HomeMy WebLinkAboutResolution - 2019-R0347 - Dearborn Life Insurance - 09_24_2019Resolution No. 2019-RO347
Item No. 6.30
E - � 4 "T*03111111 [•7a�
BE 1T 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, an Agreement by and between the City
of Lubbock and Dearborn National Life Insurance Company for term life and accidental
death and dismemberment (ADD) life insurance for full-time employees in the amount of
$10,000 per employee and to offer voluntary supplemental life insurance, ADD insurance,
Long Term Disability Insurance, and Accident Insurance for eligible employees and their
dependents with Dearborn National Life Insurance Company. Said Agreement is attached
hereto and incorporated in this resolution as if fully set forth herein and shall be included
in the minutes of the City Council; and
THAT the City Manager may execute any routine documents and forms associated
with said insurance coverage.
Passed by the City Council this September 24, 2019
DANIEL M. POPE, MAYOR
ATTEST:
roo LU.4 I
Re cca Garza, City Secreta
APPROVE] AS TO -CONTENT:
Leisa Hutcheson, Director of Human Resources
and Risk Management
opAl W__All PA! BM ►
1 �
ccdocs/RES. Dearborn Nat. Life Insurance Company
September 10, 2019
�t
Resolution No. 2019-RO347
CONTRACT
City of Lubbock, TX
Ancillary Benefits Plan for City Employees
RFP 19 -14820 -TF
This Service Agreement (this "Agreement") is entered into as of the 1 Ith day of September, 2019,
("Effective Date") by and between Dearborn Life Insurance Company (the Company), and the City of
Lubbock (the "City").
RECITALS
WHEREAS, the City has issued a Request for Proposals 19 -14820 -TF Ancillary Benefits Plan for City
Employees.
WHEREAS, the proposal submitted by the Company has been selected as the proposal which best
meets the needs of the City for this service; and
WHEREAS, Company desires to perform as an independent Company to provide Ancillary Benefits
upon terms and conditions maintained in this Agreement; and
NOW THEREFORE, for and in consideration of the mutual promises contained herein, the City and
Company agree as follows:
City and Company acknowledge the Agreement consists of the following exhibits which are attached
hereto and incorporated herein by reference, listed in their order of priority in the event of inconsistent or
contradictory provisions:
1. This Agreement
2. Exhibit A — Final Price Sheet
3. Exhibit B — General Requirements
4. Exhibit C — Sample Policies
In the event of any conflict with respect to the insurance relationship between the Parties both provided
by the insurance policies filed with and approved by the state authority ("Policies") and all matters relating
thereto, the Policies take precedence over all documents identified above.
Scope of Work
Company shall provide the services that are specified in Exhibit B. The Company shall comply with all the
applicable requirements set forth in Exhibit A and B attached hereto.
Article 1 Services
1.1 Company agrees to perform for the City in accord with the terms of the Agreement, including
the attached Exhibits, and the sample Policies. The City agrees to pay the amounts stated in
Exhibit A, to Company for performing services.
1.2 Company shall use reasonable efforts to render Services under this Agreement in a
professional and business -like manner and in accordance with the standards and practices
recognized in the industry.
{
Non -appropriation clause. All funds for payment by the City under this Agreement for
Ancillary Benefits are subject to the availability of an annual appropriation for this purpose
by the City. In the event of non -appropriation of funds by the City Council of the City of
Lubbock for the ancillary benefits provided under the Agreement, the City will terminate that
portion of the Agreement, without termination charge or other liability, on the last day of the
then -current fiscal year or when the appropriation made for the then -current year for the goods
or services covered by this Agreement is spent, whichever event occurs first. If at any time
funds are not appropriated for the continuance of this Agreement, cancellation shall be
accepted by the Company on thirty (30) days prior written notice, but failure to give such
notice shall be of no effect and the City shall not be obligated under this Agreement beyond
the date of termination.
Article 2 Miscellaneous.
2.1 This Agreement is made in the State of Texas and shall for all purposes be construed in accordance
with the laws of said State, without reference to choice of law provisions. Venue of any action
related to this Agreement is proper in Lubbock, Texas.
2.2 This Agreement, including its Exhibits, and the sample Policies set forth the entire agreement
between the parties with respect to the subject matter hereof. Understandings, agreements,
representations, or warranties not contained in the Agreement, including the Exhibits, or as written
amendment hereto, shall not be binding on either party. Except as provided herein, no alteration
of any terms, conditions, delivery, price quality, or specifications of this Agreement, including its
Exhibits, shall be binding on either party without the written consent of both parties. The insurance
relationship between the Parties will be as set forth in the policy of insurance which is filed with
and approved by the State of Texas.
2.3 This Agreement may be executed in counterparts, each of which shall be deemed an original.
2.4 In the event any provision of this Agreement is held illegal or invalid, the remaining provisions
of this Agreement shall not be affected thereby.
2.5 The waiver of a breach of any provision of this Agreement by any parties or the failure of any
parties otherwise to insist upon strict performance of any provision hereof shall not constitute a
waiver of any subsequent breach or of any subsequent failure to perform.
2.6 This Agreement shall be binding upon and inure to the benefit of the parties and their respective
heirs, representatives and successors and may be assigned by Company or the City to any successor
only on the written approval of the other party. Notwithstanding anything previously stated to the
contrary, an assignment does not include the sale of the Company or a transfer of substantially all
of the Company's assets. In the event of such sale or transfer, the Company will use its best efforts
to have the acquiring entity assume all obligations under this contract and agrees to provide at least
a ninety (90) day written notice to the City of any changes or cancellation of Agreement.
2.7 All claims, disputes, and other matters in question between the Parties arising out of or relating to
this Agreement or the breach thereof, shall be formally discussed and negotiated between the
Parties for resolution. In the event that the Parties are unable to resolve the claims, disputes, or
other matters in question within thirty (30) days of written notification from the aggrieved Party
to the other Party, the aggrieved Party shall be free to pursue all remedies available at law or in
equity.
2.8 At any time during the term of the contract, or thereafter, the City, or a duly authorized audit
representative of the City or the State of Texas, at its expense and at reasonable times, reserves
the right to audit Company's records and books relevant to all services provided to the City` under this Contract. Such an audit shall be at a time agreed to between the Parties, organized
in such a way to minimize the interruption of the Company's business operations, and subject
to any necessary confidentiality agreements. In the event such an audit by the City reveals any
errors or overpayments by the City, Company shall refund the City the full amount of such
overpayments within thirty (30) days of such audit findings. In the event that such an audit by
the City reveals errors that result in underpayments to the Company, the City shall negotiate
with the Company pursuant to Section 2.7 above to rectify such underpayment.
2.9 The City reserves the right to exercise any right or remedy to it by law, contract, equity, or
otherwise, including without limitation, the right to seek any and all forms of relief in a court
of competent jurisdiction. Further, the City shall not be subject to any arbitration process prior
to exercising its unrestricted right to seek judicial remedy. The remedies set forth herein are
cumulative and not exclusive, and may be exercised concurrently. To the extent of any conflict
between this provision and another provision in, or related to, this document, this provision
shall control. The City agrees that any conflict arising out of the Party's insurance relationship
is to be handled via the prevailing state insurance laws.
2.10 The contractor shall not assign or sublet the contract, or any portion of the contract, without
written consent from the Director of Purchasing and Contract Management. Should consent
be given, the Contractor shall insure the Subcontractor or shall provide proof of insurance
from the Subcontractor that complies with all contract Insurance requirements document, this
provision shall control. Notwithstanding anything previously stated to the contrary, an
assignment does not include the sale of the Company or a transfer of substantially all of the
Company's assets. In the event of such sale or transfer, the Company will use its best efforts
to have the acquiring entity assume all obligations under this contract and agrees to provide
the City with at least a ninety (90) day notice. Further, the City agrees that a "Subcontractor"
or a "Subcontract" does not include contracts or entities under contract with the Company as
of the effective date of this Contract, or entities that will not perform work exclusively for this
Contract, or the affiliates of Company.
2.11 Contractor acknowledges by supplying any Goods or Services that the Contractor has read,
fully understands, and will be in full compliance with all terms and conditions and the
descriptive material contained herein and any additional associated documents and
Amendments. Except as set forth in the insurance policies that are filed with and approved
by the state authority, The City disclaims any terms and conditions provided by the
Contractor unless agreed upon in writing by the parties. In the event of conflict between
these terms and conditions and any terms and the policies for insurance, the terms and
conditions in the policies for insurance shall prevail as approved by the State of Texas.
2.12 Section 2270.002, Government Code, (a) This section applies only to a contract that: (1) Is
between a governmental entity and a company with 10 or more full-time employees; and (2)
has a value of $100,000 or more that is to be paid wholly or partly from public funds of the
governmental entity. (b) A governmental entity may not enter into a contract with a
company for goods or services unless the contract contains a written verification from the
company that it: (I) does not boycott Israel; and (2) will not boycott Israel during the term of
the contract.
2.13 SB 252 prohibits the City from entering into a contract with a vendor that is identified by
The Comptroller as a company known to have contracts with or provide supplies or service
with Iran, Sudan or a foreign terrorist organization.
Article 3 Term And Termination of Agreement
3.1 Term. This Agreement shall be for a term of five (5) years, with the option of two-year
0extensions, beginning on January 1, 2020.
3.2 Termination. This Agreement may be terminated as follows:
a. By either party at the end of any month after the end of the Fee Schedule Period
specifications in Exhibit A of this Agreement with ninety (90) days prior written
notice to the other party; or
b. By both parties on any date mutually agreed to in writing; or
c. By either party, in the event of conduct by the other party constituting fraud,
misrepresentation of material fact or material breach of the terms of this Agreement,
upon written notice.
d. By the Company, if the City fails to pay timely all amounts due under this
Agreement including, but not limited to, all amounts pursuant to and in accordance
with the fee schedules in Exhibit A, upon the City's failure to cure the non-payment
within ten (10) days.
3.3 Termination of Policy. The Parties agree that any termination of the Policies issued in
accordance with this Agreement shall only be terminated in accordance with the terms of
the policy, regardless of the above referenced termination of the Agreement.
r. IN WITNESS WHEREOF, this Agreement is executed as of the Effective Date.
CITY OF LUBBOCK, TX: COMPANY: Dearborn Life Insurance Company
Daniel M. Pope, Nfayor
ATTEST:
"f�-J# 0. 0
ccaGarza, City Secre T-�)
APP,? TO CONTENT:
Lein utc eson, Director of Human Resources
and Risk Management
Vatite.
;OR
itchstant City Attorney
h k
IL�42 I f
Compan 's Signature
Michael W. Witwer
Printed Name
President and CEO
Title
t�7
EXHIBIT A
PRICE SHEET
Coverage
Dearborn National
Age
Monthly Rate Per
Under 30
$1000
Basic Life
$0.035
Accidental Death &
$0.012
Dismemberment
$0.10
Supplemental Em
to ee Life
Age
Rate Per $1,000
Under 30
$0.05
30-34
$0.06
35-39
$0.07
4044
$0.10
45-49
$0.15
50-54
$0.23
55-59
$0.43
60-64
$0.66
65-69
$1.21
70+
$2.06
Dependent Child Life
S ouse Life
Amount
Rate Per $5,000
$5,000
$0.80
$10,000
$1.60
$15,000
$2.40
$20,000
$3.20
$25,000
$4.00
$30,000
$4.80
$35,000
$5.60
$40,000
1 $6.40
$45,000
$7.20
$50,000
$8.00
Dependent Child Life
Amount
Monthly Rate Per
$2,500
$2,500
$0.50
$5,000
$1.00
$7,500
$1.50
$10,000
$2.00
Voluntary AD&D
Retiree Life
Ne
Rate Per $1000
EmployeeOnly
$0.025
Employee and Spouse Only
$0.038
Employee and Child ren Only
$0.038
Ern to ee, Spouse & Child ren
$0.038
Retiree Paid-up Life Employer paid per $1,000 $3.06
Retiree Paid-up grandfather per $1,000 $0.60
Retiree Dependent Covera e
Amount Monthly Rate Per Unit
Spouse $2,500 $1.25
Child ren $1,000 $1.25
LTD - Option 1(180 day EP)
Retiree Life
Ne
Rate Per $1,000
Under 30
$0.11
30-34
$0.12
35-39
$0.17
40-44
$0.26
45-49
$0.44
50-54
$0.78
55-59
$1.27
60-64
$1.44
65-69
$2.38
70-74
$4.12
75-79
$6.20
80+
$9.75
Retiree Paid-up Life Employer paid per $1,000 $3.06
Retiree Paid-up grandfather per $1,000 $0.60
Retiree Dependent Covera e
Amount Monthly Rate Per Unit
Spouse $2,500 $1.25
Child ren $1,000 $1.25
LTD - Option 1(180 day EP)
Age
Rate Per $100 of
Monthly Covered
Payroll
Under 25
$0.14
25-29
$0.16
30-34
$0.17
35-39
$0.18
40-44
$0.25
45-49
$0.31
50-54
$0.42
55-59
$0.64
60+
$0.79
LTD - Option 2 (90 day EP)
Age
Rate Per $100 of
Monthly Covered
Payroll
Under 25
$0.16
25-29
$0.18
30-34
$0.20
35-39
$0.21
40-44
$0.28
45-49
$0.36
50-54
$0.49
55-59
$0.74
60+
$0.91
Rate Guarantee
• The Life rates will be guaranteed for 7 years (1/1/2020 - 12/31/27).
• The LTD rates are guaranteed for 3 years with rate caps based on the incurred loss ratios for year 4
and 5 as indicated below.
Accident Poli — Month/ Rates
LTD - Year 4 and Year 5
Incurred Loss
Ratio
Maximum Renewal Rate Increase Allowed
Under 85%
0%
85%-89%
10%
90%-99%
20%
100% or more
To be negotiated between the City of Lubbock and Dearborn National
Accident Poli — Month/ Rates
Employee
Only
Employee and
Souse
Employee and
Child ren
Family
Plan 1
4.63
7.84
8.52
13.56
Plan 2
8.07
I3.46
15.38
24.21
Smart Plan 1
3.95
6.31
8.53
12.98
Smart Plan 2
4.65
7.42
10.07
15.32
EXHIBIT B
City of Lubbock, TX
RFP 19 -14820 -TF
Ancillary Benefits
General Requirements
Products and Pricing Schedule
46Al Grouo Employer -Paid Group Life/AD&D Insurance
Retiree Schedule of Benefits
ELIGIBILITY: Class 02
All eligible Retirees of the Policyholder are: ALL RETIRED
EMPLOYEES WHO RETIRED ON OR AFTER DECEMBER 1, 1995
Elect $5,000 or $2,000 benefit
Voluntary Life Benefit $10,000
Voluntary Spouse life $2,500
Voluntary Child life $1,000
All benefits are 100% Retiree paid
ELIGIBILITY: Class 03
All eligible Retirees of the Policyholder are: ALL RETIRED
EMPLOYEES WHO RETIRED ON OR AFTER APRIL 1, 1988 BUT
BEFORE DECEMBER 1, 1995
Term life benefit $2,000
Voluntary Life Benefit $10,000
Voluntary Spouse life $2,000
Voluntary Child life $1,000
All benefits are 100% Retiree paid
ELIGIBILITY: Class 04
All eligible Retirees of the Policyholder are: ALL RETIRED
EMPLOYEES WHO RETIRED ON OR AFTER JANUARY 1, 1974 BUT
BEFORE APRIL 1, 1988
Benefit at the date of retirement either $2,000 or $5,000
Employer paid benefit
Voluntary Life Benefit $10,000
Voluntary Spouse life $2,000
Voluntary Child life $2,000
All voluntary benefits are 100% Retiree paid
e
ELIGIBILITY: Class 05
All eligible Retirees of the Policyholder are: ALL RETIRED
EMPLOYEES WHO RETIRED PRIOR TO JANUARY 1, 1974
$11,000 Benefit
Employer paid benefit (monthly rate $3.06 per $1,000)
Eligibility Waiting Period: (for all classes)
Current Retirees: NONE
New Retirees: NONE
Waiting Period None
Reduction of Benefits (for all Classes) None
Benefit Eligibility Basic Life
Insured Eligibility Retiree
Portability Benefit Duration Age 65
MONTHLY RETIREE LIFE INSURANCE RATES
Age
Rate/$1,000
Under 30
.11
35-39
.17
45-49
.44
55-59
1.27
65-69
2.38
75-79
6.20
Dependent Life $2,500/spouse
$1,000/child
Active Employees Group Term Life/AD&D Insurance
Aze Rate/$1.000
30-34
.12
40-44
.26
50-54
.78
60-64
1.44
70-74
4.12
80 or Over
9.75
$1.25
$1.25
Minimum requirements:
ELIGIBILITY: Class 01
All eligible new hires and existing employees and their dependents to
enroll for coverage up to the guarantee issue level. Voluntary Life
amounts elected above the guarantee issue level will require evidence of
insurability.
Eligibility Waiting Period: (for all classes)
New Employees: Working one (1) full pay period
CLASS O1 Guarantee Issue for Supplemental Life Coverage is:
1. $250,000 for employees
2. $50,000 for spouses
1. $10,000 for children
Must accept employees that have coverage over the Guarantee Issue
amount.
Basic Life Benefit Amount $10,000
Voluntary Life Benefit in the amount of 1, 2, or 3 times annual earning to a
maximum of $500,000
Voluntary Spouse life - select $5,000 to a maximum of $50,000 in $5,000
Increments
Voluntary Child Benefit - $2,500 increments to $10,000
$0 age live birth to 14 days
$100 age 15 days to 6 months
Voluntary: Benefit amounts may be subject to Guarantee Issue limits based on participation
levels. Any Guarantee Issue Limits established are only available during initial enrollment
and for new employees who have met the Eligibility requirements. Employees must enroll
�--�f within 31 days of their eligibility date to qualify for any established Guarantee Issue.
Current Rates:
Group Term life AD&D $10,000: $.50 per person per month
Voluntary Life 1, 2, or 3 times annual earnings monthly rates
AAae
Rate/$1,000
Age
Rate/$1,000
Under 30
.050
30-34
.061
35-39
.069
40-44
.111
45-49
.160
50-54
.260
55 -59
.470
60-64
.769
65-69
1.209
70-74
2.141
75-79
3.950
80 or Over
6.920
Voluntary Spouse Life monthly rates:
Coverage Amount
Rate
$5,000
$ .80
$10,000
$1.60
$15,000
$2.41
$20,000
$3.21
$25,000
$4.01
$30,000
$4.81
A,
C
$35,000
$5.61
$40,000
$6.41
$45,000
$7.22
$50,000
$8.02
Child(ren) Life Insurance monthly rates:
Coverage Amount
Rate
$2,500
$ .50
$5,000
$1.00
$7,500
$1.50
$10,000
$1.99
Voluntary Accidental Death & Dismemberment (AD&D)
Employee only in the amounts of 1, 2, and 3 times annual salary to a
maximum of $300,000
Employee Monthly rate per 1,000 - .025
Family Monthly rate per 1,000 - .038
Basic Life and AD&D
Employer -Paid Group Life insurance
Guaranteed Issue
f Policy portability under similar terms and
conditions
Vendor Answer
$10,000
Yes
Length of time with carrier 1!112011
Minimum participation 100%
A M Best Rating of carrier (A VIII min) A
Life insurance waiver of premium Not Included l
notifications
Limitations and exclusions
Accelerated Death Benefit
Line of Duty Benefit
Benefit Reduction Schedule similar
Seat Belt Benefit
Air Bag Benefit
Career Mustment Benefit
Child Care Benefit _
Higher Education Benefit
Enrollment Guidelines Similar
We are matching the current
Included
Included (new)
We are matching current
Included
Included
ouse Training Benefit Included
Included
Included
We are matching current
Item
I Employer -Paid Group Life
Vendor Answer
1
Multi-year Rate Quote
7 Years
2
Please attach a five year rate history
Rates will be guaranteed 5 years
3
Cost per $1000
1 Basic Active Life - $0.035 AD&D - $0.012
4(D) Lona -term Disability
Disability Income Insurance — Monthil Income Benefits
Monthly Benefit
Your monthly benefit depends on the Option for which you are enrolled.
Option 1: 60% of your monthly earnings, but not more than the Maximum Monthly
Benefit.
Option 2: 67% of your monthly earnings, but not more than the
Maximum Monthly Benefit.
Your benefit may be reduced by the deductible sources of income and
disability earnings.
Some disabilities may not be covered or may be limited under this coverage.
MAXIMUM Monthly Benefit: $5,000 / $7,500
Elimination Period
Your elimination period depends on the Option for which you are enrolled. You are automatically
enrolled in Option 1 unless you choose to enroll for Option 2.
• Option 1: The longer of 180 days and the length of time for which you receive loss of time
benefits, salary continuation or accumulation of sick leave.
• Option 2: The longer of 90 days and the length of time for which you receive loss of time
benefits, salary continuation or accumulated sick leave.
Benefits begin the day after the Elimination Period is completed.
Maximum Benefit Period
Age at disability
Maximum benefit period
Under age 61
To your normal retirement age*, but not less than 60 months
61
To your normal retirement age*, but not less than 48 months
62
To your normal retirement age*, but not less than 42 months
63
To your normal retirement age*, but not less than 36 months
64
To your normal retirement age*, but not less than 30 months
65
24 months
66
21 months
67
18 months
no -I.
e
68 15 months
69 and over 12 months
*Your normal retirement age is your retirement age under the Social Security Act where
retirement age depends on your year of birth.
No contributions are required for your coverage while you are receiving payments under this plan.
Cost of Coverage: The long term disability plan is provided to you on a contributory basis. You
will be informed of the amount of your contribution when you enroll.
The above items are only highlights of coverage. For a full description please read the entire
Group Insurance Certificate.
CURRENT PRICING
Lonjg term Disability
Option 1:
Option 2:
AGE RANGE
RATE
RATE
<25
$.14
$.16
25 to 29
$.16
$.18
30 to 34
$.17
$.20
35 to 39
$.18
$.21
40 to 44
$.25
$.28
45 to 49
S.31
$.36
50 to 54
$.42
$.49
55 to 59
$.64
$.74
60+
$.79
$.91
Lonjg term Disability
Vendor Answer
Guaranteed Issue
Yes — $5,000 for the current plan and $7,500 for the
WAIVER OF PREMIUM for
Yes
disability
Portable under similar terms and
No
conditions
On duty and Off duty coverage
Yes
Length of time with carrier (1
point per
1/1/2015
Minimum participation
25%
A M Best Rating of carrier (A
A
VIII min)
Own Occupation test for wait
period?
Yes
Waiting period for illness (180
days maximum)
Option I is 180 days and Option 2 is 90 days
Waiting period for injury (180
days maximum)
Option 1 is 180 days and Option 2 is 90 days
0
Coverage period (5 year
minimum)
Benefit Duration: SSNRA
Percent of usual pay (50%
Option 1 is 60% and Option 2 is 66 2/3%
minimum
Minimum Percent of usual pay
with Social Security, Worker's
Comp or other income offset
Minimum Benefit is $100
(40% minimum)
Other features: Please list other
Work Incentive Benefit, Rehabilitative Incentive Income,
features of your policy.
3/12 pre -ex, Survivor Benefit, Rehabilitation Benefit
Item Long term Disability Insurance
1 Multi-year Rate Quote (5 points per
3 Years with an option to renew for an r
2 1 Please attach a five year rate history Rates will be guaranteed 3 years
3 1 Bi Weekly Cost per Sam le of 100 Rates are age banded. See Proposal for
Incurred Loss Ratio * Maximum Renewal Rate Increase
Under 85% 0%
85%-89% 10%
90%-99% 20%
100% or more Underwriting Discretion
*Calculated using paid claim payments, disabled claim reserves, and interest credited on claim
reserves based on the incurred date divided by premium adjusted to the current rate basis.
Year 4 and 5 renewal period: Loss ratio will be based on the most recent 24 months of experience
outside of the IBNR period
Year 6 and 7 renewal period: Loss ratio will be based on the most recent 48 months of experience
outside of the IBNR period
EXHIBIT C
SAMPLE POLICIES
Term Life and AD&D
Insurance
Employee Benefit Booklet
DeoxbOfn'ffi'A NC&IOnal0
SAMPLE TX
SAMPLETX-0001
I Class 1-01
Products and services marketed under the Dearborn National® brand and the star logo are underwritten
and/or provided by Dearborn National ® Life Insurance Company (Downers Grove, IL) in all states
(excluding New York), the District of Columbia, the United States Virgin Islands, the British Virgin
Islands, Guam and Puerto Rico.
09/07/2012
Dearborn National® Life Insurance Administrative Office:
Company 1020 31 st Street
Downers Grove IL 60515-5591
(A stock life insurance company, herein called the "We" "Us" or "Our")
Having issued Group Policy No. SAMPLETX-0001
(herein called the Policy)
to
SAMPLE TX
(herein called the Policyholder)
GROUP INSURANCE CERTIFICATE
CERTIFIES that You are insured, provided that You qualify under the ELIGIBILITY AND EFFECTIVE
DATES provision, become insured and remain insured in accordance with the terms of the Policy. Your
insurance is subject to all the definitions, limitations and conditions of the Policy, and it takes effect as
stated in the ELIGIBILITY AND EFFECTIVE DATES provision.
This Certificate describes Your eligibility for benefits and the terms and provisions of the Policy. It
replaces and cancels any other Certificate previously issued to You under the Policy.
If the terms and provisions of the Group Insurance Certificate (issued to You) are different from the policy
(issued to the Policyholder), the Policy will govern. Your coverage may be canceled or changed in whole
or in part under the terms and provisions of the Policy.
READ YOUR CERTIFICATE CAREFULLY
Signed for Dearborn National Life Insurance Company
Secretary President
Death Benefits will be reduced if an accelerated death benefit is paid.
DISCLOSURE: The Accelerated Death Benefit offered under this Policy is intended to qualify for favorable tax
treatment under the Internal Revenue Code of 1986. If the Accelerated Death Benefit qualifies for such favorable
tax treatment, the benefits will be excluded from the insured Employee's income and not subject to federal taxation.
