sponsor. Before sharing your information with any affiliate or joint marketing partner for their own marketing purposes, however, we will first notify you and give you an opportunity to opt out. Other reasons we may share your information include: • doing what a court, law enforcement, or government agency requires us to do (for example, complying with search warrants or subpoenas) • telling another company what we know about you if we are selling or merging any part of our business • giving information to a governmental agency so it can decide if you are eligible for public benefits • giving your information to someone with a legal interest in your assets (for example, a creditor with a lien on your account) • giving your information to your health care provider • having a peer review organization evaluate your information, if you have health coverage with us • those listed in our "Using Your Information" section above SECTION 7: HIPAA We will not share your health information with any other company — even one of our affiliates — for their own marketing purposes. The Health Insurance Portability and Accountability Act ("HIPAA") protects your information if you request or purchase dental, vision, long-term care and/or medical insurance from us. HIPAA limits our ability to use and disclose the information that we obtain as a result of your request or purchase of insurance. Information about your rights under HIPAA will be provided to you with any dental, vision, long- term care or medical coverage issued to you. You may obtain a copy of our HIPAA Privacy Notice by visiting our website at www.MetLife.com. For additional information about your rights under HIPAA; or to have a HIPAA Privacy Notice mailed to you, contact us at HIPAAr)dvacvAmericasUScWmetlife.com, or call us at telephone number (212) 578-0299. SECTION 8: Accessing and Correcting Your Information You may ask us for a copy of the personal information we have about you. We will provide it as long as it is reasonably locatable and retrievable. You must make your request in writing listing the account or policy numbers with the information you want to access. For legal reasons, we may not show you privileged information relating to a claim or lawsuit, unless required by law. CPN-Initial Enr/SOH and SBR (08/21) Page 2 If you tell us that what we know about you is incorrect, we will review it. If we agree, we will update our records. Otherwise, you may dispute our findings in writing, and we will include your statement whenever we give your disputed information to anyone outside MetLife. SECTION 9: Questions We want you to understand how we protect your privacy. If you have any questions or want more information about this notice, please contact us. A detailed notice shall be furnished to you upon request. When you write, include your name, address, and policy or account number. Send privacy questions to: MetLife Privacy Office P. O. Box 489 Warwick, RI 02887-9954 privacy aAmetlife.com We may revise this privacy notice. If we make any material changes, we will notify you as required by law. We provide this privacy notice to you on behalf of the MetLife companies listed at the top of the first page. CPN-Initial Enr/SOH and SBR (08/21) Page 3 MetLife HIPAA Notice of Privacy Practices for Protected Health Information THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. Dear MetLife Customer: This is your Health Information Privacy Notice from Metropolitan Life Insurance Company or a member of the MetLife, Inc. family of companies, which includes SafeGuard Health Plans, Inc., SafeHealth Life Insurance Company, and Delaware American Life Insurance Company (collectively, "MetLife"). Please read it carefully. You have received this notice because of your Dental, Vision, Long -Term Care, Cancer and Specified Disease Expense Insurance, or Health coverage with us (your "Coverage"). MetLife strongly believes in protecting the confidentiality and security of information we collect about you. This notice refers to MetLife by using the terms "us," "we," or "our." This notice describes how we protect the personal health information we have about you which relates to your MetLife Coverage ("Protected Health Information" or "PHI"), and how we may use and disclose this information. PHI includes individually identifiable information which relates to your past, present or future health, treatment or payment for health care services. This notice also describes your rights with respect to the PHI and how you can exercise those rights. We are required to provide this notice to you by the Health Insurance Portability and Accountability Act ("HIPAA"). For additional information regarding our HIPAA Medical Information Privacy Policy or our general privacy policies, please see the privacy notices contained at our website,www.metlife.com. You may submit questions to us there or you may write to us directly at MetLife, Americas — U.S. HIPAA Privacy Office, P.O. Box 902, New York, NY 10159-0902. NOTICE SUMMARY The following is a brief summary of the topics covered in this HIPAA notice. Please refer to the full notice below for details. As allowed by law, we may use and disclose PHI to: • make, receive, or collect payments; • conduct health care operations; • administer benefits by sharing PHI with affiliates and Business Associates; • assist plan sponsors in administering their plans; and • inform persons who may be involved in or paying for another's health care. In addition, we may use or disclose PHI: • where required by law or for public health activities; • to avert a serious threat to health or safety; • for health -related benefits or services; • for law enforcement or specific government functions; • when requested as part of a regulatory or legal proceeding; and • to provide information about deceased persons to coroners, medical examiners, or funeral directors. You have the right to: • receive a copy of this notice; • inspect and copy your PHI, or receive a copy of your PHI; • amend your PHI if you believe the information is incorrect; • obtain a list of disclosures we made about you (except for treatment, payment, or health care operations); • ask us to restrict the information we share for treatment, payment, or health care operations; • request that we communicate with you in a confidential manner; and • complain to us or the U.S. Department of Health and Human Services if you believe your privacy rights have been violated. We are required by law to: • maintain the privacy of PHI; • provide this notice of our legal duties and privacy practices with respect to PHI; notify affected individuals following a breach of unsecured PHI; and • follow the terms of this notice. NOTICE DETAILS We protect your PHI from inappropriate use or disclosure. Our employees, and those of companies that help us service your MetLife Coverage, are required to comply with our requirements that protect the confidentiality of PHI. They may look at your PHI only when there is an appropriate reason to do so, such as to administer our products or services. Except in the case of Long -Term Care Coverage, we will not use or disclose PHI that is genetic information for underwriting purposes. For example, we will not use information from a genetic test (such as DNA or RNA analysis) of an individual or an individual's family members to determine eligibility, premiums or contribution amounts under your Coverage. We will not sell or disclose your PHI to any other company for their use in marketing their products to you. However, as described below, we will use and disclose PHI about you for business purposes relating to your Coverage. The main reasons we may use and disclose your PHI are to evaluate and process any requests for coverage and claims for benefits you may make or in connection with other health -related benefits or services that may be of interest to you. The following describe these and other uses and disclosures. • For Payment: We may use and disclose PHI to pay benefits under your Coverage. For example, we may review PHI contained in claims to reimburse providers for services rendered. We may also disclose PHI to other insurance carriers to coordinate benefits with respect to a particular claim. Additionally, we may disclose PHI to a health plan or an administrator of an employee welfare benefit plan for various payment - related functions, such as eligibility determination, audit and review, or to assist you with your inquiries or disputes. • For Health Care Operations: We may also use and disclose PHI for our insurance operations. These purposes include evaluating a request for our products or services, administering those products or services, and processing transactions requested by you. • To Affiliates and Business Associates: We may disclose PHI to Affiliates and to business associates outside of the MetLife family of companies if they need to receive PHI to provide a service to us and will agree to abide by specific HIPAA rules relating to the protection of PHI. Examples of business associates are: billing companies, data processing companies, companies that provide general administrative services, health Information organizations e-prescribing gateways, or personal health record vendors that provide services to covered entities. PHI may be disclosed to reinsurers for underwriting, audit or claim review reasons. PHI may also be disclosed as part of a potential merger or acquisition involving our business in order that the parties to the transaction may make an informed business decision. • To Plan Sponsors: We may disclose summary health information such as claims history or claims expenses to a plan sponsor to enable it to obtain premium bids from health plans, or to modify, amend or terminate a group health plan. We may also disclose PHI to a plan sponsor to help administer its plan if the plan sponsor agrees to restrict its use and disclosure of PHI in accordance with federal law. • To Individuals Involved in Your Care: We may disclose your PHI to a family member or other individual who is involved in your health care or payment of your health care. For example, we may disclose PHI to a covered family member whom you have authorized to contact us regarding payment of a claim. • Where Required by Law or for Public Health Activities: We disclose PHI when required by federal, state or local law. Examples of such mandatory disclosures include notifying state or local health authorities regarding particular communicable diseases, or providing PHI to a governmental agency or regulator with health care oversight responsibilities. • To Avert a Serious Threat to Health or Safety: We may disclose PHI to avert a serious threat to someone's health or safety. We may also disclose PHI to federal, state or local agencies engaged in disaster relief, as well as to private disaster relief or disaster assistance agencies to allow such entities to carry out their responsibilities in specific disaster situations. • For Health -Related Benefits or Services: We may use your PHI to provide you with information about benefits available to you under your current coverage or policy and, in limited situations, about health -related products or services that may be of interest to you. However, we will not send marketing communications to you in exchange for financial remuneration from a third party without your authorization. • For Law Enforcement or Specific Government Functions: We may disclose PHI in response to a request by a law enforcement official made through a court order, subpoena, warrant, summons or similar process. We may disclose PHI about you to federal officials for intelligence, counterintelligence, and other national security activities authorized by law. • When Requested as Part of a Regulatory or Legal Proceeding: If you or your estate are involved in a lawsuit or a dispute, we may disclose PHI about you in response to a court or administrative order. We may also disclose PHI about you in response to a subpoena, discovery request, or other lawful process, but only if efforts have been made to tell you about the request or to obtain an order protecting the PHI requested. We may disclose PHI to any governmental agency or regulator with whom you have filed a complaint or as part of a regulatory agency examination. • PHI about Deceased Individuals : We may release PHI to a coroner or medical examiner to assist in identifying a deceased individual or to determine the cause of death. In addition, we may disclose a deceased's person's PHI to a family member or individual involved in the care or payment for care of the deceased person unless doing so is inconsistent with any prior expressed preference of the deceased person which is known to us. • Other Uses of PHI: Other uses and disclosures of PHI not covered by this notice and permitted by the laws that apply to us will be made only with your written authorization or that of your legal representative. If we are authorized to use or disclose PHI about you, you or your legally authorized representative may revoke that authorization in writing at any time, except to the extent that we have taken action relying on the authorization or if the authorization was obtained as a condition of obtaining your Coverage. You should understand that we will not be able to take back any disclosures we have already made with authorization. Your Riahts Retrardina Protected Health Information That We Maintain About You The following are your various rights as a consumer under HIPAA concerning your PHI. Should you have questions about or wish to exercise a specific right, please contact us in writing at the applicable Contact Address listed on the last page. • Right to Inspect and Copy Your PHI: In most cases, you have the right to inspect and obtain a copy of the PHI that we maintain about you. if we maintain the requested PHI electronically, you may ask us to provide you with the PHI in electronic format, if readily producible; or, if not, in a readable electronic form and format agreed to by you and us. To receive a copy of your PHI, you may be charged a fee for the costs of copying, mailing, electronic media, or other supplies associated with your request. You may also direct us to send the PHI you have requested to another person designated by you, so long as your request is in writing and clearly identifies the designated individual. However, certain types of PHI will not be made available for inspection and copying. This includes psychotherapy notes or PHI collected by us in connection with, or in reasonable anticipation of, any claim or legal proceeding. In very limited circumstances, we may deny your request to inspect and obtain a copy of your PHI. If we do, you may request that the denial be reviewed. The review will be conducted by an individual chosen by us who was not involved in the original decision to deny your request. We will comply with the outcome of that review. • Right to Amend Your PHI: If you believe that your PHI is incorrect or that an important part of it is missing, you have the right to ask us to amend your PHI while it is kept by or for us. You must specify the reason for your request. We may deny your request if it is not in writing or does not include a reason that supports the request. In addition, we may deny your request if you ask us to amend PHI that: • is accurate and complete; • was not created by us, unless the person or entity that created the PHI is no longer available to make the amendment; • is not part of the PHI kept by or for us; or • is not part of the PHI which you would be permitted to inspect and copy. • Right to a List of Disclosures: You have the right to request a list of the disclosures we have made of your PHI. This list will not include disclosures made for treatment, payment, health care operations, purposes of national security, to law enforcement, to corrections personnel, pursuant to your authorization, or directly to you. To request this list, you must submit your request in writing. Your request must state the time period for which you want to receive a list of disclosures. You may only request an accounting of disclosures for a period of time less than six years prior to the date of your request. Your request should indicate in what form you want the list (for example, paper or electronic). The first list you request within a 12-month period will be free. We may charge you for responding to any additional requests. We will notify you of the cost involved, and you may choose to withdraw or modify your request at that time before you incur any cost. • Right to Request Restrictions: You have the Right to request a restriction or limitation on PHI we Use or disclose about you for treatment, payment, or health care operations, or that we disclose to someone who may be involved in your care or payment for your care, like a family member or friend. While we will consider your request, we are not required to agree to it. If we do agree to it, we will comply with your request. To request a restriction, you must make your request in writing. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply (for example, disclosures to your spouse or parent). We will not agree to restrictions on PHI uses or disclosures that are legally required, or which are necessary to administer our business. • Right to Request Confidential Communications : You have the right to request that we communicate with you about PHI in a certain way or at a certain location if you tell us that communication in another manner may endanger you. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you must make your request in writing and specify how or where you wish to be contacted. We will accommodate all reasonable requests. • Contact Addresses: If you have any questions about a specific individual right or you want to exercise one of your individual rights, please submit your request in writing to the address below which applies to your Coverage: MetLife or SafeGuard Dental & Vision P.O. Box 14587 Lexington, KY 40512-4587 MetLife LTC Privacy Coordinator 1300 Hall Boulevard, 3rd Floor Bloomfield, CT 06002 Delaware American Life Insurance Company MetLife Worldwide Benefits P.O. Box 1449 Wilmington, DE 19899-1449 Cancer and Specked Disease Expense Insurance c/o Bay Bridge Administrators, LLC P.O. Box 161690 Austin, TX 78716 © 2019 MetLife Services and Solutions, LLC 210000000000002049 (0219) Printed in U.S.A • Right to File a Complaint: If you believe your Privacy rights have been violated, you may file a complaint with us or with the Secretary of the U.S. Department of Health and Human Services. To file a complaint with us, please contact MetLife, Americas — U.S. HIPAA Privacy Office, P.O. Box 902, New York, NY 10159-0902. All complaints must be submitted in writing. You will not be penalized for filing a complaint. If you have questions as to how to file a complaint, please contact us at telephone number (212) 578-0299 or at HIPAAorivacvAmericasUS &metlife.com. ADDITIONAL INFORMATION Changes to This Notice: We reserve the right to change the terms of this notice at any time. We reserve the right to make the revised or changed notice effective for PHI we already have about you, as well as any PHI we receive in the future. The effective date of this notice and any revised or changed notice may be found on the last page, on the bottom right-hand corner of the notice. You will receive a copy of any revised notice from MetLife by mail or by e-mail, if e-mail delivery is offered by MetLife and you agree to such delivery. Further Information: You may have additional rights under other applicable laws. For additional information regarding our HIPAA Medical Information Privacy Policy or our general privacy policies, please e-mail us at HIPAAorivacvAmericasUS(a.metlife.com or call us at telephone number (212) 578-0299, or write us at: MetLife, Americas U.S. HIPAA Privacy Office P.O. Box 902 New York, NY 10159-0902 Effective Date: 09202022 Uniformed Services Employment And Reemployment Rights Act This section describes the right that you may have to continue coverage for yourself and your covered dependents under the Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA) Continuation of Group Vision Insurance: If you take a leave from employment for "service in the uniformed services," as that term is defined in USERRA, and as a consequence your vision insurance coverage under your employer's group vision insurance policy ends, you may elect to continue vision insurance for yourself and your covered dependents, for a limited period of time, as described below. The law requires that your employer notify you of your rights, benefits and obligations under USERRA including instructions on how to elect to continue insurance, the amount and procedure for payment of premium. If permitted by USERRA, your employer may require that you elect to continue coverage within a period of time specified by your employer. You may be responsible for payment of the required premium to continue insurance. If your leave from employment for service in the uniformed services lasts less than 31 days, your required premium will be no more than the amount you were required to pay for vision insurance before the leave began; for a leave lasting 31 or more days, you may be required to pay up to 102% of the total vision insurance premium, including any amount that your employer was paying before the leave began. Your and your covered dependents' insurance that is continued pursuant to USERRA will end on the earliest of the following: • the end of 24 consecutive months from the date your leave from employment for service in the uniformed services begins; or • the day after the date on which you fail to apply for, or return to employment, in accordance with USERRA. You and your covered dependent may become entitled to continuation of coverage under the Consolidated Omnibus Budget Reconciliation Act ("COBRA") while you have vision insurance coverage under your employer's group vision insurance policy pursuant to USERRA. Contact your employer for more information. 4 MetLife Teresa Niner, HR Versant Template 400 Locust Street, Suite 820 Des Moines, IA 50309 Re: Metropolitan Life Insurance Company - Policy Number(s): VH504834-1-0 Certificate(s) effective [Month Day, Year] Dear Teresa Niner: To ensure our new customers receive the necessary information regarding coverage under their MetLife group insurance policy(ies), we are sending under separate cover a supply of certificates for you to distribute to all covered employees. In addition to the certificates, you may also want us to send your company an electronic version of the group insurance certificate information. In this case, the terms and conditions contained in the attached form will apply to your company's use of the electronic version of the certificate information. Please check the box if your company is requesting an electronic version of the certificate information. If you have any questions, please call me at (630) 820-7594. Sincerely, Glenda Millhouse Client Service Consultant Employee Benefits Sales Metropolitan Life Insurance Company 177 S Commons Drive, Aurora, IL 60504 Tel (630) 820-7594 Fax [Month Day, Year] cc. Shawn Domark, Acct Executive [and/or Broker, if applicable] Commented [KE21]: Delete this page and the 2 pages following Commented [WA22]: Still confirming if we need to issue cent letter. Sent the question to legal to confirm. Customer Letter G1 Request for Electronic Version of Certificate Information (Check below if applicable and sign and return a copy to MetLife) Versant Template shall not modify in any manner, and shall maintain the integrity of, the electronic version of the certificate information and the notice to insureds, which is included with the electronic version. This notice advises all who view the electronic version that: (i) Versant Template maintains the group policy (which includes the certificate of insurance), (ii) the group policy can be reviewed and copied, and (iii) the group policy controls, in all respects, as to the terms and conditions of insurance. Versant Template will indemnify MetLife from any and all claims, damages, and liability that occurs as a result of any failure to comply with the terms of this paragraph. It is requested that an electronic version of the group insurance certificate informatio n be sent by MetLife for Versant Template to use in accordance with the terms and conditions outlined above. By: Signature Title: Date: Quantity and Delivery Instructions Certificate Title (e.g. Life Class 1) Quantity Contact Name Company Address 1 (Cannot be a PO Box) Address 2 City, State, Zip Telephone Number Certificate Title (e.g. Life Class 1) Quantity Contact Name Company Address 1 (Cannot be a PO Box) Address 2 City, State, Zip Telephone Number Certificate Title (e.g. Life Class 1) Quantity Contact Name Company Address 1 (Cannot be a PO Box) Address 2 City, State, Zip Telephone Number For more than three locations or certificates, please attach additional copies of this form or an excel spreadsheet with the information shown above. i T MetLife � — Metropolitan Life Insurance Company 200 Park Avenue, New York, New York 10166 Metropolitan Life Insurance Company ("MetLife"), a stock company, will pay the benefits specified in the Exhibits of this policy subject to the terms and provisions of this policy. Policyholder: Group Policy No.: EFFECTIVE DATE CUSTOMER NAME VHXXXXXX-B-1-G This policy will take effect on May 1, 2022. POLICY ANNIVERSARIES The first Policy Anniversary will be May 1, 2023. Subsequent Policy Anniversaries will be May 1, 2024 and each May 1 st thereafter. PREMIUM PAYMENTS This policy, and the insurance provided under it, is issued in return for the payment of required Premiums. Premiums are payable at the home office of MetLife or to its authorized agent. The first Premium is due on and must be paid on or before this policy's Effective Date. Any later Premiums are due monthly in advance on the first day of each Policy Month. These dates are the Premium Due Dates. MetLife and the Policyholder may agree upon a different frequency for the payment of Premiums. In that case, Premium Due Dates will be adjusted to reflect the agreed upon frequency. POLICY SITUS This policy is issued for delivery in and governed by the laws of New Jersey. Signed as of this policy's effective date at MetLife's home office in New York, New York. .e_ - (-� .. L / �� ---� - Timothy J. Ring Secretary Michel Khalaf President GPNP15-2T-fp Page 1 TABLE OF CONTENTS Section Page POLICY FACE PAGE EffectiveDate...................................................................................................................................................1 PolicyAnniversaries.........................................................................................................................................1 PremiumPayments..........................................................................................................................................1 "".0. PolicySitus.......................................................................................................................................................1 TABLEOF CONTENTS.......................................................................................................................................2 DEFINITIONS......................................................................................................................................................3 SCHEDULEOF INSURANCE.............................................................................................................................4 ELIGIBILITY AND EFFECTIVE DATES OF INSURANCE..................................................................................4 PREMIUM RATE(S) InitialRate(s).....................................................................................................................................................5 Computationof Premium..................................................................................................................................5 Computation of Premiums for Changes in Insurance.......................................................................................5 Rightto Change Premium Rates......................................................................................................................5 GRACEPERIOD................................................................................................................................a.................7 END OF INSURANCE PROVIDED BY THIS POLICY........................................................................................8 GENERALPROVISIONS.....................................................................................................................................9 EntireContract..................................................................................................................................................9 PolicyChanges or Waivers..............................................................................................................................9 Incontestability: Statements Made by the Policyholder..................................................................................10 Incontestability: Statements Made by Covered Persons...................._._........................................................10 Certificates......................................................................................: .......................................... .....................10 Information Needed and Policy Administration..............................................................................................10 Misstatementof Age ........................................................ ......................................................................10 Non -Dividend Paying.................................................................................................................................11 ; Conformitywith Law.......................................................................................................................................11 SCHEDULE OF EXHIBITS....................................................... ................................................... SCH/EXHIBITS EXHIBIT 1: Schedule of Premium Rates...........................................................................................EXHIBIT1 EXHIBIT 2: Certificate Forms.............................................................................................................EXHIBIT2 GPNP15-2T4oc Page 2 DEFINITIONS As used in this policy, the terms listed below will have the meanings defined below. When defined terms are used in this policy, they will appear with initial capitalization. The plural use of a term defined in the singular and the singular use of a term defined in the plural will share the same meaning. Contribution means any amount the Policyholder is required to pay toward the total Premium that MetLife charges for the insurance provided by this policy. Contributory Insurance means any insurance for which the Policyholder is required to make a Contribution. Covered Person means an Employee who is the subject of insurance under the certificates attached to the policy as Exhibits. Dependent means any person who qualifies as a Dependent under the certificates attached to the policy as Exhibits. Employee means any person who qualifies as an Employee under the certificates attached to the policy as Exhibits. Employer means the Policyholder shown on the face page of this policy. Exhibit means any attachment to this policy referred to in the Schedule of Exhibits. Exhibits to this policy include the certificates and any riders attached to such certificates; a Schedule of Initial Premium Rates; and such other attachments as agreed to by MetLife and the Policyholder. Certificateholder means an Employee who is a Covered Person. Unless otherwise specified, the Certificateholder is entitled to exercise the rights and benefits granted under the certificates attached to the policy as Exhibits. Noncontributory Insurance means any insurance for which the Employee is not required to make a Contribution. Policy Anniversary means each of the Policy Anniversary dates as set forth in the Policy Anniversaries provision on the policy face page. The Policy Anniversary is also the renewal date of the policy. Policy Month means the one month period beginning on the Effective Date shown on the face page of this policy. Subsequent Policy Months will begin on the same day of each subsequent month. Policyholder means the entity listed as the Policyholder on the face page of this policy. Premium means the amount that must be paid to MetLife for all the insurance provided under this policy. Premium Due Date is defined on the face page of this policy. Signed means any symbol or method executed or adopted by a person with the present intention to authenticate a record, and which is on or transmitted by paper, electronic media, or other durable media and which is consistent with applicable law. Written or Writing means a record which is on or transmitted by paper, electronic media, or other durable media and which is consistent with applicable law. GPNP15-2T-def Page 3 SCHEDULE OF INSURANCE The schedules of insurance which apply under this policy are set forth in the Exhibits and certificates attached to this policy as Exhibits. ELIGIBILITY AND EFFECTIVE DATES OF INSURANCE The Eligibility and Effective Dates of Insurance provisions provided under this policy are set forth in the Exhibits to this policy and the appropriate records of MetLife and the Policyholder. Provisions setting forth the conditions, if any, under which MetLife requires a person to furnish evidence of good health satisfactory to MetLife to obtain coverage are also set forth in the Exhibit(s). GPNP15-2T-sch Page 4 PREMIUM RATE(S) Initial Rate(s) The initial Premium rate(s) are shown in the Exhibits to this policy. Computation of Premium The Premium due on any Premium Due Date is determined by the total number of Covered Persons, multiplied by the appropriate Premium rate(s) which are then in effect subject to any Premium adjustments, if applicable. MetLife may use any reasonable method to compute Premiums due. Computation of Premiums for Changes in Insurance For insurance that takes effect on the first day of a Policy Month, Premium will be charged from the first day of that Policy Month. For insurance that takes effect after the first day of a Policy Month, Premium will be charged from the first day of the next Policy Month. If insurance ends because this policy ends or because insurance for a class of persons ends, Premium for such insurance will be charged to the date it ends. If insurance ends for any other reason, Premium will be charged to the end of the Policy Month in which such insurance ends. If insurance ends for other reasons, Premium will be charged to the end of the Policy Month in which insurance ends. Right to Change Premium Rates Except as may be required by any Rate Guarantee Period, MetLife may change Premium rates on any date on or after the first Policy Anniversary Date; this will be done no more frequently than every 12 months and only if MetLife notifies the Policyholder, in Writing, at least 31 days before such change. In addition to the above and notwithstanding any rate guarantee period, MetLife may change Premium rates at any time for changes which materially affect the risk or cost assumed for the insurance provided by this policy, as follows: 1. when this policy is amended or endorsed; 2. when a class of eligible persons is added to or deleted from this policy for any reason including organizational restructuring, acquisition, spin-off or similar situations; 3. when a Policyholder's subsidiary, affiliate, division, branch or other similar entity is added to or deleted from this policy for any reason including organizational restructuring, acquisition, spin-off or similarsituations; 4. when there is a significant change in the geographic distribution of either Certificateholders or Employees; GPNP15-2T-premiums Page 5 PREMIUM RATES (Continued) 5. when applicable law or regulatory requirements or the administration of such law or regulatory requirements: a. requires a change in: i. the insurance provided by this policy; and/or ii. a class or classes of persons eligible for insurance under this policy; b. results in a change in the amount of benefits paid under this policy; or c. requires additional tax(es) to be paid 6. when a Premium Due Date coincides with or next follows: a. a change greater than 10% in the number of Covered Persons since the later of the policy Effective Date and the last date Premium rates were changed; or b. a change greater than 10% in the amount of insurance provided by this policy since the later of the policy Effective Date and the last date Premium rates were changed. 7. on any other date agreed to by MetLife and the Policyholder. New Premium rates will apply only to Premiums that become due on or after the date the rate change takes effect. GPNP15-2T-premiums Page 6 GRACE PERIOD Each Premium due after the effective date of such insurance may be paid up to 31 days after its Premium Due Date. This period is known as the grace period. The insurance provided by this policy for which premium has not been paid will stay in effect during the grace period. MetLife will notify the Policyholder in Writing that, if the Premium is not paid by the end of the grace period, such insurance will end at the end of the last day of the grace period. If MetLife fails to give Written notice to the Policyholder by the end of the grace period, such insurance will continue in effect until the date notice is given. Policyholder's intent to end this policy during the grace period The Policyholder may notify MetLife in Writing prior to the end of a grace period of its intent to end this policy or insurance coverage provided under it before the end of such grace period. In this case, this policy or such insurance will end on the later of. 1. the date stated in the notice; or 2. the date MetLife receives the notice. The Written notice to be given by MetLife and required by the first paragraph of this provision will not be necessary if the Policyholder replaces the insurance provided by this policy for which premium has not been paid with other group insurance or the Policyholder notifies MetLife of its intent to end this policy or such insurance. If more than one type of insurance coverage is provided under this policy then, to the extent there are different Premium Due Dates or different length grace periods for such coverages, this grace period provision will apply to each coverage independently of the others. If more than one type of insurance coverage is provided under this policy, then to the extent such coverages have the same Premium Due Dates and the same length grace period, this grace period provision will apply to all such coverages simultaneously so that in the absence of written notice from the Policyholder of its intent to end a specific coverage, failure to pay the entire premium due by the end of the grace period will end all coverage under the policy. Grace period extensions MetLife may extend the grace period by giving Written notice to the Policyholder. Such notice will state the date insurance will end if the Premium remains unpaid. Premiums must be paid for a grace period, any extension of such period and any period insurance was in effect for which Premium was not paid. GPNP15-2T-endofins Page 7 END OF INSURANCE PROVIDED BY THIS POLICY The Policyholder may end this policy by giving 60 days advance Written notice to MetLife. The policy will end on the later of: 1. the date stated in the notice; or 2. the date MetLife receives the notice. MetLife may end this policy as follows: 1. for non-payment of Premium, as set forth in the Grace Period provisions; 2. on any Premium Due Date, by giving the Policyholder 31 days advance Written notice, if fewer than: a. 5% of persons eligible under this policy are insured for Contributory Insurance; b. 10 Employees are insured by this Policy; 3. on any Premium Due Date, by giving the Policyholder 60 days advance Written notice, if the Policyholder fails to provide information on a timely basis or perform any obligations required by this policy or any applicable law; or 4. on any Policy Anniversary by giving the Policyholder 31 days advance Written notice. This policy will end on the date on which the last certificate in effect under this policy ends. If this policy ends, all Premiums due must be paid. If MetLife accepts Premium after the date this policy ends, such acceptance will not act to reinstate the policy. MetLife will refund any unearned Premium. GPNP15-2T-endofins Page 8 GENERAL PROVISIONS Entire Contract. The entire contract is made up of the following: 1. policy Exhibits including the certificates; 2. the Policyholder's application; and 3. the amendments and endorsements to this policy, if any. Policy Changes or Waivers The terms and provisions of this policy may be changed, either by amendment or endorsement. 1. The policy may be changed by amendment upon the mutual agreement of MetLife and the Policyholder. Such amendment must be in Writing and Signed by an officer of MetLife and by an authorized representative of the Policyholder. 2. The policy may be changed by an endorsement issued by MetLife without the consent of the Policyholder. Such endorsement must be in Writing and Signed by an officer of MetLife. The use of endorsements is limited to: a. changes made in response to : • applicable local, state or federal law or regulation; • a change in applicable local, state or federal law or regulation; or • the administration of applicable local, state or federal law or regulation; b. reflect changes in Metl-ife's administrative practices; c. reflect policy liberalizations to the extent that they do not increase Premiums; d. incorporate provisions agreed upon prior to issuance of this policy; and e. reflect the exercise of a right or rights set forth under -the terms of the policy. Changes to the policy may be made without the consent of the Certificateholders or anyone else with a beneficial interest in it. MetLife will only make changes that are consistent with applicable law. An amendment or endorsement may be effective retroactively if such retroactivity is not prohibited by applicable law. An officer of MetLife must approve in Writing any waiver of the terms and provisions of this policy. A sales representative or other MetLife employee, who is not an officer of MetLife does not have MetLife's authority to approve changes or waivers. A copy of the amendment or endorsement will be provided to the Policyholder for attachment to this policy. GPNP15-2T-genpro NJ Page 9 GENERAL PROVISIONS (Continued) Incontestability: Statements Made by the Policyholder Any statement made by the Policyholder will be considered a representation and not a warranty. MetLife will not use such a statement to contest insurance after such insurance has been in force for 2 years from its effective date. MetLife will not use such statement to avoid insurance, reduce benefits or defend a claim unless it is contained in a Written application. Incontestability: Statements Made by Covered Persons Any statement made by a Covered Person or a Covered Person's legal representative will be considered a representation and not a warranty. MetLife will not use statements which relate to insurability to contest insurance after such insurance has been in force for 2 years during the Covered Person's life. In addition, MetLife will not use such statements to contest an increase or benefit addition to such insurance after the increase or benefit has been in force for 2 years during the Covered Person's life. MetLife will not use such statement to avoid insurance, reduce benefits or defend a claim unless the following requirements are met: 1. the statement is in a Written application or enrollment form; 2. the Covered Person or the Covered Person's legal representative has Signed the application or enrollment form; and 3. a copy of the application or enrollment form has been given to the Covered Person, the Covered Person's legal representative or the Covered Person's beneficiary. Certificates MetLife will issue certificates to the Policyholder or the Policyholder's designee for delivery to each Certificateholder, as appropriate. Such certificate will describe the Certificateholder's benefits and rights under this policy and are Exhibits to the policy. The term "certificate" includes certificate riders. Information Needed and Policy Administration All information necessary to compute Premiums and carry out the terms of this policy will be provided by the Policyholder to MetLife. Such information: • Must be provided in a timely manner and in a format as agreed to by MetLife and the Policyholder; Will be provided, maintained and administered as agreed to in writing by an officer of MetLife and the Policyholder; and • If maintained by the Policyholder, may be examined by MetLife at any reasonable time. If MetLife or the Policyholder makes a clerical error in keeping or providing the information, the Premium and/or benefits will be adjusted as warranted, according to the correct information. An error will not end insurance validly in effect, nor will it continue insurance validly ended or create insurance coverage where no coverage existed Any act undertaken by the Policyholder that relates to the insurance provided under this policy must be consistent with the terms of such insurance and with MetLife's requirements; including but not limited to the eligibility requirements for coverage as set forth in the certificates to this policy. Misstatement of Age If a Covered Person's age is misstated, the correct age will be used to determine if insurance is in effect and, as appropriate, adjust the Premium and/or benefits. GPNP15-2T-genpro NJ Page 10 GENERAL PROVISIONS (Continued) Non -Dividend Paying This policy does not pay dividends. Conformity with Law The provisions of this policy conform to the minimum requirements of Montana law and control over any conflicting statues of any state in which an insured resides on or after the effective date of this policy. GPNP15-2T-genpro NJ Page 11 SCHEDULE OF EXHIBITS Exhibit Number Exhibit Type 1 2 Schedule of Premium Rates Certificate Forms Applies To All Covered Persons All Covered Persons Effective Date May 1, 2022 May 1, 2022 GPNP15-2T SCH-EXHIBITS DATE: May 1, 2022 Page 12 EXHIBIT 1 SCHEDULE OF INITIAL PREMIUM RATES The initial monthly Premium rates for the insurance provided by this policy are as follows: Vision Insurance: $9.26 per Employee insured hereunder for Vision Insurance. GPNP15-2T-EXHIBIT DATE: May 1, 2022 Page 13 EXHIBIT 2 CERTIFICATE FORMS Certificate Number Certificate Form Applies To GCERT2000 All Covered Persons Effective Date May 1, 2022 GPNP15-2T-EXHIBIT DATE: May 1, 2022 Page 14 THIS IS THE END OF THE GROUP INSURANCE POLICY. THE FOLLOWING IS ADDITIONAL INFORMATION REGARDING GUARANTEE ASSOCIATION NOTICES. DETACH AND SAVE THESE AS.A SEPARATE DOCUMENT. ALASKA Summary Concerning Coverage, Limitations, and Exclusions under the Alaska Life and Health Insurance Guaranty Association Act A resident of Alaska who purchases life insurance, annuities, or accident and health insurance should know that an insurance company licensed in the state to write these types of insurance is a member of the Alaska Life and Health Insurance Guaranty Association. The purpose of this association is to assure that a policyholder will be protected within statutory limits if a member insurer becomes financially unable to meet its obligations. If this should happen, the guaranty association will assess its other member insurance companies for the money to pay the claims of insured persons who live in this state, and in some cases, to keep coverage in force. However, the valuable extra protection provided by these insurers through the guaranty association is not unlimited. This protection is not a substitute for your care in selecting a company that is well managed and financially stable. The state law that provides for this safety net coverage is called the Alaska Life and Health Insurance Guaranty Association Act. The full text of the act can be found in AS 21.79.010 — 21.79.990. Provided below is a brief summary of this law's coverages, exclusions, and limits. This summary does not cover all provisions of the law, nor does it in any way change your rights or cw COVERAGE Generally, an individual will be protected by the life and health insurance guaranty association if the individual lives in Alaska and holds a life or health insurance contract or annuity contract, or if the insured is insured under a group insurance contract issued by a member insurer. The beneficiary, payee, or assignee of an insured person is protected as well, even if a non-resident of Alaska. EXCLUSIONS FROM COVERAGE The association does not protect a person holding a policy if: the individual is eligible for protection under the laws of another state (this may occur when the insolvent insurer was incorporated in another state whose guaranty association protects insureds who live outside that state); the insurer was not authorized to do business in this state; or the policy is issued by an organization that is not a member of the Alaska Life and Health Insurance Guaranty Association. The association does not provide coverage for: • a policy or portion of a policy which is not guaranteed by the insurer or for which the individual has assumed the risk, such as a variable contract sold by prospectus; • a policy of reinsurance (unless an assumption certificate was issued); • an interest rate yield that exceeds an average rate; • a dividend; • a credit given in connection with the administration of a policy by a group contract holder; • an employer's plan to the extent that it is self -funded (that is, not insured by an insurance company, even if an insurance company administers the plan); • an unallocated annuity contract issued to an employee benefit plan protected under the United States Pension Benefit Guaranty Corporation. • that part of an unallocated annuity contract not issued to a specific employee; union, association of natural persons benefit plan, or a government lottery; EN-GUAR-11-18 AK • any portion of a policy or contract to the extent that the required assessments are preempted by federal or state law; • an obligation that does not arise under the express written terms of the policy or contract issued by the insurer; • certain obligations to provide a book value accounting guaranty for defined contribution benefit plan participants; or • that part of a policy or contract that provides for interest or other changes in value to be determined by the use of an index or other external reference stated in the policy or contract. LIMITS ON AMOUNT OF COVERAGE The act also limits the amount the association is obligated to pay. The association cannot pay more than what the insurance company would owe under a policy or contract. Also, for any one insured life, no matter how many policies or contracts were issued by the same company, even if such contracts provided different types of coverages, the association will pay a maximum of. • $300,000 in net life insurance death benefits and no more than $100,000 in net cash surrender and net cash withdrawal values for life insurance; • for health insurance benefits, $100,000 for coverages not defined as disability income, health benefit plans or long-term care insurance, including any net cash surrender and net cash withdrawal values; • $300,000 for disability income insurance and long-term care insurance; • $500,000 for health benefit plans; • $250,000 in the present value of annuity benefits; including net cash surrender and net cash withdrawal value; • with respect to a structured settlement annuity, $250,000 in present value annuity benefits, in the aggregate, including net cash surrender and net cash withdrawal values; • $250,000 in the aggregate, of present -value annuity benefits, including net cash surrender and net cash withdrawal values with respect to an individual participating in a governmental retirement plan established under 26 U.S.C. 401, 26 U.S.C.403(b), or 26 U.S.C. 457 and covered by an unallocated annuity contract, or to a beneficiary of the individual if the individual is deceased; or • $5,000,000 in unallocated annuity contract benefits, irrespective of the number of contracts held by that contract holder, with respect to any one contract holder or plan sponsor whose plan owns, directly or in trust, one or more unallocated annuity contracts. Note to benefit plan trustees or other holders of unallocated annuities (GICs, DA Cs, etc.) covered by the act., for unallocated annuities that fund government retirement plans under sections 401(k), 403(b), or 457 of the Internal Revenue Code, the limit is $250,000 in present value of annuity benefits including net cash surrender and net cash withdrawal per participating individual. In no event shall the association be liable to spend more than $300,000 in the aggregate per individual. For covered unallocated annuities that fund other plans, a special limit of $5,000,000 applies to each contract holder, regardless of the number of contracts held with the same company or number of persons covered. In all cases the contract limits also apply. COMPLAINTS AND COMPANY FINANCIAL INFORMATION A written complaint to allege violation of any provision of the Alaska Life and Health Insurance Guaranty Association Act must be filed with the Division of Insurance, 550 West Seventh Avenue, Suite 1560, Anchorage, Alaska, 99501-3567; telephone (907)269-7900. Financial information for an insurance company, if the insurance information is not proprietary, is available at the same address and telephone number. The guaranty association should not be contacted regarding the financial information of an insurance company. EN-GUAR-11-18 AK The association is not an agency of the State of Alaska nor are there any guarantees by the State