Tax laws relating to Accelerated Death Benefits are complex. The insured Employee is advised to consult with a
qualified tax advisor about circumstances under which he or she could receive the Accelerated Death Benefit
excludable from income under federal law.
Receipt of the Accelerated Death Benefit payment may affect the insured Employee, his or her spouse, or his or her
family's eligibility for public assistance such as medical assistance (Medicaid), Aid to Families with Dependent
Children (AFDC), Supplementary Social Security Income (SSI), and drug assistance programs. The insured
Employee is advised to consult with a qualified tax advisor and with social service agencies concerning how receipt
of such payment will affect the insured Employee, his or her spouse, or his or her family's eligibility for public
assistance.
00124TX
Basic Group Term Life Insurance Certificate
with
Accidental Death & Dismemberment Insurance Benefits
Non -Participating
FDL 1-604-412
IMPORTANT INFORMATION ABOUT COVERAGE UNDER THE TEXAS LIFE, ACCIDENT, HEALTH
AND HOSPITAL SERVICE INSURANCE GUARANTY ASSOCIATION
(For insurers declared insolvent or impaired on or after September 1, 2005)
Texas law establishes a system, administered by the Texas Life, Accident, Health and Hospital Service Insurance
Guaranty Association (the "Association"), to protect Texas policyholders if their life or health insurance company
fails. Only the policyholders of insurance companies which are members of the Association are eligible for this
protection which is subject to the terms, limitations, and conditions of the Association law. (The law is found in the
Texas Insurance Code, Chapter 463.)
It is possible that the Association may not cover your policy in full or in part due to statutory limitations.
Eligibility for Protection by the Association
When a member insurance company is found to be insolvent and placed under an order of liquidation by a court or
designated as impaired by the Texas Commissioner of Insurance, the Association provides coverage to policyholders
who are:
• Residents of Texas at that time (irrespective of the policyholder's residency at policy issue)
• Residents of other states, ONLY if the following conditions are met:
1. The policyholder has a policy with a company domiciled in Texas;
2. The policyholder's state of residence has a similar guaranty association; and
3. The policyholder is not eligible for coverage by the guaranty association of the policyholder's state of
residence.
Limits of Protection by the Association
Accident, Accident and Health, or Health Insurance:
• For each individual covered under one or more policies: up to a total of $500,000 for basic hospital, medical -
surgical, and major medical insurance, $300,000 for disability or long term care insurance, and $200,000 for
other types of health insurance.
Life Insurance:
• Net cash surrender value or net cash withdrawal value up to a total of $100,000 under one or more policies on
any one life; or
• Death benefits up to a total of $300,000 under one or more policies on any one life; or
• Total benefits up to a total of $5,000,000 to any owner of multiple non -group life policies.
Individual Annuities:
• Present value of benefits up to a total of $100,000 under one or more contracts on any one life.
Group Annuities:
• Present value of allocated benefits up to a total of $100,000 on any one life; or
• Present value of unallocated benefits up to a total of $5,000,000 for one contract holder regardless of the
number of contracts.
Aggregate Limit:
• $300,000 on any one life with the exception of the $500,000 health insurance limit, the $5,000,000 multiple -
owner life insurance limit, and the $5,000,000 unallocated group annuity limit.
Insurance companies and 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. When you are selecting an
insurance company, you should not rely on Association coverage.
Texas Life, Accident, Health and Hospital Service Texas Department of Insurance
Insurance Guaranty Association
6504 Bridge Point Parkway, Suite 450 P.O. Box 149104
Austin, Texas 78730 Austin, Texas 78714-9104
800-982-6362 or www.txlifega.org 800-252-3439 or www.tdi.state.tx.us
TX Notice
IMPORTANT NOTICE
To obtain information or make a complaint:
You may contact your (title)
at {telephone number).
You may call Dearborn National Life Insurance
Company's toll-free telephone number for infor-
mation or to make a complaint at:
1-800-348-4512
You may also write to Dearborn National Life
Insurance Company at:
1020 31st Street, Downers Grove, IL 60515-5591
You may contact the Texas Department of Insurance
to obtain information on companies, coverages, rights
or complaints at:
1-800-252-3439
You may write the Texas Department of Insurance
P. O. Box 149104
Austin, TX 78714-9104
FAX #(512) 475-1771
Web: http:llwww.tdi.state.tx.us
E-mail: ConsumerProtection@tdi.state.tx.us
PREMIUM OR CLAIM DISPUTES: Should you
have a dispute concerning your premium or about a
claim, you should contact the company first. If the
dispute is not resolved, you may contact the Texas
Department of Insurance.
ATTACH THIS NOTICE TO YOUR POLICY:
This notice is for information only and does not
become a part or condition of the attached document.
9-632-895
AVISO IMPORTANTE
Para informacion o para someter una queja:
Peude communicarse con su (title)
al (telephone number).
Usted puede hamar al numero de telefono gratis de
Dearborn National Life Insurance Company para
informacion o para someter una queja al:
1-800-348-4512
Usted tambien escribir a Dearborn National Life
Insurance Company al:
1020 31st Street, Downers Grove, IL 60515-5591
Puede comunicarse con el Departamento de Seguros
de Texas para conseguir informacion acerca de
companias, coberturas, derechos o quejas al:
1-800-2523439
Puede escribir al Departamento de Seguros de Texas:
P. O. Box 149104
Austin, TX 78714-9104
FAX #(512) 475-1771
Web: http://www.tdi.state.tx.us
E-mail: ConsumerProtection@tdi.state.tx.us
DISPUTAS SOBRE PRIMAS O RECLAMOS: Si
tiene una disputa concemiente a su prima o a un
reclamo, debe comunicarse con la Compania primero.
Si no se resuelve la disputa, puede entonces
comunicarse con al Departamento de Seguros de
Texas.
UNA ESTE AVISO A SU POLIZA: Este aviso es
solo para proposito de informacion y no se convierte
en parte o condicion del documento adjunto.
TABLE OF CONTENTS
Schedule of Benefits
Eligibility and Effective Dates
Group Term Life Insurance Benefit
Conversion of Life Insurance
Waiver of Premium
Accelerated Death Benefit
Dependent Life Insurance
Conversion of Dependent Life Insurance.
Accidental Death, Dismemberment and Loss of Sight Benefit
Termination Provisions
General Provisions
Definitions
FDL1-604-412
Accelerated Death Benefit (ADB)
Benefit Amount 75% Basic Term Life Insurance In force
Insured Eligibility Employee
Minimum Covered Life Insurance Amount $15,000
Maximum ADB Payment $250,000
Minimum ADB Payment $7,500
GROUP ACCIDENTAL DEATH & DISMEMBERMENT
Employee Basic AD&D Coverage Amount $25,000
Reduction of Benefits Basic Accidental Death and Dismemberment benefits reduce by 35% of
the original amount at age 65 and further reduce to 50% of the original
amount at age 70. Benefits terminate at retirement.
Seat Belt Benefit 10% of Employee Coverage Amount, to a maximum of $25,000
Air Bag Benefit 5% of Employee Coverage Amount to a maximum of $5,000
Repatriation Benefit Actual costs to a maximum of $5,000
Education Benefit
Benefit Amount 3% of Employee Coverage Amount, to a maximum of $3,000 per year
Maximum Benefit Duration Benefit payable for a maximum of four (4)years
Eligible Dependents Age live birth to age 25 years
FDL 1-604-412 2
SCHEDULE OF BENEFITS
POLICYHOLDER:
SAMPLE TX
POLICY NUMBER:
SAvIPLETX-0001
EFFECTIVE DATE:
July 1, 2012
ELIGIBILITY:
All full-time Employees of the Policyholder working in the United States of America who
Class 01
are Actively at Work for the Policyholder and who have completed the Waiting Period are
eligible for the insurance. A full-time Employee is one who regularly works a minimum of
30 hours per week for the Policyholder. Part-time, seasonal and temporary Employees of
the Policyholder are not eligible.
Eligibility Waiting Period:
Current Employees: None
New Employees: First of the month following of continuous, full-time active work
Policyholder
Basic Life & AD&D 100% of premium
Contribution:
GROUP TERM LIFE INSURANCE
Employee Basic Life Benefit
Amount $25,000
Reduction of Benefits
Basic Group Term Life benefits reduce by 35% of the original amount at
age 65 and further reduce to 50% of the original amount at age 70.
Benefits terminate at retirement.
Waiver of Premium
Waiver Eligibility
Totally Disabled prior to age 60 without interruption from the last date
Insured Eligibility
worked for at least 9 months
Employee
Maximum Waiver of Premium Duration age 65
Accelerated Death Benefit (ADB)
Benefit Amount 75% Basic Term Life Insurance In force
Insured Eligibility Employee
Minimum Covered Life Insurance Amount $15,000
Maximum ADB Payment $250,000
Minimum ADB Payment $7,500
GROUP ACCIDENTAL DEATH & DISMEMBERMENT
Employee Basic AD&D Coverage Amount $25,000
Reduction of Benefits Basic Accidental Death and Dismemberment benefits reduce by 35% of
the original amount at age 65 and further reduce to 50% of the original
amount at age 70. Benefits terminate at retirement.
Seat Belt Benefit 10% of Employee Coverage Amount, to a maximum of $25,000
Air Bag Benefit 5% of Employee Coverage Amount to a maximum of $5,000
Repatriation Benefit Actual costs to a maximum of $5,000
Education Benefit
Benefit Amount 3% of Employee Coverage Amount, to a maximum of $3,000 per year
Maximum Benefit Duration Benefit payable for a maximum of four (4)years
Eligible Dependents Age live birth to age 25 years
FDL 1-604-412 2
ELIGIBILITYAND EFFECTIVE DATE PROVISIONS
Who is eligible for this insurance?
The eligibility for this insurance is as indicated in the Schedule of Benefits.
The Eligibility Waiting Period is set forth in the Schedule of Benefits.
00001
When does Your Noncontributory insurance become ef,)`ec"?
Noncontributory means the Policyholder pays 100% of the premium for this insurance.
Current Employees
If You are an eligible Employee on the Policy effective date, Your Noncontributory coverage under the
Policy will become effective on the date indicated in the Schedule of Benefits, provided You are Actively
at Work on that day.
New Employees
If You become an eligible Employee after the Policy effective date, Your Noncontributory coverage under
the Policy will become effective on the date indicated in the Schedule of Benefits, provided You are
Actively at Work on that day.
If You waive all or a portion of Your Noncontributory coverage and choose to enroll at a later date, You
are considered a late applicant and must fumish Evidence of Insurability satisfactory to Us before
coverage can become effective. Coverage will become effective on the date We determine that the
Evidence oflnsurability is satisfactory and We provide written notice of approval.
You must be Actively at Work for coverage under the Policy to become effective.
00003
Change in Family Status
If You experience a Change in Family Status, You may enroll for coverage, apply for additional coverage,
or request changes to Your current benefit program(s) without providing Evidence of Insurability,
provided the benefit change is consistent with the Change in Family Status. You must submit the
appropriate Enrollment Form within 31 days of the Change in Family Status.
Change In Family MOW means changes in the status of Your family, including but not limited to:
1. You get married or execute a Domestic Partner affidavit;
2. You have a Dependent Child, or You adopt or become the legal guardian of a Dependent child;
3. Your Spouse dies or You become divorced;
4. Your Dependent Child becomes emancipated or dies;
5. Your Spouse is no longer employed, resulting in a loss of group insurance, or;
6. You have a change in classification which results in You changing from part-time to full-time, or full-
time to part-time.
00005
FDLI-604-412
When is Evidence oflnsurabUby required?
Evidence of Insurability is required if:
1. You are a late applicant, which means You enroll for insurance more than 31 days after Your
eligibility date; or
2. You voluntarily canceled Your insurance and choose to reapply; or
3. Your coverage amount exceeds the Guarantee Issue Benefit Limit as set forth in the Schedule of
Benefits; or
4. You apply to increase Your coverage amount during the Policy year, or
5. An increase to Your Annual Earnings results in an increase to Your Life Insurance benefit of more
than $50,000, and that amount exceeds the Guarantee Issue Benefit Limit.
Receipt of premium before We have approved Evidence of Insurability will not constitute acceptance and
does not guarantee issuance of any benefit amount prior to Our approval.
Evidence of Insurability means a statement of Your medical history which We will use to determine if
You are approved for coverage. Evidence of Insurability will be provided at Your expense.
Evidence of Insurability Form means a form provided or approved by Us on which You provide a
statement of Your medical history.
You may obtain an Evidence of Insurability Form from the Policyholder.
00006
If You are not Actively at Work, when does coverage become effective? 0
If You are absent from Active Work on the date Your coverage would otherwise become effective; and
Your absence is caused by an Injury, illness or layoff,
Your effective date for any initial coverage or increased coverage will be deferred until the first day You
return to Active Work.
However, You will be considered Actively at Work on any day that is not Your regularly scheduled work
day (including but not limited to a weekend, vacation or holiday) if You were Actively at Work on the
immediately preceding scheduled work day and You were:
1. not Hospital Confined; or;
2. disabled due to an Injury or Sickness.
00008
Changes to Your coverage
A change in Your coverage may occur if:
1. There is a Policy change; or
2. You enter another class and become eligible for a change in benefits; or
3. You experience a qualified Change in Family Status
4. There is a change in Your Annual Earnings, which results in an increased benefit amount
If You are eligible for additional coverage due to a Policy change, the additional coverage will be
effective on the date the Policy change is effective, as requested by the Policyholder and agreed upon by
Us.
FDLI -604-412 4
Additional coverage for reasons other than a Policy change will be effective as indicated in the "When
Does Your Non -Contributory insurance become effective?" section, or the later of:
1. The date You enroll for the additional coverage; or
2. The date You become eligible for the additional coverage, if enrollment is not required; or
3. The date We approve Your coverage if Evidence of lnsurability is required.
In order for Your additional coverage to begin, You must be Actively at Work.
Additional Contributory coverage is subject to payment of premium.
00010
Eligibility after You Terminate Employment
If Your coverage ends due to termination of employment, You must meet all the requirements of a new
Employee if You are rehired at a later date.
Exception: If Your coverage ends due to termination of employment and You return to Active Work in an
eligible class within 6 months, we will not:
1. apply a new Eligibility Waiting Period, or
2. require Evidence of Insurability.
If You converted all or part of Your group life insurance when employment terminated, the individual
policy must be surrendered upon return to Active Work.
00611
FDLI-604-412
TERM LIFE INSURANCE BENEFIT
THIS BENEFIT ONLYAPPLIES TO YOU IF YOU HAVE ELECTED TERM LIFE INSURANCE
AND YOU HAVE PAID OR AGREED TO PAY THE APPLICABLE PREMIUM.
When is a Life Insurance Benefit payable?
We will pay Your beneficiary the amount of life insurance in force as of the date of Your death provided:
1. You are insured under the Policy on the date of death, and
2. We receive proof of death.
We will determine the amount of insurance payable based upon the Schedule of Benefits.
00012 TX
Who will receive Your Life Insurance Benefits?
Your beneficiary designation must be made on a form which We provide or on a form accepted by Us. If
two or more beneficiaries are named, payment of proceeds will be apportioned equally unless You had
specified otherwise. The Policyholder may not be named as beneficiary. Unless You provide otherwise,
if a beneficiary dies before You, We will divide that beneficiary's share equally between any remaining
named beneficiaries.
If a beneficiary is a minor, or is not able to give a valid release for any payment of benefits made, We will
not make payment until a claim is made by the person or entity which, by court order, has been granted
control of the estate of such beneficiary. This provision does not prevent Us from making payment to or
for the benefit of a minor beneficiary in accordance with the applicable state law.
Facility of Payment
If no named beneficiary survives You or if You do not name a beneficiary, We will pay the amount of
insurance:
1. to Your spouse, if living; if not,
2. in equal shares to Your then living natural or legally adopted children, if any; if none,
3. in equal shares to Your father and mother, if living; if not,
4. in equal shares to Your brothers and/or sisters, if living; if not,
5. to Your estate.
If any benefits under this provision are to be paid to Your estate, We may pay an amount not greater than
$250 to any person We consider equitably entitled by reason of having incurred funeral or other expenses
incident to Your death. Any and all payments made by Us shall fully discharge Us in the amount of such
payment.
00014 TX
May You change Your beneficiary?
You may change Your beneficiary at any time by completing a form provided or accepted by Us, and
sending it to the Policyholder. Your written request for change of beneficiary will not be effective until it
is recorded by the Policyholder. After it has been so recorded, it will take effect on the later of the date
You signed the change request form or the date You specifically requested. If You die before the change
has been recorded, We will not alter any payment that We have already made. Any prior payment shall
fully discharge Us from further liability in that amount.
FDLI-604-412
If You are approved for continued life coverage under the Waiver of Premium, You may be asked to name
a beneficiary. A beneficiary designation made in connection with Waiver of Premium, if different from
the designation on Your enrollment form, shall constitute a change of beneficiary under the Policy. Such
change of beneficiary only applies while You qualify for continued coverage under the Waiver of
Premium provision.
If continuation of life insurance under the Waiver of Premium provision ceases, and You are employed by
the Policyholder, You must make a new beneficiary designation. If You do not name a new beneficiary,
We will pay death benefits in accordance with the Facility of Payment provision.
00015
CONVERSION OF LIFE INSURANCE
How much Life Insurance may You convert ifeligibility terminates?
You may convert to an individual policy of life insurance if Your life insurance, or a portion of it, ceases
because:
1. You are no longer employed by the Policyholder; or
2. You are no longer in a class which is eligible for life insurance.
In either of these situations, You may convert all or any portion of Your life insurance which was in force
on the date Your life insurance ceased.
How much Life Insurance may You convert if the policy terminates or is amended?
You may also convert to an individual policy of life insurance if Your life insurance ceases because:
1. life insurance benefits under the Policy cease; or
2. the Policy is amended making You ineligible for life insurance; however, in either of these situations,
You must have been insured under the Policy, or the Policy it replaced, for at least five {5} years. The
amount of insurance converted in either of these situations will be the lesser of:
1. the amount of life insurance in force, less any amount for which You become eligible under this or
any other group policy within 31 days after the date Your life insurance ceased; or
2. $10,000.
How to apply for conversion
We must receive written application and the first premium for the individual life insurance policy within
31 days after life insurance under the Policy ceased. No Evidence of Insurability will be required.
The individual policy will be a policy of whole life insurance. It will not contain waiver of premium,
accelerated death benefit, disability benefits, accidental death and dismemberment benefits or any other
ancillary benefits.
The minimum issue amount of an individual conversion policy is $2,000. The premium for the individual
policy will be based on:
1. Our current rates based upon Your attained age; and
2. the amount of the individual policy.
FDL 1-604-4I 2
If application is made for an individual policy, the coverage under the individual policy will be effective
on the day following the 31 -day period during which You could apply for conversion.
If You die during a period when You would have been entitled to have an individual policy issued to You
and if You die before such an individual policy became effective, We will pay Your beneficiary the
greatest amount of group term life insurance for which an individual policy could have been issued,
provided:
1. Your death occurred during the 31 -day period within which You could have made application; and
2. We receive proof of death.
If life insurance benefits are paid under the Policy, payment will not be made under the converted policy,
and premiums paid for the converted policy will be refunded.
Notice. If the Policyholder fails to notify You at least 15 days prior to the date insurance under the Policy
would cease, You shall have an additional period within which to elect conversion coverage; but nothing
herein shall be construed to continue any insurance beyond the period provided for in the Policy. The
additional election period shall expire 15 days immediately after the Policyholder gives You notice, but in
no event shall it extend beyond 60 days immediately after the expiration of the 31 -day period explained
above.
00016 TX
WAIVER OF PREMIUM
What is the Waiver of Premium benefit?
We will continue Your Basic life insurance benefit under the Policy without further payment of life
insurance premium if You become Totally Disabled, provided:
1. You are insured under the Policy and were Actively at Work on or after the effective date of the
Policy; and
2. You are under the age of 60; and
3. You provide Us with satisfactory written proof within 12 months after the date You became Totally
Disabled; and
4. Your Total Disability has continued without interruption for at least 9 months; and
5. You are still Totally Disabled when You submit the proof of disability; and
6. all required premium has been paid.
Total Disability or Totally Disabled means You are diagnosed by a Doctor to be completely unable
because of Sickness or Injury to engage in any occupation for wage or profit or any occupation for which
You become qualified by education, training or experience.
We will waive premium beginning the month after We receive satisfactory proof that You have been
Totally Disabled for at least 9 months. Premium will continue to be waived provided You:
1. remain Totally Disabled; and
2. provide satisfactory written proof of continuing Total Disability upon request. We will not request
proof of continuing Total Disability more frequently than once every three months during the first
two years of Total Disability, and not more frequently than once a year after the Insured has been
Totally Disabled for two years.
FDLI-604-412
You are responsible for obtaining initial and continuing proof of Total Disability
You will be covered for the amount of life insurance in force as of the date Total Disability commenced.
The amount of life insurance continued in force will be subject to any reduction in benefits as shown on
the Schedule of Benefits or which are the result of an amendment to the Policy, but in no event will the
insurance amount increase while Your life insurance is continued under Waiver of Premium. This life
insurance coverage will continue without the payment of premium until You are no longer Totally
Disabled, or attain the Maximum Waiver of Premium Duration as set forth in the Schedule of Benefits or
retire, whichever occurs first.
We may have You examined at reasonable intervals during the period of claimed Total Disability, but not
more frequently than once every three months during the first two years of Total Disability, and not more
frequently than once a year after the Insured has been Totally Disabled for two years. Continuation of life
insurance under the Waiver of Premium provision shall end immediately and without notice if You refuse
to be examined as and when required.
If You are approved for continued coverage under the Waiver of Premium provision, You will be asked to
name a beneficiary. That beneficiary designation:
1. will only apply while Your coverage continues under this Waiver of Premium provision; and
2. if different from the designation on Your enrollment form, shall constitute a change of beneficiary
under the Policy.
We will pay the amount of life insurance in force to Your beneficiary if You die before furnishing
satisfactory proof of Total Disability, if:
1. You die within one year from the date You became Totally Disabled; and
2. We receive proof that You were continuously Totally Disabled until the date of death; and
3. We receive proof of death.
If continuation of life insurance under the Waiver of Premium provision ceases while the Policy is still in
force, and You are employed by the Policyholder, Your life insurance will continue provided premium
payments begin on the next premium due date. if You return to work with the Policyholder, You must
make a new beneficiary designation. If You do not name a new beneficiary, We will pay death benefits in
accordance with the Facility of Payment provision.
If continuation of life insurance under the Waiver of Premium provision ceases, and You are no longer
employed by the Policyholder, You may apply for an individual life insurance policy in accordance with
the Conversion of Life Insurance provision of this Certificate.
How does termination of the Policy affect Your insurance under the Waiver of Premium Benefit?
Termination of the Policy will not affect any insurance that has been continued under this Provision prior
to the termination date.
What if You are Totally Disabled and the Policy ends before You satisfy the Elimination Period?
Your coverage under the Policy will end if the Policy ends before You satisfy the Elimination Period.
However, when the Policy ends You may be entitled to convert Your coverage to an individual plan of life
insurance as described in the Conversion of Life Insurance provision.
You may still submit a claim for Waiver of Premium Benefits after the Policy ends. However, You must
be Totally Disabled, pay the Conversion premium for the full length of the Elimination Period and qualify
for the Waiver of Premium Benefits.
FDLI-604-412 9
At no time can You be covered under both the individual conversion policy and this Policy.
Upon receipt of timely notice and due proof of Your Total Disability We will evaluate Your claim. If We
determine that You qualify and You pay all applicable premiums, We will approve Your Waiver of
Premium claim under the Policy and agree to rescind any individual policy of life insurance issued to You
under the Conversion privilege. We will refund any premiums paid for such coverage. Insurance under
the Policy will not go into effect until We approve your claim in writing.
00017rXe
FDLI-604-412 10
ACCELERATED DEATH BENEFIT
What is the Accelerated Death Benefit?
The Accelerated Death Benefit is a percentage of Your group Basic term life insurance which is payable
to You prior to Your death if We receive acceptable proof that You have a Terminal Condition. The
Accelerated Death Benefit is limited to the maximum and minimum amounts shown on the Schedule of
Benefits, and is payable only once to any one Insured.
The Accelerated Death Benefit is calculated on the group Basic term life insurance benefit amount in
force under the Policy on the date You are diagnosed with a Terminal Condition. If Your group term life
insurance will reduce, due to age, within 12 months after the date We receive proof, the Accelerated
Death Benefit will be calculated on the reduced group Basic term life insurance benefit.
Who is Eligible for an Accelerated Death Benefit?
This benefit only applies to Insureds with at least the Minimum Covered Life Insurance Benefit amounts
set forth in the Schedule of Benefits. You must have been Actively at Work on or after the effective date
of the Policy to be eligible for an Accelerated Death Benefit.
This benefit does not apply to Accidental Death and Dismemberment benefits.
Terminal Condition means You have been examined and diagnosed by Your Doctor as having a non -
correctable health condition that, with reasonable medical certainty, will result in Your death within 12
months from the date of the Doctor's Statement.
Doctor's Statement means a written medical opinion of a Doctor currently licensed to practice in the
United States which:
1. is made at Your expense; and
2. indicates that You have a Terminal Condition; and
3. includes all medical test results, laboratory reports, and any other information on which the medical
opinion is based; and
4. indicates Your expected remaining life span; and
5. is acceptable to Us.
The Accelerated Death Benefit Payment
We will pay the benefit during Your lifetime if You are diagnosed with a Terminal Condition if You or
Your legal representative submits a claim for an Accelerated Death Benefit and provides satisfactory
proof. The benefit will be paid in one sum to You. There is no cost for an Accelerated Death Benefit. At
the time of the payment of the Accelerated Death Benefit, We will send a statement to the certificate
holder specifying the amount of benefits paid, the effect of the Accelerated Death Benefit payment on the
death benefit face amount, and the amount of benefits remaining available for acceleration.
Are there any exceptions to the payment of the Accelerated Death Benefit?