of Alaska regarding the payment of claims by the association. The guaranty association is not your insurance company. Alaska Life and Health Insurance Guaranty Association P.O. Box 220207 Anchorage, Alaska 99522-0207 (907)243-2311 Division of Insurance 550 West Seventh Avenue, Suite 1560 Anchorage, Alaska 99501-3567 (907)269-7900 .4 EN-GUAR-11-18 AK TEXAS How you're protected if your life or health insurance company fails The Texas Life and Health Insurance Guaranty Association protects you by paying your covered claims if your life or health insurance company is insolvent (can't pay its debts). This notice summarizes your protections. The Association will pay your claims, with some exceptions required by law, if your company is licensed in Texas and a court has declared it insolvent. You must live in Texas when your company fails. If you don't live in Texas, you may still have some protections. For each insolvent company, the Association will pay a person's claims only up to these dollar limits set by law: • Accident, accident and health, or health insurance (including HMOs): o Up to $500,000 for health benefit plans, with some exceptions. o Up to $300,000 for disability income benefits. o Up to $300,000 for long-term care insurance benefits. o Up to $200,000 for all other types of health insurance. • Life insurance: Up to $100,000 in net cash surrender or withdrawal value. o Up to $300,000 in death benefits. • Individual annuities: Up to $250,000 in the present value of benefits, including cash surrender and net cash withdrawal values. • Other policy types: Limits for group policies, retirement plans and structured settlement annuities are in Chapter 463 of the Texas Insurance Code. • Individual aggregate limit: Up to $300,000 per person, regardless of the number of policies or contracts. A limit of $500,000 may apply for people with health benefit plans. • Parts of some policies might not be protected: For example, there is no protection for parts of a policy or contract that the insurance company doesn't guarantee, such as some additions to the value of variable life or annuity policies. To learn more about the Association and your For questions about insurance, contact: protections, contact: Texas Life and Health Insurance Guaranty Texas Department of Insurance Association P.O. Box 149104 515 Congress Avenue, Suite 1875 Austin, TX 78714-9104 Austin, TX 78701 1-800-252-3439 or www.tdi.texas.gov 1-800-982-6362 or www.b(lifega.org Note: Yo&e receiving this notice because Texas law requires your insurance company to send you a summary of your protections under the Texas Life and Health Insurance Guaranty Association Act (Insurance Code, Chapter 463). These protections apply to insolvencies that occur on or after September 1, 2019. There may be other exceptions that aren't included in this notice. When choosing an insurance company, you should not rely on the Association's coverage. Texas law prohibits companies and agents from using the Association as an inducement to buy insurance or HMO coverage. Chapter 463 controls if there are differences between the law and this summary. EN-GUAR-12-19 TX ARKANSAS LIMITATIONS AND EXCLUSIONS UNDER THE ARKANSAS LIFE AND HEALTH INSURANCE GUARANTY ASSOCIATION ACT Residents of this state who purchase life insurance, annuities or health insurance should know that the insurance companies licensed in this state to write these types of insurance are members of the Arkansas Life and Health Insurance Guaranty Association ("Guaranty Association"). The purpose of the Guaranty Association is to assure that policy and contract owners will be protected, within certain limits, in the unlikely event that a member insurer becomes financially unable to meet its obligations. If this should happen, the Guaranty Association will assess its other member insurance companies for the money to pay the claims of policy and contract owners who live in this state and, in some cases, to keep coverage in force. Please note that the valuable extra protection provided by the member insurers through the Guaranty Association is limited. This protection is not a substitute for a consumers' careful consideration in selecting insurance companies that are well managed and financially stable. DISCLAIMER The Arkansas Life and Health Insurance Guaranty Association ("Guaranty Association") provides coverage of claims under some types of policies or contracts if the insurer or health maintenance organization becomes impaired or insolvent. COVERAGE MAY NOT BE AVAILABLE FOR YOUR POLICY. Even if coverage is provided, there are significant limits and exclusions. Coverage is always conditioned on residence in the State of Arkansas. Other conditions may also preclude coverage. The Guaranty Association will respond to any questions you may have which are not answered by this document. Your insurer or health maintenance organization and agent are prohibited by law from using the existence of the association or its coverage to sell you an insurance policy or health maintenance organization coverage. You should not rely on availability of coverage under the Guaranty Association when selecting an insurer or health maintenance organization. The Arkansas Life and Health Insurance Guaranty Association c/o The Liquidation Division 1023 West Capitol Little Rock, Arkansas 72201 Arkansas Insurance Department 1 Commerce Way, Suite 102 Little Rock, Arkansas 72202 The state law that provides for this safety net is called the Arkansas Life and Health Insurance Guaranty Association Act ("Act"), which is codified at Ark. Code Ann. §§ 23-96-101, et. seq. Below is a brief summary of the Act's coverages, exclusions and limits. This summary does not cover all provisions of the Act, nor does it in any way change any person's rights or obligations under the Act or the rights or obligations of the Guaranty Association. EN-GUAR-11-21 AR COVERAGE Generally, individuals will be protected by the Guaranty Association if they live in this state and hold a life, annuity or health insurance contract or policy, or if they are insured under a group insurance contract issued by a member insurer. The beneficiaries, payees or assignees of policy or contract owners are protected as well, even if they live in another state. EXCLUSIONS FROM COVERAGE However, persons owning such policies are NOT protected by the Guaranty Association if: • They are eligible for protection under the laws of another state (this may occur when the insolvent insurer was incorporated in another state whose guaranty association protects insureds who live outside that state); • The insurer was not authorized to do business in this state; or • Their policy or contract was issued by a hospital or medical service organization, a fraternal benefit society, a mandatory state pooling plan, a mutual assessment company or similar plan in which the policy or contract owner is subject to future assessments, or by an insurance exchange. The Guaranty Association also does NOT provide coverage for: • Any policy or contract or portion thereof which is not guaranteed by the insurer or for which the owner has assumed the risk, such as non -guaranteed amounts held in a separate account under a variable life or variable annuity contract; • Any policy of reinsurance (unless an assumption certificate was issued); • Interest rate yields that exceed an average rate; • Dividends, voting rights and experience rating credits; • Credits given in connection with the administration of a policy by a group contract holder; • Employer plans to the extent they are self funded (that is, not insured by an insurance company, even if an insurance company administers them); • Unallocated annuity contracts (which give rights to group contractholders, not individuals); • Unallocated annuity contracts issued to or in connection with benefit plans protected under Federal Pension Benefit Corporation ("FPBC") regardless of whether the FPBC is yet liable; • Portions of an unallocated annuity contract not owned by a benefit plan or a government lottery (unless the owner is a resident) or issued to a collective investment trust or similar pooled fund offered by a bank or other financial institution); • Portions of a policy or contract to the extent assessments required by law for the Guaranty Association are preempted by state or federal law; • Obligations that do not arise under the policy or contract, including claims based on marketing materials or side letters, riders, other documents which do not meet filing requirements, claims for policy misrepresentations, and extra -contractual or penalty claims: or • Contractual agreements establishing the member insurer's obligations to provide book value accounting guarantees for defined contribution benefit plan participants by reference to a portfolio of assets owned by a nonaffiliate benefit plan or its trustee(s). EN-GUAR-11-21 AR LIMITS ON AMOUNT OF COVERAGE The Act also limits the amount the Guaranty Association is obligated to cover. The Guaranty Association cannot pay more than what the insurance company would owe under a policy or contract. Also, for any one insured life, the Guaranty Association will pay a maximum of $300,000 in life insurance death benefits without regard to the number ofpolicies and contracts there were with the same company, even if they provided different types of coverages. The Guaranty Association will pay a maximum of $500,000 in health benefits, provided that coverage for disability insurance benefits and long-term care insurance benefits shall not exceed $300,000. The Guaranty Association will pay $300,000 in present value of annuity benefits, including net cash surrender and net cash withdrawal values. There is a $1,000,000 limit with respect to any contract holder for unallocated annuity benefits. These are limitations under which the Guaranty Association is obligated to operate prior to considering either its subrogation and assignment rights or the extent to which those benefits could be provided from assets of the impaired or insolvent insurer. EN-GUAR-11-21 AR CALIFORNIA NOTICE OF PROTECTION PROVIDED BY CALIFORNIA LIFE AND HEALTH INSURANCE GUARANTEE ASSOCIATION This notice provides a brief summary regarding the protections provided to policyholders by the California Life and Health Insurance Guarantee Association ("the Association"). The purpose of the Association is to assure that policyholders will be protected, within certain limits, in the unlikely event that a member insurer of the Association becomes financially unable to meet its obligations. Insurance companies licensed in California to sell life insurance, health insurance, annuities and structured settlement annuities are members of the Association. The protection provided by the Association is not unlimited and is not a substitute for consumers' care in selecting insurers. This protection was created under California law, which determines who and what is covered and the amounts of coverage. Below is a brief summary of the coverages, exclusions and limits provided by the Association. This summary does not cover all provisions of the law; nor does it in any way change anyone's rights or obligations or the rights or obligations of the Association. • Persons Covered Generally, an individual is covered by the Association if the insurer was a member of the Association and the individual lives in California at the time the insurer is determined by a court to be insolvent. Coverage is also provided to policy beneficiaries, payees or assignees, whether or not they live in California. • Amnuntc of Cnvarana The basic coverage protections provided by the Association are as follows • Life Insurance. Annuities and Structured Settlement Annuities For life insurance policies, annuities and structured settlement annuities, the Association will provide the following: • Life Insurance 80% of death benefits but not to exceed $300,000 80% of cash surrender or withdrawal values but not to exceed $100,000 • Annuities and Structured Settlement Annuities 80% of the present value of annuity benefits, including net cash withdrawal and net cash surrender values but not to exceed $250,000 The maximum amount of protection provided by the Association to an individual, for a// life insurance, annuities and structured settlement annuities is $300,000, regardless of the number of policies or contracts covering the individual. • Health Insurance The maximum amount of protection provided by the Association to an individual, as of October 1, 2016, is $554,556. This amount will increase or decrease based upon changes in the health care cost component of the consumer price index to the date on which an insurer becomes an insolvent insurer. EN-GUAR-11-16 CA The Association may not provide coverage for this policy. Coverage by the Association generally requires residency in California. You should not rely on coverage by the Association in selecting an insurance company or in selecting an insurance policy. The following policies and persons are among those that are excluded from Association coverage: • A policy or contract issued by an insurer that was not authorized to do business in California when it issued the policy or contract • A policy issued by a health care service plan (HMO), a hospital or medical service organization, a charitable organization, a fraternal benefit society, a mandatory state pooling plan, a mutual assessment company, an insurance exchange, or a grants and annuities society • If the person is provided coverage by the guaranty association of another state. • Unallocated annuity contracts; that is, contracts which are not issued to and owned by an individual and which do not guaranty annuity benefits to an individual • Employer and association plans, to the extent they are self -funded or uninsured • A policy or contract providing any health care benefits under Medicare part C or Part D • An annuity issued by an organization that is only licensed to issue charitable gift annuities • Any policy or portion of a policy which is not guaranteed by the insurer or for which the individual has assumed the risk, such as certain investment elements of a variable life insurance policy or a variable annuity contract • Any policy of reinsurance unless an assumption certificate was issued • Interest rate yields (including implied yields) that exceed limits that are specified in Insurance Code Section 1607.02(b)(2)(C). Insurance companies or their agents are required by law to give or send you this notice. Policyholders with additional questions should first contact their insurer or agent. To learn more about coverages provided by the Association, please visit the Association's website at www.califega.org, or contact with of the following: California Life and Health Insurance Guarantee Association P.O. Box 16860, Beverly Hills, CA 90209-3319 (323) 782-0182 California Department of Insurance Consumer Communications Bureau 300 South Spring Street Los Angeles, CA 90013 (800) 927-4357 Insurance companies and agents are not allowed by California law to use the existence of the Association or its coverage to solicit, induce or encourage you to purchase any form of insurance. When selecting an insurance company, you should not rely on Association coverage. If there is any inconsistency between this notice and California law, then California law will control. EN-GUAR-11-16 CA COLORADO NOTICE OF PROTECTION PROVIDED BY LIFE AND HEALTH INSURANCE PROTECTION ASSOCIATION This notice provides a brief summary of the Life and Health Insurance Protection Association ("the Association") and the protection it provides for policyholders. This safety net was created under Colorado law, which determines who and what is covered and the amounts of coverage. The Association was established to provide protection in the unlikely event that your life, annuity or health insurance company becomes financially unable to meet its obligations and is taken over by its Insurance Department. If this should happen, the Association will typically arrange to continue coverage and pay claims, in accordance with Colorado law, with funding from assessments paid by other insurance companies. The basic protections provided by the Association are: Life Insurance $300,000 in death benefits $100,000 in cash surrender or withdrawal values Health Insurance $500,000 in hospital, medical and surgical insurance benefits $300,000 in disability insurance benefits $300,000 in long-term care insurance benefits $100,000 in other types of health insurance benefits Annuities $250,000 in withdrawal and cash values In general, the maximum amount of protection for each individual, regardless of the number of policies or contracts, is $300,000. Special rules may apply with regard to hospital, medical and surgical insurance benefits. Note: Certain policies and contracts may not be covered or fully covered. For example, coverage does not extend to any portion(s) of a policy or contract that the insurer does not guarantee, such as certain investment additions to the account value of a variable life insurance policy or a variable annuity contract. There are also various residency requirements and other limitations under Colorado law. To learn more about the above protections, as well as protections relating to group contracts or retirement plans, please visit the Associatiorns website www.colifeaa.ora or contact: Colorado Life and Health Insurance Protection Association 201 Robert S. Kerr Ave. Suite 600 Oklahoma City, OK 73102 1-800-337-7796 Colorado Division of Insurance 1560 Broadway, Suite 850 Denver, CO 80202 (303) 894-7499 Insurance companies and agents are not allowed by Colorado law to use the existence of the Association or its coverage to encourage you to purchase any form of insurance. When selecting an insurance company, you should not rely on Association coverage. If there is any inconsistency between this notice and Colorado law, then Colorado law will control. EN-GUAR-2-19 CO DISTRICT OF COLUMBIA CONSUMER-• • General Purooses Residents of the District of Columbia should know that licensed insurers who sell health insurance, life insurance, and annuities in the District of Columbia are members of the District of Columbia Life and Health Insurance Guaranty Association ("Guaranty Association"). The purpose of the Guaranty Association is to provide statutorily -determined benefits associated with covered policies and contracts in the unlikely event that a member insurer is unable to meet its financial obligations and is found by a court of law to be insolvent. When a member insurer is found by a court to be insolvent, the Guaranty Association will assess the other member insurers to satisfy the benefits associated with any outstanding covered claims of persons residing in the District of Columbia. However, the protection provided through the Guaranty Association is subjected to certain statutory limits explained under "Coverage Limitations" section, below. In some cases, the Guaranty Association may facilitate the reassignment of policies or contracts to other licensed insurance companies to keep the coverage in -force, with no change in contractual rights or benefits. Coverage The Guaranty Association, established pursuant to the Life and Health Guaranty Association Act of 1992 ("Act"), effective July 22, 1992 (D.C. Law 9-129; D.C. Official Code Section 31-5401 et seq.), provides insolvency protection for certain types of insurance policies and contracts. The insolvency protections provided by the Guaranty Association is generally conditioned on a person being 1) a resident of the District of Columbia and 2) the individual insured or owner under a health insurance, life insurance, or annuity contract issued by a member insurer, or insured under a group policy insurance contract issued by a member insurer. Beneficiaries, payees, or assignees of District insureds are also covered under the Act, even if they reside in another state. Coverayg imitations The Act also limits the amount the Guaranty Association is obligated to pay. The benefits for which the Guaranty Association may become liable shall be limited to the lesser of: * The contractual obligations for which the insurer is liable or for which the insurer would have been liable if it were not an impaired or insolvent insurer; or EN-GUAR-7-19 DC With respect to any one life, regardless of the number of policies, contracts, or certificates: o $300,000 in life insurance death benefits for any one life; including net cash surrender or net cash withdrawal values; o $300,000 in the present value of annuity benefits, including net cash surrender or net cash withdrawal values; o $300,000 in the present value of structured settlement annuity benefits, including net cash surrender or net cash withdrawal values; o $300,000 for long-term care insurance benefits; o $300,000 for disability insurance benefits; o $500,000 for basic hospital, medical, and surgical insurance, or major medical insurance benefits; a $100,000 for coverage not defined as disability insurance or basic hospital, medical and surgical insurance or major medical insurance or long term care insurance including any net cash surrender and net cash withdrawal values. In no event is the Guaranty Association liable for more than $300,000 with respect to any one life ($500,000 in the event of basic hospital, medical, and surgical insurance, or major medical insurance). Additionally, the Guaranty Association is not obligated to cover more than $5,000,000 for multiple non -group policies of life insurance with one owner of regardless of the number of policies owned. Exclusions Examples Policy or contract holders are not protected by the Guaranty Association if: * They are eligible for protection under the laws of another state (this may occur when the insolvent insurer was domiciled in a state whose guaranty association law protects insureds that live outside of that state); * Their insurer was not authorized to do business in the District of Columbia; or * Their policy was issued by a charitable organization, a fraternal benefit society, a mandatory state pooling plan, a mutual assessment company, an insurance exchange, a non-profit hospital or medical service organization, a health maintenance organization, or a risk retention group. The Guaranty Association also does not cover: * Any policy or portion of a policy which is not guaranteed by the insurer or for which the individual has assumed the risk; * Any policy of reinsurance (unless an assumption certificate was issued); EN-GUAR-7-19 DC * Any plan or program of an employer or association that provides life, health, or annuity benefits to its employees or members and is self -funded; * Interest rate guarantees which exceed certain statutory limitations; * Dividends, experience rating credits or fees for services in connection with a policy; * Credits given in connection with the administration of a policy by a group contract holder; or * Unallocated annuity contacts. Consumer Protection To learn more about the above referenced protections, please visit the Guaranty Association's website at www.dclifega.org. Additional questions may be directed to the District of Columbia Department of Insurance, Securities and Banking (DISB) and they will respond to questions not specifically addressed in this disclosure document. Policy or contract holders with additional questions may contact either: District of Columbia Department of Insurance, Securities and Banking 1050 First St NE #801 Washington, DC 20002 Ph: (202) 727-8000 Fax: (202) 354-1085 District of Columbia Life and Health Guaranty Association 1200 G Street, N.W. Washington, DC 20005 Ph: (202) 434-8771 Fax: (202) 347-2990 Pursuant to the Act (D.C. Official Code Section 31-5416), insurers are required to provide notice to policy and contract holders of the existence of the Guaranty Association and the amounts of coverage provided under the Act. Your insurer and agent are prohibited by law from using the existence of the Guaranty Association and the protection it provides to market insurance products. You should not rely on insolvency protection provided under the Act when selecting an insurer or insurance product. If you have obtained this document from an agent in connection with the purchase of a policy or contract, you should be aware that such delivery does not guarantee that the Guaranty Association would cover your policy or contract. Any determination of whether a policy or contract will be covered will be determined solely by the coverage provisions of the Act. This disclosure is intended to summarize the general purpose of the Act and does not address all the provisions of the Act. Moreover, the disclosure is not intended and should not be relied upon to alter any rights established in any policy or contract or under the Act. EN-GUAR-7-19 DC HAWAII NOTICE CONCERNING COVERAGE LIMITATIONS AND EXCLUSIONS UNDER THE HAWAII LIFE AND DISABILITY INSURANCE GUARANTY ASSOCIATION ACT Residents of Hawaii who purchase life insurance, annuities or disability insurance should know that the insurance companies licensed in this state to write these types of insurance are members of the Hawaii Life and Disability Insurance Guaranty Association. The purpose of this Association is to assure that policyholders will be protected, within limits, in the unlikely event that a member insurer becomes financially unable to meet its obligations. If this should happen, the Guaranty Association will assess its other member insurance companies for the money to pay the claims of insured persons who live in this state and, in some cases, to keep coverage in force. The valuable extra protection provided by these insurers through the Guaranty Association is not unlimited, however. And, as noted in the box below, this protection is not a substitute for consumers' care in selecting companies that are well -managed and financially stable. The Hawaii Life and Disability Insurance Guaranty Association may not provide coverage for this policy. If coverage is provided, it may be subject to substantial limitations or exclusions, and require continued residency in Hawaii. You should not rely on coverage by the Hawaii Life and Disability Insurance Guaranty Association in selecting an insurance company or in selecting an insurance policy. Coverage is NOT provided for your policy or any portion of it that is not guaranteed by the insurer or for which you have assumed the risk, such as a variable contract sold by prospectus. Insurance companies or their agents are required by law to give or send you this notice. However, insurance companies and their agents are Prohibited by law from using the existence of the guaranty association to induce you to Purchase any kind of insurance Policy. The Hawaii Life and Disability Insurance Guaranty Association 1132 Bishop Street, Suite 1590 Honolulu, Hawaii 96813 Department of Commerce & Consumer Affairs Insurance Division P.O. Box 3614 Honolulu, Hawaii 96811 The state law that provides for this safety -net coverage is called the Hawaii Life and Disability Insurance Guaranty Association Act. Below is a brief summary of this