The Accelerated Death Benefit will not be payable:
I. for any amount of group term life insurance which is less than the Minimum ADB Payment as set
forth in the Schedule of Benefits; or
2. if Your Terminal Condition is the result of.
a. attempted suicide, while sane or insane; or
�f' = b. intentionally self-inflicted injury; or
3. if Your group term life insurance benefit has been assigned; or
FDL 1-604-412 11
4. if Your group term life insurance benefit is payable to an irrevocable beneficiary, including
notification to Us that such benefit or a portion of such benefit is to be paid to a former spouse as part
of a divorce or separation agreement; or Y
5. to retirees.
Notice and Proof of Claim
You must elect the Accelerated Death Benefit in writing on a form that is acceptable to Us. You must
furnish proof that You have a Terminal Condition, including a Doctor's Statement within 91 days of the
notice of claim. If proof is not given within 91 days, the claim will not be reduced or denied if proof is
given as soon as reasonably possible.
Effect on Insurance
The Accelerated Death Benefit is in lieu of the group term life insurance benefit that would have been
paid upon Your death. When the Accelerated Death Benefit is paid:
1. the term life insurance benefit otherwise payable upon Your death will be reduced by the amount of
the Accelerated Death Benefit. Any portion of the death benefit remaining after reduction of the
death benefit due to payment of an Accelerated Death Benefit shall be paid upon the death of the
Insured.
2. the amount of group term life insurance which could otherwise have been converted to an individual
contract will be reduced by the amount of the Accelerated Death Benefit; and
3. the premium due for group term life insurance will be calculated on the amount of such insurance
remaining in force after deducting the Accelerated Death Benefit.
The payment of an Accelerated Death Benefit and the balance of the death benefit under the Policy shall
constitute full settlement of the face amount of the Policy.
00020 Tx 0
O
FDL 1-604-412 12
ACCIDENTAL DEATH & DISMEMBERMENT BENEFIT (AD&D)
What is the AD&D Benefit?
If, while insured under the Policy, You suffer an Injury in an Accident, We will pay for those Losses set
forth in the "Table of Losses" below. The amount paid will be the percentage stated in the Table of Losses
but not more than the Coverage Amount set forth in the Schedule of Benefits. The Loss must:
1. occur within 365 days of the Accident, and
2. be the direct and sole result of the Accident; and
3. be independent of all other causes.
TABLE OF LOSSES
% OF COVERAGE
AMOUNT PAYABLE
Loss of Life
1000/0
Loss of Both Hands
1000/0
Loss of Both Feet
1000/0
Loss of Entire Sight of Both Eyes
1000/0
Loss of One Hand and One Foot
100%
Loss of Speech and Hearing
1000/0
Quadriplegia
100%
Paraplegia
75%
Loss of One Hand
50%
Loss of One Foot
50%
Loss of Entire Sight of One Eye
50%
Loss of Speech
50%
Loss of Hearing (both ears)
50%
Hemiplegia
50%
Loss of Thumb and Index Finger (on same hand)
25%
Uniplegia
25%
Definitions which apply to the AD&D Provision:
Accident or Accidental means a sudden, unexpected event that was not reasonably foreseeable.
Hemiplegia means total Paralysis of one arm and one leg on the same side of the body.
Loss, with respect to hand or foot, means actual and permanent severance from the body at or above the
wrist or ankle joint, as applicable. With respect to eyes, speech and hearing, loss means entire and
irrecoverable loss of sight, speech or hearing. With respect to thumb and index finger, loss means
complete severance of entire digit at or above joints.
Paralysis means loss of use without severance of a limb as a result of an Injury to the Spinal Cord, which
has continued for 12 months. Paralysis must be determined by a Doctor to be permanent, total and
irreversible.
Paraplegia means total Paralysis of both legs.
Quadriplegia means total Paralysis of both arms and both legs.
Uniplegia means total Paralysis of one limb.
FDL 1-604-412 13
The total amount of AD&D benefits payable for all Losses for any Insured resulting from any one
Accident will not be greater than the Coverage Amount set forth in the Schedule of Benefits.
Except as provided in a particular AD&D benefit provision, We will pay benefits for loss of life to the
same beneficiary(ies) named to receive life insurance benefits. Benefits for all other Losses will be paid
to You.
00030
SEAT BELT BENEFIT
What is the Seat Belt Benefit?
We will pay an additional amount, as set forth in the Schedule of Benefits, if a benefit is payable under the
AD&D Benefit for Your loss of life as the result of an Accident which occurs while You were driving or
riding in an Automobile, if:
1. the Automobile is equipped with Seat Belts.
2. the Seat Belt was in actual use and properly fastened at the time of the Accident.
3. the position of the Seat Belt is certified in the official report of the Accident or by the investigating
officer. A copy of the police accident report must be submitted with the claim.
4. You were driving or riding in an Automobile driven by a licensed driver who was neither:
a. intoxicated or driving while impaired. Intoxication and impairment shall be determined, with or
without conviction, by the law of the jurisdiction in which the Accident occurs or .08% blood
alcohol content if the jurisdiction in which the Accident occurred does not define intoxication; nor
b. under the influence of any narcotic, hallucinogen, barbiturate, amphetamine, gas or fumes, poison
or any other controlled substance as defined in Title II of the Comprehensive Drug Abuse
prevention and Control Act of 1970, as now or hereafter amended, unless as prescribed by a
licensed physician and used in the manner prescribed. Conviction is not necessary for a
determination of being under the influence.
If the required certification is not available and if it is unclear whether You were properly wearing a Seat
Belt, then We will pay an additional benefit of $1,000.
Automobile means a validly registered private passenger car (or policyholder -owned car), station wagon,
jeep -type vehicle, SW, pick-up truck or van -type car that is not licensed commercially or being used for
commercial purposes.
Seat Belt means those belts that form an occupant restraint system.
00031
AIR BAG BENEFIT
What is the Air Bag Benefit?
We will pay an additional amount as set forth in the Schedule of Benefits if a benefit is payable under the
AD&D Benefit for Your loss of life as the result of an Accident which occurs while You are driving or
riding in an Automobile provided that:
1. You were positioned in a seat that was equipped with an Air Bag;
2. You were properly strapped in the Seat Belt when the Air Bag inflated; and
3. the police report establishes that the Air Bag inflated properly upon impact.
If it is unclear whether You were properly wearing Seat Belt(s) or if it is unclear whether the Air Bag
inflated properly, then the Air Bag Benefit will be $1,000.
FDLI -604-412 14
Air Bag means an inflatable supplemental passive restraint system installed by the manufacturer of the
Automobile, or proper replacement parts as required by the automobile manufacturer's specifications, that
inflates upon collision to protect an individual from injury and death. A Seat Belt is not considered an Air
Bag.
00032
REPATRIATION BENEFIT
What is the Repatriation Benefit?
We will pay an additional amount, as set forth in the Schedule of Benefits, for the preparation and
transportation of Your body to a mortuary if:
1. the Coverage Amount under the AD&D Benefit is payable for Your loss of life; and
2. Your death occurs at least 75 miles away from Your principal residence.
00033
EDUCATION BENEFIT
What is the Education Benefit?
We will pay an additional amount, as set forth in the Schedule of Benefits to Your Dependent Student if
an AD&D benefit is payable for Your loss of life. We will only pay one Education Benefit to any one
Dependent Student during any one school year. If the Dependent Student is a minor, We will pay the
benefit to the legal representative of the minor.
Definitions which apply to the Education Benefit:
Student means an Eligible Dependent child who, on the date of Your death, is:
„�. 1. A full-time post -high school student in a School of Higher Education; or
2. A student in the 12'" grade but who becomes a full-time post -high school student in a School of
Higher Education within 365 days after Your death.
School of Higher Education means an institution which:
1. is legally authorized by the State in which it is located; and
2. provides either a program for:
a. Bachelor's degrees or not less than a two year program with full credit towards a Bachelor's
degree; or
b. Gainful employment as long as such program is at least one year of training; and
3. is accredited by an Agency or association recognized by the U.S. Department of Education under the
Higher Education Assistance Act as may be amended from time to time.
When Benefit Ends: A Dependent Student will no longer be eligible to receive the Dependent Education
Benefit upon the earlier of the following:
1. Our payment of the fourth installment of the Dependent Education Benefit on behalf of or to the
Dependent Student, or
2. At the end of the period during which due Proof must be submitted if no due Proof is submitted.
Special Child Education Benefit: If Your Eligible Dependent child does not qualify as a Student, but is
enrolled in an elementary or high school, We will pay a Child Education Benefit in the amount of $1,000.
This benefit is payable once upon proof that You died as a result of an Accident for which the Accidental
FDL 1-604-412 15
Death & Dismemberment benefit is payable and that, within 12 months after Your death, Your Eligible
Dependent Child is a full-time student in an elementary or high school.
00034 0
EXPOSURE AND DISAPPEARANCE
If, as a result of an Accident while insured for this benefit, if You are unavoidably exposed to the elements
and suffer a Loss as a result of that exposure, that Loss will be covered. If Your body has not been found
within one (1) year of an Accidental disappearance, forced landing, sinking or wrecking of a conveyance
in which You were occupants, You will be deemed to have suffered loss of life.
00043
LIMITATIONS
Are there any Limitations for losses due to an Accident?
We will not pay any benefit for any Loss that, directly or indirectly, results in any way from or is
contributed to by:
1. any disease or infirmity of mind or body, and any medical or surgical treatment thereof; or;
2. any infection, except a pus -forming infection of an Accidental cut or wound; or
3. suicide or attempted suicide, while sane or insane; or
4. any intentionally self-inflicted Injury; or
5. war, declared or undeclared, whether or not You are a member of any armed forces; or
6. travel or flight in an aircraft while a member of the crew, or while engaged in the operation of the
aircraft, or giving or receiving training or instruction in such aircraft; or
7. commission of, participation in, or an attempt to commit an assault or felony; or
8. under the influence of any narcotic, hallucinogen, barbiturate, amphetamine, gas or fumes, poison or
any other controlled substance as defined in Title II of the Comprehensive Drug Abuse Prevention
and Control Act of 1970, as now or hereafter amended, unless as prescribed by a licensed physician
and used in the manner prescribed. Conviction is not necessary for a determination of being under
the influence; or
9. intoxication as defined by the laws of the jurisdiction in which the Accident occurred or .08% blood
alcohol content if the jurisdiction in which the Accident occurred does not define intoxication.
Conviction is not necessary for a determination of being intoxicated; or
10. active participation in a Riot. Riot means all forms of public violence, disorder, or disturbance of the
public peace, by three or more persons assembled together, whether with or without a common intent
and whether or not damage to person or property or unlawful act is the intent or the consequence of
such disorder.
X0050
UNIFORM PROVISIONS
(Applicable to Dismemberment Coverage Only)
Initial Notice of Claim
We must receive written notice of Loss within 30 days of the date of Loss, or as soon as reasonably
possible. The Policyholder can assist with the appropriate telephone number and address of Our Claim
Department. Notice may be sent to Our Claim Department at the address shown on the claim form or
given to Our Agent. 0
FDLI-604-412 16
Claim Forms
Within 15 days of Our being notified in writing of a claim, We will supply the claimant with the
necessary claim forms. The claim form is to be completed and signed by the claimant, the Policyholder
and the claimant's Doctor. If the appropriate claim forms are not received within 15 days, then the
claimant will be considered to have met the requirements for written proof of lass if We receive written
proof, which describes the occurrence, extent and nature of the Loss.
Time Limit for Filing Your Claim
We must receive written proof of loss within 91 days after the date a Loss is incurred. If it is not possible
to give Us written proof within 91 days, the claim is not affected if the proof is given as soon as possible.
However, unless the claimant is legally incapacitated, written proof of loss mast be given no later than
one year after the time proof is otherwise due.
No benefits are payable for claims submitted more than 1 year after the time proof is due. However,
benefits may be paid for late claims if it can be shown that:
1. It was not reasonably possible to give written proof during the one year period, and
2. Proof of loss satisfactory to Us was given as soon as was reasonably possible.
For the Education Benefit, proof of loss must:
1. Include proof of Dependent Student status; and
2. Be submitted no later than
a. Two months after completion of course work for that particular school year if the Dependent
Student is enrolled in a School of Higher Education at the time of Your death. School year shall
be deemed to begin on September 1 st and end on August 31 st; or
b. Within six (6) months after enrollment in a School of Higher Education if the Dependent Student
is in the 12th grade at the time of Your death.
After the first year in a School of Higher Education, due proof must be submitted in accordance with
the time limits defined in Item (a) above.
Physical Examination/Autopsy
Upon receipt of a claim, We may examine an Insured, at Our expense, at any reasonable time. We
reserve the right to perform an autopsy, at Our expense, if it is not prohibited by any applicable local
law(s).
00051 Tx
FDL 1-604-412 17
TERMINA TION PR 0 VISIONS 01
When does Your coverage under the Policy end?
Your coverage will terminate on the earliest of the following dates. Termination will not affect Your
claim for a covered Loss which occurred while the coverage was in force.
1. the date on which the Policy is terminated;
2. the date You stop making any required contribution toward payment of premiums;
3. the effective date of an amendment to the Policy which terminates insurance for the class to which
You belong; or
4. the date You:
a. are no longer a member of a class eligible for this insurance,
b. request termination of coverage under the Policy,
c. are retired or pensioned, or
d. are no longer Actively at Work as a result of a disability, layoff, leave of absence, sabbatical or
military leave. However, You may continue to be eligible for group insurance coverage, as
follows:
Disability Until the end of the twelfth month following the month in which the disability began,
provided all premiums are paid when due, the Policy is in force, and Your coverage is
not replaced with group life insurance provided by a new carrier.
Layoff Until the end of the month following the month during which the layoff began,
provided all premiums are paid when due, the Policy is in force, and Your coverage is
not replaced with group life insurance provided by a new carrier.
Leave of Until the end of the month following the month during which the leave of absence
Absence began, or, the period of time in accordance with the FMLA provision below, provided
all premiums are paid when due, the Policy is in force, and Your coverage is not
replaced with group life insurance provided by a new carrier.
Sabbatical Until the end of the month following the sixth month in which the sabbatical began,
provided all premiums are paid when due, the Policy is in force, and Your coverage is
not replaced with group life insurance proved by a new carrier.
Military Until the end of the twelfth month following the month in which the military leave
Leave began, provided all premiums are paid when due, the Policy is in force, and Your
coverage is not replaced with group life insurance provided by a new carrier.
For the purposes of this Termination Provision only, Disability means You are unable to perform all of the
Material and Substantial Duties of Your Regular Occupation,
C,(H)52TXa
FDL l -604-412 18
Will coverage be continued if You are eligible for leave under FMLAY
`---w In the event You are eligible for and the Policyholder approves a leave under the Family and Medical
Leave Act of 1993 (FMLA), or any applicable state family and medical leave law (State FML), provided
the required premium continues to be paid, the Policy is in force and Your coverage is not replaced with
group life insurance provided by a new carrier, Your insurance will continue for a period of up to the later
of:
1. the leave period permitted by the federal Family and Medical Leave Act of 1993 and any
amendments; or
2. the leave period permitted by applicable state law.
You are eligible for leave under this Act in order to provide care:
1. After the birth of a child; or
2. After the legal adoption of a child; or
3. After the placement of a foster child in Your home; or
4. To a spouse, child or parent due to their serious illness; or
S. For Your own serious health condition.
While granted a Family or Medical Leave of Absence:
1. The Policyholder must remit the required premium according to the terms of the Policy; and
2. coverage will terminate if You do not return to work as scheduled according to the terms of Your
agreement with the Policyholder.
pdaft 00053a
5
FDL1-604-412 19
GENERAL PROVISIONS
Entire Contract, Changes
The Policy, the Policyholder's Application, the Employee's Certificate of coverage, and Your application,
if any, and any other attached papers, form the entire contract between the parties. Coverage under the
Policy can be amended by mutual consent between the Policyholder and Us. No change in the Policy is
valid unless approved in writing by one of Our officers. No agent has the right to change the Policy or to
waive any of its provisions.
Statements on the Application
In the absence of fraud, all statements made in any signed application are considered representations and
not warranties (absolute guarantees). No representation by:
I. the Policyholder in applying for the Policy will make it void unless the representation is contained in
his signed Application; or
2. any Employee in applying for insurance under the Policy will be used to reduce or deny a claim
unless a copy of the application for insurance, signed by the Employee, is or has been given to the
Employee.
Legal Actions
Unless otherwise provided by federal law, no legal action of any kind may be filed against Us:
0
1. until 60 days after proof of claim has been given; or
2. more than 3 years after proof of Loss must be filed, unless the law in the state where You live allows a
longer period of time. 0
Clerical Error
Clerical error or omission by Us to the Policyholder will not:
I . Prevent You from receiving coverage, if You are entitled to coverage under the terms of the Policy; or
2. Cause coverage to begin or coverage to continue for You when the coverage would not otherwise be
effective.
If the Policyholder gives Us information about You that is incorrect, We will:
1. Use the facts to decide whether You have coverage under the Policy and in what amounts; and
2. Make a fair adjustment of the premium.
Incontestability
The validity of the Policy shall not be contested, except for non-payment of premiums, after it has been in
force for two years from the date of issue. The validity of the Policy shall not be contested on the basis of
a statement made relating to insurability by any person covered under the Policy after such insurance has
been in force for two years during such person's lifetime, and shall not be contested unless the statement
is contained in a written instrument signed by the person making such statement.
Premlum Provisions
Premiums are payable in United States dollars on or before their due dates.
Premium charges for increases in insurance amounts becoming effective during a policy month will begin
on the next premium due date. Premium charges for insurance terminating during a policy month will
cease at the end of the month in which such insurance terminates. This method of charging premium is
FDL 1 -604-412 20
for accounting purposes only. It will not extend any insurance coverage beyond the date it would
r — �
otherwise have terminated.
(7-
Misstatement of Age
If You have misstated Your age, the true age will be used to determine:
1. the effective date or termination date of insurance; and
2. the amount of insurance; and
3. any other rights or benefits.
Premiums will be adjusted to reflect the premiums that would have been paid if the true age had been
known.
Conformity with State Statutes and Regulations
If any provision of the Policy conflicts with the statutes and regulations of the state in which the Policy
was issued or delivered, it is automatically changed to meet the minimum requirements of the statute.
Assignment
You may assign any incident of ownership You may possess of the life insurance benefits provided under
the Policy to anyone other than the Policyholder. We are not responsible for the validity or legal effect of
any assignment. Collateral assignments, by whatever name called, are not permitted.
FDLI-604-747-Gents REV2011
);DLI -604-412 2 L
DEFINITIONS
This section tells You the meaning of special words and phrases used in this Certificate. To help
You recognize these special words and phrases, the first letter of each word, or each word in the
phrase, is capitalized wherever it appears.
Actively at Work or Active Work means that You must:
1. work for the Policyholder on a full-time active basis; or
2. work at least the minimum number of hours set forth in the Schedule of Benefits: and either:
a. work at the Policyholder's usual place of business; or
b. work at a location to which the Policyholder's business requires You to travel;
3. be paid regular earnings by the Policyholder, and
4. not be a temporary or seasonal Employee.
You will be considered Actively at Work if You were actually at work on the day immediately preceding:
1. a weekend (except for one or both of these days if they are scheduled days of work);
2. holidays (except when such holiday is a scheduled work day);
3. paid vacations;
4. any non-scheduled work day;
5. excused leave of absence (except medical leave and lay-off); and
6. emergency leave of absence (except emergency medical leave); and
You were not Hospital Confined or disabled due to an Injury or Sickness.
00061 0
Activities of Daily Living means:
1. Eating — Feeding oneself by getting food into the body from a receptacle (such as a plate, cup or
table) or by a feeding tube or intravenously.
2. Toileting — Getting to and from the toilet, getting on and off the toilet and performing associated
personal hygiene.
3. Transferring — Moving into or out of a bed, chair or wheelchair.
4. Bathing — Washing oneself by sponge bath; or in either a tub or shower, including the task of getting
into or out of the tub or shower.
5. Dressing — Putting on and taking off all items of clothing and any necessary braces, fasteners or
artificial limbs.
6. Continence — Ability to maintain control of bowel and bladder function; or when unable to maintain
control of bowel or bladder function, the ability to perform associated personal hygiene (including
caring for catheter or colostomy bag).
00062
Application means the document which sets forth the eligible classes, the amounts of insurance, and other
relevant information pertaining to the plan of insurance for which the Policyholder applied.
00066
Doctor means a person legally licensed to practice medicine, psychiatry, psychology or psychotherapy,
who is neither You nor a member of Your immediate family. A licensed medical practitioner is a Doctor
if applicable state law requires that such practitioners be recognized for purposes of certification of Total
FDL 1-604-412 22
Disability, Terminal Condition or covered Loss, and the treatment provided by the practitioner is within
the scope of his or her license.
00073
Doctor's Statement means a written medical opinion of a Doctor currently licensed to practice in the
United States which:
1. is made at Your expense; and
2. indicates that You have a Terminal Condition; and
3. includes all medical test results, laboratory reports, and any other information on which the medical
opinion is based; and
4. indicates Your expected remaining life span; and
5. is acceptable to Us.
00125TX
Employee means an Actively at Work full-time employee whose principal employment is with the
Policyholder, at the Policyholder's usual place of business or such place(s) that the Policyholder's normal
course of business may require, who is Actively at Work for the minimum hours per week as set forth in
the Schedule of Benefits and is reported on the Policyholder's records for Social Security and
withholding tax purposes.
00074
Gainful Occupation means any work or employment in which the insured Employee:
1. is or could reasonably become qualified, considering his or her education, training, experience, and
mental or physical abilities;
2. could reasonably find work or employment, considering the demand in the national labor force; and
3. could earn (or reasonably expect to earn) a before -tax income at least equal to 60% of his or her Pre-
disability Income.
00078
Hospital Confined means that, upon the recommendation of a Doctor, You are registered as an inpatient
in a hospital, nursing home or other medical facility which provides skilled medical care or as an
outpatient in a hospital because of surgery. You are not Hospital Confined if You are receiving emergency
treatment or if You are hospitalized solely because of non-surgical medical or diagnostic test.
00081
Injury means bodily injury resulting directly from an Accident and independently of all other causes.
00082
Insured means an Employee covered under the Policy.
00083
Male Pronoun whenever used includes the female.
00088
Material and Substantial Duties means duties that are normally required for the performance of Your
Regular Occupation and cannot be reasonably omitted or modified.
00089
Non -Contributory means the Policyholder pays 100% of the premium for this insurance.
00092
PDL 1-604-412 23
Policy means this contract between the Policyholder and Us including the attached Application, which
provides group insurance benefits.,
00097
Policyholder means the person, firm, or institution to whom the Policy was issued. Policyholder also
means any covered subsidiaries or affiliates set forth on the face of the Policy.
00098 TX
Registered Domestic Partner means an adult of the same or opposite gender who has an emotional,
physical and financial relationship to You, similar to that of a Spouse, as evidenced by the following:
I - You and Your Domestic Partner share financial responsibility for a joint household and intend to
continue an exclusive relationship indefinitely;
2. You and Your Domestic Partner each are at least eighteen (l 8) years of age;
3. You and Your Domestic Partner are both mentally competent to enter into a binding contract;
4. You and Your Domestic Partner share a residence and have done so for at least 12 months;
5. Neither You nor Your Domestic Partner are married to or legally separated from anyone else;
6. You and Your Domestic Partner are not related to one another by blood closer than would bar
marriage; and
Neither You nor Your Domestic Partner is a Domestic Partner of anyone else.
Where the laws of the governing jurisdiction mandate a definition of Registered Domestic Partner other
than shown above, that definition will be used in the Policy.
00104
Regular Occupation means the occupation that You are routinely performing when Your life insurance
terminates due to Disahility. We will look at Your occupation as it is normally performed in the national
economy, instead of how the work tasks are performed for a specific Policyholder or at a specific
location.
00105
Sickness means illness, disease, pregnancy or complications of pregnancy.
00109
Terminal Condition means You have been examined and diagnosed by Your Doctor as having a non -
correctable health condition that, with reasonable medical certainty, will result in Your death within 12
months from the date of the Doctor's Statement.
00115 TX
We, Our and Us means Dearborn National Life Insurance Company, Chicago, Illinois.
00119
You, Your and Yours means the eligible Employee to whom this Certificate is issued and whose insurance
is in force under the terms of the Policy.
00120
FDLI-604-412 24
Administrative Office: 1020 31g Street
Downers Grove, Illinois 60515
DEARBORN NATIONAL® LIFE INSURANCE COMPANY
Chicago, Illinois
RIDER
This Rider is made a part of the Policy or Certificate (hereafter "the Policy") to which it is attached. It
takes effect and ends at the same time as the Policy. All provisions of the Policy, including any other
Riders or Amendatory Endorsements will apply to this Rider, except that in the event of a conflict, the
specific provisions of this Rider will govern.
Travel Resource Services
What is the Travel Resource Services?
Travel Resource Services is a non -insurance benefit made available to You which provides access at no
additional cost to the following services:
• Access to a toll free number in the event You encounter an emergency while traveling more than
100 miles from Your principal residence.
• Access to on-line tools and resources for any pre -trip assistance You may need.
How is Travel Resource Services accessed?
Your employer will provide You with an identification card to be used whenever services are needed.
This card will give You access to the toll-free number used to initiate the services.
The Travel Resource Services program is administered and provided by Europ Assistance USA, Inc.
Dearborn National Life Insurance Company does not underwrite or administer this program.
When do the Travel Resource Services terminate?
The Travel Resource Services terminate if Your coverage is terminated under the section on When does
Your coverage under the Policy end? found in the Termination Provision of the Policy.
President
Nothing contained in this Rider shall be held to alter or affect any provision or condition of the Policy other than as
stated above.
FDLI-NIB-TRS-210
NOTICE
to
the Policyholder and Certificate holder under
the Group Term Life Insurance Policy
Provided by Dearborn National Life Insurance Company
Regarding the Travel Resource Services Noninsurance Benefit
This notice is to advise you that Your Group Term Life Insurance program also provides a non -
insurance benefit: Travel Resource Services.