law's coverages, exclusions and limits. This summary does not cover all provisions of the law; nor does it in any way change anyone's rights or obligations under the act or the rights or obligations of the Guaranty Association. Hawaii COVERAGE Generally, individuals will be protected by the Hawaii Life and Disability Insurance Guaranty Association if they live in this state and hold a life or disability insurance contract, or an annuity, or if they are insured under a group insurance contract, issued by a member insurer. The beneficiaries, payees or assignees of insured persons are protected as well, even if they live in another state. EXCLUSIONS FROM COVERAGE However, persons holding such policies are not protected by the Guaranty Association if: * they are eligible for protection under the laws of another state (this may occur when the insolvent insurer was incorporated in another state whose guaranty association protects insureds who live outside that state); or * the insurer was not a member of the Guaranty Association. A nonprofit hospital or medical service organization (the "Blues"), an HMO, a fraternal benefit society, a mandatory state pooling plan, a mutual assessment company or similar plan in which the policyholder is subject to future assessments, or an insurance exchange are examples of nonmember insurers. The Guaranty Association also does not provide coverage for: * any policy or portion of a policy which is not guaranteed by the insurer or for which the individual has assumed the risk, such as a variable contract sold by prospectus; * any policy of reinsurance (unless an assumption certificate was issued); * interest rate yields that exceed an average rate; * dividends; * credits given in connection with the administration of a policy by a group contractholder; * employers' plans to the extent they are self -funded (that is, not insured by an insurance company, even if an insurance company administers them); * unallocated annuity contracts (which give rights to group contractholders, not individuals). LIMITS ON AMOUNT OF COVERAGE The Act also limits the amount the Guaranty Association is obligated to pay out. The basic protections provided by the Association are: — Life Insurance $300,000 in death benefits $100,000 in cash surrender or withdrawal values — Health Insurance $500,000 in hospital, medical and surgical insurance benefits $300,000 in disability insurance benefits $300,000 in long-term care insurance benefits $100,000 in other types of health insurance benefits — Annuities $250,000 in withdrawal and cash values The maximum amount of protection for each individual, regardless of the number of policies or contracts, is $300,000. Special rules may apply with regard to hospital, medical and surgical insurance benefits and with regard to one owner or multiple non -group policies of life insurance. Hawaii ILLINOIS NOTICE OF PROTECTION PROVIDED BY ILLINOIS LIFE AND HEALTH INSURANCE GUARANTY ASSOCIATION This notice provides a brief summary description of the Illinois Life and Health Insurance Guaranty Association ("the Association") and the protection it provides for policyholders. This safety net was created under Illinois law which determines who and what is covered and the amounts of coverage. The Association was established to provide protection in the unlikely event that your member life, annuity, health maintenance organization or health insurance company becomes financially unable to meet its obligations and is placed into Receivership by the Insurance Department of the state in which the company is domiciled. If this should happen, the Association will typically arrange to continue coverage, pay claims, or otherwise provide protection in accordance with Illinois law, with funding from assessments paid by other insurance companies and health maintenance organizations. The basic protections provided by the Association per insured in each insolvency are: Life Insurance o $300,000 for death benefits o $100,000 for cash surrender or withdrawal values Health Insurance o $500,000 for health benefit plans* o $300,000 for disability insurance benefits o $300,000 for long-term care insurance benefits o $100,000 for other types of health insurance benefits Annuities o $250,000 for withdrawal and cash values *The maximum amount of protection for each individual, regardless of the number of policies or contracts, is $300,000, except special rules apply with regard to health benefit plan benefits for which the maximum amount of protection is $500,000. Note: Certain policies and contracts may not be covered or fully covered. For example, coverage does not extend to any portion of a policy or contract that the insurer does not guarantee, such as certain investment additions to the account value of a variable life insurance policy or a variable annuity contract. There are also residency requirements and other limitations under Illinois law. To learn more about these protections, as well as protections relating to group contracts or retirement plans, please visit the Association's website at www.ilhiga.org or contact: Illinois Life and Health Insurance Guaranty Association 901 Warrenville Road, Suite 400 Lisle, Illinois 60532-4324 Illinois Department of Insurance 4th Floor 320 West Washington Street Springfield, Illinois 62767 Insurance companies, health maintenance organizations and agents are not allowed by Illinois law to use the existence of the Association or its coverage to encourage you to purchase any form of insurance. When selecting an insurance company or health maintenance organization, you should not rely on Association coverage. If there is any inconsistency between this notice and Illinois law, then Illinois law will control. The Association is not an insurance company or health maintenance organization. If you wish to contact your insurance company or health maintenance organization, please use the phone number found in your policy or contact the Illinois Department of Insurance at DOI.InfoDesk@illinois.gov. EN -GUAR 3-19 IL INDIANA NOTICE OF PROTECTION PROVIDED BY THE INDIANA LIFE AND HEALTH INSURANCE GUARANTY ASSOCIATION This Notice provides a brief summary of the Indiana Life and Health Insurance Guaranty Association ("ILHIGA") and the protection it provides for policyholders. This safety net was created under Indiana law, which determines who and what is covered and the amounts of coverage. ILHIGA was established to provide protection to policyholders in the unlikely event that your life, annuity or health insurance company becomes financially unable to meet its obligations and is taken over by its insurance department. If this should happen, ILHIGA will typically arrange to continue coverage and pay claims, in accordance with Indiana law, with funding from assessments paid by other insurance companies. (For the purposes of this Notice, the terms "insurance company" and "insurer" mean and include health maintenance organizations ("HMOs")). Generally, an individual is covered by ILHIGA if the insurer was a member of ILHIGA and the individual lives in Indiana at the time the insurer is ordered into liquidation with a finding of insolvency. The coverage limits below apply only for companies placed in rehabilitation or liquidation on or after July 1, 2018. The benefits that ILHIGA is obligated to cover are not to exceed the lessor of (a) the contractual obligations for which the member insurer is liable or would have been liable if the member insurer were not an insolvent insurer, or (b) the limits indicated below: Life Insurance $300,000 in death benefits $100,000 in net cash surrender or net cash withdrawal values Health Insurance Annuities $500,000 for health plan benefits (see definition below) $300,000 in disability income and long-term care insurance benefits $100,000 in other types of health insurance benefits $250,000 in present value of annuity benefits (including net cash surrender and net cash withdrawal values) The maximum amount of protection for each individual, regardless of the number of policies or contracts, is $300,000. Special rules may apply with regard to health benefit plans and covered unallocated annuities. "Health benefit plan" is defined in IC 27-8-8-2(o), and generally includes hospital or medical expense policies, certificates, HMO subscriber contracts or certificates or other similar health contracts that provide comprehensive forms of coverage for hospitalization or medical services, but excludes policies that provide coverages for limited benefits (such as accident -only, credit, dental - only or vision -only insurance), Medicare Supplement insurance, disability income insurance and long-term care insurance. EN-GUAR-5-19 IN The protections listed above apply only to the extent that benefits are payable under covered policy(s). In no event will the ILHIGA provide benefits greater than the contractual obligations in the life, annuity, or health insurance policy or contract. The statutory limits on ILHIGA coverage have changed over the years and coverage in prior years may not be the same as that set forth in this Notice. Note: Certain policies and contracts may not be covered or fully covered. For example, coverage does not extend to any portion(s) of a policy or contract that the insurer does not guarantee, such as certain investment additions to the account value of a variable life insurance policy or variable annuity contract. Benefits provided by a long-term care (LTC) rider to a life insurance policy or annuity contract shall be considered the same type of benefits as the base life insurance policy or annuity to which it relates. To learn more about the protections provided by ILHIGA, please visit the ILHIGA website at www.inlifeaa.org or contact: Indiana Life & Health Insurance Guaranty Association 3502 Woodview Trace Suite 100 Indianapolis, IN 46268 (317) 636-8204 Indiana Department of Insurance 311 West Washington Street, Suite 103 Indianapolis, IN 46204 (317) 232-2385 The policy or contract that this Notice accompanies might not be fully covered by ILHIGA and even if coverage is currently provided, coverage is (a) subject to substantial limitations and exclusions (some of which are described above), (b) generally conditioned on continued residence in Indiana, and (c) subject to possible change as a result of future amendments to Indiana law and court decisions. Complaints to allege a violation of any provision of the Indiana Life and Health Insurance Guaranty Association Act must be filed with the Indiana Department of Insurance, 311 W. Washington Street, Suite 103, Indianapolis, IN 46204; (telephone) 317-232-2385. Insurance companies and agents are not allowed by Indiana law to use the existence of ILHIGA or its coverage to encourage you to purchase any form of insurance or HMO coverage. (IC27-8-8-18(a)). When selecting an insurance company, you should not rely on ILHIGA coverage. If there is any inconsistency between this Notice and Indiana law, Indiana law will control. Questions regarding the financial condition of a company or your life, health insurance policy or annuity should be directed to your insurance company or agent. EN-GUAR-5-19 IN NOTICE OF PROTECTION PROVIDED BY IOWA LIFE AND HEALTH INSURANCE GUARANTY ASSOCIATION This notice provides a brief summary of the Iowa Life and Health Insurance Guaranty Association (the "Association") and the protection it provides for policyholders. This safety net was created under Iowa law, which determines who and what is covered and the amounts of coverage. The Association was established to provide protection in the unlikely event that your life, annuity or health insurance company becomes financially unable to meet its obligations and is taken over by its Insurance Department. If this should happen, the Association will typically arrange to continue coverage and pay claims, in accordance with Iowa law, with funding from assessments paid by other insurance companies. The basic protections provided by the Association are: Life Insurance - $300,000 in death benefits - $100,000 in cash surrender and withdrawal values Health Insurance - $500,000 in basic hospital, medical -surgical and major medical insurance benefits - $300,000 in disability income insurance benefits - $300,000 in long-term care insurance benefits - $100,000 in other types of health insurance benefits Annuities - $250,000 in annuity benefits, cash surrender and withdrawal values The maximum amount of protection for each individual, regardless of the number of policies or contracts, is $350,000. Special rules may apply with regard to hospital, medical -surgical and major medical insurance benefits. Note: Certain policies and contracts may not be covered or fully covered. If coverage is available, it will be subject to substantial limitations and exclusions. For example, coverage does not extend to any portion(s) of a policy or contract that the insurer does not guarantee, such as certain investment additions to the account value of a variable life insurance policy or a variable annuity contract. There are also various residency requirements under Iowa law. To learn more about the Association and the protections it provides, as well as those relating to group contracts or retirement plans, please visit the Association's website at www.ialifega.orct, or contact: Iowa Life and Health Insurance Guaranty Association 700 Walnut Street, Suite 1600 Des Moines, IA 50309 (515) 248-5712 Iowa Insurance Division 330 Maple Street Des Moines, IA 50319 (515) 281-5705 Iowa Information about the financial condition of insurers is available from a variety of sources, including financial rating agencies such as AM Best Company, Fitch Inc., Moody's Investors Service, Inc., and Standard & Poor's. That information may be accessed from the "Helpful Links & Information" page located on the website of the Iowa Insurance Division at www.iid.state.ia.us. The Association is subject to supervision and regulation by the Commissioner of the Iowa Insurance Division. Persons who desire to file a complaint to allege a violation of the laws governing the Association may contact the Iowa Insurance Division. State law provides that any suit against the Association shall be brought in the Iowa District Court in Polk County, Iowa. Insurance companies and agents are not allowed by Iowa law to use the existence of the Association or its coverage to encourage you to purchase any form of insurance. When selecting an insurance company, you should not rely on Association coverage. If there is any inconsistency between this notice and Iowa law, then Iowa law will control. Iowa KANSAS GENERAL PURPOSES AND LIMITATIONS OF THE KANSAS LIFE AND HEALTH INSURANCE GUARANTY ASSOCIATION K.S.A. 40-3001, et. seq. THE KANSAS LIFE AND HEALTH INSURANCE GUARANTY ASSOCIATION MAY NOT PROVIDE COVERAGE FOR ALL OR A PORTION OF THIS POLICY. IF COVERAGE IS PROVIDED, IT MAY BE SUBJECT TO SUBSTANTIAL LIMITATIONS AND EXCLUSIONS, AND IS CONDITIONED UPON RESIDENCY IN THIS STATE. THEREFORE, YOU SHOULD NOT RELY UPON COVERAGE BY THE KANSAS LIFE AND HEALTH INSURANCE GUARANTY ASSOCIATION IN SELECTING AN INSURANCE COMPANY OR IN SELECTING AN INSURANCE POLICY. INSURANCE COMPANIES AND THEIR AGENTS ARE PROHIBITED BY LAW FROM USING THEEXISTENCE OF THE KANSAS LIFE AND HEALTH INSURANCE GUARANTY ASSOCIATION IN SELLING YOU ANY FORM OF AN INSURANCE POLICY, OR TO INDUCE YOU TO PURCHASE ANY FORM OF AN INSURANCE POLICY. EITHER THE KANSAS LIFE AND HEALTH INSURANCE GUARANTY ASSOCIATION OR THE KANSAS INSURANCE DEPARTMENT WILL RESPOND TO ANY QUESTIONS YOU HAVE REGARDING THIS DOCUMENT. Kansas Life and Health Insurance Kansas Insurance Department Guaranty Association 1300 SW Arrowhead Road 3745 SW Wanamaker Road, Suite C Topeka, KS 66604 Topeka, KS 66610 This is a brief summary of the Kansas Life and Health Insurance Guaranty Association ("the Association") and the protection it provides for policyholders. If there is any inconsistency between this notice and Kansas law, then Kansas law will control. The Association was established to provide protection in the unlikely event that your life, annuity or health insurance company becomes financially unable to meet its obligations and is taken over by its Insurance Department. If this should happen, the Association will typically arrange to continue coverage and pay claims, in accordance with Kansas law, with funding from assessments paid by other insurance companies. This safety net was created under Kansas law, which determines who and what is covered and the amounts of coverage. The basic protections provided by the Association are: Life Insurance $300,000 in death benefits $100,000 in cash surrender or withdrawal values Health Insurance $500,000 in hospital, medical and surgical insurance benefits $300,000 in disability insurance benefits $300,000 in long-term care insurance benefits $100,000 in other types of health insurance benefits Annuities $250,000 in withdrawal and cash values The maximum amount of protection for each individual, regardless of the number of policies or contracts, is $300,000. Special rules may apply with regard to hospital, medical and surgical insurance benefits, as well as certain aggregate limits. EN GUAR-12-19-KS LOUISIANA Summary of the Louisiana Life and Health Insurance Guaranty Association Law and Notice Concerning Coverage Limitations and Exclusions Residents of Louisiana who purchase life insurance, annuities or health insurance should know that the insurance companies licensed in this state to write these types of insurance are required by law to be members of the Louisiana Life and Health Insurance Guaranty Association (LLHIGA). The purpose of LLHIGAis to assure that policyholders will be protected, within limits, in the unlikely event that a member insurer becomes financially unable to meet its obligations. If this happens, LLHIGA will assess its other member insurance companies for the money to pay the claims of insured persons who live in this state, and in some cases, to keep coverage in force. However, the valuable extra protection provided by these insurers through LLHIGA is limited. As noted in the disclaimer below, this protection is not a substitute for consumers' care in selecting companies that are well -managed and financially stable. Disclaimer The Louisiana Life and Health Insurance Guaranty Association provides coverage of claims under some types of policies if the insurer becomes impaired or insolvent. COVERAGE MAY NOT BE AVAILABLE FOR YOUR POLICY. Even if coverage is provided, there are significant limits and exclusions. Coverage isgenerally conditioned upon residence in this state. Other conditions may also preclude coverage. Insurance companies and insurance agents are prohibited by law from using the existence of the association or its coverage to sell you an insurance policy. You should not rely on the availability of coverage under the Louisiana Life and Health Insurance Guaranty Association when selecting an insurer. The Louisiana Life and Health Insurance Guaranty Association or the Department of Insurance will respond to any questions you may have which are not answered by this document. LLHIGA Department of Insurance P.O. Box 3337 P.O. Box 94214 Baton Rouge, Louisiana 70821 Baton Rouge, Louisiana 70804-9214 The state law that provides for this safety -net coverage is called the Louisiana Life and Health Insurance Guaranty Association Law Ohe Law), and is set forth at R.S. 22:2081 et seq. The following is a brief summary of this Law's coverages, exclusions and limits. This summary does not cover all provisions of the Law; nor does it in any way change any person's rights or obligations under the Law or the rights or obligations of LLHIGA. Generally, individuals will be protected by the Life and Health Insurance Guaranty Association if they live in this state and hold a covered life, health, or annuity policy, plan or contract issued by an insurer (including a health maintenance organization) authorized to conduct business in Louisiana. The beneficiaries, payees or assignees of insured persons may also be protected as well even if they live in another state unless they are afforded coverage by the guaranty association of another state, or other circumstances described under the Law are applicable. EN-GUAR-2-20 LA _i 9\m=t6vimelviAlf A person who holds a covered life, health, or annuity policy, plan or contract is not protected by LLHIGA if: (1) He is eligible for protection under the laws of another state (This may occur when the insolvent insurer was incorporated in another state whose guaranty association protects insureds who live outside that state.); (2) The insurer was not authorized to do business in this state; (3) His policy was issued by a profit or nonprofit hospital or medical service organization, a fraternal benefit society, a mandatory state pooling plan, a mutual assessment company or similar plan in which the policyholder is subject to future assessments, an insurance exchange, an organization that issues charitable gift annuities as is defined in R.S. 22:952(A)(3), or any entity similar to any of these. LLHIGA also does not provide coverage for: (1) Any policy or portion of a policy which is not guaranteed by the insurer or for which the individual has assumed the risk, such as a variable contract sold by prospectus; (2) Any policy of reinsurance (unless an assumption certificate was issued); (3) Interest rate or crediting rate yields, or similar factors employed in calculating changes in value, that exceed an average rate; (4) Dividends, premium refunds, or similar fees or allowances described under the Law; (5) Credits given in connection with the administration of a policy by a group contract holder; (6) Employers', associations' or similar entities' plans to the extent they are self -funded (that is, not insured by an insurance company, even if an insurance company administers them) or uninsured; (7) Unallocated annuity contracts (which give rights to group contract holders, not individuals), except unallocated annuity contracts and defined contribution government plans qualified under section 403(b) of the United States Internal Revenue Code (26 U.S.C. §403(b)). (8) An obligation that does not arise under the express written terms of the policy or contract issued by the insurer to the policy owner or contract owner, including but not limited to, claims described under the Law; (9) A policy or contract providing any hospital, medical, prescription drug or other health care benefits pursuant to "Medicare Part A Coverage", "Medicare Part B-Coverage", "Medicare Part C Coverage", "Medicare Part D Coverage" or "Medicaid" and any regulations issued pursuant to those parts; (10) Interest or other changes in value to be determined by the use of an index or other external references but which have not been credited to the policy or contract or as to which the policy or contract owner's rights are subject to forfeiture, as of the date the member insurer becomes an impaired or insolvent insurer, whichever is earlier. LIMITS ON AMOUNTS OF COVERAGE The Louisiana Life and Health Insurance Guaranty Association Law also limits the amount that LLHIGA is obligated to pay out. The benefits for which LLHIGA may become liable shall in no event exceed the lesser of the following: (1) LLHIGAcannot pay more than what the insurance company would owe under a policy or contract if it were not an impaired or insolvent insurer. (2) For any one insured life, regardless of the number of policies or contracts there are with the same company, LLHIGA will pay a maximum of $300,000 in life insurance death benefits, but not more than $100,000 in net cash surrender and net cash withdrawal values for life insurance. (3). For any one insured life, regardless of the number of policies and contracts there are with the same company, LLHIGA will pay a maximum of $500,000 in health insurance benefits, and LLHIGA will pay a maximum of $250,000 in present value of annuities, including net cash surrender and net cash withdrawal values. In no event, regardless of the number of policies and contracts there were with the same company, and no matter how many different types of coverages, LLHIGA shall not be liable to expend more than $500,000 in the aggregate with respect to any one individual. EN-GUAR-2-20 LA MARYLAND NOTICE OF PROTECTION PROVIDED BY MARYLAND LIFE AND HEALTH INSURANCE GUARANTY CORPORATION This notice provides a brief summary of the Maryland Life and Health Insurance Guaranty Corporation (the Corporation) and the protection it provides for policyholders and contract holders. This safety net was created under Maryland law, which determines who and what is covered and the amounts of coverage. The Corporation is not a department or unit of the State of Maryland and the liabilities or debts of the Life and Health Insurance Guaranty Corporation are not liabilities or debts of the State of Maryland. The Corporation was established to provide protection in the unlikely event that your health maintenance organization or your life, annuity, or health insurance company becomes financially unable to meet its obligations and is taken over by its Insurance Department. If this should happen, the Corporation will typically arrange to continue coverage and pay claims, in accordance with Maryland law, with funding from assessments paid by other insurance companies and health maintenance organizations. The basic protections provided by the Corporation are: - Life Insurance - $300,000 in death benefits - $100,000 in cash surrender or withdrawal values - Health Insurance or Health Benefit Plans - $500,000 for coverage provided by health benefit plans - $300,000 for disability insurance - $300,000 for long-term care insurance - $100,000 for a type of health insurance not listed above, including any net cash surrender and net cash withdrawal values under the types of health insurance listed above - Annuities - $250,000 in the present value of annuity benefits, including net cash withdrawal values and net cash surrender values - With respect to each payee under a structured settlement annuity, or beneficiary of the payee, $250,000 in present value annuity benefits, in the aggregate, including any net cash surrender and net cash withdrawal values The maximum amount of protection for each individual, regardless of the number of policies or contracts, is: - $300,000 in aggregate for all types of coverage listed above, with the exception of coverage provided by health benefit plans - $500,000 in aggregate for coverage provided by health benefit plans NOTE: Certain policies and contracts may not be covered or fully covered. For example, coverage does not extend to any portion(s) of a policy or contract that the insurer does not guarantee, such as certain investment additions to the account value of a variable life insurance policy or a variable annuity contract. There are also various residency requirements and other limitations under Maryland law. EN-GUAR-9-21 MD To learn more about the above protections, please visit the Corporation's website at www.mdlifega.org, or contact: Maryland Life and Health Insurance Guaranty