Noninsurance Benefit Description
Travel Resource Services is a service that provides telephonic access to emergency assistance while
traveling more than one hundred (100) miles from Your home and access to on-line travel tools and
resources when preparing a trip.
This noninsurance benefit is available at the option of the Policyholder without any action required on the
part of an insured person to either accept or decline the service.
There is no charge for this noninsurance benefit.
The service is currently administered by Europ Assistance USA, Inc.
Dearborn National Life Insurance Company (sometimes referred to as "We" or "Our") makes this
program available, but it does not underwrite or administer the Travel Resource Services program.
Why This Service is Beine Made Available
We are making this service available to provide support and assistance to persons who are traveling or
preparing to travel, in addition to the group life and accidental death benefits available under this Policy.
If an emergency occurs on a trip, counselors are available to assist in locating nearby hospitals, assist in
recovering lost passports, medical evacuations, and other emergencies. Advice at the planning stage of a
trip is available.
Accessine Travel Resource Services
Services may be accessed by contacting the program administrator at 1-877-715-2593.,
Termination of the Noninsurance Benefit
This noninsurance benefit is provided free of charge as a courtesy. It is subject to termination at our
option or at the option of the program administrator.
If We discontinue this service We will notify the Policyholder not less than thirty (30) days in advance of
the discontinuance of this service.
If the current program administrator discontinues the program and we are unable to find a replacement,
we will notify the Policyholder as soon as is reasonable under the circumstances. If discontinued, the
services available under this noninsurance benefit will no longer be available.
Unless terminated by Us or by the Program administrator, the Travel Resource Services noninsurance
benefit is available following a covered loss for as long as you remain covered under the group term life
insurance policy and such policy remains in effect.
n
NEB -TRS -Notice (4:2412)
ERISA INFORMATION STATEMENT*
The benefits described in your certificate are insured by a Policy issued by Dearborn National Life Insurance
Company ("Dearborn National"), pursuant to an Employee Welfare Benefit Plan (" the Plan") established by your
employer ("the Company"). This ERISA Information Statement ("EIS") describes some of the key provisions of the
Plan in effect as of the Effective Date of the Policy.
It is not the intention of the EIS to cover all situations that may arise, but to provide you with a general
understanding of your benefits. In the case of any item not covered by the EIS or in the event of any conflict
between the EIS and the Policy, the Plan will always control. You should not rely on any oral explanation,
description, or interpretation of the Plan because the written terms of the Plan will govern. Your right to any benefit
depends on the actual facts and terms and conditions of the particular Plan; no rights accrue by reason of or arising
out of any statement shown in or omitted from this EIS.
A. ADMINISTRATION OF THE PLAN
The Plan Administrator is responsible for the administration of the Plan. The Plan Administrator has full
discretionary authority and control over the Plan. This authority provides the Plan Administrator with the power
necessary to operate, manage and administer the Plan. This authority includes, but is not limited to, the power to
interpret the Plan and determine who is eligible to participate, to determine the amount of benefits that may be paid
to a participant or his or her beneficiary, and the status and rights of participants and beneficiaries. The Plan
Administrator also has the authority to prescribe the rules and procedures under which the Plan shall operate, to
request information, and to employ or appoint persons to aid the Plan Administrator in the administration of the
Plan.
Failure by the Plan or the Plan Administrator to insist upon compliance with any provisions of the Plan at any time
or under any set of circumstances shall not operate to waive or modify the provision or in any manner render it
unenforceable as to any other time or as to any other occurrence, whether the circumstances are or are not the same.
No waiver of any term or condition of the Plan shall be valid unless contained in a written memorandum expressing
the waiver and signed by the person authorized by the Plan Administrator to sign the waiver.
The Plan may be amended, terminated or suspended in whole or in part, at any time without the consent of the
employees or beneficiaries. Any amendment, termination or suspension shall be in writing, and attached to the Plan.
Any amendment, termination or suspension shall be executed according to the Employer's authorized procedures.
Any such authorization may be specific to the Plan or persons authorized to act on behalf of the Employer or may be
general as to duties of such person. Except for termination or suspensions, any amendments affecting the Policy
and/or Certificate must also be approved in writing by an officer of Dearborn National and shall be effective as of
the date agreed to, in writing by the Plan Sponsor and Dearborn National. Notwithstanding anything to the contrary
in this document, the Policy shall terminate according to the provisions in the Policy.
The Plan has other fiduciaries, advisors and service providers. The Plan Administrator may allocate fiduciary
responsibility among the Plan's fiduciaries and may delegate responsibilities to others. Any allocation or delegation
must be done in writing and kept with the records of the Plan. The Plan's life benefits are provided pursuant to an
insurance policy issued to the Company. Dearborn National's (the Insurer's) services shall be limited to, and the
Plan Administrator has the foil discretionary and final authority to:
resolve all matters when a review pursuant to the claims procedures has been requested;
- interpret, establish and enforce rules and procedures for the administration of the Policy and any claim
under it; and
determine eligibility of Employees and Dependents for benefits and their entitlement to and the amount of
benefits.
Each fiduciary is solely responsible for its own improper acts or omissions. Except to the extent required by ERISA,
no fiduciary has the duty to question whether any other fiduciary is fulfilling all of the responsibilities imposed upon
the other fiduciary by law. Nor is a fiduciary liable for a breach of fiduciary duty committed before it became, or
after it stopped being, a fiduciary. However, a fiduciary may be liable for a breach of fiduciary responsibility of any
Plan fiduciary, to the extent provided in ERISA Section 405(a). The Employer makes no promise to continue these
" If this Plan is an ERISA plan, these ERISA provisions apply. However, your employer may issue a Summary Plan Description
("SPD"). If it does, and if there are any conflicts between the SPD and the EIS in regards to your ERISA rights, the SPD
provisions will always control.
FDL EIS Standard 4/2009 rev'd
benefits in the future and rights to future benefits will never vest. Retirement does not give any retiree any vested
right to continue to participate or receive Plan benefits. 0
B. CLAIMS PROCEDURE:
When you or your Beneficiary are eligible to receive benefits, you or your Beneficiary, or your authorized
representative (collectively, "you") must notify the Plan Administrator by submitting the proper form in writing.
You may do this by sending notice of your claim to the PIan Administrator who has been appointed to assist
Dearborn National in the claims processing for this Plan or by contacting Dearborn National directly at:
Claims Department
Dearborn National Life Insurance Company
1020 31 st Street
Downers Grove, IL. 50515-5591
1-800-348-4512
For the purpose of this Section, including Subsections 1 and 2 below, the terms "written" and "in writing"
include "electronic." Any action required to be "written" or "in writing," may be done electronically, where
available. If Dearborn National uses electronic notices, it will do so in accordance with 29 CFR 2520.104b -
10(i), (iii) and (iv).
I. Disability Insurance Plans
Dearborn National will give you a written response to your claim, usually within 45 days. The time for decision
may be extended for two additional 30 day periods provided that, prior to any extension period, Dearborn National
notifies you in writing that an extension is necessary due to matters beyond the control of the Plan, identifies those
matters and gives the date by which it expects to render its decision. If the extension is due to your failure to submit
information necessary to decide your claim, the time for decision shall be tolled from the date on which we send you
notice of the extension until the date we receive your response to our request. This period will be no longer than 45
days after we have requested the information. At that time we will decide your claim based on the information we
have at that time. 0
If the claim is denied, in whole or in part, you will receive a written notice giving the following:
the reason for the denial;
the Policy provisions on which the denial is based;
an explanation of what other information, if any, may be needed to process the claim and why it is needed;
the steps that you have to follow to have the claim reviewed;
a statement that you have the right to bring a civil action under section 502(a) of ERISA after you appeal
our decision and after you receive a written denial on appeal; and
- if an internal rule, guideline, protocol, or other similar criterion was relied upon in making the denial, either
(i) the specific rule, guideline, protocol or other similar criterion; or (ii) a statement that such a rule,
guideline, protocol or other similar criterion was relied upon in making the denial and that a copy will be
provided free of charge to you upon request; and
if denial is based on medical judgment, either (i) an explanation of the scientific or clinical judgment for the
determination, applying the terms of the Plan to your medical circumstances, or (ii) a statement that such
explanation will be provided to you free of charge upon request.
If the claim has been denied, in whole or in part, you can appeal the denial to us for a full and fair review. You have
at least 180 days to appeal from the claim denial.
You may:
a. request a review upon written application within 180 days of the claim denial;
b. request, free of charge, copies of all documents, records and other information relevant to your claim; and
* If this Plan is an ERISA plan, these ERISA provisions apply. However, your employer may issue a Summary Plan Description
("SPD"). If it does, and if there are any conflicts between the SPD and the EIS in regards to your ERISA rights, the SPD
provisions will always control.
FDL EIS Standard 412009 rev'd.
C. submit written comments, documents, records and other information relating to your claim, without regard
to whether such information was submitted or considered in the initial benefit determination.
Dearborn National will make a decision no more than 45 days after we receive your appeal. The time for decision
may be extended for one additional 45 day period provided that, prior to the extension, Dearborn National notifies
you in writing that an extension is necessary due to special circumstances, identifies those circumstances and gives
the date by which it expects to render its decision. If your claim is extended due to your failure to submit
information necessary to decide your claim on appeal, the time for your decision shall be tolled from the date on
which the notification of the extension is sent to you until the date we receive your response to the request. The
written decision will include specific references to the Plan provisions on which the decision is based and any other
notice(s), statement(s) or information required by applicable law.
2. Life Insurance Plans
Dearborn National will give you a decision no more than 90 days after receipt of due proof of loss, except in special
circumstances (such as the need to obtain further information), but in no case more than 180 days after the due proof
of loss is received. The written decision will include specific reasons for the decision and specific references to the
Plan provisions on which the decision is based.
If the claim is denied, in whole or in part, the claimant will receive a written notice giving the following:
the reason for the denial;
the Policy provisions on which the denial is based;
an explanation of what other information, if any, may be needed to process the claim and why it is needed;
and
the steps that have to be followed to have the claim reviewed.
Any denied claim may be appealed to the Insurer for a hill and fair review. The claimant may:
a) request a review upon written application within 60 days of receipt of claim denial;
b) upon request and free of charge, review pertinent documents, records and other information relevant to the
claim and receive copies of same; and
C) submit issues, comments, records, and other information in writing.
A decision will be made by the Insurer no more than 60 days after receipt of the request for review, except in special
circumstances (such as the need to obtain additional evidence), but in no case more than 120 days after the request
for review is received. The written decision will include specific reasons for the decision and specific references to
the Plan provisions on which the decision is based. The decision will advise you of any other appeal rights you have
under the Plan, as well as your right to bring an action under Section 502(x) of ERISA.
C. ERISA NOTICE OF YOUR RIGHTS
As a participant in the Plan you are entitled to certain rights and protections under the Employee Retirement Income
Security Act of 1974 ("ERISA"). ERISA provides that all Plan participants shall be entitled to:
Examine, without charge, at the Plan Administrator's office and at other locations, such as work sites and union
halls, all Plan documents, including insurance contracts, collective bargaining agreements and copies of all
documents filed with the U.S. Department of Labor, such as detailed annual reports and Plan descriptions.
Obtain copies of all Plan documents and other Plan information upon written request to the Plan Administrator. The
Plan Administrator may make a reasonable charge for the copies. Receive a summary of the Plan's annual financial
report. The Plan Administrator is required to furnish each participant with a copy of this summary annual report.
In addition to creating rights for the Plan participants, ERISA imposes duties upon the people who are responsible
for the operation of the employee benefit Plan. The people who operate your Plan, called "fiduciaries" of the Plan,
have a duty to do so prudently and in the interest of you and other Plan participants and beneficiaries.
No one, including your employers, your union, or any other persons, may fire you or otherwise discriminate against
you in any way to prevent you from obtaining a welfare benefit or exercising your rights under ERISA. If your
claim for a welfare benefit is denied in whole or in part you must receive a written explanation of the reason for the
• If this Plan is an ERISA plan, these ERISA provisions apply. However, your employer may issue a Summary Plan Description
("SPD"). If it does, and if there are any conflicts between the SPD and the EIS in regards to your ERISA rights, the SPD
provisions will always control.
FDL EIS Standard 4!2009 rev'd
denial. You have the right to have the Plan review and reconsider your claim. Under ERISA, there are steps you
can take to enforce your rights. For instance, if you request materials from the plan and do not receive them within
30 days, you may file a suit in federal court. In such a case, the court may require the Plan Administrator to provide
the materials and pay you up to $110 a day until you receive the materials, unless the materials were not sent
because of reasons beyond the control of the Plan Administrator.
If you have a claim for benefits which is denied or ignored, in whole or in part, you may file suit in a state or federal
court. If it should happen that Plan fiduciaries misuse the Plan's money, or if you are discriminated against for
asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in federal
court. The court will decide who should pay costs and legal fees. If you are successful the court may order the
person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees,
for example, if it finds your claim is frivolous.
If you have any questions about this statement or about your rights under ERISA, you should contact the nearest
office of the Pension and Welfare Benefits Administration, United States Department of Labor, listed in your
telephone directory or the Division of Technical Assistance and Inquiries, Employee Benefit Security
Administration, United States Department of Labor, 200 Constitution Avenue, NW Washington DC 20210.
D. PARTICIPANT'S RIGHTS
This Plan shall not be deemed to constitute a contract between the Company and any participant or to be
consideration or an inducement for the employment of any participant or employee. Nothing contained in this Plan
shall be deemed to give any participant or employee the right to be retained in the service of the Company or to
interfere with the right of the Company to discharge any participant or employee at any time regardless of the effect
which such discharge shall have upon him or her as a participant of this Plan.
101
* If this Plan is an ERISA plan, these ERISA provisions apply. However, your employer may issue a Summary Plan Description
("SPD"). If it does, and if there are any conflicts between the SPD and the EIS in regards to your ERISA rights, the SPD
provisions will always control.
FDL EIS Standard 4/2009 rev'd
Dearborn � rrational0
Administrative Office:
1020 31st Street- Downers Grove, IL 60515-5591
Products and services marketed under the Dearborn National brand and the star logo are underwritten
and/or provided by Dearborn National ® Life Insurance Company (Downers Grove, IL) in all states
(excluding New York), the District of Columbia, the United States Virgin Islands, the British Virgin
Islands, Guam and Puerto Rico.
Dearborn National® Life Insurance Administrative Office:
Company 1020 31st Street
t Downers Grove IL 60515-5591
(A stock life insurance company, herein called the "We" "us" or "Our")
Policyholder: SAMPLE TX
Policy Number: SAMPLETX-0001
Policy Effective Date: July 1, 2012
Anniversary Date: July 1
We agree with the Policyholder to insure certain eligible Employees of the Policyholder. We promise to pay
benefits for loss covered by the Policy in accordance with its provisions. The Policyholder should read this
Policy carefully and contact Dearborn National& Life Insurance Company promptly with any questions.
Policyholder means the Employer to whom the Policy is issued and who sponsored the coverage for its
Employees.
Employer means the Policyholder and includes any division, subsidiary, or affiliated company named in the
Policy.
POLICY EFFECTIVE DATE AND TERM
The Policy takes effect on the Policy Effective Date stated above subject to any participation requirement stated in
the Policy. All insurance periods will be computed from that date. The Policy remains in force for the period for
which premium has been paid. It may be renewed for further successive periods by payment of premium as stated
in the Policy.
All periods of insurance begin and end at 12:01 A.M., Standard Time, at the Policyholder's address as stated in
the Policy, and on the Application.
Signed for Dearborn National Life Insurance Company
Secretary
President
Basic Group Term Life Insurance Policy
with
Accidental Death & Dismemberment Insurance Benefits
Non -Participating
FDL 1-504-412 TX
TABLE OF CONTENTS
PROVISION PAGE
Premium.
Premium Rate Guarantee
Policy Termination
Additional Provisions
Rate Addendum
Application Attached
ATTACHMENTS:
• Master Application
• Certificate of Insurance
D
FDL 1-504-412 TX 2
._,
PREMIUM
How is the initial premium cakuhded?
Initial life, AD&D and Dependent Life insurance premium is calculated in accordance with the rates set forth on
the attached Rate Addendum.
When is premium paid?
The Policy is issued in consideration of the payment in advance of premium on the premium due date indicated on
the Application. Payment must be made by the premium due date as shown on the Application.
If an addition, termination or change in insurance takes place other than on a regular due date, any premium
adjustment will take effect on the next due date.
Is premium payable while an Insured receives benefits?
We will waive premium for an insured Employee in accordance with the Waiver of Premium provision of the
Policy.
Is there a grace period for premium payment?
We will allow a grace period of 31 days for the payment of any premiums due except the first, Insurance
coverage shall continue in force during the grace period unless the Policyholder has given Us advance written
notice of cancellation in accordance with the terms of this Policy. If premium is not received by the end of the
grace period, this Policy will terminate as of the last date for which premium was paid.
The Policyholder is liable for premium due on coverage provided during the grace period.
If We receive written notice during the grace period that the Policy is to be canceled, We will cancel it as of the
later of -
1. the date requested in the cancellation notice; or
2. the date We receive such notice. The Policyholder must pay a pro rata premium for any coverage
provided during the grace period.
PREMIUM RATE GUARANTEE
What is the initial premium rate guarantee?
A change in premium rates will not take effect before July 1, 2013. However, We may change premium rates if
the risk assumed changes. Premium rates may change if the following occurs:
1. a change in the Policy design;
2. a change in the terms of the Policy;
3. addition or deletion of a division, subsidiary or affiliated company;
4. a change in the number of Insureds by 10% or more from the number of Insureds on the initial Effective
Date;
S. a change in the laws or regulations or other government action which applies to the Policy;
6. for reasons other than 1-5 above such as but not limited to a change in factors bearing on the risk
assumed.
The Policyholder must furnish notice and documentation satisfactory to Us within 31 days of the occurrence of
any event which would cause a change in rates as described above. If the Policyholder fails to provide such
timely notice, we will apply new rates retroactively to the date of the event.
We will notify the Policyholder in writing at least 31 days in advance of any premium rate changes. A change
may take effect on an earlier date if both the Policyholder and We agree.
FDLI-504-412 TX 3
POLICY TERMINATION
Who nray cancel the Policy or a plan under the Policy?
The Policy or a plan under the Policy can be canceled by the Policyholder with 31 days written notice delivered to
Us. This Policy will terminate for any of the following reasons:
1. If the Policyholder fails to pay any premium within the 31 -day Grace Period, this Policy will terminate in
accordance with the terms set forth in the Grace Period provision.
2. We may terminate this Policy on any premium due date if-
a.
f
a. coverage is Contributory and less than 75% of the eligible Employees participate; or
b. coverage is Noncontributory and less than 104% of the eligible Employees participate; or
c. the Policyholder fails to perform any of its obligations that relate to the Policy; or
d. the Policyholder does not promptly provide Us with information that is reasonably required; or
e. fewer than 2 Employees are insured under the Policy.
If We cancel the Policy, for reasons other than the Policyholder's failure to pay premium, a written notice will be
delivered to the Policyholder at least 31 days prior to the cancellation date.
ADDITIONAL PROVISIONS
What happens if an inadvertent error occurs?
Clerical error or omission by Us to the Policyholder will not:
1. Prevent an Employee from receiving coverage, if he is entitled to coverage under the terms of the Policy;
or
2. Cause coverage to begin or coverage to continue for an Employee when the coverage would not otherwise
be effective. 0
If the Policyholder gives Us information about an Employee that is incorrect, We will:
1. Use the facts to decide whether the Employee has coverage under the Policy and in what amounts; and
2. Make a fair adjustment of the premium.
Will certifuates be issued?
We will deliver certificates of insurance to the Policyholder for issuance to each insured Employee. The
certificates will describe the benefits, to whom they are payable, the Policy limitations and where the Policy may
be inspected.
What is considered to be the entire contract?
This entire Policy consists of:
1. all Policy provisions and any amendments and/or attachments issued;
2. the Certificate of Coverage; and
3. the Policyholder's signed Application.
FDL1-504-412 TX 4
RATE ADDENDUM
(All Rates Per $1, 000 Per Month unless otherwise stated)
Term Life: $0.00
Accidental Death & Dismemberment: $0.11
FDLI-504-412 TX
STATE SUPPLEMENT
The following policies apply only to those individuals in your group insurance program who reside in the
referenced states.
Arizona and Maine
Except as otherwise permitted by law, we will not disclose collected personal information about an individual to a
nonaffiliated third party with whom we jointly offer products without giving the individual an opportunity to tell
us that he or she does not want us to share his or her personal information.
Minnesota and Montana
Except as otherwise permitted by law, we will not disclose collected personal information about an individual to a
nonaffiliated third party with whom we jointly offer products without obtaining the individual's written
authorization.
Montana
Upon written request, an individual who has authorized the collection of health information is entitled to receive a
record of Dearborn National's disclosures of any of his medical record information made within the preceding 3
years.
Oregon
An individual has the right to authorize disclosure of his or her personal information to an insurance company.
An Oregon resident can exercise this right by requesting an authorization form in writing. Our address is:
Dearborn National® Life Insurance Company
1020 31 st Street
Downers Grove, IL 60515
FDL1-504-412 TX
ERISA INFORMATION STATEMENT*
The benefits described in your certificate are insured by a Policy issued by Dearborn National Life Insurance
Company ("Dearborn National"), pursuant to an Employee Welfare Benefit Plan (" the Plan") established by your
employer ("the Company"). This ERISA Information Statement ("EIS") describes some of the key provisions of the
Plan in effect as of the Effective Date of the Policy.
It is not the intention of the EIS to cover all situations that may arise, but to provide you with a general
understanding of your benefits. In the case of any item not covered by the EIS or in the event of any conflict
between the EIS and the Policy, the Plan will always control. You should not rely on any oral explanation,
description, or interpretation of the Plan because the written terms of the Plan will govern. Your right to any benefit
depends on the actual facts and terms and conditions of the particular Plan; no rights accrue by reason of or arising
out of any statement shown in or omitted from this EIS.
A. ADMINISTRATION OF THE PLAN
The Plan Administrator is responsible for the administration of the Plan. The Plan Administrator has full
discretionary authority and control over the Plan. This authority provides the Plan Administrator with the power
necessary to operate, manage and administer the Plan. This authority includes, but is not limited to, the power to
interpret the Plan and determine who is eligible to participate, to determine the amount of benefits that may be paid
to a participant or his or her beneficiary, and the status and rights of participants and beneficiaries. The Plan
Administrator also has the authority to prescribe the rules and procedures under which the Plan shall operate, to
request information, and to employ or appoint persons to aid the Plan Administrator in the administration of the
Plan.
Failure by the Plan or the Plan Administrator to insist upon compliance with any provisions of the Plan at any time
or under any set of circumstances shall not operate to waive or modify the provision or in any manner render it
unenforceable as to any other time or as to any other occurrence, whether the circumstances are or are not the same.
No waiver of any term or condition of the Plan shall be valid unless contained in a written memorandum expressing
the waiver and signed by the person authorized by the Plan Administrator to sign the waiver.
The Plan may be amended, terminated or suspended in whole or in part, at any time without the consent of the
employees or beneficiaries. Any amendment, termination or suspension shall be in writing, and attached to the Plan.
Any amendment, termination or suspension shall be executed according to the Employer's authorized procedures.
Any such authorization may be specific to the Plan or persons authorized to act on behalf of the Employer or may be
general as to duties of such person. Except for termination or suspensions, any amendments affecting the Policy
and/or Certificate must also be approved in writing by an officer of Dearborn National and shall be effective as of
the date agreed to, in writing by the Plan Sponsor and Dearborn National. Notwithstanding anything to the contrary
in this document, the Policy shall terminate according to the provisions in the Policy.
The Plan has other fiduciaries, advisors and service providers. The Plan Administrator may allocate fiduciary
responsibility among the Plan's fiduciaries and may delegate responsibilities to others. Any allocation or delegation
must be done in writing and kept with the records of the Plan. The Plan's life benefits are provided pursuant to an
insurance policy issued to the Company. Dearborn National's (the Insurer's) services shall be limited to, and the
Plan Administrator has the full discretionary and final authority to:
resolve all matters when a review pursuant to the claims procedures has been requested;
interpret, establish and enforce rules and procedures for the administration of the Policy and any claim
under it; and
determine eligibility of Employees and Dependents for benefits and their entitlement to and the amount of
benefits.
Each fiduciary is solely responsible for its own improper acts or omissions. Except to the extent required by ERISA,
no fiduciary has the duty to question whether any other fiduciary is fulfilling all of the responsibilities imposed upon
the other fiduciary by law. Nor is a fiduciary liable for a breach of fiduciary duty committed before it became, or
after it stopped being, a fiduciary. However, a fiduciary may be liable for a breach of fiduciary responsibility of any
Plan fiduciary, to the extent provided in ERISA Section 405(a). The Employer makes no promise to continue these
* If this Plan is an ERISA plan, these ERISA provisions apply. However, your employer may issue a Summary Plan Description
("SPD"). If it does, and if there are any conflicts between the SPD and the EIS in regards to your ERISA rights, the SPD
provisions will always control.
FDL EIS Standard 4/2009 rev d.
benefits in the future and rights to future benefits will never vest. Retirement does not give any retiree any vested
right to continue to participate or receive Plan benefits.
B. CLAIMS PROCEDURE:
When you or your Beneficiary are eligible to receive benefits, you or your Beneficiary, or your authorized
representative (collectively, "you") must notify the Plan Administrator by submitting the proper form in writing.
You may do this by sending notice of your claim to the Plan Administrator who has been appointed to assist
Dearborn National in the claims processing for this Plan or by contacting Dearborn National directly at:
Claims Department
Dearborn National Life Insurance Company
1020 31 st Street
Downers Grove, IL. 60515-5591
1-800-348-4512
For the purpose of this Section, including Subsections 1 and 2 below, the terms "written" and "in writing"
include "electronic." Any action required to be "written" or "in writing," may be done electronically, where
available. If Dearborn National uses electronic notices, it will do so in accordance with 29 CFR 2520.104b -
10(i), (iii) and (iv).