Corporation 6210 Guardian Gateway Suite 195APG Aberdeen, Maryland 21005 410-248-0407 Insurance companies, health maintenance organizations and insurance producers are not allowed by Maryland law to use the existence of the Corporation or its coverage to encourage you to purchase any form of insurance or a health benefit plan. When selecting an insurance company or health maintenance organization, you should not rely on Corporation coverage. If there is any inconsistency between this notice and Maryland law, then Maryland law will control. EN-GUAR-9-21 MD MINNESOTA Metropolitan Life Insurance Company 200 Park Avenue New York, New York 10166 1-800-638-5433 NOTICE CONCERNING POLICYHOLDER RIGHTS IN AN INSOLVENCY UNDER THE MINNESOTA LIFE AND HEALTH INSURANCE GUARANTY ASSOCIATION LAW If the insurer who issued your life, annuity, or health insurance policy becomes impaired or insolvent, you are entitled to compensation for your policy from the assets of that insurer. The amount you recover will depend on the financial condition of the insurer. In addition, residents of Minnesota who purchase life insurance, annuities, or health insurance from insurance companies authorized to do business in Minnesota are protected, SUBJECT TO LIMITS AND EXCLUSIONS, in the event the insurer becomes financially impaired orinsolvent. This protection is provided by the Minnesota Life and Health Insurance Guaranty Association. Minnesota Life and Health Insurance Guaranty Association 3300 Wells Fargo Center 90 South 7th Street Minneapolis, MN 55402 Phone: 612-322-8713 Fax: 402-474-5393 The maximum amount the guaranty association will pay for all policies issued on one life by the same insurer is limited to $500,000. Subject to this $500,000 limit, the guaranty association will pay up to $500,000 in life insurance death benefits, $130,000 in net cash surrender and net cash withdrawal values for life insurance, $500,000 in health insurance benefits, including any net cash surrender and net cash withdrawal values, $250,000 in the present value of annuity benefits, including net cash surrender and net cash withdrawal values, $410,000 in present value of annuity benefits for annuities which are part of a structured settlement orfor annuities in regard to which periodic annuity benefits, for a period of not less than the annuitant's lifetime or for a period certain of not less than ten years, have begun to be paid on or before the date of impairment or insolvency, or if no coverage limit has been specified for a covered policy or benefit, the coverage limit shall be $500,000 in present value. Unallocated annuity contracts issued to retirement plans, other than defined benefit plans, established under Section 401, 403(b), or 457 of the Internal Revenue Code of 1986, as amended through December 31, 1992; are covered up to $250,000 in net cash surrender and net cash withdrawal values, for Minnesota residents covered by the plan provided, however, that the association shall not be responsible for more than $10,000,000 in claims from all Minnesota residents covered by the plan. If total claims exceed $10,000,000, the $10,000,000 shall be prorated among all claimants. These are the maximum claim amounts. Coverage by the guaranty association is also subject to other substantial limitations and exclusions and requires continued residency in Minnesota. If your claim exceeds the guarantyassociation's limits, you may still recover a part or all of that amount from the proceeds of the liquidation of theinsolvent insurer, if any exist. Funds to pay claims may not be immediately available. The guaranty association assesses insurers licensed to sell life and health insurance in Minnesota after the insolvency occurs. Claims are paid from this assessment. THE COVERAGE PROVIDED BY THE GUARANTY ASSOCIATION IS NOT SUBSTITUTE FOR USING CARE IN SELECTING INSURANCE COMPANIES THAT ARE WELL MANAGED AND FINANCIALLY STABLE. IN SELECTING AN INSURANCE COMPANY OR POLICY, YOU SHOULD NOT RELY ON COVERAGE BY THE GUARANTY ASSOCIATION. THIS NOTICE IS REQUIRED BY MINNESOTA STATE LAW TO ADVISE POLICYHOLDERS OF LIFE, ANNUITY, OR HEALTH INSURANCE POLICIES OF THEIR RIGHTS IN THE EVENT THEIR INSURANCE CARRIER BECOMES FINANCIALLY INSOLVENT. THIS NOTICE IN NO WAY IMPLIES THAT THE COMPANY CURRENTLY HAS ANY TYPE OF FINANCIAL PROBLEMS. ALL LIFE, ANNUITY AND HEALTH INSURANCE POLICIES ARE REQUIRED TO PROVIDE THIS NOTICE. EN-GUAR-6-19 MN MISSISSIPPI NOTICE OF PROTECTION PROVIDED BY MISSISSIPPI LIFE AND HEALTH INSURANCE GUARANTY ASSOCIATION This notice provides a brief summary of the Mississippi Life and Health Insurance Guaranty Association (the "Association") and the protection it provides for policyholders. This safety net was created by Mississippi law, which determines who and what is covered and the amounts of coverage. The Association was established to provide protection in the unlikely event that your life, annuity or health insurer becomes financially unable to meet its obligations. If this should happen, the Association will typically arrange to continue coverage and pay claims, in accordance with Mississippi law, with funding from assessments paid by other insurance companies. (For purposes of this notice, the terms "insurance company" and insurer" include health maintenance organizations (HMOs).) The basic protections provided by the Association are: Life Insurance - $300,000 in death benefits $100,000 in net cash surrender and net cash withdrawal values Health Insurance - $500,000 for health benefit plans (see definition below) - $300,000 in disability income insurance benefits - $300,000 in long-term care insurance benefits - $100,000 in other types of health insurance benefits Annuities - $250,000 in the present value of annuity benefits, including net cash surrender and net cash withdrawal values. The maximum amount of protection for each individual, regardless of the number of policies or contracts, is $300,000. Special rules may apply with regard to health benefit plans. "Health benefit plan" is defined in Miss. Code Ann. § 83-23-209 and generally includes hospital or medical expense policies, contracts or certificates, or HMO subscriber contracts that provide comprehensive forms of coverage for hospitalization or medical services, but excludes policies that provide coverages for limited benefits (such as dental -only or vision -only insurance), Medicare Supplement insurance, disability income insurance and long-term care insurance (LTCI). Note: Certain policies and contracts may not be covered or fully covered. For example, coverage does not extend to any portion(s) of a policy or contract that the insurer does not guarantee, such as certain investment additions to the account value of a variable life insurance policy or a variable annuity contract. There are also various residency requirements and other limitations under Mississippi law. Benefits provided by a long-term care (LTC) rider to a life insurance policy or annuity contract shall be considered the same type of benefits as the base life insurance policy or annuity contract to which it relates. EN-GUAR-12-20-MS To learn more about the above protections, limitations and exclusions, as well as protections relating to group contracts or retirement plans, please visit the Association's website at www.mslifega.org, or contact: Mississippi Life and Health Insurance Guaranty Association 330 North Mart Plaza Jackson, MS 39206-5327 601-981-0755 Mississippi Insurance Department Woolfolk Building 501 N. West Street, Suite 1001 Jackson, MS 39201 601-359-3569 To file a complaint or seek information about the financial condition of an insurer, contact the Mississippi Insurance Department. Your insurer is required by law to provide you with this notice. However, insurance companies and their agents are prohibited by law from using the existence of the Association for the purpose of sales, solicitation or inducement to purchase any form of insurance. EN-GUAR-12-20-MS MISSOURI NOTICE OF PROTECTION PROVIDED BY MISSOURI LIFE AND HEALTH INSURANCE GUARANTY ASSOCIATION This notice provides a brief summary of the Missouri Life and Health Insurance Guaranty Association ("the Association") and the protection it provides for policyholders. This safety net was created under Missouri law, which determines who and what is covered and the amounts of coverage. The Association was established to provide protection in the unlikely event that your life, annuity, or health insurance company becomes financially unable to meet its obligations and is taken over by its insurance department. If this should happen, the Association will typically arrange to continue coverage and pay claims, in accordance with Missouri law, with funding from assessments paid by other insurance companies. (For purposes of this notice, the terms "insurance company" and "insurer" include health maintenance organizations (HMOs).) The basic protections provided by the Association are as follows: Life Insurance " $300,000 in death benefits, but not more than $100,000 in net cash surrender and net cash withdrawal values " Health Insurance $500,000 for health benefit plans " $300,000 in disability insurance benefits " $300,000 in long-term care insurance benefits * $100,000 in other types of health insurance benefits Annuities $250,000 in the present value of annuity benefits, including net cash surrender and net cash withdrawal values The maximum amount of protection for each individual, regardless of the number of policies or contracts, is as follows: " $300,000 in aggregate for all types of coverage listed above, with the exception of health benefit plans " $500,000 in aggregate for health benefit plans " $5,000,000 to one policy owner of multiple nongroup policies of life insurance, whether the policy owner is an individual, firm, corporation, or other person, and whether the persons insured are officers, managers, employees, or other persons "Health benefit plan" is defined in section 376.718, RSMo. Note: Certain policies and contracts may not be covered or fully covered. For example, coverage does not extend to any portion(s) of a policy or contract that the insurer does not guarantee, such as certain investment additions to the account value of a variable life insurance policy or a variable annuity contract. There are also various residency requirements and other limitations under Missouri law. Benefits provided bya long-term care (LTC) rider to a life insurance policy or annuity contract shall be considered the same type of benefits as the basic life insurance policy or annuity contract to which it relates. To learn more about the above protections, as well as protections relating to group contracts or retirement plans, please visit the Association's website at www.mo-iga.org, or contact: Missouri Life and Health Insurance Missouri Department of Commerce and Insurance, Guaranty Association 301 West High Street, Room 530 2210 Missouri Boulevard Jefferson City, Missouri 65101 Jefferson City, Missouri 65109 Ph.: 573-522-6115 Ph,: 573-634-8455 Fax: 573-634-8488 Insurance companies and agents are not allowed by Missouri law to use the existence of the Association or its coverage to encourage you to purchase any form of insurance or HMO coverage. When selecting an insurance company, you should not rely on Association coverage. If there is any inconsistency between this notice and Missouri law, then Missouri law will control. EN-GUAR-12-20-MO MONTANA NOTICE OF PROTECTION PROVIDED BY MONTANA LIFE AND HEALTH INSURANCE GUARANTY ASSOCIATION This notice provides a brief summary of the Montana Life and Health Insurance Guaranty Association (the Association) and the protection it provides for policyholders. The Association was established under Montana law to provide protection in the unlikely event that a life, annuity or health insurance issuer becomes financially unable to meet its obligations and is placed into liquidation. If this should happen, the Association will typically arrange to continue coverage and pay claims, in accordance with Montana law, with funding from assessments paid by other insurance companies. In the event a company is placed into liquidation, benefits provided by the Association are payable according to the insurance policy or certificate, and subject to the following maximum limits: Life Insurance - $300,000 in death benefits, but limited to - $100,000 in cash surrender and net cash withdrawal values Health Insurance - $500,000 in health insurance benefits - $300,000 in disability income insurance benefits - $300,000 in long-term care insurance benefits - $100,000 in other types of health insurance benefits Annuities - $250,000 present value, including net cash surrender and net cash withdrawal values The maximum amount of protection is $300,000 in benefits with respect to any one life regardless of the number of policies or contracts, except with respect to the $500,000 maximum in health insurance benefits but not including disability, long term care or other types of health insurance benefits. Note: Other restriction to coverage apply. Certain policies and contracts may not be covered or fully covered. For example, coverage does not extend to any portion(s) of a policy or contract that the insurer does not guarantee, such as certain investment additions to the account value of a variable life insurance policy or a variable annuity contract. There are also various residency requirements and other limitations under Montana law. To learn more about the above protections, as well as protections relating to group contracts or retirement plans, please visit the Association's web site at www.mtlifega.org or contact: EN-GUAR-10-19-MT Montana Life and Health Insurance Office uf the Montana State Auditor Guaranty Association Commissioner of Securities and Insurance PO Box 8247 840 Helena Ave. Missoula, MT 59807 Helena, MT 59601 877-678-1048 or administrator@mtlifega.org 406-444-2040 IF YOUR INSURANCE COMPANY IS IN GOOD STANDING AND NOT IN LIQUIDATION, PLEASE DIRECT QUESTIONS ABOUT YOUR POLICY TO YOUR INSURANCE COMPANY! Insurance companies and agents are not allowed by Montana law to use the existence of the Association or its coverage to encourage you to purchase any form of insurance. When selecting an insurance company, you should not rely on Association coverage. If there is any inconsistency between this notice and Montana law, then Montana law will control. EN-GUAR-10-19-MT NEVADA NEVADA LIFE AND HEALTH INSURANCE GUARANTY ASSOCIATION GUARANTY ASSOCIATION ACT SUMMARY DOCUMENT Effective January 1, 2020 Residents of Nevada who purchase life insurance, annuities, health insurance or Health Maintenance Organization (HMO) insurance should know that the insurance companies licensed in this State to write these types of insurance are members of the Nevada Life and Health Insurance Guaranty Association (Association). The purpose of the Association is to assure that policyholders will be protected, within limits, in the unlikely event that a member insurer becomes financially unable to meet its obligations and becomes insolvent. If this should happen, the Association assesses its other member insurance companies for the money to pay the claims of the insured persons who live in this State and, in some cases, to keep coverage in force. This valuable extra protection provided by these insurers through the Association is not unlimited, however, as noted in the bold written information below, this protection is not a substitute for consumers' care in selecting companies that are well -managed and financially stable. The Nevada Life and Health Insurance Guaranty Association may not provide coverage for certain types of policies, however, if coverage is provided, it will be subject to substantial limitations and exclusions, and require continued residency in Nevada. A person should not rely on coverage by the Association when selecting an insurance company or when selecting an insurance policy. Coverage is NOT provided for a policy or any portion of it that is not guaranteed by the Insurer or for which the policyholder has assumed the risk, such as a variable contract sold by prospectus. Insurance companies are required by law to deliver this notice to you. However. insurance companies and their agents are prohibited by lays from using the existence of the Association for sales, solicitation or to induce the purchase of any kind of insurance policv. The State law that provides for this safety -net coverage is called the Nevada Life and Health Insurance Guaranty Association. Below is a brief summary of this law's coverages, exclusions and limits. The summary does not cover all provisions of the law, nor does it in any way change anyone's rights or obligations under the act or the rights or obligations of the Association. Anyone may obtain additional information from the and Hgalth [murancs Guaranty Association, The Nevada Life and Health Insurance Guaranty Association 4600 Kietzke Lane, Suite 0-269 Reno, Nevada 89502 (Business and Mailing address) Commissioner of Insurance, State of Nevada Department of Business and Industry, Division of Insurance 1818 E. College Parkway, Suite 103 Carson City, Nevada 89706 Page 1 EN-GUAR-11-19 NV Generally, individuals will be protected by the Association if they live in this State and hold a life, health or HMO insurance contract, or an annuity, or if they are insured under a group insurance contract issued by a member insurer. The beneficiaries, payees or assignees of the insured persons are protected as well if they live in another state. MAXIMUM BENEFIT LIMITS (For any one policyholder per company no matter how many policies you have) Life Insurance: $300,000 or $100,000 for cash surrenders Annuities: $250,000 or $250,000 for cash surrenders, including Structured settlement annuities. Disability Income Insurance: $300,000 Long Term Care: $300,000 Basic Hospital, Medical and Surgical Insurance or Major Medical Insurance and HMOs (Known as Health Benefit Plans as defined in NRS 687B.470): For any one person: $100,000, excluding benefits for basic hospital, medical and surgical insurance or major medical insurance; or an aggregate of $500,000 in benefits, including benefit for basic hospital, medical or surgical insurance or major medical insurance. With respect to one owner of several non -group policies of life insurance, whether the owner is a natural person or an organization and whether the persons insured are officers, managers, employees or other persons, the Association will not pay more than $5,000,000 in benefits, regardless of the number of policies and contracts held by the owner. With respect to each participant in a governmental retirement plan covered by an unallocated annuity contract as described in NRS 686C, the maximum allowed is an aggregate of $250,000 regardless of the number of contracts issued by any one member company. EXCLUSIONS FROM COVERAGE Not covered by the Nevada Guaranty Association: If they are eligible for protection under the law by another State Guaranty Association; The insurer is not authorized to do business in the State of Nevada; If the policy was insured by a fraternal benefit society, a mandatory state pooling plan, or a mutual assessment company or similar plan in which the policyholder is subject to future assessments, or by an insurance exchange. The Association also does NOT provide coverage for: Any policy or portion of a policy which is not guaranteed by the member insurer or for which the individual has assumed the risk, such as a variable contract sold by prospectus; Where interest rate yields exceed an average rate; Credits given in connection with the administration of a policy by a group contract holder; Any dividends; Employers' plans to the extent they are self -funded (that is, not insured by an insurance company or administered by an insurance company; Unallocated annuity contracts (which gives rights to group contract holders and not to individuals) other than annuity owned by a governmental retirement plan established under section 401, 403(b) or 457 of the Internal Revenue Code and the Nevada Revised Statute 686C.130; or Medicare or Medicare Advantage contracts. FOR MORE INFORMATION AND ANSWERS TO MOST ASKED QUESTIONS, PLEASE VISIT THE ASSOCIATION'S WEB SITE: www.nvlifega.org Page 2 EN-GUAR-11-19 NV NEW HAMPSHIRE SUMMARY OF THE NEW HAMPSHIRE LIFE AND HEALTH INSURANCE GUARANTY ASSOCIATION ACT of 2019 (RSA 408-F) (the Act) AND NOTICE CONCERNING COVERAGE AND LIMITATIONS AND EXCLUSIONS This notice provides a brief summary of the purpose of the New Hampshire Life and Health Insurance Guaranty Association (Association) and the protection it provides for policyholders. This safety net was created under New Hampshire law, which determines who and what is covered and the amounts of coverage. This summary does not cover all provisions of the lawand it does not in any way change one's rights or obligations under the Act or the rights or obligations of the Association. The Association was established to provide protection in the unlikely event that your life, annuity, or health insurance company becomes financially unable to meet its obligations and is taken over by its insurance department. If this should happen, the Association will typically arrange to continue coverage and pay claims, in accordance with New Hampshire law, with funding from assessments paid by other insurance companies, including health maintenance organizations (HMOs). DISCLAIMER: The Association may not cover your policy or contract or, if coverage is available, it may be subject to substantial limitations and exclusions and conditioned on continued residence in the state. This protection is not a substitute for consumers' care in selecting companies that are well managed and financially stable and consumers should not rely on coverage under this Act when selecting an insurer or HMO. The valuable protection through the Guaranty Association is not unlimited. COVERAGE: Generally, individuals will be protected by the New Hampshire Life and Health Insurance Guaranty Association if they live in this state and hold a life or health insurance policy or an annuity contract, or if they are insured under a group insurance contract, issued by a member insurer. The beneficiaries, assignees or payees of insured persons are protected as well, even if they live in another state. Coverage provided under the current, amended Act may be different from coverage provided prior to 2020, as coverage is determined by the governing Act in effect on the date that the Association becomes obligated. BASIC LIMITS ON AMOUNT OF COVERAGE: Tfie Act limits the amount the Association is obligated to pay. The Association cannot pay more than what the insurance company would owe under a policy or contract. The basic protections provided by the Association are limited to: Life Insurance • $300,000 in death benefits • $100,000 in cash surrender and withdrawal values EN GUAR 2-21 NH Health Insurance • $500,000 for health benefit plans (see definition below) • $300,000 in disability (income) insurance benefits • $300,000 in long-term care insurance benefits $100,000 in other types of health insurance benefits Annuities • $250,000 in the present value of annuity benefits, including net cash surrender and net cash withdrawal values With respect to any one life, the Association will pay a maximum of $300,000 no matter how many policies and contracts there were with the same company, even if they provided different types of coverages, except with respect to benefits for basic hospital, medical and surgical insurance and major medical insurance, in which case the aggregate liability of the Association shall not exceed $500,000 with respect to any one individual. "Health benefit plan" is defined in RSA 408-FA,VI and generally includes hospital or medical expense policies, contracts or certificates, or HMO subscriber contracts that provide comprehensive forms of coverage for hospitalization or medical services, but excludes policies that provide coverages for limited benefits (such as dental -only or vision -only insurance), Medicare Supplement insurance, disability income insurance and long-term care insurance. Benefits provided by a long-term care (LTC) rider to a life insurance policy or an annuity contract shall be considered the same type of benefits as the base life insurance policy or annuity contract to which it relates. NOTE: Certain policies and contracts may not be covered or may not be fully covered. For example, coverage does not extend to a portion(s) of a policy or contract that the insurer does not guarantee, such as certain investment additions to the account value of a variable life insurance policy or a variable annuity contract. Insurance companies or their agents are required by law to give or send you this notice. However, insurance companies and their agents are prohibited by law from using the existence of the Association to induce you to purchase any kind of insurance policy. This information is provided by: New Hampshire Life and Health Insurance Guaranty Association 10 Chestnut Drive, Unit B Bedford, NH 03110 (603) 472-3734 www.nhlifega.org New Hampshire Department of Insurance 21 South Fruit Street, Suite 14 Concord, NH 03301 (603) 271-2261 http://www.nh.aov/insurance/ February 2020 EN GUAR 2-21 NH NORTH CAROLINA NOTICE CONCERNING COVERAGE LIMITATIONS AND EXCLUSIONS UNDER THE NORTH CAROLINA LIFE AND HEALTH INSURANCE GUARANTY ASSOCIATION ACT Residents of this state who purchase life insurance, annuities or health insurance should know that the insurance companies and Health Maintenance Organizations (HMOs) licensed in this state to write these types of insurance are members of the North Carolina Life and Health Insurance Guaranty Association. The purpose of this association is to assure that policyholders will beprotected, within limits, in the unlikely event that a member insurer or HMO becomes financially unable to meet its obligations. If this should happen, the guaranty association will assess its other member companies for the money to pay the claims of the insured persons who live in this state and, in some cases, to keep coverage in force. The valuable extra protection provided by these insurers through the guaranty association is not unlimited, however. And, as noted in the box below,this protection is not a substitute for consumers' care in selecting companies that are well -managed and financially stable. The North Carolina Life and Health Insurance Guaranty Association may not provide coverage for this policy. If coverage is provided, it may be subject to substantial limitations or exclusions, and require continued residency in North Carolina. You should not rely on coverage by the North Carolina Life and Health Insurance Guaranty Association in selecting an insurance company or in selecting an insurance policy. Coverage is NOT provided for your policy or any portion of it that is not guaranteed by the insurer or for which you have assumed the risk, such as a variable contract sold by prospectus. Insurance companies or their agents are required by law to give or send you this notice. However, insurance companies and their agents are prohibited by law from using the existence of the guaranty association to induce you to purchase any kind of insurance policy. The North Carolina Life and Health Insurance Guaranty Association Post Office Box 10218 Raleigh, North Carolina 27605-0218 North Carolina Department of Insurance, Consumer Services Division 1201 Mail Service Center Raleigh, North Carolina 27699-1201 The state law that provides for this safety -net coverage is called the North Carolina Life and Health Insurance Guaranty Association Act. On the back of this page is a brief summary of this law's coverages, exclusions and limits. This summary does not cover all provisions of the law; nor does it in any way change anyone's rights or obligations under the act or the rights or obligations of the guaranty association. EN-GUAR-11-19-NC COVERAGE Generally, individuals will be protected by the life and health guaranty association if they live in this state and hold a life or health insurance contract, or an annuity, or if they are insured under a group insurance contract, issued by a member insurer or HMO. The beneficiaries, payees or assignees of insured persons are protected as well, even if they live in another state. EXCLUSIONS FROM COVERAGE However, persons holding such policies are not protected by this association if: • They are eligible for protection under the laws of another state (this may occur when the insolvent insurer was incorporated in another state whose guaranty association protects insureds who live outside that state); • The insurer was not authorized to do business in this state; • Their policy was issued by a fraternal benefit society, a mandatory state pooling plan, a mutual assessment company or similar plan in which the policyholder is subject to future assessments, or by an insurance exchange; • They acquired rights to receive payments through a structured settlement factoring transaction. The association also does not provide coverage for: • Any policy or portion of a policy which is not guaranteed by the insurer or for which the individual has assumed the risk, such as a variable contract sold by prospectus; • Any policy of reinsurance (unless an assumption certificate was issued); • Interest rate yields that exceed the average rate specified in the law; • Dividends; • Experience or other credits given in connection with the administration of a policy by a group contractholder; • Employers' plans to the extent they are self: -ended (that is, not insured by an insurancecompany, even if an insurance company administers them); • Unallocated annuity contracts (which give rights to group contractholders, not individuals), unless they fund a government lottery or a benefit plan of an employer, association or union, except that unallocated annuities issued to employee benefit plans protected by the Federal Pension Benefit Guaranty Corporation are not covered. • A policy or contract commonly known as Medicare Part C, Medicare Part D, Medicaid or any regulations issued pursuant thereto. LIMITS ON AMOUNT OF COVERAGE The act also limits the amount the association is obligated to pay out as follows: (1) The guaranty association cannot pay out more than the insurance company would owe under the policy or contract. (2) Except as provided in (3), (4) and (5) below, the guaranty association will pay a maximum of $300,000 per individual, per insolvency, no matter how many policies or types of policies issued by the insolvent company. (3) The guaranty association will pay a maximum of $500,000 with respect to a health benefit plan. (4) The guaranty association will pay a maximum of $1,000,000 with respect to the payee of a structured settlement annuity. (5) The guaranty association will pay a maximum of $5,000,000 to any one unallocated annuity contract holder. EN-GUAR-11-19-NC NORTH DAKOTA NOTICE OF PROTECTION PROVIDED BY THE NORTH DAKOTA LIFE AND HEALTH INSURANCE GUARANTY ASSOCIATION This notice provides a brief summary of the North Dakota Life and Health Insurance Guaranty Association ("the Association") and the protection it provides for policyholders. This safety net was created under North Dakota law, which determines who and what is covered and the amounts of coverage. The Association was established to provide protection in the unlikely event that your life, annuity or health insurance company becomes financially unable to meet its obligations and is taken over by its Insurance Department. If this should happen, the Association will typically arrange to continue coverage and pay claims, in accordance with North Dakota law, with funding from assessments paid by other insurance companies. (For purposes of this notice, the terms "insurance company" and "insurer" include health maintenance organizations (HMOs).) The protections provided by the Association are based on contract obligations up to the following amounts: 1. Life Insurance a. $300,000 in death benefits b. $100,000 in cash surrender or withdrawal values 2. Health Insurance a. $500,000 for health benefit plans (see definition below) b. $300,000 in disability income insurance benefits c. $300,000 in long-term care insurance benefits i" d. $100,000 in other types of health insurance benefits 3. Annuities a. $250,000 in the present value of annuity benefits, including net cash surrender and net cash withdrawal values. The maximum amount of protection for each individual, regardless of type of coverage is $300,000; however, may be up to $500,000 with regard to health benefit plans. "Health benefit plan" is defined in North Dakota Century Code Section 26.1-38.1-02(10) and generally includes hospital or medical expense policies, contracts or certificates, or HMO subscriber contracts that provide comprehensive forms of coverage for hospitalization or medical services, but excludes policies that provide coverages for limited benefits (such as dental -only or vision -only insurance), Medicare Supplement insurance, disability income insurance, and long-term care insurance (LTCI). Benefits provided by a long-term care (LTC) rider to a life insurance policy of annuity contract shall be considered the same type of benefits as the base life insurance policy or annuity contract to which it relates. Note: Certain policies and contracts may not be covered or fully covered. For example, coverage does not extend to any portion(s) of a policy or contract that the insurer does not guarantee, such as certain investment additions to the account value of a variable life insurance policy or a variable annuity contract. If coverage is available, it will be subject to substantial limitations. There are also various residency requirements and other limitations under North Dakota law. To learn more about the above protections, as well as protections relating to group contracts or retirement plans, please visit the Association's website at www.ndlifega.org or contact: North Dakota Life and Health Insurance Guaranty Association P.O. Box 2422 Fargo, ND 58108 North Dakota Insurance Department 600 East Boulevard Avenue, Dept. 401 Bismarck, ND 58505 COMPLAINTS AND COMPANY FINANCIAL INFORMATION A written complaint to allege a violation of any provision of the Life and Health Insurance Guaranty Association Act must be filed with the North Dakota Insurance Department, 600 East Boulevard Avenue, Dept. 401, Bismarck, North Dakota 58505; telephone (701) 328-2440. Financial information for an insurance company, if the information is not proprietary, is available at the same address and telephone number and on the Insurance Department website at www.nd.gov/ndins. EN-GUAR-2-21 ND Insurance companies and agents are not allowed by North Dakota law to use the existence of the Association or its coverage to sell, solicit or induce you to purchase any form of insurance or HMO coverage. When selecting an insurance company, you should not rely on Association coverage. If there is any inconsistency between this notice and North Dakota law, then North Dakota law will control. a EN-GUAR-2-21 ND NEW JERSEY NOTICE NEW JERSEY LIFE AND HEALTH INSURANCE GUARANTY ASSOCIATION ACT Residents of New Jersey who purchase life insurance, annuities or health insurance should know that the insurance companies licensed in this state to write these types of insurance are membersof the New Jersey Life and Health Insurance Guaranty Association. The purpose of this association is to assure that policyholders will be protected, within limits, in the unlikely event that a member insurer becomes financially unable to meet its obligations. If this should happen, the Guaranty Association will assess its other member insurance companies for themoney to pay the claims of insured persons who live in this state and, in some cases, to keep coverage in force. The valuable extra protection provided by these insurers through the Guaranty Association is not unlimited, however. And, as noted below, this protection is not a substitute for consumers' care in selecting companies that are well -managed and financially stable. DISCLAIMER The New Jersey Life and Health Insurance Guaranty Association may not provide coverage for this policy. If coverage is provided, it may be subject to substantial limitations or exclusions, and require continued residency in New Jersey. You should not rely on coverage by the New Jersey Life and Health Insurance Guaranty Association in selecting an insurance company or in selecting an insurance policy. Coverage is NOT provided for your policy or any portion of it that is not guaranteed by the insurer or for which you had assumed the risk, such as a variable contract sold by prospectus. Insurance companies or their -agents are required by law to give or send you this notice. However, insurance companies and their agents are prohibited by law from using the existence of the guaranty association to induce you to purchase any kind of insurance policy. The The New Jersey Life and Health Insurance Guaranty Association 521 Newman Springs Road, Suite 22 Lincroft, NJ 07738 State of New Jersey Department of Banking and Insurance 20 West State Street P.O. Box 325 Trenton, NJ 08625 The state law that provides for this safety -net coverage is called the New Jersey Life and Health Insurance Guaranty Association Act, N.J.S.A. 17B:32A-1, et seq. (the "Act"). EN-GUAR-5-21 NJ COVERAGE The following is a brief summary of this law's coverages, exclusions and limits. This summary does not cover all provisions of the law; nor does it in any way change anyone's rights or obligations under the Act or the rights or obligations of the guaranty association. Generally, individuals will be protected by the Life and Health Insurance Guaranty Association if they live in New Jersey and hold a life, health or long-term care insurance contract, annuity contract, or if they are insured under a group insurance contract, issued by a member insurer. The beneficiaries, payees or assignees of insured persons are protected as well, even if they live in another state. EXCLUSIONS FROM COVERAGE However, persons holding such policies are not protected by this Association if: they are eligible for protection under the laws of another state (this may occur when the insolvent insurer was incorporated in another state whose guaranty association protects insureds who live outside that state); the insurer was not authorized to do business in this state; the policy is issued by an organization which is not a member of the New Jersey Life and Health Insurance Guaranty Association. The Association also does not provide coverage for: any policy or portion of a policy which i of guaranteed by the insurer or for which the individual has assumed the risk, such as a variable contract sold by prospectus; any policy of reinsurance (unless an assumption certificate was issued); interest rate yields that exceed an average rate as more fully described in Section 3 of the Act; dividends; credits given in connection with the administration of a policy by a group contractholder; employers' plans to the extent they are self -funded (that is, not insured by an insurance company, even if an insurance company administers them). LIMITS ON AMOUNT OF COVERAGE The Act also limits the amount the Association is obligated to pay out. The Association cannot pay more than what the insurance company would owe under a policy or contract. With respect to any one insured individual, regardless of the number of policies or contracts, the Association will pay not more than $500,000 in life insurance death benefits and present value annuity benefits, including net cash surrender and net cash withdrawal values. Within this overall limit, the Association will not pay more than $100,000 in cash surrender values for annuity benefits, $500,000 in life insurance death benefits or $500,000 in present value of annuities --again no matter EN-GUAR-5-21 NJ how many policies and contracts that were with the same company, and no matter how many different types of coverages. The Association will not pay more than $2,000,000 in benefits to any one contractholder under any one unallocated annuity contract. There are no limits on the benefits the Association will pay with respect to any one group, blanket or individual accident and health insurance policy. EN-GUAR-5-21 NJ NEW MEXICO NOTICE OF PROTECTION PROVIDED BY NEW MEXICO LIFE INSURANCE GUARANTY ASSOCIATION This notice provides a brief summary of the New Mexico Life Insurance Guaranty Association ("the Association") and the protection it provides for policyholders. This safety net was created under New Mexico law, which determines who and what is covered and the amounts of coverage. The Association was established to provide protection in the unlikely event that your life, annuity or health insurance company becomes financially unable to meet its obligations and is taken over by its Insurance Department. If this should happen, the Association will typically arrange to continue coverage and pay claims, in accordance with New Mexico law, with funding from assessments paid by other insurance companies. The basic protections provided by the Association are: Life Insurance $300,000 in death benefits $100,000 in cash surrender or withdrawal values Health Insurance - $500,000 in hospital, medical and surgical insurance benefits - $300,000 in disability income insurance benefits - $300,000 in long-term care insurance benefits - $100,000 in other types of health insurance benefits Annuities $250,000 in present value of annuity benefits The maximum amount of protection for each individual, regardless of the number of policies or contracts, is $300,000 ($500,000 for hospital, medical and surgical insurance policies). Note to benefit plan trustees or other holders of unallocated annuities covered under the act: For unallocated annuities that fund certain governmental retirement plans, the limit is $250,000 in present value of annuity benefits per plan participant. For covered unallocated annuities that fund other plans, a special limit of $5,000,000 applies to each contract holder, regardless of the number of contracts held or number of persons covered. Note: Certain policies and contracts may not be covered or fully covered. For example, coverage does not extend to any portion(s) of a policy or contract that the insurer does not guarantee, such as certain investment additions to the account value of a variable life insurance policy or a variable annuity contract. There are also various residency requirements and other limitations under New Mexico law. To learn more about the above protections, please visit the Association's website at www.nmlifega.org, or contact: New Mexico Life Insurance Insurance Division Guaranty Association Public Regulation Commission PO Box 2880 PO Box 1269 Santa Fe, NM 87504-2880 Santa Fe, NM 87504-1269 505-820-7355 888-427-5772 Insurance companies and agents are not allowed by New Mexico law to use the existence of the Association or its coverage to encourage you to purchase any form of insurance. When selecting an insurance company, you should not rely on Association coverage. If there is any inconsistency between this notice and New Mexico law, then New Mexico law will control. New Mexico •• • Notice Concerning Coverage Limitations and Exclusions under the Ohio Life and Health Insurance Guaranty Association Act Residents of Ohio who purchase life insurance, annuities or health insurance should know that the insurance companies licensed in this state to write these types of insurance are members of the Ohio Life and Health Insurance Guaranty Association. The purpose of this association is to assure that policyholders will be protected, within limits, in the unlikely event that a member insurer becomes financially unable to meet its obligations. If this should happen, the guaranty association will assess its other member insurance companies for the money to pay the claims of insured persons who live in this state and, in some cases, to keep coverage in force. The valuable extra protection provided by these insurers through the guaranty association is not unlimited, however. And, as noted in the box below, this protection is not a substitute for consumers' care in selecting companies that are well -managed and financially stable. The Ohio Life and Health Insurance Guaranty Association may not provide coverage for this policy. If coverage is provided, it may be subject to substantial limitations or exclusions, and require continued residency in Ohio. You should not rely on coverage by the Ohio Life and Health Insurance Guaranty Association in selecting an insurance company or in selecting an insurance policy. Coverage is NOT provided for your policy or any portion of it that is not guaranteed by the insurer or for which you have assumed the risk, such as a variable contract sold by prospectus. You should check with your insurance company representative to determine if you are only covered in part or not covered at all. Insurance companies or their agents are required by law to give or send you this notice. However, insurance companies and their agents are prohibited by law from using the existence of the guaranty association to induce you to purchase any kind of insurance policy. Ohio Life and Health Insurance Guaranty Association 5005 Horizons Drive, Suite 200 Columbus, OH 43220 Ohio Department of Insurance 50 West Town Street Third Floor -Suite 300 Columbus, OH 43215 The state law that provides for this safety -net coverage is called the Ohio Life and Health Insurance Guaranty Association Act. On the back of this page is a brief summary of this law's coverages, exclusions and limits. This summary does not cover all provisions of the law nor does it in any way change anyone's rights or obligations under the act or the rights or obligations of the guaranty association. COVERAGE Generally, individuals will be protected by the life and health insurance guaranty association if they live in Ohio and hold a life or health insurance contract, annuity contract, unallocated annuity contract; if they are insured under a group insurance contract, issued by a member insurer; or if they are the payee or beneficiary of a structured settlement annuity contract. The beneficiaries, payees or assignees of insured persons are protected as well, even if they live in another state. EN-GUAR-2-19 OH EXCLUSIONS FROM COVERAGE However, persons holding such policies are not protected by this association if: they are eligible for protection under the laws of another state (this may occur when the insolvent insurer was incorporated in another state whose guaranty association protects insureds who live outside that state); the insurer was not authorized to do business in this state; their policy was issued by a medical, health or dental care corporation, an HMO, a fraternal benefit society, a mutual protective association or similar plan in which the policyholder is subject to future assessments, or by an insurance exchange. The association also does not provide coverage for: • any policy or portion of a policy which is not guaranteed by the insurer or for which the individual has assumed the risk, such as a variable contract sold by prospectus; • any policy of reinsurance (unless an assumption certificate was issued); • interest rate yields that exceed an average rate; • dividends; • credits given in connection with the administration of a policy by a group contract holder; • employers' plans to the extent they are self -funded (that is, not insured by an insurance company, even if an insurance company administers them). 4111l1&PIM—K1•111112k1o]3d•ITI4 7_LrI The act also limits the amount the association is obligated to pay out: The association cannot pay more than what the insurance company would owe under a policy or contract. Also, for any one insured life, the association will pay a maximum of $300,000, except as specified below, no matter how many policies and contracts there were with the same company, even if they provided different types of coverages. Theassociation will not pay more than $100,000 in cash surrender values, $500,000 in major medical insurance benefits, $300,000 in disability or long-term care insurance benefits, $100,000 in other health insurance benefits, $250,000 in present value of annuities, or $300,000 in life insurance death benefits. Again, no matterhow many policies and contracts there were with the same company, and no matter how many different typesof coverages, the association will pay a maximum of $300,000, except for coverage involving major medical insurance benefits, for which the maximum of all coverages is $500,000. Note to benefit plan trustees or other holders of unallocated annuities (GICs, DA Cs, etc.) covered by the act. - For unallocated annuities that fund governmental retirement plans under §§401, 403(b) or 457 of the Internal Revenue Code, the limit is $250,000 in present value of annuity benefits including net cash surrender and net cash withdrawal per participating individual. In no event shall the association be liable to spend more than $300,000 in the aggregate per individual, except as noted above. For covered unallocated annuities that fund other plans, a special limit of $1,000,000 applies to each contract holder, regardless of the number of contracts held with the same company or number of persons covered. In all cases, of course, the contract limits also apply. For more information about the Ohio Life &Health Insurance Guaranty Association, visit our website at: www.olhiga.org. As of 1111512018 EN-GUAR-2-19 OH OKLAHOMA NOTICE OF PROTECTION PROVIDED BY OKLAHOMA LIFE AND HEALTH INSURANCE GUARANTY ASSOCIATION This notice provides a brief summary of the Oklahoma Life and Health Insurance Guaranty Association (the Association) and the protection it provides for policyholders. This safety net was created under Oklahoma law, which determines who and what is covered and the amounts of coverage. The Association was established to provide protection in the unlikely event that your life, annuity or health insurance company becomes financially unable to meet its obligations and is taken over by its Insurance Department. If this should happen, the Association will typically arrange to continue coverage and pay claims, in accordance with Oklahoma law, with funding from assessments paid by other insurance companies (For purposes of this notice, the terms "insurance company" and "insurer" include health maintenance organizations (HMOs).) The basic protections provided by the Association are: Life Insurance o $300,000 in death benefits o $100,000 in cash surrender or withdrawal values Health Insurance o $500,000 for health benefit plans (see definition below) o $300,000 in disability income insurance benefits o $300,000 in long-term care insurance benefits o $100,000 in other types of health insurance benefits Annuities o $300,000 in the present value of annuity benefits, including net cash surrender and net cash withdrawal values The maximum amount of protection for each individual, regardless of the number of policies or contracts, is $300,000, except with regard to health benefit plans for which, the maximum amount of protection is $500,000 for each individual. "Health benefit plan" is defined in 36 O.S. §2024(7) and generally includes hospital or medical expense policies, contracts or certificates, or HMO subscriber contracts that provide comprehensive forms of coverage for hospitalization or medical services, but excludes policies that provide coverages for limited benefits (such as dental -only or vision -only insurance), Medicare Supplement insurance, disability income insurance and long-term care insurance (LTCI). Note: Certain policies and contracts may not be covered or fully covered. For example, coverage does not extend to any portion(s) of a policy or contract that the insurer does not guarantee, such as certain investment additions to the account value of a variable life insurance policy or a variable annuity contract. There are also various residency requirements and other limitations under Oklahoma law. To learn more about the above protections, please visit the Association's website at www.oklifega.org, or contact: Oklahoma Life & Health Insurance Guaranty Association Oklahoma Department of Insurance 201 Robert S. Kerr, Suite 600 400 NE 50th Street Oklahoma City, OK 73102 Oklahoma City, OK 73105 1-800-522-0071 or (405) 521-2828 Insurance companies and agents are not allowed by Oklahoma law to use the existence of the Association or its coverage to encourage you to purchase any form of insurance or HMO coverage. When selecting an insurance company, you should not rely on Association coverage. If there is any inconsistency between this notice and Oklahoma law, then Oklahoma law will control. EN-GUAR-8-20 OK PENNSYLVANIA NOTICE OF PROTECTION PROVIDED BY This notice provides a brief summary regarding the protections provided to policyholders by the Pennsylvania Life and Health Insurance Guaranty Association ("the Association"). This protection was created under Pennsylvania law, which determines who and what is covered and the amounts of coverage. The Association was established to provide protection in the unlikely event that your member life, annuity, or health insurance company, RANLI PPO, hospital plan corporation, professional health services plan corporation or health maintenance organization (member insurer) becomes financially unable to meet its obligations. If this should happen, the Association will typically arrange to provide coverage, pay claims, or otherwise provide protection in accordance with Pennsylvania law. The protection provided by the Association is not unlimited and is not a substitute for consumers' care in selecting companies that are well managed and financially stable. Below is a brief summary of the coverages, exclusions and limits provided by the Association. This summary does not cover all provisions of the law; nor does it in any way change anyone's rights or obligations or the rights or obligations of the Association. Persons Covered Generally, individuals will be protected by the Association if the member