1. Disability Insurance Plans
Dearborn National will give you a written response to your claim, usually within 45 days. The time for decision
may be extended for two additional 30 day periods provided that, prior to any extension period, Dearborn National
notifies you in writing that an extension is necessary due to matters beyond the control of the Plan, identifies those
matters and gives the date by which it expects to render its decision. If the extension is due to your failure to submit
information necessary to decide your claim, the time for decision shall be tolled from the date on which we send you
notice of the extension until the date we receive your response to our request. This period will be no longer than 45
days after we have requested the information. At that time we will decide your claim based on the information we
have at that time. 0
If the claim is denied, in whole or in part, you will receive a written notice giving the following:
the reason for the denial;
the Policy provisions on which the denial is based;
- an explanation of what other information, if any, may be needed to process the claim and why it is needed;
- the steps that you have to follow to have the claim reviewed;
- a statement that you have the right to bring a civil action under section 502(a) of ERISA after you appeal
- our decision and after you receive a written denial on appeal; and
if an internal rule, guideline, protocol, or other similar criterion was relied upon in making the denial, either
(i) the specific rule, guideline, protocol or other similar criterion; or (ii) a statement that such a rule,
guideline, protocol or other similar criterion was relied upon in making the denial and that a copy will be
provided free of charge to you upon request; and
if denial is based on medical judgment, either (i) an explanation of the scientific or clinical judgment for the
determination, applying the terms of the Plan to your medical circumstances, or (ii) a statement that such
explanation will be provided to you free of charge upon request.
If the claim has been denied, in whole or in part, you can appeal the denial to us for a full and fair review. You have
at least 180 days to appeal from the claim denial.
You may:
a. request a review upon written application within 180 days of the claim denial;
b. request, free of charge, copies of all documents, records and other information relevant to your claim; and
* If this Plan is an ERISA plan, these ERISA provisions apply, However, your employer may issue a Summary Plan Description
("SPD"). If it does, and if there are any conflicts between the SPD and the EIS in regards to your ERISA rights, the SPD
provisions will always control.
FDL EIS Standard 4/2409 rev'd.
e-1 C. submit written comments, documents, records and other information relating to your claim, without regard
to whether such information was submitted or considered in the initial benefit determination.
Dearborn National will make a decision no more than 45 days after we receive your appeal. The time for decision
may be extended for one additional 45 day period provided that, prior to the extension, Dearborn National notifies
you in writing that an extension is necessary due to special circumstances, identifies those circumstances and gives
the date by which it expects to render its decision. If your claim is extended due to your failure to submit
information necessary to decide your claim on appeal, the time for your decision shall be tolled from the date on
which the notification of the extension is sent to you until the date we receive your response to the request. The
written decision will include specific references to the Plan provisions on which the decision is based and any other
notice(s), statement(s) or information required by applicable law.
2. Life Insurance Plans
Dearborn National will give you a decision no more than 90 days after receipt of due proof of loss, except in special
circumstances (such as the need to obtain further information), but in no case more than 180 days after the due proof
of loss is received. The written decision will include specific reasons for the decision and specific references to the
Plan provisions on which the decision is based.
If the claim is denied, in whole or in part, the claimant will receive a written notice giving the following:
the reason for the denial;
the Policy provisions on which the denial is based;
an explanation of what other information, if any, may be needed to process the claim and why it is needed;
and
the steps that have to be followed to have the claim reviewed.
Any denied claim may be appealed to the Insurer for a full and fair review. The claimant may:
a) request a review upon written application within 60 days of receipt of claim denial;
b) upon request and free of charge, review pertinent documents, records and other information relevant to the
claim and receive copies of same; and
C) submit issues, comments, records, and other information in writing.
A decision will be made by the Insurer no more than 60 days after receipt of the request for review, except in special
circumstances (such as the need to obtain additional evidence), but in no case more than 120 days after the request
for review is received. The written decision will include specific reasons for the decision and specific references to
the Plan provisions on which the decision is based. The decision will advise you of any other appeal rights you have
under the Plan, as well as your right to bring an action under Section 502(a) of ERISA.
C. ERISA NOTICE OF YOUR RIGHTS
As a participant in the Plan you are entitled to certain rights and protections under the Employee Retirement Income
Security Act of 1974 ("ERISA"). ERISA provides that all Plan participants shall be entitled to:
Examine, without charge, at the Plan Administrator's office and at other locations, such as work sites and union
halls, all Plan documents, including insurance contracts, collective bargaining agreements and copies of all
documents filed with the U.S. Department of Labor, such as detailed annual reports and Plan descriptions.
Obtain copies of all Plan documents and other Plan information upon written request to the Plan Administrator. The
Plan Administrator may make a reasonable charge for the copies. Receive a summary of the Plan's annual financial
report. The Plan Administrator is required to furnish each participant with a copy of this summary annual report.
In addition to creating rights for the Plan participants, ERISA imposes duties upon the people who are responsible
for the operation of the employee benefit Plan. The people who operate your Plan, called "fiduciaries" of the Plan,
have a duty to do so prudently and in the interest of you and other Plan participants and beneficiaries.
No one, including your employers, your union, or any other persons, may fire you or otherwise discriminate against
you in any way to prevent you from obtaining a welfare benefit or exercising your rights under ERISA. If your
claim for a welfare benefit is denied in whole or in part you must receive a written explanation of the reason for the
* If this Plan is an ERISA plan, these ERISA provisions apply. However, your employer may issue a Summary Plan Description
("SPD"). If it does, and if there are any conflicts between the SPD and the EIS in regards to your ERISA rights, the SPD
provisions will always control.
FDL EIS Standard 4/2009 rev'd.
denial. You have the right to have the Plan review and reconsider your claim. Under ERISA, there are steps you
can take to enforce your rights. For instance, if you request materials from the plan and do not receive them within
30 days, you may file a suit in federal court. In such a case, the court may require the Plan Administrator to provide
the materials and pay you up to $110 a day until you receive the materials, unless the materials were not sent
because of reasons beyond the control of the Plan Administrator.
If you have a claim for benefits which is denied or ignored, in whole or in part, you may file suit in a state or federal
court. If it should happen that Plan fiduciaries misuse the Plan's money, or if you are discriminated against for
asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in federal
court. The court will decide who should pay costs and legal fees. If you are successful the court may order the
person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees,
for example, if it finds your claim is frivolous.
If you have any questions about this statement or about your rights under ERISA, you should contact the nearest
office of the Pension and Welfare Benefits Administration, United States Department of Labor, listed in your
telephone directory or the Division of Technical Assistance and Inquiries, Employee Benefit Security
Administration, United States Department of Labor, 200 Constitution Avenue, NW Washington DC 20210.
D. PARTICIPANT'S RIGHTS
This Plan shall not be deemed to constitute a contract between the Company and any participant or to be
consideration or an inducement for the employment of any participant or employee. Nothing contained in this Plan
shall be deemed to give any participant or employee the right to be retained in the service of the Company or to
interfere with the right of the Company to discharge any participant or employee at any time regardless of the effect
which such discharge shall have upon him or her as a participant of this Plan.
' If this Plan is an ERISA plan, these ERISA provisions apply. However, your employer may issue a Summary Plan Description
("SPD"). If it does, and if there are any conflicts between the SPD and the EIS in regards to your ERISA rights, the SPD
provisions will always control.
PDI, EIS Standard 4/2009 rev'd
Voluntary Term Life and AD&D
Insurance
Employee Benefit Booklet
SAMPLE TEXAS
SAMPLE TX -0001
Class 1-01
A
6
lonal9
Products and services marketed under the Dearborn National® brand and the star logo are underwritten
and/or provided by Dearborn National® Life Insurance Company (Downers Grove, IL) in all states
(excluding New York), the District of Columbia, the United States Virgin Islands, the British Virgin
Islands, Guam and Puerto Rico.
12/20/2012
Dearborn National® Life Insurance Administrative Office:
Company 1020 31 st Street
p y Downers Grove IL 60515-5591
(A stock life insurance company, herein called the "We" "Us" or "Our")
Having issued Group Policy No. SAMPLE TX -0001
herein called the Polic
to
SAMPLE TEXAS
(herein called the Policyholder)
GROUP INSURANCE CERTIFICATE
CERTIFIES that You are insured, provided that You qualify under the ELIGIBILITY AND EFFECTIVE
DATES provision, become insured and remain insured in accordance with the terms of the Policy. Your
insurance is subject to all the definitions, limitations and conditions of the Policy, and it takes effect as
stated in the ELIGIBILITY AND EFFECTIVE DATES provision.
This Certificate describes Your eligibility for benefits and the terms and provisions of the Policy. It
replaces and cancels any other Certificate previously issued to You under the Policy.
If the terms and provisions of the Group Insurance Certificate (issued to You) are different from the policy
(issued to the Policyholder), the Policy will govern. Your coverage may be canceled or changed in whole
or in part under the terms and provisions of the Policy.
READ YOUR CERTIFICATE CAREFULLY
Signed for Dearborn National Life Insurance Company
Secretary President
Death Benefits will be reduced if an accelerated death benefit is paid.
DISCLOSURE: The Accelerated Death Benefit offered under this Policy is intended to qualify for favorable tax
treatment under the Internal Revenue Code of 1986. If the Accelerated Death Benefit qualifies for such favorable
tax treatment, the benefits will be excluded from the insured Employee's income and not subject to federal taxation.
Tax laws relating to Accelerated Death Benefits are complex. The insured Employee is advised to consult with a
qualified tax advisor about circumstances under which he or she could receive the Accelerated Death Benefit
excludable from income under federal law.
Receipt of the Accelerated Death Benefit payment may affect the insured Employee, his or her spouse, or his or her
family's eligibility for public assistance such as medical assistance (Medicaid), Aid to Families with Dependent
Children (AFDC), Supplementary Social Security Income (SSI), and drug assistance programs. The insured
Employee is advised to consult with a qualified tax advisor and with social service agencies concerning how receipt
of such payment will affect the insured Employee, his or her spouse, or his or her family's eligibility for public
assistance.
00 124T
Voluntary Group Term Life Insurance Certificate
with
Accidental Death & Dismemberment and Dependent Life Insurance with Dependent Accidental Death
and Dismemberment Benefits
Non -Participating
FDL I -604-412
IMPORTANT INFORMATION ABOUT COVERAGE UNDER THE TEXAS LIFE, ACCIDENT, HEALTH
AND HOSPITAL SERVICE INSURANCE GUARANTY ASSOCIATION
(For insurers declared insolvent or impaired on or after September 1, 2005)
Texas Iaw establishes a system, administered by the Texas Life, Accident, Health and Hospital Service Insurance
Guaranty Association (the "Association"), to protect Texas policyholders if their life or health insurance company
fails. Only the policyholders of insurance companies which are members of the Association are eligible for this
protection which is subject to the terms, limitations, and conditions of the Association law. (The law is found in the
Texas Insurance Code, Chapter 463.)
It is possible that the Association may not cover your policy in full or in part due to statutory limitations.
Eligibility for Protection by the Association
When a member insurance company is found to be insolvent and placed under an order of liquidation by a court or
designated as impaired by the Texas Commissioner of Insurance, the Association provides coverage to policyholders
who are:
Residents of Texas at that time (irrespective of the policyholder's residency at policy issue)
Residents of other states, ONLY if the following conditions are met:>1,�Y
1. The policyholder has a policy with a company domiciled in Texas; A
2. The policyholder's state of residence has a similar guaranty association; and
3. The policyholder is not eligible for coverage by the guaranty association of the policyholder's state of
residence. ..
Limits of Protection by the Association
Accident, Accident and Health, or Health Insurance: 19;5,b,
• For each individual covered under one or more policies: up to a total of $500,000 for basic hospital, medical -
surgical, and major medical insurance, $300,000 for disability or long term care insurance, and $200,000 for
other types of health insurance.
Life Insurance:
• Net cash surrender value or net cash withdrawal value up to a total of $100,000 under one or more policies on
any one life; or
• Death benefits up to a total of $300,000 under one or more policies on any one life; or
• Total benefits up to a total of $5,000,000 to any owner of multiple non -group life policies.
Individual Annuities: 'Vett;_
• Present value of benefits up to a total of $100,000 under one or more contracts on any one life.
Group Annuities: % i111'11'11 - 11'100.1-1'-j?-//,
• Present value of allocated benefits up to a total of $100,000 on any one life; or
• Present value of unallocated benefits up to a total of $5,000,000 for one contract holder regardless of the
number of contracts.,,,,.,;,-,,
Aggregate Limit: x
• $300,000 on any one life with the exception of the $500,000 health insurance limit, the $5,000,000 multiple -
owner life insurance limit, and the $5,000,000 unallocated group annuity limit.
Insurance companies and 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. When you are selecting an
insurance company, you should not rely on Association coverage.
Texas Life, Accident, Health and Hospital Service
Insurance Guaranty Association
6504 Bridge Point Parkway, Suite 450
Austin, Texas 78730
800-982-6362 or www,txiifega.org
TX Notice
Texas Department of Insurance
P.O. Box 149104
Austin, Texas 78714-9104
800-252-3439 or www.tdi.state.tx.us
IMPORTANT NOTICE
To obtain information or make a complaint:
You may contact your (title)
at (telephone number).
You may call Dearborn National Life Insurance
Company's toll-free telephone number for infor-
mation or to make a complaint at:
1-800-348-4512
You may also write to Dearborn National Life
Insurance Company at:
1020 31st Street, Downers Grove, IL 60515-5591
You may contact the Texas Department of Insurance
to obtain information on companies, coverages, rights
or complaints at:
1-800-252-3439
You may write the Texas Department of Insurance:
P. O. Box 149104
Austin, TX 78714-9104
FAX #(512) 475-1771
Web: http:/lwww.tdi.state.tx.us
E-mail: ConsumerProtection@tdi.state.tx.us
PREMIUM OR CLAIM DISPUTES: Should you
have a dispute concerning your premium or about a
claim, you should contact the company first. If the
dispute is not resolved, you may contact the Texas
Department of Insurance.
ATTACH THIS NOTICE TO YOUR POLICY:
This notice is for information only and does not
become a part or condition of the attached document.
9-632-895
AVISO IMPORTANTE
Para informacion o para someter una queja:-••
Peude communicarse con su (title)
al (telephone number).
Usted puede llamar al numero de telefono gratis de
Dearborn National Life Insurance Company para
informacion o para someter una queja al:
1.800-348-4512
Usted tambien escribir a Dearborn National Life
Insurance Company al:
1020 31st Street, Downers Grove, IL 60515-5591
Puede comunicarse con el Departamento de Seguros
de Texas para conseguir informacion acerca de
companias, coberturas, derechos o quejas al:
1-800-252-3439
Puede escribir aI Departamento de Seguros de Texas:
P. O. Box 149104
Austin, TX 787I4-9104
FAX #(512) 475-1771
Web: http://www.tdi.statc.tx.us
E-mail: ConsumerProtection@tdi.state.tx.us
DISPUTAS SOBRE PRIMAS O RECLAMOS: Si
tiene una disputa concerniente a su prima o a un
reclamo, debe comunicarse con la compania primero.
Si no se resuelve la disputa, puede entonces
comunicarse con al Departamento de Seguros de
Texas.
UNA ESTE AVISO A SU POLIZA: Este aviso es
solo para proposito de informacion y no se convierte
en parte o condicion dei documento adjunto.
Schedule of Benefits
Eligibility and Effective Dates
Group Term Life Insurance Benefit
Conversion of Life Insurance
Waive
Accele
Portab
Dependent
Conve
Accidental
Terminatio
General Pr,
Definitions
TABLE OF CONTENTS
FDL 1-604-412
POLICYHOLDER:
POLICY NUMBER:
EFFECTIVE DATE:
ANNUAL ENROLLMENT
PERIOD:
SCHEDULE OF BENEFITS
SAMPLE TEXAS
SAMPLE TX -0001
January 1, 2013
12/1-12131
ELIGIBILITY: All full-time Employees of the Policyholder working in the United States of America who
Class 01 are .fictively at Work for the Policyholder and who have completed the Waiting Period are
eligible for the insurance. A full-time Employee is one who regularly works a minimum of
30 hours per week for the Policyholder. Part-time, seasonal and temporary Employees of
the Policyholder are not eligible.
Eligibility Waiting Period: Current Employees: First of the month following 30 Days of continuous, full-time
active work
New Employees: First of the month following 30 Days of continuous, full-time
active work
Policyholder Contribution: Voluntary Life & AD&D 0% of premium
Dependent Life & AD&D 0% of premium
GROUP TERM LIFE INSURANCE
Employee Voluntary Life Benefit Amount
Reduction of Benefits
Waiver of Premium
Waiver Eligibility
Insured Eligibility
Maximum Waiver of Premium Duration
Accelerated Death Benefit (ADB)
Benefit Amount
Insured Eligibility
Minimum Covered Life Insurance Amount
Maximum ADB Payment
Minimum ADB Payment
Portability
Benefit Eligibility
Insured Eligibility
Portability Benefit Duration
Additional Purchase Option
Maximum Additional Purchase Amount
Incremental selection from a minimum of $10,000 to a maximum of
$500,000 in increments of $10,000
Voluntary: Benefit amounts may be subject to Guarantee Issue limits
based on participation levels as determined by Us. Any Guarantee Issue
Limits established are only available during Your group's initial
enrollment and for new employees who have met the Eligibility
requirements. Employees must enroll within 31 days of their eligibility
date to qualify for any established Guarantee Issue.
None. Benefits terminate at retirement.
Totally Disabled prior to age 60 without interruption from the last date
worked for at least 9 months
Employee
age 65
75% of Voluntary Term Life Insurance In force
Employee
$20,000
$250,000
$7,500
Voluntary Life
Employee & Spouse
Age 65
Up to $50,000 of term life insurance
FDL 1-604-412 2
0
L
Ee
DEPENDENT TERM LIFE INSURANCE
Spouse Benefit Amount
Voluntary: The amount elected on Your Enrollment Form, not to exceed
Includes Registered Domestic Partner
$250,000
Children) Benefit Amount
Voluntary:
$0 - Age live birth to 14 days
$100 - age 14 days to 6 months
Choice of $5,000 or $10,000 as elected on Your enrollment form - age 6
months to 25 years
GROUP ACCIDENTAL DEATH & DISMEMBERMENT
Employee Voluntary AD&D Coverage
Incremental selection from a minimum of $10,000 to a maximum of
Amount
$500,000 in increments of $10,000
Dependent AD&D Benefit Amount
50% of the Employee Coverage Amount
Spouse
Dependent Child(ren)
10% of the Employee Coverage Amount
Reduction of Benefits
Voluntary Accidental Death and Dismemberment benefits reduce to 65%
of the original amount at age 65, further reduce to 50% of the original
amount at age 70, further reduce to 25% of the original amount at age 75,
and further reduce to 15% of the original amount at age 80. Benefits
terminate at retirement.
Seat Belt Benefit
10% of Employee Coverage Amount, to a maximum of $25,000
Air Bag Benefit
5% of Employee Coverage Amount to a maximum of $5,000
Repatriation Benefit
Actual costs to a m ximum of $5,000
Education Benefit
Benefit Amount
3% of Employee Coverage Amount, to a maximum of $3,000 per year
Maximum Benefit Duration
Benefit payable for a maximum of four (4) years
Eligible Dependents �t f�Yh
Age live birth to age 25 years
U,,VP
`1, f'
Common Disaster Benefit
Employee Coverage Amount to a maximum of $150,000
FDL1-604-412 3
ELIGIBILITYAND EFFECTIVE DATE PROVISIONS
Who is eligible for this insurance?
The eligibility for this insurance is as indicated in the Schedule of Benefits.
The Eligibility Waiting Period is set forth in the Schedule of Benefits.
00001
When floes Your Contributory insurance become effective?
Contributory means You pay all or a portion of the premium for this insurance coverage.
You may apply for Voluntary insurance coverage during the Annual Enrollment Period as indicated in the
Schedule of Benefits. Your coverage will become effective as follows, provided You are Actively at Work
on that date:
Your Contributory coverage for amounts up to the Guarantee Issue Benefit Limit will become effective
on the latest of the following dates provided You are Actively at Work on that date:
1. If You enroll for coverage prior to the Policy effective date, the Policy effective date;
2. If You enroll for coverage within 31 days of Your eligibility date, on the first of the month that falls
on or next follows the date You sign the Enrollment Form;
3. If You do not enroll for Voluntary coverage within 31 days after Your eligibility date, You must wait
until the next Annual Enrollment Period to apply, unless You qualify because of a Change in Family
Status. 0
a. Initial requests for coverage or requests for changes to existing coverage made during the
Annual Enrollment Period will become effective on the Policy anniversary date.
b. Coverage requested within 31 days of a Change in Family Status will become effective
on the first of the month that falls on or next follows the date You sign the Enrollment
Form.
You must be Actively at Work for coverage under the Policy to become effective.
Enrollment Form means the application You complete to apply for coverage under the Policy.
00004
Change in Family Status
If You experience a Change in Family Status, You may enroll for Voluntary coverage, apply for additional
coverage, or request changes to Your current Voluntary benefit program(s) without providing Evidence of
Insurability, provided the benefit change is consistent with the Change in Family Status. You must
submit the appropriate Enrollment Form within 31 days of the Change in Family Status.
Change in Family Status means changes in the status of Your family, including but not limited to:
1. You get married or execute a Domestic Partner affidavit;
2. You have a Dependent Child, or You adopt or become the legal guardian of a Dependent child;
3. Your Spouse dies or You become divorced;
4. Your Dependent Child becomes emancipated or dies; X11
FDL 1-644-412 4
5. Your Spouse is no longer employed, resulting in a loss of group insurance, or;
6. You have a change in classification which results in You changing from part-time to full-time, or full-
time to part-time.
00005
When is Evidence of Insurability required?
Evidence oflnsurability is required if:
1. You are a late applicant, which means You enroll for insurance more than 31 days after Your
eligibility date; or
2. You voluntarily canceled Your insurance and choose to reapply; or
3. Your coverage amount exceeds the Guarantee Issue Benefit Limit as set forth in the Schedule of
Benefits; or
4. You apply to increase Your coverage amount during an Annual Enrollment period; or
5. You enroll for additional coverage that is greater than the next higher coverage option.
Receipt of premium before We have approved Evidence of Insurability will not constitute acceptance and
does not guarantee issuance of any benefit amount prior to Our approval.
j z
Evidence of Insurability means a statement of Your medical history which We will use to determine if
You are approved for coverage. Evidence of Insurability will be provided at Our expense if You enroll
within 31 days after Your eligibility date. Evidence of Insurability will be provided at Your expense if
You are a late applicant, which means You enroll for insurance more than 31 days after Your eligibility
date.
Evidence of Insurability Form means(W-form provided or approved by Us on which You provide a
statement of Your medical history.
You may obtain an Evidence oflnsurability Form from the Policyholder.
00006
What is an Annual Enrollment period?
Unless otherwise specified, Annual Enrollment Period means a period of time during which eligible
Employees may apply for Voluntary life coverage or request changes to their life benefit plan. The
Annual Enrollment Period is shown on the Schedule of Benef ts.
Eligible Employees may enroll for coverage, apply for additional coverage, or request changes to their
current Voluntary benefit program(s) only during the Annual Enrollment, unless they qualify because of a
Change in Family Status.
Employees hired after an Annual Enrollment period may enroll within 31 days after their eligibility date.
If a new Employee does not elect Voluntary coverage within that time period, he must wait for the next
Annual Enrollment to enroll unless he qualifies because of a Change in Family Status.
Initial requests for coverage or requests for changes to existing coverage made during the Annual
Enrollment period will become effective on the Policy anniversary date.
00007
FDL 1-644-412
If You are not Actively at Work, when does coverage become effective?
If You are absent from Active Work on the date Your coverage would otherwise become effective; and
Your absence is caused by an Injury, illness or layoff, 0
Your effective date for any initial coverage or increased coverage will be deferred until the first day You
return to Active Work.
However, You will be considered Actively at Work on any day that is not Your regularly scheduled work
day (including but not limited to a weekend, vacation or holiday) if You were Actively at Work on the
immediately preceding scheduled work day and You were:
1. not Hospital Confined; or;
2. disabled due to an Injury or Sickness.
00008
Changes to Your coverage
A change in Your coverage may occur if:
1. You enroll for a different coverage option; or
2. There is a Policy change; or
3. You enter another class and become eligible for a change in benefits; or
4. You experience a qualified Change in Family Status
If You are eligible for additional coverage due to a Policy change, the additional coverage will be
effective on the date the Policy change is effective, as requested by the Policyholder and agreed upon by
Us.
Additional coverage for reasons other than a Policy change will be effective as indicated in the "When
Does Your Contributory insurance become effective?" section, or the later of:
1. The date You enroll for the additional coverage; or
2. The date You become eligible for the additional coverage, if enrollment is not required; or
3. The date We approve Your coverage if Evidence of Insurability is required.
In order for Your additional coverage to begin, You must be Actively at Work.
Additional Contributory coverage is subject to payment of premium.
Any decrease in coverage will take effect immediately.
Exception: Increases or decreases to Your Voluntary benefit program elected during the Annual
Enrollment Period will become effective on the next Policy anniversary date, provided You are Actively at
Work on that day.
00010
Eligibility after You Terminate Employment
If Your coverage ends due to termination of employment and You do not elect continued coverage under
the Portability Benefit provision, You must meet all the requirements of a new Employee if You are
rehired at a later date.
Exception: If Your coverage ends due to termination of employment and You return to Active Work in an
eligible class within 6 months, we will not:
1. apply a new Eligibility Waiting Period; or
FDL 1-604-412
e
9
2. require Evidence of Insurability.
If You converted all or part of Your group life insurance when employment terminated, the individual
policy must be surrendered upon return to Active Work.
00011
FDL1-504-412
TERM LIFE INSURANCE BENEFIT
THIS BENEFIT ONLY APPLIES TO YOU IF YOU HAVE ELECTED TERM LIFE INSURANCE
AND YOU HAVE PAID OR AGREED TO PAY THE APPLICABLE PREMIUM.
When is a Life Insurance Benefit payable?