insurer was a member of the Association and the individual lives in Pennsylvania at the time the member insurer is determined by a court to be insolvent. Coverage is also provided to policy beneficiaries, payees or assignees of such individuals. Amounts of Coverage The basic coverage protections provided by the Association per insured in each insolvency are limited in the aggregate to $300,000 (or $500,000 in the case of health benefit plans), including specific limits for the following types of coverage but not in excess of the contractual obligations of the member insurer; Life insurance: o Up to $300,000 in death benefits including up to $100,000 in net cash surrender or withdrawal value. Accident, accident and health, or health insurance (including HMOs): o Up to $500,000 for health benefit plans, with some exceptions. o Up to $300,000 for disability income benefits. o Up to $300,000 for long-term care insurance benefits. o Up to $100,000 for all other types of health insurance. Individual annuities o Up to $250,000 in the present value of benefits, including cash surrender and net cash withdrawal values. The Association also does not provide coverage for: • any policy or contract or portion of a policy or contract which is not guaranteed by the member insurer or for which the individual has assumed the risk, such as a variable contract sold by prospectus; • claims based on marketing materials or other documents which are not approved policy or contract forms, claims based on misrepresentations of policy or contract benefits, and other extra -contractual claims; • any policy of reinsurance (unless an assumption certificate was issued); • interest rate yields or increases based on an index that exceed an average rate specified by statute; • dividends, experience rating credits, or credits given in connection with the administration of a policy or contract by a group contractholder; • employers' plans that are self -funded (that is, not insured by member insurer, even if member insurer administers them); • unallocated annuity contracts (which give rights to group contractholders, not individuals) other than in limited circumstances and amounts; EN-GUAR-11-20 PA • certain contracts which establish benefits by reference to a portfolio of assets not owned by the member insurer; or • policies providing health care benefits for Medicare Parts C or D coverage, for Medicaid or under the Pennsylvania program for Comprehensive Health Care for Uninsured Children. The following policies and persons are among those that are excluded from Association coverage: • A policy or contract issued by an insurer that was not authorized to do business in Pennsylvania when it issued the policy or contract • If the person is provided coverage by the guaranty association of another state • A policy issued by a fraternal benefit society, a mandatory state pooling plan, a mutual assessment company or similar plan in which the policyholder is subject to future assessments, or by an insurance exchange NOTICES Member insurers or their agents are required by law to give or send you this notice, and are prohibited by law from using the existence of the Association to induce you to purchase any kind of insurance or other coverage. Policyholders with additional questions should first contact their member insurer or agent. To learn more about coverages provided by the Association, please visit the Association's website at www.palifega.om. You can obtain additional information from the Association by contacting it at the address below. You may also contact the Pennsylvania Insurance Department to file a complaint with the Pennsylvania Insurance Commissioner to allege a violation of any provisions of Pennsylvania laws and regulations relating to insurance including the law establishing the Association: Pennsylvania Life and Health Insurance Guaranty Association 290 King of Prussia Road Radnor Station Building 2, Suite 218 Radnor, PA 19087 (610) 975-0572 Pennsylvania Insurance Department 1209 Strawberry<Square Harrisburg, PA 17120 1-877-881-6388 www.insurance.pa.gov The summary information provided by this notice and on the Association's web site do not limit or alter the more comprehensive and detailed provisions of the law and are subject to change without notice. The statements made herein are for information purposes -only. The Association has not reviewed any specific policy, or verified the information provided regarding residency or other relevant factors. Moreover, whether coverage will be provided to any specific policyholder can only be determined by reference to the statute in effect, at the earliest, at the time that the member insurer is declared insolvent. No final determination of coverage can be made until a member insurer is declared insolvent and the specific factual and legal circumstances can be reviewed. Nothing contained herein is intended to guarantee coverage for any insured, or to bind the Association in any way. Finally, this summary and the Association's web site are for general information purposes and should not be relied upon as legal advice. EN-GUAR-11-20 PA RHODE ISLAND Metropolitan Life Insurance Company SUMMARY COVERAGE, LIMITATIONS AND EXCLUSIONS UNDER RHODE ISLAND LIFE AND HEALTH INSURANCE GUARANTY ASSOCIATION ACT ("Act") A resident of Rhode Island who purchases life insurance, annuities, long-term care, or accident and health insurance should know that an insurance company licensed in Rhode Island to write these types of insurance is a member of the Rhode Island Life and Health Insurance Guaranty Association ("Association"). The purpose of the Association is to assure that a policyholder will be protected within the statutory limits, if a member insurer becomes financially unable to meet its obligations. If this should happen, the Association will, within the statutory limits, pay the claims of insured persons who live in this state, and in some cases, keep coverage in force. However, the protection provided through the Association is not unlimited. This protection is not a substitute for your care in selecting a company that is well managed and financially stable. LIFE AND HEALTH INSURANCE GUARANTY ASSOCIATION DISCLAIMER The Rhode Island Life and Health Insurance Guaranty Association provides coverage of claims under some types of policies if the insurer becomes impaired or insolvent. COVERAGE MAY NOT BE AVAILABLE FOR YOUR POLICY. Even if coverage is provided, there are significant limits and exclusions. Coverage is always conditioned on residence in this state. Other conditions may also preclude coverage. The Life and Health Insurance Guaranty Association will respond to any questions you may have which are not answered by this document. Your insurer and agent are prohibited by law from using the existence of the association or its coverage to sell you an insurance policy. You should not rely on availability of coverage under the Life and Health Insurance Guaranty Association when selecting an insurer. RHODE ISLAND LIFE AND HEALTH INSURANCE GUARANTY ASSOCIATION 235 Promenade Street, #426 Providence, RI 02908 TEL (401) 273-2921 RHODE ISLAND DIVISION OF INSURANCE 1511 Pontiac Avenue Cranston, RI 02920 (401) 462-9520 EN-GUAR-2-19 RI The full text of the state law that provides for this safety net coverage, Rhode Island Life and Health Insurance Guaranty Association Act, ("the Act"), can be found beginning at R.I. Gen Laws section 27-34.3-3. A brief summary of the Act is provided below. This summary does not cover all provisions of the law, nor does it in any way change your rights or obligations or those of the Association under the Act. COVERAGE Generally, individuals will be protected by the Association if the individual lives in Rhode Island and: Holds a life or health insurance contract, long-term care contract or annuity contract; or is insured under a group insurance contract issued by a member insurer. The beneficiaries, payees, or assignees of insured persons are protected as well, even if they live elsewhere. EXCLUSIONS FROM COVERAGE The Association does NOT protect a person holding a policy if: • the individual is eligible for protection under a similar law of another state; • the insurer was not authorized to do business in this state; • the policy is issued by an organization that is not a member of the Association; • the policy was issued by a nonprofit hospital or medical service organization (such as, the "Blues"), an HMO, a fraternal benefit society, a mandatory state pooling plan, a mutual assessment company or similar plan in which the policyholder is subject to future assessments or by an insurance exchange. The Association does not provide coverage for: • a policy or portion of a policy not guaranteed by the insurer or for which the individual has assumed the risk, such as a variable contract sold by prospectus; a policy of reinsurance (unless an assumption ceftcate was issued); • interest rate yields that exceed a rate specified by statute; • dividends; • credits given in connection with the administration of a policy by a group contract holder; • an employer's plan to the extent that it is self -funded (that is, not insured by an insurance company, even if an insurance company administers the plan); • an unallocated annuity contract issued to an employee benefit plan protected under the United States Pension Benefit Guaranty Corporation; • that part of an unallocated annuity contract not issued to a specific employee, union, association of natural persons benefit plan, or a government lottery; • certain contracts which establish benefits by reference to a portfolio of assets not owned by the insurer; • any portion of a policy or contract to the extent that the required assessments are preempted by federal or state law; • an obligation that does not arise under the express written terms of the policy or contract issued by the insurer. • a policy or contract providing any hospital, medical, prescription drug or other health care benefits pursuant to Part C or Part D of Subchapter XVIII, Chapter 7 of Title 42 of the United States Code (commonly known as Medicare Part C & D) or any regulations issued pursuant thereto. EN-GUAR-2-19 RI LIMITATIONS ON COVERAGE The Act limits the amount the Association is obligated to pay. The Association cannot pay more than what the insurer would have owed under a policy or contract. Also for any one insured life, no matter how many policies or contracts were in force with the same insurer, the Association will pay no more than: • $300,000 in life insurance death benefits and no more than $100,000 in net cash surrender and net cash withdrawal values for life insurance; • $100,000 for health insurance benefits, coverages not defined as disability, basic hospital, medical, and surgical, major medical insurance, or long-term care insurance including any net cash surrender and net cash withdrawal values; • $300,000 for disability insurance; • $300,000 for long-term care insurance; • $500,000 for basic hospital, medical, and surgical insurance; • $250,000 in the present value of annuity benefits, including net cash surrender and net cash withdrawal value; • $250,000 in present value per payee with respect to a structured settlement annuity benefits, in the aggregate, including net cash surrender and net cash withdrawal values; • $250,000, in the aggregate, in present value of annuity benefits, including net cash surrender and net cash withdrawal values, with respect to an individual participating in a governmental retirement plan established under 26 U.S.C. §§401, 403(b), or 457 covered by an unallocated annuity contract, or the beneficiaries of each such individual if deceased; • $5,000,000 in unallocated annuity contract benefits, irrespective of the number of contracts with respect to the contract owner or plan sponsor whose plan owns, directly or in trust, one or more unallocated annuity contracts. Note to benefit plan trustees or other holders of unallocated annuities (GICs, DACs, etc.) covered by the Act: for unallocated annuities that fund government retirement plans under sections 401, 403(b), or 457 of -the Internal Revenue Code, the limit is $250,000 in present value of annuity benefits including net cash surrender and net cash withdrawal per participating individual. In no event shall the Association be liable to spend more than $300,000 in the aggregate per individual except hospital insurance up to $500,000 per individual. For covered unallocated annuities that fund other plans, a special limit of $5,000,000 applies to each contract holder, regardless of the number of contracts held with the same company or number of persons covered. In all cases, the contract limits also apply. These general statements as to Limitations on Coverage are only summaries of the law. The actual limitations are set forth in R.I. Gen Laws section 27-34.3-3. Any alleged violations of the provisions of the Rhode Island Life and Health Insurance Guaranty Association Act may be reported to the Rhode Island Division of Insurance at the address and telephone number above. This information is provided by: The Association and by the Division of Insurance, whose respective addresses are provided in the Disclaimer, above. EN-GUAR-2-19 RI SOUTH CAROLINA Summary of the South Carolina Life and Accident and Health Insurance Guaranty Association Act and Notice Concerning Coverage Limitations and Exclusions Residents of South Carolina who hold life insurance, annuities, or health insurance policies should know that the insurance companies and health maintenance organizations (HMOs) licensed in this state to write these types of insurance are required by law to be members of the South Carolina Life and Accident and Health Insurance Guaranty Association (SCLAHIGA). The purpose of SCLAHIGA is to assure that policyholders will be protected, within limits, in the unlikely event that a member insurer becomes financially unable to meet its obligations. If this happens, SCLAHIGA will assess its other member insurance companies for the money to pay the claims of insured persons who live in this state and, in some cases, to keep coverage in force. However, the valuable extra protection provided by these insurers through SCLAHIGA is limited. Consumers should shop around for insurance coverage and exercise care and diligence when selecting insurance coverage. Disclaimer under South Carolina law, the South Carolina Life and Accident and Health Insurance Guaranty Associatii SCLAHIGA) may provide coverage of certain direct life insurance policies, accident and health insuran rolicies, annuity contracts and contracts supplemental to life, accident and health insurance policies and annu ;ontract claims (covered claims) if the insurer becomes impaired or insolvent. South Carolina law does r equire the SCLAHIGA to provide coverage for every policy. COVERAGE MAY NOT BE AVAILABLE FC SOUR POLICY. ge is generally conditioned upon residence in this state. Other conditions that may preclude or e le are described in this notice. Even if coverage is provided, there are significant limits and excl read the entire notice for further details on limitations and exclusions. urance companies and insurance agents are prohibited by law from using the existence of the SCLAH its coverage to sell you an insurance policy. You should not rely on the availability of coverage ur LAHIGA when selecting an insurer. The South Carolina Life and Accident and Health Insurance Guar, sociation or the Department of Insurance will respond to any questions you may have which are not answ( this document. you think the law has been violated, you may file a written complaint with the SCLAHIGA or the South Caroli epartment of Insurance at the addresses listed below: south Carolina Life and Accident and Health South Carolina Department of Insurance nsurance Guaranty Association Attention: Office of Consumer Services kttention: Executive Director 1201 Main Street, Suite 1000 '.O. Box 8625 Columbia, SC 29201 ;olumbia, SC 29202 Electronic complaint submission via www.doi.sc.gov/complaint Lectr se attach copies of all pertinent documentation. You may submit a written complaint or a complaintil onically to the Department through submission of the electronic form on the Department's website a adoi.sG.00v/complaint. You should receive a response to your complaint within 10 days. This safety -net coverage is provided for in the South Carolina Life and Accident and Health Insurance Guaranty Association Act (the Act). The following summary of the Act's coverages, exclusions and limits doesnot cover all provisions of the Act; nor does it in any way change any person's rights or obligations under the Act or the rights or obligations of the SCLAHIGA. EN-GUAR-12-20 SC COVERAGE Generally, individuals will be protected by the SCLAHIGA if they live in this state and hold a covered life, accident, health or annuity policy, plan or contract issued by an insurer (including a health maintenance organization) authorized to conduct business in South Carolina. The beneficiaries, payees or assignees of insured persons may also be protected if they live in another state unless circumstances described under the Act exclude coverage. EXCLUSIONS FROM COVERAGE Persons who hold a covered life, accident, health or annuity policy, plan or contract are r1 of protected by SCLAHIGA if: • They are eligible for protection under the laws of another state (This may occur when the insolvent insurer was incorporated in another state whose guaranty association protects insureds who live outside that state.); • The insurer was not authorized to do business in this state; or • They acquired rights to receive payments through a structured settlement factoring agreement. SCLAHIGA also does not provide coverage for: •A portion of a policy or contract or part thereof not guaranteed by the member insurer, or under which the risk is bome by the policy or contract owner; • A policy or contract of reinsurance, unless assumption certificates have been issued; • Interest rate or crediting rate yields or similar factors employed in calculating value changes that exceed an average rate; -Any policy or contract issued by assessment mutuals, fratemals, and nonprofit hospital and medical service plans; -Benefits payable by an employer, association or other person under: (a) a multiple employer welfare arrangement; (b) a minimum premium group insurance plan; (c) a stop -loss group insurance plan; or (d) an administrative services contract; •A portion of a policy or contract to the extent that it provides for (a) dividends or experience rating credits; (b) voting rights; or (c) payment of any fees or allowances to any person, including the policy or contract owner, in connection with the service to or administration of the policy or contract; •A portion of a policy or contract to the extent that the assessments required by Section 38-29-80 with respect to the policy or contract are preempted by federal or state law; -An obligation that does not arise under the express written terms of the policy or contract issued by the member insurer to the enrollee, certificate holder, contract owner or policy owner, including without limitation: (a) Claims based on marketing materials; (b) Claims based on side letters, riders or other documents that were issued by the member insurer without meeting applicable policy or contract form filing or approval requirements; (c) Misrepresentations of or regarding policy or contract benefits; (d) Extra -contractual claims; or (e) A claim for penalties or consequential or incidental damages; • An unallocated annuity contract; •A policy or contract providing any`hospital, medical, prescription drug or other health care benefits pursuant to Medicare Part C or Dor Medicaid; or • Interest or other changes in value to be determined by the use of an index or other external references but which have not been credited to the policy or contract or as to which the policy or contract owner's rights are subject to forfeiture, as offthe date the member insurer becomes impaired or insolvent insurer, whichever is earlier. LIMITS OtJ,fj,MQUNTS OF COVERAGE The South Carolina Life and Accident and Health Insurance Guaranty Association Act also limits the amount that SCLAHIGA is obligated to pay for covered claims. The benefits for which SCLAHIGA may become liable shall in no event exceed the lesser of the following: -With respect to one life, regardless of the number of policies or contracts: $300,000 in life insurance death benefits, or not more than $300,000 in net cash surrender and net cash withdrawal values for life insurance; -For health insurance benefits: (a) $300,000 for coverages not defined as disability income insurance or health benefit plans or long-term care insurance, including any net cash surrender and net cash withdrawal values; (b) $300,000 for disability income insurance; (c) $300,000 for long-term care insurance; (d) $500,000 for health benefit plans; or •$300,000 in the present value of annuity benefits, including net cash surrender and net cash withdrawal values. EN-GUAR-12-20 SC EN-GUAR-12-20 SC SOUTH DAKOTA NOTICE CONCERNING COVERAGE LIMITATIONS AND EXCLUSIONS UNDER THE SOUTH DAKOTA LIFE AND HEALTH INSURANCE GUARANTY ASSOCIATION ACT Residents of South Dakota who purchase life insurance, annuities or health insurance should know that the insurance companies licensed in this state to write these types of insurance are members of the South Dakota Life and Health Insurance Guaranty Association. The purpose of this association is to assure that policy owners, contract owners, and certificate owners will be protected, within limits, in the unlikely event that a member insurer becomes financially unable to meet its obligations. If this should happen, the Guaranty Association will assess its other member insurance companies for the money to pay the claims of insured persons who live in this state and, in some cases, to keep coverage in force. The valuable extra protection provided by these insurers through the Guaranty Association is not unlimited, however. And, as noted in the box below, this protection is not a substitute for consumers' care in selecting companies that are well -managed and financially stable. The Guaranty Association does not provide coverage for all types of life, health, or annuity benefits, and the Guaranty Association may not provide coverage for this policy or contract. If coverage is provided, it may be subject to substantial limitations or exclusions, and require continued residency in South Dakota. You should not relyon coverage by the South Dakota Life and Health Insurance Guaranty Association in selecting an insurance company or in selecting an insurance policy or contract. Coverage is NOT provided for your policy or contract for any portion of it that is not guaranteed by the insurer or for which you have assumed the risk, such as a variable contract sold by prospectus. Insurance companies or their agents are required by law to give or send you this notice. However, insurance companies and their agents are prohibited by law from using the existence of the Guaranty Association for the purpose of sales, solicitation, or inducement to purchase any kind of insurance policy or contract. The South Dakota Life and Health Insurance Guaranty Association Charles D. Gullickson, Executive Director 206 West 14th Street Sioux Falls, South Dakota 57104 Tel. (605) 336-0177 www.sdlifega.org South Dakota Division of Insurance 124 S. Euclid Avenue, 2^d Floor Pierre, South Dakota 57501 Tel. (605) 773-3563 www.dir.sd.gov/insurance The state law that provides for this safety -net coverage is called the South Dakota Life and Health Insurance Guaranty Association Act. Below is a brief summary of this law's coverages, exclusions and limits. This summary does not cover all provisions of the law, nor does it in any way change anyone's rights or obligations under the act or the rights or obligations of the Guaranty Association. (please see next page) EN-GUAR-12-20 SC COVERAGE Generally, individuals will be protected by the Guaranty Association if they live in this state and hold a life or health insurance contract, or an annuity, or if they are an insured certificateholder under a group insurance contract, issued by a member insurer. The beneficiaries, payees or assignees of insured persons are protected as well, even if they live in another state. Coverage is also provided by the Guaranty Association to persons eligible to receive payment under structured settlement annuities who are residents of this state and, under certain conditions, such persons even if they are not a resident of this state. EXCLUSIONS FROM COVERAGE However, persons holding such policies or contracts are aa protected by the Guaranty Association if: they are eligible for protection under the laws of another state (this may occur when the insolvent insurer was incorporated in another state whose guaranty association protects insureds who live outside that state); the insurer was not authorized to do business in this state; their policy or contract was issued by an HMO, a fraternal benefit society, a mandatory state pooling plan, a mutual assessment company or similar plan in which the policy owner, contract owner, or certificate owner is subject to future assessments, or by an insurance exchange. The Guaranty Association also does n2l provide coverage for: any policy or contract or portion of a policy or contract which is not guaranteed by the insurer or for which the individual has assumed the risk, such as a variable contract sold by prospectus; claims based on marketing materials or other documents which are not approved policy or contract forms, claims based on misrepresentations of policy or contract benefits, and other extra -contractual claims; any policy of reinsurance (unless an assumption certificate was issued); interest rate yields that exceed an average rate specified by statute; dividends; credits given in connection with the administration of a policy or contract by a group contractholder; employer's plans to the extent they are self -funded (that is, not insured by an insurance company, even if an insurance company administers them); ' unallocated annuity contracts (which give rights to group contractholders, not individuals); certain contracts which establish benefits by reference to a portfolio of assets not owned by the insurer; or policies providing health care benefits for Medicare Parts C or D coverage. LIMITS ON AMOUNT OF COVERAGE The Guaranty Association in no event will pay more than what an insurance company would owe under a policy or contract. In addition, state law limits the amount of benefits the guaranty association will pay for any one insured life, and no matter how many policies or contracts there are with the same company, as follows: (i) for life insurance, not more than $300,000 in death benefits and not more than $100,000 in net cash surrender and net cash withdrawal values; (ii) for health benefit plans, not more than $500,000, but not more than $300,000 for disability insurance and long term care insurance, and not more than $100,000 for other types of health insurance; and (iii) for annuities, not more than $250,000 in the present value of annuity benefits, including net cash surrender and net cash withdrawal values. However, in no event will the Guaranty Association be obligated to cover more than an aggregate of $300,000 in benefits with respect to any one life except with respect to health benefit plans, for which the aggregate liability of the guaranty association may not exceed $500,000. These general statements of the limits on coverage are only summaries and the actual limitations are set forth in South Dakota law. (please see next page) EN-GUAR-12-20 SC ADDITIONAL INFORMATION The statutes which govern the Guaranty Association are contained in SDCL Chapter 58-29C. Additional information about the Guaranty Association may be found at www.sdlifeaa.org, which contains a link to SDCL Chapter 58-29C. Information about the financial condition of insurers is available from a variety of sources, including financial rating agencies such as AM Best Company, Fitch Ratings, Moody's Investors Service, Inc., and Standard & Poor's. Additional information about financial rating agencies may be obtained by clicking on "Useful Links" on the website of the South Dakota Division of Insurance at www.dlr.sd.gov/insurance. The Guaranty Association is subject to supervision and regulation by the director of the South Dakota Division of Insurance. Persons who desire to file a complaint to allege a violation of the statutes governing the Guaranty Association may contact the Division of Insurance. State law provides that any suit against the Guaranty Association shall be brought in Hughes County, South Dakota. EN-GUAR-12-20 SC TENNESSEE NOTICE CONCERNING COVERAGE UNDER THE TENNESSEE LIFE AND HEALTH INSURANCE GUARANTY ASSOCIATION ACT Insurance companies and health maintenance organizations (HMOs) licensed in this state to write life insurance, annuities or health insurance are members of the Tennessee Life and Health Insurance Guaranty Association. The purpose of this association is to provide a safety -net of coverage within limits, in the unlikely event that a member insurer becomes financially unable to meet its obligations. If this should happen, the Guaranty Association will assess its other member insurance companies for the money to pay the claims of insured persons who live in the state and, in some cases, to keep coverage in force. The valuable extra protection provided by these insurers through the Guaranty Association is not unlimited, however. And, as noted below, this protection is not a substitute for consumers' care in selecting companies that are well managed and financial lystable. The state law that provides for this safety -net coverage is called the Tennessee Life and Health Insurance Guaranty Association Act. The following is a brief summary of this law's coverage, exclusions and limits. This summary does not cover all provisions ofthe law or describe all of the conditions and limitations relating to coverage. This summary does not in any way change anyone's rights or obligations under the act orthe rights or obligations of the Guaranty Association. COVERAGE Generally, individuals will be protected by the Life and Health Insurance Guaranty Association if they live in this state and hold a life or health insurance contract, HMO contract or an annuity, or if they are insured under a group insurance contract issued by an insurer authorized to conduct business in Tennessee. Health insurance includes disability and long term care policies. The beneficiaries, payees or assignees of insured persons areprotected as well, even if they live in another state. EXCLUSIONS FROM COVERAGE However, persons holding such policies are not protected by this Guaranty Association if: (1) they are eligible for protection under the laws of another state (this may occur when the insolvent insurer was incorporated in another state whose guaranty association protects insured who live outside that state); (2) the insurer was not authorized to do business in this state; (3) their policy was issued by a fraternal benefit society, a mandatory statepooling plan, a mutual assessment company or similar plan in which the policyholder is subject to future assessments, or by an insurance exchange. EN-GUAR-11-19 TN The Guaranty Association also does not provide coverage for: (1) any policy or portion of a policy which is not guaranteed by the insurer or for which the individual has assumed the risk, such as a variable contract sold by prospectus; (2) any policy of reinsurance (unless an assumption certificate was issued); (3) interest rate yields that exceed an average rate; (4) dividends; (5) credits given in connection with the administration of a policy by a group contractholder; (6) employers' plan to the extent they are selffunded (that is, not insured by an insurance company, even if an insurance company administers them); (7) unallocated annuity contracts (which give rights to group contractholders, not individuals). LIMITS ON AMOUNT OF COVERAGE The act also limits the amount the Guaranty Association is obligated to pay out. The Guaranty Association cannot pay more than what the insurance company would owe under a policy or contract. For any one insured life, the Guaranty Association guarantees payments up to a stated maximum no matter how many policies and contracts there were with the same company, even if they provided different types of coverage. These aggregate limits per life are as follows: • $300,000 for policies and contracts of all types, except as described in the next point • $500,000 for basic hospital, medical and surgical insurance and major medical insurance issued by companies that become insolvent after January 1, 2010 Within these overall limits, the Guaranty Association cannot guarantee payment of benefit greater than the following: • life insurance death benefits - $300,000 • life insurance cash surrender value - $100,000 • present value of annuity benefits for companies insolvent before July 1, 2009 - $100,000 • present value of annuity benefits for companies insolvent after June 30, 2009 - $250,000 EN-GUAR-11-19 TN health insurance benefits for companies declared insolvent before January 1, 2010 - $100,000 health insurance benefits for companies declared insolvent on or after January 1, 2010: o $100,000 for limited benefits and supplemental health coverages o $300,000 for disability and long term care insurance o $500,000 for basic hospital, medical and surgical insurance or major medical insurance NOTE The Tennessee Life and Health Insurance Guaranty Association may not provide coverage for this policy. If coverage is provided, it may be subject to substantial limitations or exclusions, and require continued residency in Tennessee. You should not rely on coverage by the Tennessee Life and Health Insurance Guaranty Association in selecting aninsurance company or in selecting an insurance policy. Coverage is NOT provided for your policy or any portion of it that is not guaranteed by the insurer for which you have assumed the risk, such as a variable contract sold by prospectus. Insurance companies or their agents are required by law to give or send you this notice. However, insurance companies and their agents are prohibited by law from using the existence of the Guaranty Association to induce you to purchase any kind of insurance policy. Tennessee Life and Health Insurance Guaranty Association P.O. Box 190434 Nashville, TN 37201 Website: www.tnlifega.org Tennessee Department of Commerce and Insurance 500 James Robertson Parkway Nashville, TN 37243 EN-GUAR-11-19 TN UTAH NOTICE OF PROTECTION PROVIDED BY THE UTAH LIFE AND HEALTH INSURANCE GUARANTY ASSOCIATION This disclaimer provides a brief summary of the Utah Life and Health Insurance Guaranty Association ("Association") and the protection it provides for policyholders. The safety net was created under Utah law, which determines who and what is covered and the amounts of coverage. The Association was established to provide protection in the unlikely event that your life, annuity or health insurance company becomes financially unable to meet its obligations and is taken over by its insurance department. If this should happen, the Association will typically arrange to continue coverage and pay claims, in accordance with Utah law, with the funding from assessments paid by other insurance companies. (For the purposes of this notice, the terms "insurance company" and "insurer" include health maintenance organizations (HMOs) and limited health plans.) The basic protections provided by the Association are: • Life Insurance o $500,000 in death benefits o $200,000 in cash surrender or withdrawal values • Accident and Health Insurance o $500,000 for health benefit plans o $500,000 in disability income insurance benefits o $500,000 in long-term care insurance benefits o $500,000 in other types of health insurance benefits • Annuities o $250,000 the present value of annuity benefits in aggregate, including any net cash surrender and net cash withdrawal values The maximum amount of protection for each individual, regardless of the number of policies or contracts, is $500,000. Special rules may apply with regard to health benefit plans. Note: Certain policies and contracts may not be covered or fully covered. For example, coverage does not extend to any portion(s) of a policy or contract that the insurer does not guarantee, such as certain investment additions to the account value of a variable life insurance policy or a variable annuity contract. There are also various residency requirements and other limitations under Utah law. Benefits provided by a long-term care rider to a life insurance or annuity contract shall be considered the same type of benefit as the base life insurance policy or annuity contract to which it relates. EN-GUAR-7-19 UT To learn more about the above protections, please visit the Association's website at www.ulhiga.org or contact: Utah Life and Health Insurance Guaranty Assoc. 32 West 200 South, #150 Salt Lake City, UT 84101 (801)320-9955 Utah Insurance Department State Office Bldg., Rm. 3110 Salt Lake City, UT 84114 (801) 538-3800 EN-GUAR-7-19 UT VIRGINIA NOTICE OF PROTECTION PROVIDED BY VIRGINIA LIFE, ACCIDENT AND SICKNESS INSURANCE GUARANTY ASSOCIATION This notice provides a brief summary of the Virginia Life, Accident and Sickness Insurance Guaranty Association ("the Association") and the protection it provides for policyholders. This safety net was created under Virginia law, which determines who and what is covered and the amounts of coverage. The Association was established to provide protection in the unlikely event that a life, annuity or accident and sickness insurance company (including a health maintenance organization) licensed in the Commonwealth of Virginia becomes financially unable to meetits obligations and is taken over by its Insurance Department. If this should happen, the Association will typically arrange to continue coverage and pay claims, in accordance with Virginia law, with funding from assessments paid by other life and health insurance companies licensed in the Commonwealth of Virginia. The basic protections provided by the Association are: • Life Insurance o $300,000 in death benefits o $100,000 in cash surrender and withdrawal values • Health Insurance o $500,000 for health benefit plans o $300,000 in disability [income] insurance benefits o $300,000 in long-term care insurance benefits o $100,000 in other types of accident and sickness insurance benefits • Annuities o $250,000 in withdrawal and cash values The maximum amount of protection for each individual, regardless of the number of policies or contracts, is $350,000, except for health benefit plans, for which the limit is increased to $500,000. Note: Certain policies and contracts may not be covered or fully covered. For example, coverage does not extend to any portion(s) of a policy or contract that the insurer does not guarantee, such as certain investment additions to the account value of a variable life insurance policy or a variable annuity contract. There are also various residencyrequirements and other limitations under Virginia law. EN-GUAR-6-18 VA To learn more about the above protections, please visit the Association's website at www.valifega.org or contact: VIRGINIA LIFE, ACCIDENT AND SICKNESS INSURANCE GUARANTY ASSOCIATION c/o APM Management Services, Inc. 1503 Santa Rosa Road, Suite 101 Henrico, VA 23229-5105 804-282-2240 STATE CORPORATION COMMISSION Bureau of Insurance P. O. Box 1157 Richmond, VA 23218-1157 804-371-9741 Toll Free Virginia only: 1-800-552-7945 hftp://scc.virginia.gov/boi/index.aspx Insurance companies and agents are not allowed by Virginia law to use the existence of the Association or its coverage to encourage you to purchase any form of insurance. When selecting an insurance company, you should not rely on Association coverage. If there is any inconsistency between this notice and Virginia law, then Virginia law will control. EN-GUAR-6-18 VA WEST VIRGINIA SUMMARY OF THE WEST VIRGINIA LIFE AND HEALTH INSURANCE GUARANTY ASSOCIATION ACT (Effective July 1, 2019) Residents of West Virginia who purchase life insurance, annuities or health insurance should know that the insurance companies and health maintenance organizations licensed in this state to write these types of insurance are members of the West Virginia Life and Health Insurance Guaranty Association. The purpose of this Association is to assure that policy and contract owners, certificate holders and enrollees of covered policies and contracts will be protected, within limits, in the unlikely event that a member insurer becomes financially unable to meet its obligations. If this should happen, the Guaranty Association will assess its other member insurers for the money to pay the claims of covered persons who live in this state and, in some cases, to keep coverage in force. The valuable extra protection provided by these member insurers through the Guaranty Association is not unlimited, however, and, as noted in the box below, this protection is not a substitute for consumers' care in selecting companies that are well -managed and financially stable. The West Virginia Life and Health Insurance Guaranty Association may not provide coverage for this policy or contract. If coverage is provided, it may be subject to substantial limitations or exclusions, and require continued residency in West Virginia. You should not rely on coverage by the West Virginia Life and Health Insurance Guaranty Association in selecting an insurance company or health maintenance organization or in selecting an insurance policy or contract. For a complete description of coverage, consult Article 26A, Chapter 33 of the West Virginia Code. Coverage is NOT provided for any portion OF YOUR CONTRACT that is not guaranteed by the insurer or for which you have assumed the risk. Insurance companies and health maintenance organizations or their agents are required by law to give or send you this notice. However, insurance companies, health maintenance organizations and their agents are prohibited by law from using the existence of the guaranty association to induce you to purchase any kind of insurance policy or health maintenanceorganization coverage. The Guaranty Association or the West Virginia Insurance Commission will respond to questions you may have which are not answered by this document. Policyholders with additional questions may contact: West Virginia Life and Health Insurance Guaranty Association P.O. Box 816 Huntington, West Virginia 25712 West Virginia Insurance Commissioner Consumer Services Division 900 Pennsylvania Avenue P. O. Box 50540 Charleston, West Virginia 25305 0540 (304) 558-3386 Toll Free 1-888-879-9842 TDD 1-800-435-7381 The state law that provides for this safety -net coverage is called the West Virginia Life and Health Insurance Guaranty Association Act. On the back of this page is a brief summary of this law's coverages, exclusions and limits. This summary does not cover all provisions of the law, nor does it in any way change anyone's rights or obligations under the act or the rights or obligations of the Guaranty Association. EN-GUAR-7-19 WV COVERAGE Generally, individuals will be protected by the West Virginia Life and Health Insurance Guaranty Association if they live in West Virginia and hold a life, health or annuity policy, plan or contract, or if they are insured under a group life, health or annuity policy, plan or contract, issued by a member insurer. Member insurer also includes non-profit service corporations (W. Va. Code §33-24), health care corporations (W. Va. Code §33-25) and health maintenance organizations (W. Va. Code §33- 25A). The beneficiaries, payees or assignees of insured persons are protected as well, even if they live in another state. EXCLUSIONS FROM COVERAGE However, persons holding such policies, plans or contracts are not protected by this Guaranty Association if: • They are eligible for protection under the laws of another state (this may occur when the insolvent member insurer was incorporated in another state whose guaranty association protects insureds who live outside that state); • The member insurer was not authorized to do business in this state; • The policy, plan or contract was issued at a time when the member insurer was not licensed or authorized to do business in the state; • The policy, plan or contract was issued by a fraternal benefit society, mandatory state pooling plan, a mutual protective association or similar plan in which the policy, plan or contract holder is subject to future assessments, an insurance exchange, an organization that has a certificate or license limited to the issuance of charitable gift annuities or any entity similar to the above. The Guaranty Association also does not provide coverage for: • Any policy, plan or contract, or portion of a policy, plan or contract that is not guaranteed by the member insurer or for which the individualor contract holder has assumed the risk; • Any policy of reinsurance (unless an assumption certificate was issued); • Interest rate yields that exceed an average rate; • Dividends; • Credits given in connection with the administration of a policy, plan or contract by a group contract holder; • Employer or association plans to the extent they are self -funded (that is, not insured by an insurance company, even if an insurance company administers them) or uninsured, including: I. multiple employer welfare arrangement; II. minimum premium group insurance plan; III. stop less group insurance plan; or IV. administrative services only contract; • Any u allocated annuity contract issued to or in connection with a benefit plan protected under the federal pension guaranty corporation; • Any portion of any unallocated contract that is not issued to or in connection with a specific employee, union or association's benefit plan or a governmental lottery; • Any policy, plan or contract providing any hospital, medical, prescription drug or other health care benefits pursuant to Medicare Part C and D or Medicaid; • An obligation that does not arise under the written terms of the policy, plan or contract, including claims based on marketing materials, claims based on side letters or riders not approved by the Commissioner, misrepresentations regarding policy benefits, extracontractual claims or claims for penalties or consequential or incidental damages; • A contractual agreement that establishes the member insurer's obligation to provide a book value accounting guaranty for defined contribution benefit plan participants by reference to a EN-GUAR-7-19 WV portfolio of assets that is owned by the benefit plan or trustee, which is not an affiliate of the insurer; Structured settlement annuity benefits, the rights to which have been transferred by the payee or beneficiary in a structured settlement factoring transaction. LIMITS ON AMOUNT OF COVERAGE The Act also limits the amount the Guaranty Association is obligated to pay out. The Guaranty Association cannot pay more than what the member insurer would owe under a policy, plan or contract. Also for any one insured life, regardless of the number of policies, plans or contracts, the Guaranty Association will only pay: • $300,000 in life insurance benefits, but no more than $100,000 in net cash surrender and net cash withdrawal values; • $300,000 for disability income insurance; • $300,000 for long term care insurance; • $250,000 in the present value of annuity benefits, including net cash surrender and net cash withdrawal values; • $500,000 for health benefit plans (W. Va. Code §33-26A-5(10)); and • $100,000 for all other types of accident and sickness insurance coverages not defined as disability income insurance, long term care insurance, or health benefit plans. Also for any one insured life, the Guaranty Association will only pay a maximum of $300,000 — no matter how many policies and contracts there were with the same company - for all policies or contracts other than health benefit plans, in which case the aggregate limit shall not exceed $500,000 with respect to any one individual. Note to benefit plan trustees or other holders of unallocated annuities (GICs, DACs, etc.) covered by the Act: for unallocated annuities that fund governmental retirement plans under §§ 401(k), 403(b) or 457 of the Internal Revenue Code, the limit is $250,000 in the present value of annuity benefits, including net cash surrender and net cash withdrawal values, per participating individual.ln no event shall the Guaranty Association be liable to spend more than $300,000 in the aggregate per individual. For covered unallocated annuities that fund other plans, a special limit of $5,000,000 applies to each contract holder, regardless of the number of contracts held with the same company or number of persons covered. In all cases, of course, the contract limits also apply. EN-GUAR-7-19 WV WYOMING NOTICE OF PROTECTION PROVIDED BY WYOMING LIFE AND HEALTH INSURANCE GUARANTY ASSOCIATION This notice provides a brief summary of the Wyoming Life and Health Insurance Guaranty Association ("the Association") and the protection it provides for policyholders. This safety net was created under Wyoming law, which determines who and what is covered and the amounts of coverage. The Association was established to provide protection in the unlikely event that your life, annuity or health insurance company or health maintenance organization becomes financially unable to meet its obligations and is taken over by its Insurance Department. If this should happen, the Association will typically arrange to continue coverage and pay claims, in accordance with Wyoming law, with funding from assessments paid by other insurance companies and health maintenance organizations. The basic protections provided by the Association are: * Life Insurance - $300,000 in death benefits - $100,000 in cash surrender or withdrawal values * Health Insurance * Annuities - $300,000 in health benefit plan benefits - $300,000 in disability insurance benefits - $300,000 in disability income insurance - $300,000 in long-term care insurance benefits - $100,000 in other types of health insurance benefits - $250,000 in present value of benefits including net withdrawal and cash values The maximum amount of protection for each individual, regardless of the number of policies or contracts, is $500,000. Note: Certain policies and contracts may not be covered or fully covered. For example, coverage does not extend to any portion(s) of a policy or contract that the insurer or health maintenance organization does not guarantee, such as certain investment additions to the account value of a variable life insurance policy or a variable annuity contract. There are also various residency requirements and other limitations under Wyoming law. EXCLUSIONS FROM COVERAGE Policy owners, contract owners, policy holders, certificate holders and enrollees are not protected by this Association if: - they are eligible for protection under the laws of another state (this may occur when the insolvent insurer or health maintenance organization was incorporated in another state whose guaranty association protects insureds who live outside that state); - the insurer or health maintenance organization was not authorized to do business in this state; - their policy was issued by a fraternal benefit society, a mandatory state pooling plan, a stipulated premium insurance company, a local mutual burial association, a mutual assessment company or similar plan in which the policy -holder is subject to future assessments, by an insurance exchange, or by an entity similar to those listed here. EN-GUAR-7-19 WY The Association also does not provide coverage for: - any policy or portion of a policy which is not guaranteed by the insurer or health maintenance organization or for which the individual has assumed the risk, such as a variable contract sold by prospectus, claims based on side letters or other documents, or misrepresentations of or regarding policy benefits; -any policy of reinsurance (unless an assumption certificate was issued pursuant to the reinsurance policy or contract); - interest rate yields that exceed an average rate or interest earned on an equity indexed policy; - dividends; - experience rating credits given in connection with the administration of a policy to a group contract holder; -annuity contracts issued by a nonprofit insurance company exclusively for the benefit of nonprofit educational institutions and their employees; - unallocated annuity contracts (which give rights to group contract holders, not individuals); - any plan or program of an employer or association that provides life, health or annuity benefits to its employees or members to the extent the plan is self -funded or uninsured; - an obligation that does not arise under the express written terms of the policy or contract; -any policy providing benefits under Medicare Part C, Medicare Part D, or Medicaid; - rights to receive payments acquired through a structured settlement factoring transaction. To learn more about the above protections, protections relating to group contracts or retirement plans, and all exclusions from coverage, please visit the Association's website at www.wylifega.org or contact: Wyoming Life and Health Insurance Guaranty Association 6700 N. Linder Rd, Suite 156, Box 139 Meridian, ID 83646 Toll Free: (800) 362-0944 Fax: (208) 968-0206 Website: www.wylifega.org Email: administrator@wylifega.org Wyoming Department of Insurance 106 East 6th Avenue Cheyenne, WY 82002 Phone: (307) 777-7401 Toll Free: (800) 438-5768 Fax: (307) 777-2446 Website: doi.wyo.gov Email: wvinsdep(ZDwvo.gov Insurance companies and agents are not allowed by Wyoming law to use the existence of the Association or its coverage to encourage you to purchase any form of insurance. When selecting an insurance company, you should not rely on Association coverage. If there is any inconsistency between this notice and Wyoming law, then Wyoming law will control. EN-GUAR-7-19 WY