We will pay Your beneficiary the amount of life insurance in force as of the date of Your death provided:
1. You are insured under the Policy on the date of death, and
2. We receive proof of death.
We will determine the amount of insurance payable based upon the Schedule of Benefits.
00012 TX
Are Life Insurance Benefits payable for death by suicide?
Life Insurance benefits including Waiver of Premium, increased benefit amounts elected during
subsequent Annual Enrollment periods and Accelerated Death Benefits, will not be payable for a loss
caused by suicide or attempted suicide, while sane or insane, within one (1) year from the effective date
of Your Term Life Insurance or the effective date of any increased amount of life insurance. Our liability
for a death claim by suicide will be limited to the return of premium paid for this life insurance.
If You:
1. were covered for life insurance under a prior carrier's policy; and
2. were insured under the Policy on its effective date;
3. and there was no lapse in coverage,
We will consider the time You were covered under the Policy and under the prior carrier's policy in
determining if benefits are payable for death by suicide. The death benefit, if payable under this
provision, will be the lesser of the benefit under the Policy or the benefit under the prior carrier's policy.
00013
Who will receive Your Life Insurance Benefits?
Your beneficiary designation must be made on a form which We provide or on a form accepted by Us. If
two or more beneficiaries are named, payment of proceeds will be apportioned equally unless You had
specified otherwise. The Policyholder may not be named as beneficiary. Unless You provide otherwise,
if a beneficiary dies before You, We will divide that beneficiary's share equally between any remaining
named beneficiaries.
If a beneficiary is a minor, or is not able to give a valid release for any payment of benefits made, We will
not make payment until a claim is made by the person or entity which, by court order, has been granted
control of the estate of such beneficiary. This provision does not prevent Us from making payment to or
for the benefit of a minor beneficiary in accordance with the applicable state law.
Facility of Payment
If no named beneficiary survives You or if You do not name a beneficiary, We will pay the amount of
insurance:
1. to Your spouse, if living; if not,
2. in equal shares to Your then living natural or legally adopted children, if any; if none,
FDL l -604-412 R
3. in equal shares to Your father and mother, if living; if not,
r—� 4. in equal shares to Your brothers and/or sisters, if living; if not,
5. to Your estate.
If any benefits under this provision are to be paid to Your estate, We may pay an amount not greater than
$250 to any person We consider equitably entitled by reason of having incurred funeral or other expenses
incident to Your death. Any and all payments made by Us shall fully discharge Us in the amount of such
payment.
00014 Tx
May You change Your beneficiary?
You may change Your beneficiary at any time by completing a form provided or accepted by Us, and
sending it to the Policyholder. Your written request for change of beneficiary will not be effective until it
is recorded by the Policyholder. After it has been so recorded, it will take effect on the later of the date
You signed the change request form or the date You specifically requested. If You die before the change
has been recorded, We will not alter any payment that We have already made. `4Any prior payment shall
fully discharge Us from further liability in that amount.
,fir
If You are approved for continued life coverage under the Waiver of Premium or Portability provision,
You may be asked to name a beneficiary. A beneficiary designations made in connection with Waiver of
Premium or Portability, if different from the designation oPYour enrollment form, shall constitute a
change of beneficiary under the Policy. Such change of beneficiary only applies while You qualify for
continued coverage under the Waiver of Premium or Portability provision.
If continuation of life insurance under the Waiver of?Premiuin'�or Portability provision ceases, and You are
I.employed by the Policyholder, You must make a'% neW-beneficiary designation. If You do not name a new
beneficiary, We will pay death benefits,,in accordance with;the-Facility of Payment provision.
frrl1 yi rJVS r. rr - ��y ti�.
V•. 3r.�I !
00015
CONVERSION OF'LIFE INSURANCE
How much Life Insurance OWYou convert f eligibility terminates?
You may convert to an individual,policyofilife insurance if Your life insurance, or a portion of it, ceases
because:110f -
1. You are no longer,employed• by the Policyholder; or
2. You are no longer iiiiafclass which is eligible for life insurance.
In either of these situations, You may convert all or any portion of Your life insurance which was in force
on the date Your life'riisuance ceased.
How much Life Insurance may You convert if the policy terminates or is amended?
You may also convert to an individual policy of life insurance if Your life insurance ceases because:
1. life insurance benefits under the Policy cease; or
2. the Policy is amended making You ineligible for life insurance; however, in either of these situations,
You must have been insured under the Policy, or the Policy it replaced, for at least five (5) years. The
amount of insurance converted in either of these situations will be the lesser of:
1. the amount of life insurance in force, less any amount for which You become eligible under this or
r any other group policy within 31 days after the date Your life insurance ceased; or
FDL 1-604-412
2. $10,000.
How to apply for conversion
We must receive written application and the first premium for the individual life insurance policy within
31 days after life insurance under the Policy ceased. No Evidence of Insurability will be required.
The individual policy will be a policy of whole life insurance. It will not contain waiver of premium,
accelerated death benefit, disability benefits, accidental death and dismemberment benefits or any other
ancillary benefits.
The minimum issue amount of an individual conversion policy is $2,000. The premium for the individual
policy will be based on:
1. Our current rates based upon Your attained age; and
2. the amount of the individual policy.
If application is made for an individual policy, the coverage under the individual policy will be effective
on the day following the 31 -day period during which You could apply for conversion.
If You die during a period when You would have been entitled to have an individual policy issued to You
and if You die before such an individual policy became effective, We will pay Your beneficiary the
greatest amount of group term life insurance for which an individual policy could have been issued,
provided:
1. Your death occurred during the 31 -day period within which You could have made application; and
2. We receive proof of death. 0
If life insurance benefits are paid under the Policy, payment will not be made under the converted policy,
and premiums paid for the converted policy will be refunded.
If You have elected Portability, conversion is not available for amounts continued under Portability unless
coverage under Portability terminates. Conversion from Portability will be as specified under Portability.
Notice. If the Policyholder fails to notify You at least 15 days prior to the date insurance under the Policy
would cease, You shall have an additional period within which to elect conversion coverage; but nothing
herein shall be construed to continue any insurance beyond the period provided for in the Policy. The
additional election period shall expire 15 days immediately after the Policyholder gives You notice, but in
no event shall it extend beyond 60 days immediately after the expiration of the 31 -day period explained
above.
00016 TX
WAIVER OF PREMIUM
What is the Waiver of Premium benefit?
We will continue Your Voluntary life insurance benefit under the Policy without further payment of life
insurance premium if You become Totally Disabled, provided:
1. You are insured under the Policy and were Actively at Work on or after the effective date of the
Policy; and
2. You are under the age of 60; and
FDL 1-604-412 10
3. You provide Us with satisfactory written proof within 12 months after the date You became Totally
Disabled; and
4. Your Total Disability has continued without interruption for at least 9 months; and
5. You are still Totally Disabled when You submit the proof of disability; and
6. all required premium has been paid.
Total Disability or Totally Disabled means You are diagnosed by a Doctor to be completely unable
because of Sickness or Injury to engage in any occupation for wage or profit or any occupation for which
You become qualified by education, training or experience.
We will waive premium beginning the month after We receive satisfactory proof that You have been
Totally Disabled for at least 9 months. Premium will continue to be waived provided You:
1. remain Totally Disabled; and 4 f lT4
2. provide satisfactory written proof of continuing Total Disability upon regiiest. We wiltmot request
proof of continuing Total Disability more frequently than once every threeiiionths during the first
two years of Total Disability, and not more frequently than once a year after�� a Insured has been
Totally Disabled for two years. r '`
You are responsible for obtaining initial and continuing proof oo'ff TotallDisability.�111'
You will be covered for the amount of life insurance'`in,force as of the date Total Disability commenced.
The amount of life insurance continued in force will be subject to any reduction in benefits as shown on
the Schedule of Benefits or which are the result of an amendment to the Policy, but in no event will the
insurance amount increase while Your life insurance is continued under Waiver of Premium. This life
insurance coverage will continue without the payment of premium until You are no longer Totally
Disabled, or attain the Maximum Waiver of PreniiumS�D`uration as set forth in the Schedule of Benefits or
retire, whichever occurs first.
We may have You examined at reasonable intervals during the period of claimed Total Disability, but not
more frequently than once,eygry three months during the first two years of Total Disability, and not more
frequently than once a yearafiter the Insured has been Totally Disabled for two years. Continuation of life
insurance under the Waiver of Premium provision shall end immediately and without notice if You refuse
to be examined as and when required.
If You are approved for continued coverage under the Waiver of Premium provision, You will be asked to
name a beneficiary`:�'Ib4t�benefic%ry designation:
1. will only apply while Your coverage continues under this Waiver of Premium provision; and
2. if different frorri�Ci'designation on Your enrollment form, shall constitute a change of beneficiary
under the Policy.
We will pay the amount of life insurance in force to Your beneficiary if You die before furnishing
satisfactory proof of Total Disability, if -
1.
f
1. You die within one year from the date You became Totally Disabled; and
2. We receive proof that You were continuously Totally Disabled until the date of death; and
3. We receive proof of death.
If continuation of life insurance under the Waiver of Premium provision ceases while the Policy is still in
force, and You are employed by the Policyholder, Your life insurance will continue provided premium
FDL 1-604-412 11
payments begin on the next premium due date. If You return to work with the Policyholder, You must
make a new beneficiary designation. If You do not name a new beneficiary, We will pay death benefits in
accordance with the Facility of Payment provision. C,
If continuation of life insurance under the Waiver of Premium provision ceases, and You are no longer
employed by the Policyholder, You may apply for an individual life insurance policy in accordance with
the Conversion of Life Insurance provision of this Certificate.
How does termination of the Policy affect Your insurance under the Waiver of Premium Benefit?
Termination of the Policy will not affect any insurance that has been continued under this Provision prior
to the termination date.
What if You are Totally Disabled and the Policy ends before You satisfy the Elimination Period?
Your coverage under the Policy will end if the Policy ends before You satisfy the Elimination Period.
However, when the Policy ends You may be entitled to convert Your coverage to an individual plan of life
insurance as described in the Conversion of Life Insurance provision.
You may still submit a claim for Waiver of Premium Benefits after the Policy ends. However, You must
be Totally Disabled, pay the Conversion premium for the full length of the Elimination Period and qualify
for the Waiver of Premium Benefits.
At no time can You be covered under both the individual conversion policy and this Policy.
Upon receipt of timely notice and due proof of Your Total Disability We will evaluate Your claim. If We
determine that You qualify and You pay all applicable premiums, We will approve Your Waiver of
Premium claim under the Policy and agree to rescind any individual policy of life insurance issued to You
under the Conversion privilege. We will refund any premiums paid for such coverage. Insurance under
the Policy will not go into effect until We approve your claim in writing. 0
00017TXa
FDL 1-604-412 12
ACCELERATED DEATH BENEFIT
What is the Accelerated Death Benefit?
The Accelerated Death Benefit is a percentage of Your group Voluntary tern life insurance which is
payable to You prior to Your death if We receive acceptable proof that You have a Terminal Condition.
The Accelerated Death Benefit is limited to the maximum and minimum amounts shown on the Schedule
of Benefits, and is payable only once to any one Insured.
The Accelerated Death Benefit is calculated on the group Voluntary term life insurance benefit amount in
force under the Policy on the date You are diagnosed with a Terminal Condition. if Your group term life
insurance will reduce, due to age, within 12 months after the date We receive -proof, the Accelerated
Death Benefit will be calculated on the reduced group Voluntary term life insurance benefit.
Who is Eligible for an Accelerated Death Benefit? 17�Y%
Ili
This benefit only applies to Insureds with at least the Minimum Covered Life Insurance Benefit amounts
set forth in the Schedule of Benefits. You must have been Actively at Work on or after the�effective date
of the Policy to be eligible for an Accelerated Death Benefit.
This benefit does not apply to Accidental Death and Dismemberment benefits.
Terminal Condition means You have been examined and d Sagnosed l y�,Your Doctor as having a non -
correctable health condition that, with reasonable medical certainty, will result in Your death within 12
months from the date of the Doctor's Statement:
Doctor's Statement means a written medical'." "inion of a'136ctor, currently licensed to practice in the
United States which:
1. is made at Your expense; and;yyf,sk
2. indicates that You have a Terminal'Condition;,and
r>J"
3. includes all medical test results, laboratory'%reports, and any other information on which the medical
opinion is based; and +rf,
4. indicates Your expected remaining life span;,and
5. is acceptable to Us. �� "`7i
1f �rt�J;i'c
The Accelerated Death Benefit -Payment
A -
We will pay the benefit durinik our lifetime if You are diagnosed with a Terminal Condition if You or
Your legal representative submits a claim for an Accelerated Death Benefit and provides satisfactory
proof. The benefit will be,paid in one sum to You. There is no cost for an Accelerated Death Benefit. At
the time of the payment of the Accelerated Death Benefit, We will send a statement to the certificate
holder specifying the.amount of benefits paid, the effect of the Accelerated Death Benefit payment on the
death benefit face amount, and the amount of benefits remaining available for acceleration.
Are there any exceptions to the payment of the Accelerated Death Benefit?
The Accelerated Death Benefit will not be payable:
1. for any amount of group term life insurance which is less than the Minimum ADB Payment as set
forth in the Schedule of Benefits; or
2. if Your Terminal Condition is the result of:
a. attempted suicide, while sane or insane; or
b. intentionally self-inflicted injury; or
3. if Your group term life insurance benefit has been assigned; or
FDLI-604-412 13
4. if Your group term life insurance benefit is payable to an irrevocable beneficiary, including
notification to Us that such benefit or a portion of such benefit is to be paid to a former spouse as part
of a divorce or separation agreement; or
5. to retirees.
Notice and Proof of Claim
You must elect the Accelerated Death Benefit in writing on a form that is acceptable to Us. You must
furnish proof that You have a Terminal Condition, including a Doctor's Statement within 91 days of the
notice of claim. If proof is not given within 91 days, the claim will not be reduced or denied if proof is
given as soon as reasonably possible.
Effect on Insurance
The Accelerated Death Benefit is in lieu of the group term life insurance benefit that would have been
paid upon Your death. When the Accelerated Death Benefit is paid:
1. the term life insurance benefit otherwise payable upon Your death will be reduced by the amount of
the Accelerated Death Benefit. Any portion of the death benefit remaining after reduction of the
death benefit due to payment of an Accelerated Death Benefit shall be paid upon the death of the
Insured.
2. the amount of group term life insurance which could otherwise have been converted to an individual
contract will be reduced by the amount of the Accelerated Death Benefit; and
3. the premium due for group term life insurance will be calculated on the amount of such insurance
remaining in force after deducting the Accelerated Death Benefit.
The payment of an Accelerated Death Benefit and the balance of the death benefit under the Policy shall
constitute full settlement of the face amount of the Policy.
09020 TX 0
FDL 1-604-412 14
PORTABILITY BENEFIT
What is the Portability Benefit?
If Your Voluntary Group Life Insurance, or any portion of it, terminates, You may elect to continue Your
Life Insurance in accordance with the terms of the Policy by paying premiums directly to Us. If You
elect Portability, You may also elect to continue Dependent Life Insurance under the conditions set forth
below, but You may not apply for Dependent Life Insurance at the time you apply for Portability. The
coverages eligible for Portability and the Portability Benefit Duration are set forth in the Schedule of
Benefits.
The premiums for the coverage continued under the Portability Benefit willYnQt be the same as the
premium You are charged for Your group Life insurance under the Policy.Artability premium will be
based on: .1,yfiR
1. Our current rates for the applicant's age and class of risk at the time he elects P,ortability; and
2. the amount of insurance continued under Portability. ".
The maximum amount of Life Insurance which may be continued under Portabilityf i's:the amount of Life
Insurance in force at the time the Portability Benefit is elected." f
A beneficiary designation on the Application for Portability, if different from the designation on Your
enrollment form, shall constitute a change of beneficiary funder the��Policy, and that beneficiary
designation will only apply while Your coverage continues. under this Portability Benefit provision.
The Waiver of Premium is not available for any. Insured wlidse Total Disability begins after coverage
under Portability becomes effective. The Accelerated;Death Benefit is not available for any Insured who
is diagnosed with a Terminal Condition. after coverage under Portability becomes effective.
What is the Additional Purchase Option?Qr`
Each Employee who elects portable coverage may Se entitled to purchase an additional amount of term
life insurance with Evidenq f.9f Insurability, provided he has not converted under the group Policy the
amount of group life inshe elects under the Additional Purchase Option. The maximum amount
available under this Additional Purchase Option is shown on the Schedule of Benefits. We will bill this
additional coverage at the sy e rate and in the same premium mode as coverage continued under
Portability,:�`The Additional Purchase Option does not apply to Spouse or Dependent Child coverage.
What are Eligibility Requirements for Employee Portability?
To be eligible for Portability, You must meet the following conditions:
r
1. You must have lieeif insured under the Policy for at least one year prior to electing Portability; and
2. Your Life Insurance, or a portion of it, must have terminated for reasons other than Sickness, Injury,
retirement or termination of the master Policy; and
3. You must be less than 65 years of age; and
4. You must be able to perform the Material and Substantial duties of any Gainful Occupation for which
You are qualified by education, training or experience; and
5. You must not have exercised the right to convert under the Conversion of Life Insurance provision the
amount of Life Insurance You elect under the Portability Benefit. If You elect the Portability benefit,
any amounts of Life Insurance which are not ported may be converted in accordance with the terms of
} the Conversion of Life Insurance provision.
FDL I -604-412 15
You must submit an application for Portability and the first premium within 31 days after the date Your
Life Insurance terminated. 0
We reserve the right to rescind any coverage amounts continued under Portability if it can be shown that
You misrepresented any of the information provided to support eligibility for Portability.
Can Dependent Life Insurance be Ported if Your Eligibility Terminates or if Your Spouse's Coverage
Terminates?
Yes, You or Your insured Spouse may elect Portability of Dependents' Life Insurance if Dependents'
insurance coverage ceases as follows:
1. You may apply for Portability of Dependent Life Insurance if You meet the eligibility requirements to
port Your Life Insurance as shown above and You are covered for Dependent Life insurance on the
date Your coverage ceases.
2. Your insured Spouse may apply for Portability of his Group Life Insurance, and/or life insurance on
covered Dependent Child(ren) provided:
a. Your Spouse's life insurance terminates because You die or Your eligibility for Dependent Life
Insurance ceased for reasons other than retirement or termination of the master Policy and Your
Spouse is less than 65 years of age.
b. Your Spouse had elected Dependent Life on eligible Dependent Child(ren) and such coverage is
still in force when Your eligibility for Dependents Life Insurance ceased for reasons other than
retirement or termination of the master Policy.
c. Your Spouse must have been insured for such coverage(s) under the Policy for at least one year
prior to electing Portability.
d. Portability is not available if Your Spouse's life insurance terminates because he no longer meets
the Policy definition of an Eligible Dependent Spouse.
3. You or Your Spouse must not have exercised the right to convert under the Dependent Conversion
Privilege provision of the Policy the amount of coverage You or Your Spouse elect under the
Portability Benefit. If You elect portability of Dependent Life Insurance, any amounts of Dependent
Life Insurance which are not ported may be converted in accordance with the terms of the Policy.
If these criteria are met, You or Your Spouse, must submit an Application for Portability and the first
premium within 31 days after the date such eligible Dependent Life Insurance terminated.
We reserve the right to rescind any coverage amounts continued under Portability if it can be shown that
You or Your Spouse misrepresented any of the information provided to support eligibility for Portability
of Dependent Life Insurance.
When will Portable Coverage Terminate?
Insurance continued under the Portability Benefit provision of the Policy will terminate at the earliest of
the following:
1. the date You return to work with the Policyholder while the Policy is still in force; or
2. the date You or Your Spouse fail to pay the required premiums when due; or
3. the end of the Portability Benefit Duration set forth in the Schedule of Benefits; or
4. the premium due date following the date a Dependent ceases to meet the definition of an Eligible
Dependent.
If continuation of life insurance under the Portability Benefit provision ceases while the Policy is still in
force, and You are employed by the Policyholder, Your life insurance will continue provided premium
payments begin on the next premium due date. If You return to work with the Policyholder, You must
FDL 1-604-412 16
make a new beneficiary designation. If You do not name a new beneficiary, we will pay death benefits
according to the Facility of Payment provision.
Is Conversion available after coverage under Portability ends?
If coverage under Portability terminates according to (3) or (4) above, You may convert to an individual
policy of whole life insurance in accordance with the terms of the Conversion provisions of the Policy.
No Evidence of Insurability will be required. The amount of the conversion policy may not exceed the
amount of life insurance which terminated as set forth above.
00022
FDL 1-604-412
17
DEPENDENT LIFE INSURANCE
THIS BENEFIT ONLYAPPLIES IF YOU HAVE ELECTED DEPENDENT TERM LIFE0
INSURANCE AND YOU HA VE PAID OR AGREED TO PA Y THE APPLICABLE PREMIUM.
What is the Dependent Life Insurance Benefit?
We will pay You the amount of insurance set forth in the Schedule of Benefits on the life of Your
Dependent(s) while Your insurance is in force. Payment will be in one lump sum.
If You are not living at the time Dependent life insurance benefits become payable, We will pay the
benefit:
L to Your Spouse, if living; if not,
2. in equal shares to Your then living natural or legally adopted children, if any; if none,
3. in equal shares to Your father and mother, if living; if not,
4. in equal shares to Your brothers and sisters, if living; otherwise
5. to Your estate.
Are Life Insurance Benefus payable for death by suicide?
Life Insurance benefits will not be payable for a loss caused by suicide or attempted suicide, while sane or
insane, within one (1) year from the effective date of Your covered Dependent's Term Life Insurance or
the effective date of any increased amount of life insurance. Our liability for a death claim by suicide will
be limited to the return of premium paid for this life insurance.
If Your covered Dependent(s):
1. were covered for life insurance under a prior carrier's policy; and 0
2. were insured under the Policy on its effective date;
3. and there was no lapse in coverage,
We will consider the time Your covered Dependent(s) were covered under the Policy and under the prior
carrier's policy in determining if benefits are payable for death by suicide. The death benefit, if payable
under this provision, will be the lesser of the benefit under the Policy or the benefit under the prior
carrier's policy.
00023
Who is eligible for Dependent Life Insurance?
If You or Your Spouse are insured for life insurance under the Policy and belong to a class listed in the
Schedule of Benefits as eligible for Dependent Life Insurance benefits, You are eligible to enroll for this
benefit. If You or Your Spouse are enrolled for Dependent Life Insurance and subsequently acquire a new
Eligible Dependent, that Dependent will automatically be covered.
Note: No eligible person may be covered more than once under the Policy. If a person is covered as an
Employee, he cannot be covered as a Spouse or Dependent Child of another Employee. If both parents are
covered as insured Employees under the Policy, only one may enroll for life insurance coverage on
Eligible Dependent Child(ren).
When does Dependent Life Insurance become effective?
Provided You:
1. have completed any required Employee Eligibility Waiting Period; and
FDL l -604-412 18
2. apply for Dependent Life Insurance no later than 31 days after becoming eligible for this benefit; and
3. have paid or are obligated to pay any applicable premium,
Life insurance for Your Eligible Dependents) will become effective on the later of -
I . the date Your group insurance coverage becomes effective;
2. the effective date of the Dependent Life Insurance benefit; or
3. the first of the month that falls on or next follows date You enroll Your Eligible Dependent(s);
4. the first of the month that falls on or next follows the date You acquire Your Eligible Dependent(s);
5. if Evidence of Insurability is required, the date We determine that evidence is satisfactory and We
provide notice of approval.
If You enroll for Dependent Life Insurance more than 31 days after You are eligible to do so, You must
furnish Evidence of Insurability satisfactory to Us for each Dependent, and coverage will become
effective as set forth above.
If an Eligible Dependent is required to submit satisfactory Evidence of Insurability for any reason,
insurance in the amount for which We require such evidence will become effective on the date We
determine that the evidence is satisfactory and We provide notice of approval.
If an Eligible Dependent is Hospital Confined on the date coverage would otherwise become effective,
insurance will not become effective until the date the Eligible Dependent is No Longer Hospital Confined
or Your Spouse is able to perform at least two of the Activities of Daily Living.
When do changes in the Dependent Life Insurance benefit become effective?
If no Evidence of Insurability is required, increases in the amount of Dependent Life Insurance will
become effective immediately on the date of the change, provided the Dependent is not Hospital Confined
on that day. If the Dependent is Hospital Confined, the increase will become effective on the date the
Dependent is No Longer Hospital Confined.
For amounts on which Evidence of Insurability is required, increases in the amount of Dependent Life
Insurance will be effective on the date We determine that evidence is satisfactory and We provide notice
of approval date. 1Y ` f
,� I
�x.
Any decrease in the amount of.;Dependent Life Insurance will become effective immediately on the date
of the change
00024
a
Definitions which apply to the Dependent Life Insurance provision:
Eligible Dependent means.
I. the Spouse or Domestic Partner of each individual eligible to be insured under the Policy;
2. a natural or adopted child of each individual eligible to be insured under the policy if the child is:
a. younger than 25 years of age; or
b. physically or mentally disabled and under the parents' supervision; or
a natural or adopted grandchild of each individual eligible to be insured under the policy if the child
is:
a. younger than 25 years of age; and
FDLI-604-412 19
b. a dependent of the insured for federal income tax purposes at the time the application for
coverage of the child is made.
Dependent Child - See Dependent or Eligible Dependent
No Longer Hospital Confined means the Eligible Dependent has been discharged from a hospital,
nursing home or other medical facility which provides skilled medical care. This provision does not apply
to Your Dependent Child born while You are insured under the Policy or covered under the prior policy.
Spouse means lawful spouse in the jurisdiction in which You reside. Spouse will include Your Registered
Domestic Partner.
00026 TXa
CONVERSION OF DEPENDENT LIFE INSURANCE
Can Dependent Life Insurance be converted if Eligibility Terminates?
Yes, a Dependent may convert to an individual policy of life insurance if his life insurance, or any portion
of it, ceases because:
1. You are no longer employed by the Policyholder; or
2. You are no longer in a class which is eligible for Dependent Life Insurance; or
3. You die; or
4. a Dependent Child reaches the limiting age under the Policy; or
5. a Dependent Spouse is no longer eligible as a result of divorce or dissolution of marriage; or
6. a Dependent is no longer eligible as defined in this provision. 0
In any of these situations, the Dependent may convert up to the amount which was in force on the date
insurance was terminated provided You do not elect continued Dependent Life Insurance coverage under
the Portability Benefit provision.
How much can Your covered Dependent convert if the Policy is terminated or amended?
A Dependent may also convert to an individual policy of life insurance if his life insurance ceases
because:
1. Dependent Life Insurance benefits under the Policy cease; or
2. the Policy is amended making the insured Dependent ineligible for Dependent Life Insurance;
however,
he must have been insured under the Policy, or the policy it replaced, for at least five (5) years. The
amount of insurance converted in either of these situations will be the lesser of:
the amount of life insurance in force, less any amount for which the Dependent becomes eligible
under this or any other group policy within 31 days after the date his life insurance ceased; or
2. $ 10,000.
How to apply for conversion
We must receive written application and the first premium for the individual life insurance policy within.
31 days after life insurance under the Policy ceases. No Evidence of Insurability will be required.
FDL 1-604-412 20
The individual policy will be a policy of whole life insurance. It will not contain Accidental Death and
Dismemberment benefits or any other supplementary benefits.
The minimum issue amount of an individual conversion policy is $2,000. The premium for the individual
policy will be based on:
1. Our current rates based upon the applicant's attained age; and
2. the amount of the individual policy.
If the Dependent applies for an individual policy, the coverage under the individual policy will be
effective on the day following the 31 -day period during which he could apply for conversion.
If the Dependent dies during a period when he would have been entitled to have an individual policy
issued to him and if he dies before such an individual policy became effective, We will pay the greatest
amount of group term life insurance for which an individual policy could have been issued, provided:
1. the death occurred during the 31 -day period during which he could have made application; and
2. We receive proof of death.
If life insurance benefits are paid under the Policy, payment will not be made under the converted policy,
and We will refund any premiums paid for the converted policy.
00027 Tx
FDL 1-504-412
21
ACCIDENTAL DEATH & DISMEMBERMENT BENEFIT (AD&D)
THIS BENEFIT ONLY APPLIES TO YOU IF YOU HAVE ELECTED ADHD INSURANCE
AND YOU HAVE PAID OR AGREED TO PAY THE APPLICABLE PREMIUM.
COVERAGE PLANS AVAILABLE
Individual Plan: If You enroll in the Individual Plan, You may select a Coverage Amount within the
range set forth in the Schedule of Benefits, and You will be covered for the amount selected while
coverage remains in force, subject to any adjustments resulting from an increase in age.
Family Plan: If You enroll in the Family Plan, You may select a Coverage Amount within the range
shown on the Schedule of Benefits, and Your Eligible Dependents will be covered for a percentage of
Your Coverage Amount as shown on the Schedule of Benefits.
Note: No eligible person may be covered more than once under the Policy. If a person is covered as an
Employee, he cannot be covered as a Spouse or Dependent Child of another Employee. If both parents are
covered as insured Employees under the Policy, only one may enroll for life insurance coverage on
Dependent Child(ren).
00029
What is the AD&D Benefit?
If, while insured under the Policy, You or Your covered Dependent suffer an Injury in an Accident, We
will pay for those Losses set forth in the "Table of Losses" below. The amount paid will be the percentage
stated in the Table of Losses but not more than the Coverage Amount set forth in the Schedule of
Benefits. The Loss must:
1. occur within 365 days of the Accident; and
2. be the direct and sole result of the Accident; and
3. be independent of all other causes. 0
TABLE OF LOSSES
% OF COVERAGE
AMOUNT PAYABLE
Loss of Life
100%
Loss of Both Hands
100%
Loss of Both Feet
100%
Loss of Entire Sight of Both Eyes
1000/0
Loss of One Hand and One Foot
100%
Loss of Speech and Hearing
100%
Quadriplegia
100%
Paraplegia
75%
Loss of One Hand
50%
Loss of One Foot
50%
Loss of Entire Sight of One Eye
50%
Loss of Speech
50%
Loss of Hearing (both ears)
50%
Hemiplegia
50%
Loss of Thumb and Index Finger (on same hand)
25%
Uniplegia
25%
Definitions which apply to the AD&D Provision:
Accident or Accidental means a sudden, unexpected event that was not reasonably foreseeable.
FDL 1-604-412 22
Hemiplegia means total Paralysis of one arm and one leg on the same side of the body.
Loss, with respect to hand or foot, means actual and permanent severance from the body at or above the
wrist or ankle joint, as applicable. With respect to eyes, speech and hearing, loss means entire and
irrecoverable loss of sight, speech or hearing. With respect to thumb and index finger, loss means
complete severance of entire digit at or above joints.
Paralysis means loss of use without severance of a limb as a result of an Injury to the Spinal Cord, which
has continued for 12 months. Paralysis must be determined by a Doctor to be permanent, total and
irreversible.
Paraplegia means total Paralysis of both legs.
Quadriplegia means total Paralysis of both arms and both legs.
Unlplegla means total Paralysis of one limb.
The total amount of AD&D benefits payable for all Losses for any Insured resulting from any one
Accident will not be greater than the Coverage Amount set forth in the Schedule of Benefits.
Except as provided in a particular AD&D benefit provision, We will pay benefits for loss of life to the
Y� n A—
same beneficiary(ies) named to receive life insurance benefits. Benefits�forlall other Losses will be paid
to You.
rr�(�
00034 sf��1 ��. riS�✓ .
SEATBELT BENEFIT
What is the Seat Belt Benefit?
We will pay an additional amount, as?set,forth.in the Schedule of Benefits, if a benefit is payable under the
AD&D Benefit for Your loss of life as''the result`'of an Accident which occurs while You were driving or
riding in an Automobile,; if:
1. the Automobile is equipped with Seat Belts.
2. the Seat Belt was in actual use .and properly fastened at the time of the Accident.
3. the position of the Seat Belt is certified in the official report of the Accident or by the investigating
officer. A copy of the police accident report must be submitted with the claim.
4. You wete driving or riding in an Automobile driven by a licensed driver who was neither:
a. intoxicated or driving while impaired. Intoxication and impairment shall be determined, with or
without conviction, by the law of the jurisdiction in which the Accident occurs or .08% blood
alcohol content if the jurisdiction in which the Accident occurred does not define intoxication; nor
b. under the influence of any narcotic, hallucinogen, barbiturate, amphetamine, gas or fumes, poison
or any other controlled substance as defined in Title 11 of the Comprehensive Drug Abuse
prevention and Control Act of 1970, as now or hereafter amended, unless as prescribed by a
licensed physician and used in the manner prescribed. Conviction is not necessary for a
determination of being under the influence.
If the required certification is not available and if it is unclear whether You were properly wearing a Seat
Belt, then We will pay an additional benefit of $1,000.
Automobile means a validly registered private passenger car (or policyholder -owned car), station wagon,
jeep -type vehicle, SUV, pick-up truck or van -type car that is not licensed commercially or being used for
commercial purposes.
FDL 1-404-412 23
Seat Belt means those belts that form an occupant restraint system.
00031
*hat is the Air Bag Benefit? AIR BAG BENEFIT
We will pay an additional amount as set forth in the Schedule of Benefits if a benefit is payable under the
AD&D Benefit for Your loss of life as the result of an Accident which occurs while You are driving or
riding in an Automobile provided that:
1. You were positioned in a seat that was equipped with an Air Bag;
2. You were property strapped in the Seat Belt when the Air Bag inflated; and
3. the police report establishes that the Air Bag inflated properly upon impact.
If it is unclear whether You were properly wearing Seat Belt(s) or if it is unclear whether the Air Bag
inflated properly, then the Air Bag Benefit will be $1,000.
Air Bag means an inflatable supplemental passive restraint system installed by the manufacturer of the
Automobile, or proper replacement parts as required by the automobile manufacturer's specifications, that
inflates upon collision to protect an individual from injury and death. A Seat Belt is not considered an Air
Bag.
00032
REPATRIATIONBENEFIT
What is the Repatriation Benefit?
We will pay an additional amount, as set forth in the Schedule of Benefits, for the preparation and
transportation of Your body to a mortuary if:
1, the Coverage Amount under the AD&D Benefit is payable for Your loss of life; and
2. Your death occurs at least 75 miles away from Your principal residence.
00033
EDUCATIONBENEFIT
What is the Education Benefit?
We will pay an additional amount, as set forth in the Schedule of Benefits to Your Dependent Student if
an AD&D benefit is payable for Your loss of life. We will only pay one Education Benefit to any one
Dependent Student during any one school year. If the Dependent Student is a minor, We will pay the
benefit to the legal representative of the minor.
Definitions which apply to the Education Benefit:
Student means an Eligible Dependent child who, on the date of Your death, is:
1- A full-time post -high school student in a School of Higher Education; or
2. A student in the 120' grade but who becomes a full-time post -high school student in a School of
Higher Education within 365 days after Your death.
School of Higher Education means an institution which:
1. is legally authorized by the State in which it is located; and
FDL 1-604-412 24
2. provides either a program for:
a. Bachelor's degrees or not less than a two year program with full credit towards a Bachelor's
f i degree; or
b. Gainful employment as long as such program is at least one year of training; and
3. is accredited by an Agency or association recognized by the U.S. Department of Education under the
Higher Education Assistance Act as may be amended from time to time.
When Benefit Ends: A Dependent Student will no longer be eligible to receive the Dependent Education
Benefit upon the earlier of the following:
1. Our payment of the fourth installment of the Dependent Education Benefit on behalf of or to the
Dependent Student; or
2. At the end of the period during which due Proof must be submitted if no. due Proof is submitted.
Special Child Education Benefit: If Your Eligible Dependent child does not qualify as a Student, but is
enrolled in an elementary or high school, We will pay a Child Education Benefit in the amount of $1,000.
This benefit is payable once upon proof that You died as a result of an Accident for, which the Accidental
All
Death & Dismemberment benefit is payable and that, within 12 months after Yourpdeath Your Eligible
Dependent Child is a full-time student in an elementary or high school. ftr
00034
3`r
COMMON DISASTER BENEFIT'
What is the Common Disaster Benefit?
We will pay an additional amount, as set forth,
1. You and Your covered spouse die as a res
Accidents that occur within the,same 24 hour
2. loss of Life occurs for both You and..Your'Spo
3. a benefit is payable under the AD&D Benefit
Y �
Schedule '.of Benefits, if;
,??Injury received in the same Accident or separate
within 90 days of the Accident(s); and
death and the death of Your Spouse, then
We will increase the am6iEi under the AD&D Benefit for Your Spouse (the "Spousal AD&D Benefit") to
equal the Coverage Amount uinder'Tour AD&D Benefit, if greater than the Spousal AD&D Benefit. The
Spousal AD&D Benefit under this Common Disaster Benefit may not exceed the Maximum Common
Disaster Benefit shown on the;Schedule of Benefits.
00037 A
,S:1riYf, EXPOSURE AND DISAPPEARANCE
If, as a result of an Accident while insured for this benefit, if You or Your Insured Dependents are
unavoidably exposed jo' the elements and suffer a Loss as a result of that exposure, that Loss will be
covered. If Your or Your Insured Dependents body has not been found within one (1) year of an
Accidental disappearance, forced landing, sinking or wrecking of a conveyance in which You or Your
insured Dependents were occupants, You or Your Insured Dependents will be deemed to have suffered
loss of life.
00043
FDL 1-604-412 25
LIMITATIONS
Are there any Limitations for losses due to an Accident?
We will not pay any benefit for any Loss that, directly or indirectly, results in any way from or is
contributed to by:
1. any disease or infirmity of mind or body, and any medical or surgical treatment thereof; or;
2. any infection, except a pus -forming infection of an Accidental cut or wound; or
3. suicide or attempted suicide, while sane or insane; or
4. any intentionally self-inflicted Injury; or
5. war, declared or undeclared, whether or not You or Your Insured Dependent is a member of any
armed forces; or
6. travel or flight in an aircraft while a member of the crew, or while engaged in the operation of the
aircraft, or giving or receiving training or instruction in such aircraft; or
7. commission of, participation in, or an attempt to commit an assault or felony; or
8. under the influence of any narcotic, hallucinogen, barbiturate, amphetamine, gas or fumes, poison or
any other controlled substance as defined in Title 1I of the Comprehensive Drug Abuse Prevention
and Control Act of 1970, as now or hereafter amended, unless as prescribed by a licensed physician
and used in the manner prescribed. Conviction is not necessary for a determination of being under
the influence; or
9. intoxication as defined by the laws of the jurisdiction in which the Accident occurred or .08% blood
alcohol content if the jurisdiction in which the Accident occurred does not define intoxication.
Conviction is not necessary for a determination of being intoxicated; or
10. active participation in a Riot. Riot means all forms of public violence, disorder, or disturbance of the
public peace, by three or more persons assembled together, whether with or without a common intent
and whether or not damage to person or property or unlawful act is the intent or the consequence of
such disorder.
00050
UNIFORM PROVISIONS
(Applicable to Dismemberment Coverage Only)
Initial Notice of Claim
We must receive written notice of Loss within 30 days of the date of Loss, or as soon as reasonably
possible. The Policyholder can assist with the appropriate telephone number and address of Our Claim
Department. Notice may be sent to Our Claim Department at the address shown on the claim form or
given to Our Agent.
Claim Forms
Within 15 days of Our being notified in writing of a claim, We will supply the claimant with the
necessary claim forms. The claim form is to be completed and signed by the claimant, the Policyholder
and the claimant's Doctor. If the appropriate claim forms are not received within 15 days, then the
claimant will be considered to have met the requirements for written proof of loss if We receive written
proof, which describes the occurrence, extent and nature of the Loss.
Time Limit for Filing Your Claim
We must receive written proof of loss within 91 days after the date a Loss is incurred. If it is not possible
to give Us written proof within 91 days, the claim is not affected if the proof is given as soon as possible.
FDL 1-604-412 26
However, unless the claimant is legally incapacitated, written proof of loss must be given no later than
one year after the time proof is otherwise due.
No benefits are payable for claims submitted more than 1 year after the time proof is due. However,
benefits may be paid for late claims if it can be shown that:
1. It was not reasonably possible to give written proof during the one year period, and
2. Proof of loss satisfactory to Us was given as soon as was reasonably possible.
For the Education Benefit, proof of loss must:
1. Include proof of Dependent Student status; and
2. Be submitted no later than
a. Two months after completion of course work for that particular school year if the Dependent
Student is enrolled in a School of Higher Education at the time of Your death. School year shall
be deemed to begin on September 1 st and end on August 31 st; or
b. Within six (6) months after enrollment in a School of Higher Education if the Dependent Student
is in the 12th grade at the time of Your death.
After the first year in a School of Higher Education, due proof must be submitted in accordance with
the time limits defined in Item (a) above.
Physical Examination/Autopsy
Upon receipt of a claim, We may examine an Insured, at Our expense, at any reasonable time. We
reserve the right to perform an autopsy, at Our expense, if it is not prohibited by any applicable local
law(s).
00051 Tx
FDL1-644-412 27
TERMINATION PROVISIONS
When does Your coverage under t ?"
g he Policy end.
Your coverage will terminate on the earliest of the following dates. Termination will not affect Your
claim for a covered Loss which occurred while the coverage was in force.
1. the date on which the Policy is terminated;
2. the date You stop making any required contribution toward payment of premiums;
3. the effective date of an amendment to the Policy which terminates insurance for the class to which
You belong; or
4. the date You:
a. are no longer a member of a class eligible for this insurance,
b. request termination of coverage under the Policy,
c. are retired or pensioned, or
d. are no longer Actively at Work as a result of a disability, layoff, leave of absence, sabbatical or
military leave. However, You may continue to be eligible for group insurance coverage, as
follows:
Disability Until the end of the twelfth month following the month in which the disability began,
provided all premiums are paid when due, the Policy is in force, and Your coverage is
not replaced with group life insurance provided by a new carrier.
Layoff Until the end of the month following the month during which the layoff began,
provided all premiums are paid when due, the Policy is in force, and Your coverage is
not replaced with group life insurance provided by a new carrier.
Leave of Until the end of the month following the month during which the leave of absence
Absence began, or, the period of time in accordance with the FMLA provision below, provided
all premiums are paid when due, the Policy is in force, and Your coverage is not
replaced with group life insurance provided by a new carrier.
Sabbatical Until the end of the month following the sixth month in which the sabbatical began,
provided all premiums are paid when due, the Policy is in force, and Your coverage is
not replaced with group life insurance proved by a new carrier.
Military Until the end of the twelfth month following the month in which the military leave
Leave began, provided all premiums are paid when due, the Policy is in force, and Your
coverage is not replaced with group life insurance provided by a new carrier.
For the purposes of this Termination Provision only, Disability means You are unable to perform all of the
Material and Substantial Duties of Your Regular Occupation.
00052TXa
FDL 1-604-412 29
Will coverage be continued if You are efigible for leave under FMLA?
In the event You are eligible for and the Policyholder approves a leave under the Family and Medical
Leave Act of 1993 (FMLA), or any applicable state family and medical leave law (State FML), provided
the required premium continues to be paid, the Policy is in force and Your coverage is not replaced with
group life insurance provided by a new carrier, Your insurance will continue for a period of up to the later
of:
1. the leave period permitted by the federal Family and Medical Leave Act of 1993 and any
amendments; or
2. the leave period permitted by applicable state law.
You are eligible for leave under this Act in orde
1. After the birth of a child; or
2. After the legal adoption of a child; or
3. After the placement of a foster child in Yot,
4. To a spouse, child or parent due to their sei
5. For Your own serious health condition.
While granted a Family or Medical Leave of A
1. The Policyholder must remit the required premium according to the terms of the Policy; and
2. coverage will terminate if You do not return to work as scheduled according to the terms of Your
agreement with the Policyholder. tif
00053a j•�%f 11M,
afrih f
When does Dependent Life Insurance coverage end.,?
Unless life and AD&D insurance is continued under the Portability Benefit provision, Dependent Life
Insurance coverage will end on the earliest of
1. the date You are no longer Actively at Work (except in the case of disability, layoff or leave of
absence as set forth above); or
2. the date on which the Policy is terminated;
3. the date You stop making any required contribution toward payment of premiums;
4. the effective date of an amendment to the Policy which terminates insurance for the class to which
You belong; or
5. the date You.
a. are no longer a member of a class eligible for this insurance,
b. request termination of coverage under the Policy,
c. are retired or pensioned, or
6. the date a Dependent Child or Spouse no longer meets the Policy definition of Eligible Dependent
Note: Coverage will continue past the age limit for eligible Dependent Children who are primarily
dependent upon You for support and who cannot work to support themselves due to a physical or mental
incapacity which began before the age limit was reached. Proof of such incapacity must be provided to
Us upon request.
00054 TX
FDL 1-604-412 29
GENERAL PROVISIONS
Entire Contract; Changes
The Policy, the Policyholder's Application, the Employee's Certificate of coverage, and Your application,
if any, and any other attached papers, form the entire contract between the parties. Coverage under the
Policy can be amended by mutual consent between the Policyholder and Us. No change in the Policy is
valid unless approved in writing by one of Our officers. No agent has the right to change the Policy or to
waive any of its provisions.
Statements on the Application
In the absence of fraud, all statements made in any signed application are considered representations and
not warranties (absolute guarantees). No representation by:
1. the Policyholder in applying for the Policy will make it void unless the representation is contained in
his signed Application; or
2. any Employee in applying for insurance under the Policy will be used to reduce or deny a claim
unless a copy of the application for insurance, signed by the Employee, is or has been given to the
Employee.
Legal Actions
Unless otherwise provided by federal law, no legal action of any kind may be filed against Us:
1. until 60 days after proof of claim has been given; or
2. more than 3 years after proof of Loss must be filed, unless the law in the state where You live allows a
longer period of time.
Clerical Error
Clerical error or omission by Us to the Policyholder will not:
1. Prevent You from receiving coverage, if You are entitled to coverage under the terms of the Policy; or
2. Cause coverage to begin or coverage to continue for You when the coverage would not otherwise be
effective.
If the Policyholder gives Us information about You that is incorrect, We will.
1. Use the facts to decide whether You have coverage under the Policy and in what amounts; and
2. Make a fair adjustment of the premium.
Incontestability
The validity of the Policy shall not be contested, except for non-payment of premiums, after it has been in
force for two years from the date of issue. The validity of the Policy shall not be contested on the basis of
a statement made relating to insurability by any person covered under the Policy after such insurance has
been in force for two years during such person's lifetime, and shall not be contested unless the statement
is contained in a written instrument signed by the person making such statement.
Premium Provisions
Premiums are payable in United States dollars on or before their due dates. The Policyholder has agreed
to deduct from Your pay any premiums payable for Your voluntary coverage. The Policyholder agrees to
remit such premiums for the entire time coverage under the Policy is in effect.
FDL 1-604-412 30
6
Premium charges for increases in insurance amounts becoming effective during a policy month will begin
on the next premium due date. Premium charges for insurance terminating during a policy month will
cease at the end of the month in which such insurance terminates. This method of charging premium is
for accounting purposes only. It will not extend any insurance coverage beyond the date it would
otherwise have terminated.
Misstatement ofAge
If You have misstated Your age or the age of a Dependent, the true age will be used to determine:
1. the effective date or termination date of insurance; and
2. the amount of insurance; and
3. any other rights or benefits.
Premiums will be adjusted to reflect the premiums that would have been paid if the true age had been
known.
Conformity with State Statutes and Reguladons
If any provision of the Policy conflicts with the statutes and regulations of the state in which the Policy
was issued or delivered, it is automatically changed to meet the minimum requirements of the statute.
Assignment
You may assign any incident of ownership You may possess of the life insurance benefits provided under
the Policy to anyone other than the Policyholder. We are not responsible for the validity or legal effect of
any assignment. Collateral assignments, by whatever name called, are not permitted.
FDLI-604-707-GenPTX REV2011 {'j�'lArrf,. , V{�
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FDL 1-644-412 31
DEFINITIONS
This section tells You the meaning of special words and phrases used in this Certificate. To help
You recognize these special words and phrases, the first letter of each word, or each word in the
phrase, is capitalized wherever it appears.
Actively at Work or Active Work means that You must:
1. work for the Policyholder on a full-time active basis; or
2. work at least the minimum number of hours set forth in the Schedule of Benefits: and either:
a. work at the Policyholder's usual place of business; or
b. work at a location to which the Policyholder's business requires You to travel;
3. be paid regular earnings by the Policyholder, and
4. not be a temporary or seasonal Employee.
You will be considered Actively at Work if You were actually at work on the day immediately preceding:
1. a weekend (except for one or both of these days if they are scheduled days of work);
2. holidays (except when such holiday is a scheduled work day);
3. paid vacations;
4. any non-scheduled work day;
5. excused leave of absence (except medical leave and lay-off); and
6. emergency Ieave of absence (except emergency medical leave); and
You were not Hospital Confined or disabled due to an Injury or Sickness.
00061 0
Activities of Daily Living means:
I . Eating — Feeding oneself by getting food into the body from a receptacle (such as a plate, cup or
table) or by a feeding tube or intravenously.
2. Toileting — Getting to and from the toilet, getting on and off the toilet and performing associated
personal hygiene.
3. Transferring — Moving into or out of a bed, chair or wheelchair.
4. Bathing — Washing oneself by sponge bath; or in either a tub or shower, including the task of getting
into or out of the tub or shower.
5. Dressing — Putting on and taking off all items of clothing and any necessary braces, fasteners or
artificial limbs.
6. Continence — Ability to maintain control of bowel and bladder function; or when unable to maintain
control of bowel or bladder function, the ability to perform associated personal hygiene (including
caring for catheter or colostomy bag).
00062
Annual Enrollment Period means a period of time prior to the Policy anniversary date during which
eligible Employees may apply for life coverage or request changes to their life benefit plan. The Annual
Enrollment Period is shown on the Schedule of Benefits.
00064
FDL i -604-412 32
Application means the document which sets forth the eligible classes, the amounts of insurance, and other
relevant information pertaining to the plan of insurance for which the Policyholder applied.
00066
Contributory means You pay all or a portion of the premium for this insurance coverage.
00070
Dependent or Eligible Dependent means:
1. the Spouse or Domestic Partner of each individual eligible to be insured under the Policy;
2. a natural or adopted child of each individual eligible to be insured under the policy if the child is:
a. younger than 25 years of age; or
b. physically or mentally disabled and under the parents' supervision;,
3. a natural or adopted grandchild of each individual eligible to be insured underr'Jrtlhe;policy if the child
is: ,l e7 r r
a. younger than 25 years of age; and r� ,
b. a dependent of the insured for federal income taVpurposes at the time;,the application for
coverage of the child is made. 0 ` lie
Dependent Child - See Dependent or Eligible Dependent
��Y ••h'
00072 TXa
t ff
Doctor means a person legally licensed to practice medicine, psychiatry, psychology or psychotherapy,
who is neither You nor a member of Your immediate famI qy A licensed medical practitioner is a Doctor
if applicable state law requires that such practitioners be recognized for purposes of certification of Total
Disability, Terminal Condition or covered Loss,,.and; a treatment provided by the practitioner is within
the scope of his or her license.
00073
Doctor's Statement means a written medical opinion of a Doctor currently licensed to practice in the
United States which:r�,,.,_
1. is made at Your expense;aff&
2. indicates that You have a. I err
3. includes all medical test resul
opinion is based; and y
4. indicates Your expected remai
5. is acceptable to Us. IF
00125TX
n; and
reports, and any other information on which the medical
life span; and
Employee means an'Actrvely at Work full-time employee whose principal employment is with the
Policyholder, at the Policyholder's usual place of business or such place{s} that the Policyholder's normal
course of business may require, who is Actively at Work for the minimum hours per week as set forth in
the Schedule of Benefits and is reported on the Policyholder's records for Social Security and
withholding tax purposes.
00074
Gainful Occupation means any work or employment in which the insured Employee:
1. is or could reasonably become qualified, considering his or her education, training, experience, and
mental or physical abilities;
2. could reasonably find work or employment, considering the demand in the national labor force; and
FDLI-604-412 33
3, could earn (or reasonably expect to earn) a before -tax income at least equal to 60% of his or her Pre-
disability Income.
00078 0
Hospital Confined means that, upon the recommendation of a Doctor, You are registered as an inpatient
in a hospital, nursing home or other medical facility which provides skilled medical care or as an
outpatient in a hospital because of surgery. You are not Hospital Confined if You are receiving emergency
treatment or if You are hospitalized solely because of non-surgical medical or diagnostic test.
00081
Injury means bodily injury resulting directly from an Accident and independently of all other causes.
00082
Insured means an Employee or Eligible Dependent covered under the Policy.
00083
Male Pronoun whenever used includes the female.
00088
Material and Substantial Duties means duties that are normally required for the performance of Your
Regular Occupation and cannot be reasonably omitted or modified.
00089
Policy means this contract between the Policyholder and Us including the attached Application, which
provides group insurance benefits.
00097
Policyholder means the person, firm, or institution to whom the Policy was issued. Policyholder also
means any covered subsidiaries or affiliates set forth on the face of the Policy.
W098 TX
Registered Domestic Partner means an adult of the same or opposite gender who has an emotional,
physical and financial relationship to You, similar to that of a Spouse, as evidenced by the following:
1. You and Your Domestic Partner share financial responsibility for a joint household and intend to
continue an exclusive relationship indefinitely;
2. You and Your Domestic Partner each are at least eighteen (18) years of age;
3. You and Your Domestic Partner are both mentally competent to enter into a binding contract;
4. You and Your Domestic Partner share a residence and have done so for at least 12 months;
5. Neither You nor Your Domestic Partner are married to or legally separated from anyone else;
6. You and Your Domestic Partner are not related to one another by blood closer than would bar
marriage; and
Neither You nor Your Domestic Partner is a Domestic Partner of anyone else.
Where the laws of the governing jurisdiction mandate a definition of Registered Domestic Partner other
than shown above, that definition will be used in the Policy.
00104
FDL 1-644-412 34
Regular Occupation means the occupation that You are routinely performing when Your life insurance
terminates due to Disability. We will look at Your occupation as it is normally performed in the national
economy, instead of how the work tasks are performed for a specific Policyholder or at a specific
location.
00105
Sickness means illness, disease, pregnancy or complications of pregnancy.
00109
Terminal Condition means You have been examined and diagnosed by Your Doctor as having a non -
correctable health condition that, with reasonable medical certainty, will result in Your death within 12
months from the date of the Doctor's Statement.
00115 TX
Voluntary means coverage for which You pay 100% of the premium.
00118
¢y�
We, Our and Us means Dearborn National Life Insurance Company, Chicago, Illinois. r
00119
You, Your and Yours means the eligible Employee to whom this Certificate is issued and whose insurance
is in force under the terns of the Policy.
00120
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FDLI-604-412 35
Administrative Office: 1020 31st Street
Downers Grove, IL 60515
DEARBORN NATIONAL ® LIFE INSURANCE COMPANY
Chicago, Illinois
RIDER
This Rider is made a part of the Policy or Certificate (hereafter "the Policy") to which it is attached. It takes effect
and ends at the same time as the Policy. All provisions of the Policy, including any other Riders or Amendatory
Endorsements will apply to this Rider, except that in the event of a conflict, the specific provisions of this Rider will
govern.
Beneficiary Resource Services
What is the Beneficiary Resource Services?
The Beneficiary Resource Services is a non -insurance benefit made available to You or Your beneficiaries which
provides access at no additional cost to the following services.
• Unlimited telephone access to grief counselors, legal advisors and financial advisors for up to one year
from the date of loss; and,
• Five (5) face-to-face sessions, or equivalent professional time, with a grief counselor, legal advisor and/or a
financial advisor for up to one year from the date of loss.
How the Beneficiary Resource Services are accessed
You or Your beneficiaries may access these services by contacting Bensinger, DuPont & Associates at 1- 800-769-
9187, the program administrator for Beneficiary Resource Services. Additional contact information will be provided
at the time a claim for a loss covered under the Policy is made. Dearborn National Life Insurance Company® does
not underwrite or administer the Beneficiary Resource Services program.
When do the Beneficiary Resource Services Terminate? 0
The services available under this Rider will end as follows:
• On the date Your coverage is terminated under the section When Does Your coverage under the Policy
end? found in the Termination Provision of the Policy; or
• One year from the date of loss if the loss occurs while the Policy is in effect.
Important Terms
For purposes of this Rider, "date of loss" means the date of death of the named insured or the date the named insured
became eligible for benefits under the Accelerated Death Benefit provision of the Policy to which this Rider is
attached. If the named insured becomes eligible for and receives benefits under the Accelerated Death Benefits
provision of the Policy, and subsequently dies, the date of loss remains the date the named insured became eligible
for benefits under the Accelerated Death Benefit provision of the Policy to which this Rider is attached.
President
Nothing contained in this Rider shall be held to alter or affect any provision or condition of the Policy other than as
stated above.
FDL I -NIB-BRS-4/2012
NOTICE
to
the Policyholder and Cerdficateholder Insured under
the Group Term Life Insurance Policy
Provided by Dearborn National Life Insurance Company®
Regarding the Beneficiary Resource Services Noninsurance Benefit
This notice is to advise you that Your Group Term Life Insurance program also provides a non -insurance
benefit: Beneficiary Resource Services.
Noninsurance Benefit Description
Beneficiary Resource Services is a service that provides unlimited telephone access to grief counselors, legal
advisors and financial advisors, as well as five (S) face-to-face sessions for up to one year following the date of loss.
(Date of loss is defined in the Beneficiary Resource Services Rider attached to the Policy.)
This noninsurance benefit is available at the option of the Policyholder without any action required on the part of an
insured person to either accept or decline the service.
� pf''t�7i ff..Sr
There is no charge for this service. _�• C��
F
The service is currently administered by Bensinger, DuPont & Associates.
Dearborn National Life Insurance Company (sometimes referred to as "We" or "Our") makes this program
available, but it does not underwrite or administer the Beneficiary Resource Services program.
Why This Service is Being Made Available
We are making this service available to provide support and assistance to persons who have suffered a loss that is
covered by the group term life insurance policy. The death or terminal illness of a loved one has a significant impact
and support services help deal with the grief legal or financial issues experienced during the critical months
following a loss. ;sy.,, VI,%
�.
Accessin¢ Beneficiary Resource Services nr�r1�;.,,,.
Services may be accessed by contacting the program administrator named in the Rider at 1-800-769-9187.
Termination of the Noninsurance Benefit
This noninsurance benefit is provided free of charge. It is subject to termination at our option or at the option of the
program administrator.
If We discontinue this service We will notify the Policyholder not less than thirty (30) days in advance of the
discontinuance of this service.
If the current program administrator discontinues the program and we are unable to find a replacement, we will
notify the Policyholder as soon as is reasonable under the circumstances. If discontinued, the services available
under this noninsurance benefit will no longer be available.
Unless terminated by Us or by the Program administrator, the Beneficiary Resource Services noninsurance benefit is
available following a covered loss for as long as you remain covered under the group term life insurance policy and
such policy remains in effect, subject to the time periods stated above.
NIB-BRS-Notice (412012)
Administrative Office: 1020 31 st Street
Downers Grove, IL 60515
DEARBORN NATIONALS LIFE INSURANCE COMPANY
Chicago, Illinois
RIDER
This Rider is made a part of the Policy or Certificate (hereafter "the Policy") to which it is attached. It
takes effect and ends at the same time as the Policy. All provisions of the Policy, including any other
Riders or Amendatory Endorsements will apply to this Rider, except that in the event of a conflict, the
specific provisions of this Rider will govern.
On -Line Will Preparation Service
What is the On -Line Will Preparation Service?
On-line Will Preparation Service is a non -insurance benefit made available to You which provides access
at no additional cost to the following service:
• Access to on-line tools and resources to help You create Your will.
How is the On-line Will Preparation Service Accessed?
Your employer will give you a promotional code to access the EstateGuidance® web service at
EstateGuidance.com. This code will give you access to the will preparation services.
The On-line Will Preparation Service program is administered and provided by ComPsyche. Corporation.
Dearborn National Life Insurance Company does not underwrite or administer this program.
When does the On -Line Will Preparation Service Terminate?
The On -Line Will Preparation Service terminates if Your coverage is terminated under the section on
When does Your coverage under the Policy end? found in the Termination Provision of the Policy.
Nothing contained in this Rider
stated above.
FDL 1-NIB-OWP-412012
President
be held to alter or affect any provision or condition of the Policy other than as
NOTICE
to
Provided by Dearborn National L fe Insurance Company
the Policyholder and Certificate holder under
the Group Term Life Insurance Policy
Regarding the On -Line Will Preparation Noninsurance Benefit
This notice is to advise you that Your Group Term Life Insurance program also provides a non -
insurance benefit: On -Line Will Preparation Service.
Noninsurance Benefit Description
On -Line Will Preparation Service is a service that provides access to a website to help in the preparation
of a Last Will and Testament.
This noninsurance benefit is available at the option of the Policyholder without any action required on the
part of an insured person to either accept or decline the service.
There is no charge for this noninsurance benefit.°
The service is currently administered by ComPsych® Corporation..
Dearborn National Life Insurance Company (sometimesrreferred oto as "We" or "Our") makes this
"'Wil
program available, but it does not underwrite or administer`tirp'prograxn Y� ;
Why This Service is Beine Made Available ,y
By using the EstateGuidance® web service at. EstateGuidance.com, You will have access to on-line tools
and resources to create Your will, utilizing the, services provided by ComPysch Corporation. In addition
to acquiring group term life insurance, preparing a will is lMther important way to protect your loved
ones.
Accessing On -Line Will Preparation Service
Your employer will distribute promotional material, website information, and a promotional code for you
to use. This promotional code will provide will preparation services free of charge on the website.
I
When Does the On -Line Will Preparation Service Terminate?
This noninsurance benefit .is provided free of,charge as a courtesy. It is subject to termination at our
option or at the option of the program'administrator.
If We discontinue this service We will notify the Policyholder not less than thirty (30) days in advance of
the discontinuance of this service.
11
If the current program administrator discontinues the program and we are unable to find a replacement,
we will notify the Policytioii�der as soon as is reasonable under the circumstances.
Unless terminated by UJor by the Program administrator, the On -Line Will Preparation Service
noninsurance benefit is available for as long as you remain covered under the group term life insurance
policy and such policy, remains in effect.
If discontinued, the services available under this noninsurance benefit will no longer be available.
EstateGuidance® is offered by ComPsych® Corporation. EstateGuidanceO is administered by ComPsych®
Corporation. Dearborn National Life Insurance Company® does not underwrite or administer the EstateGuidance®
program.
NIB-OWP-Notice (412012)
Administrative Office: 1020 3is' Street
Downers Grove, Illinois 60515
DEARBORN NATIONAL® LIFE INSURANCE COMPANY
Chicago, Illinois
RIDER
This Rider is made a part of the Policy or Certificate (hereafter "the Policy") to which it is attached. It
takes effect and ends at the same time as the Policy. All provisions of the Policy, including any other
Riders or Amendatory Endorsements will apply to this Rider, except that in the event of a conflict, the
specific provisions of this Rider will govern.
Travel Resource Services
What is the Travel Resource Services?
Travel Resource Services is a non -insurance benefit made available to You which provides access at no
additional cost to the following services:
• Access to a toll free number in the event You encounter an emergency while traveling more than
100 miles from Your principal residence.
• Access to on-line tools and resources for any pre -trip assistance You may need.
How is Travel Resource Services accessed?
Your employer will provide You with an identification card to be used whenever services are needed.
This card will give You access to the toll-free number used to initiate the services.
The Travel Resource Services program is administered and provided by Europ Assistance USA, Inc.
Dearborn National Life Insurance Company does not underwrite or administer this program.
When do the Travel Resource Services terminate?
The Travel Resource Services terminate if Your coverage is terminated under the section on When does
Your coverage under the Folicy end? found in the Termination Provision of the Policy.
President
Nothing contained in this Rider shall be held to alter or affect any provision or condition of the Policy other than as
stated above.
FDL I -NIB -TRS (412012)
r --w NOTICE
to
the Policyholder and Certificate holder under
the Group Term Life Insurance Policy
Provided by Dearborn National Life Insurance Company
Regarding the Travel Resource Services Noninsurance Benefit
This notice is to advise you that Your Group Term Life Insurance program also provides a non -
insurance benefit: Travel Resource Services.
Noninsurance Benefit Description
fol
Travel Resource Services is a service that provides telephonic access to emergency assistance while
traveling more than one hundred (100) miles from Your home and access to on-line travel tools and
resources when preparing a trip.
This noninsurance benefit is available at the option of the Policyholder without any action required on the
part of an insured person to either accept or decline the service.
There is no charge for this noninsurance benefit. .%,
The service is current!y administered by Europ Assistance USA, Inc.A ,11=
Dearborn National Life Insurance Company (sometimes referred to "�asA"We" or "Our") makes this
�f 4, fir. ?1XI-
program available, but it does not underwrite or administer the Travel Resource Services program.
Why This Service is Being Made Available
We are making this service available to provide support and assistance to persons who are traveling or
preparing to travel, in addition to the group life and accidental death benefits available under this Policy.
If an emergency occurs on a trip; counselors are �availaU assist in locating nearby hospitals, assist in
aybl
recovering lost passports, medical evacuations,,and,otherremergencies. Advice at the planning stage of a
trip is available.;:rr sryi
Accessiniz Travel Resource Services
Services may be
accessed by�contacttngtherprogram administrator at 1-877-715-2593.,
Termination of the Noninsurance Benefit
VV �..•f� 1 �%;l� ti ..
This noninsuranceQn,efit"is provided free of charge as a courtesy. It is subject to termination at our
11
option or at the option of the program administrator.
If We discontinue this service We will notify the Policyholder not less than thirty (30) days in advance of
the discontinuance of this service.
If the current program administrator discontinues the program and we are unable to find a replacement,
we will notify the Policyholder as soon as is reasonable under the circumstances. If discontinued, the
services available under this noninsurance benefit will no longer be available.
Unless terminated by Us or by the Program administrator, the Travel Resource Services noninsurance
benefit is available following a covered loss for as long as you remain covered under the group term life
insurance policy and such policy remains in effect.
NIB -TRS -Notice (4/2012)
ERISA INFORMATION STATEMENTS 0
The benefits described in your certificate are insured by a Policy issued by Dearborn National Life Insurance
Company ("Dearborn National"), pursuant to an Employee Welfare Benefit Plan (" the Plan") established by your
employer ("the Company"). This ERISA Information Statement ("EIS") describes some of the key provisions of the
Plan in effect as of the Effective Date of the Policy.
It is not the intention of the EIS to cover all situations that may arise, but to provide you with a general
understanding of your benefits. In the case of any item not covered by the EIS or in the event of any conflict
between the EIS and the Policy, the Plan will always control. You should not rely on any oral explanation,
description, or interpretation of the Plan because the written terms of the Plan will govern. Your right to any benefit
depends on the actual facts and terms and conditions of the particular Plan; no rights accrue by reason of or arising
out of any statement shown in or omitted from this EIS.
A. ADMINISTRATION OF THE PLAN
The Plan Administrator is responsible for the administration of the Plan. The Plan Administrator has full
discretionary authority and control over the Plan. This authority provides the Plan Administrator with the power
necessary to operate, manage and administer the Plan. This authority includes, but is not limited to, the power to
interpret the Plan and determine who is eligible to participate, to determine the amount of benefits that may be paid
to a participant or his or her beneficiary, and the status and rights of participants and beneficiaries. The Plan
Administrator also has the authority to prescribe the rules and procedures under which the Plan shall operate, to
request information, and to employ or appoint persons to aid the Plan Administrator in the administration of the
Plan.
Failure by the Plan or the Plan Administrator to insist upon compliance with any provisions of the Plan at any time
or under any set of circumstances shall not operate to waive or modify the provision or in any manner render it
unenforceable as to any other time or as to any other occurrence, whether the circumstances are or are not the same.
No waiver of any term or condition of the Plan shall be valid unless contained in a written memorandum expressing
the waiver and signed by the person authorized by the Plan Administrator to sign the waiver.
The Plan may be amended, terminated or suspended in whole or in part, at any time without the consent of the
employees or beneficiaries. Any amendment, termination or suspension shall be in writing, and attached to the Plan.
Any amendment, termination or suspension shall be executed according to the Employer's authorized procedures.
Any such authorization may be specific to the Plan or persons authorized to act on behalf of the Employer or may be
general as to duties of such person. Except for termination or suspensions, any amendments affecting the Policy
and/or Certificate must also be approved in writing by an officer of Dearborn National and shall be effective as of
the date agreed to, in writing by the Plan Sponsor and Dearborn National. Notwithstanding anything to the contrary
in this document, the Policy shall terminate according to the provisions in the Policy.
The Plan has other fiduciaries, advisors and service providers. The Plan Administrator may allocate fiduciary
responsibility among the Plan's fiduciaries and may delegate responsibilities to others. Any allocation or delegation
must be done in writing and kept with the records of the Plan. The Plan's life benefits are provided pursuant to an
insurance policy issued to the Company. Dearborn National's (the Insurer's) services shall be limited to, and the
Plan Administrator has the full discretionary and final authority to:
resolve all matters when a review pursuant to the claims procedures has been requested;
interpret, establish and enforce rules and procedures for the administration of the Policy and any claim
under it; and
determine eligibility of Employees and Dependents for benefits and their entitlement to and the amount of
benefits.
Each fiduciary is solely responsible for its own improper acts or omissions. Except to the extent required by ERISA,
no fiduciary has the duty to question whether any other fiduciary is fulfilling all of the responsibilities imposed upon
the other fiduciary by law. Nor is a fiduciary liable for a breach of fiduciary duty committed before it became, or
after it stopped being, a fiduciary. However, a fiduciary may be liable for a breach of fiduciary responsibility of any
Plan fiduciary, to the extent provided in ERISA Section 405(a). The Employer makes no promise to continue these
* If this Plan is an ERISA plan, these ERISA provisions apply. However, your employer may issue a Summary Plan Description
("SPD"), If it does, and if there are any conflicts between the SPD and the EIS in regards to your ERISA rights, the SPD
provisions will always control.
FDL EIS Standard 412009 rev'd.
benefits in the future and rights to future benefits will never vest. Retirement does not give any retiree any vested
right to continue to participate or receive Plan benefits.
B. CLAIMS PROCEDURE:
When you or your Beneficiary are eligible to receive benefits, you or your Beneficiary, or your authorized
representative (collectively, "you") must notify the Plan Administrator by submitting the proper form in writing.
You may do this by sending notice of your claim to the Plan Administrator who has been appointed to assist
Dearborn National in the claims processing for this Plan or by contacting Dearborn National directly at:
Claims Department
Dearborn National Life Insurance Company
1020 31st Street
Downers Grove, IL. 60515-5591,
4!�L 1-800-788-2281 .,b�
For the purpose of this Section, including Subsections 1 and 2 below, the terms' - written" and "in writing"
include "electronic." Any action required to be "written" or "in writing," may be done electronically, where
available. If Dearborn National uses electronic notices, it will do so in accordance with 29 CFR 2520.104b -
10(i), (iii) and (iv). AM, 140.
1. Disability Insurance Plans
Dearborn National will give you a written response to your' claim, usually within 45 days. The time for decision
may be extended for two additional 30 day periods provided that, prior to any extension period, Dearborn National
notifies you in writing that an extension is necessary due to matters beyond the control of the Plan, identifies those
matters and gives the date by which it expects to render its decision. If the extension is due to your failure to submit
information necessary to decide your claim, the time for decision shall be tolled from the date on which we send you
notice of the extension until the date we receive your response to our.request. This period will be no longer than 45
days after we have requested the information. At that iime,we will decide your claim based on the information we
iSS+r>r
have at that time. �
If the claim is denied, in whole or in part; youywill receive a written notice giving the following:
- the reason for the denial;
the Policy provisions on, which the deniil,is based;
IKOYf.+r,'Vf
an explanation of what other;infoyry•mqation, if any, may be needed to process the claim and why it is needed;
the steps that you have'to follow to!hr� ave the claim reviewed;
a statement that you have.the right to bring a civil action under section 502(a) of ERISA after you appeal
our decision and after you receive a written denial on appeal; and
if an`lir nile,guideli e, protocol, or other similar criterion was relied upon in making the denial, either
(i) the specific rule,�Pguideline, protocol or other similar criterion; or (ii) a statement that such a rule,
guideline, prococol;or other similar criterion was relied upon in making the denial and that a copy will be
provided free of charge to you upon request; and
if denial is based on medical judgment, either (i) an explanation of the scientific or clinical judgment for the
determination, applying the terms of the Plan to your medical circumstances, or (ii) a statement that such
explanation will be provided to you free of charge upon request.
If the claim has been denied, in whole or in part, you can appeal the denial to us for a full and fair review. You have
at least 180 days to appeal from the claim denial.
You may:
a. request a review upon written application within 180 days of the claim denial;
b. request, free of charge, copies of all documents, records and other information relevant to your claim; and
* If this Plan is an ERISA plan, these ERISA provisions apply. However, your employer may issue a Summary Plan Description
("SPD"). If it does, and if there are any conflicts between the SPD and the EIS in regards to your ERISA rights, the SPD
provisions will always control.
FDL EIS Standard 412009 rev'd.
C. submit written comments, documents, records and other information relating to your claim, without regard
to whether such information was submitted or considered in the initial benefit determination.
Dearborn National will make a decision no more than 45 days after we receive your appeal. The time for decision
may be extended for one additional 45 day period provided that, prior to the extension, Dearborn National notifies
you in writing that an extension is necessary due to special circumstances, identifies those circumstances and gives
the date by which it expects to render its decision. If your claim is extended due to your failure to submit
information necessary to decide your claim on appeal, the time for your decision shall be tolled from the date on
which the notification of the extension is sent to you until the date we receive your response to the request. The
written decision will include specific references to the Plan provisions on which the decision is based and any other
notice(s), statement(s) or information required by applicable law.
2. Life Insurance Plans
Dearborn National will give you a decision no more than 90 days after receipt of due proof of loss, except in special
circumstances (such as the need to obtain further information), but in no case more than 180 days after the due proof
of loss is received. The written decision will include specific reasons for the decision and specific references to the
Plan provisions on which the decision is based.
If the claim is denied, in whole or in part, the claimant will receive a written notice giving the following:
- the reason for the denial;
- the Policy provisions on which the denial is based;
- an explanation of what other information, if any, may be needed to process the claim and why it is needed;
and
- the steps that have to be followed to have the claim reviewed.
Any denied claim may be appealed to the Insurer for a full and fair review. The claimant may:
a) request a review upon written application within 60 days of receipt of claim denial;
b) upon request and free of charge, review pertinent documents, records and other information relevant to the
claim and receive copies of same; and
C) submit issues, comments, records, and other information in writing.
A decision will be made by the Insurer no more than 60 days after receipt of the request for review, except in special
circumstances (such as the need to obtain additional evidence), but in no case more than 120 days after the request
for review is received. The written decision will include specific reasons for the decision and specific references to
the Plan provisions on which the decision is based. The decision will advise you of any other appeal rights you have
under the Plan, as well as your right to bring an action under Section 502(a) of ERISA.
C. ERISA NOTICE OF YOUR RIGHTS
As a participant in the Plan you are entitled to certain rights and protections under the Employee Retirement Income
Security Act of 1974 ("ERISA"). ERISA provides that all Plan participants shall be entitled to:
Examine, without charge, at the Plan Administrator's office and at other locations, such as work sites and union
halls, all Plan documents, including insurance contracts, collective bargaining agreements and copies of all
documents filed with the U.S. Department of Labor, such as detailed annual reports and Plan descriptions.
Obtain copies of all Plan documents and other PIan information upon written request to the Plan Administrator. The
Plan Administrator may make a reasonable charge for the copies. Receive a summary of the Plan's annual financial
report. The Plan Administrator is required to furnish each participant with a copy of this summary annual report.
In addition to creating rights for the Plan participants, ERISA imposes duties upon the people who are responsible
for the operation of the employee benefit Plan. The people who operate your Plan, called "fiduciaries" of the Plan,
have a duty to do so prudently and in the interest of you and other Plan participants and beneficiaries.
No one, including your employers, your union, or any other persons, may fire you or otherwise discriminate against
you in any way to prevent you from obtaining a welfare benefit or exercising your rights under ERISA. If your
claim for a welfare benefit is denied in whole or in part you must receive a written explanation of the reason for the
* If this Plan is an ERISA plan, these ERISA provisions apply. However, your employer may issue a Summary Plan Description
("SPD"). If it does, and if there are any conflicts between the SPD and the EIS in regards to your ERISA rights, the SPD
provisions will always control.
FDL EIS Standard 412009 rev'd.
denial. You have the right to have the Plan review and reconsider your claim. Under ERISA, there are steps you
can take to enforce your rights. For instance, if you request materials from the plan and do not receive them within
30 days, you may file a suit in federal court. In such a case, the court may require the Plan Administrator to provide
the materials and pay you up to $110 a day until you receive the materials, unless the materials were not sent
because of reasons beyond the control of the Plan Administrator.
If you have a claim for benefits which is denied or ignored, in whole or in part, you may file suit in a state or federal
court. If it should happen that Plan fiduciaries misuse the Plan's money, or if you are discriminated against for
asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in federal
court. The court will decide who should pay costs and legal fees. If you are successful the court may order the
person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees,
for example, if it finds your claim is frivolous.
If you have any questions about this statement or about your rights under ERISA, you should contact the nearest
office of the Pension and Welfare Benefits Administration, United States Department of Labor, listed in your
telephone directory or the Division of Technical Assistance and Inquiries, Employee Benefit Security
Administration, United States Department of Labor, 200 Constitution Avenue, NW Washington DC 20210.
D. PARTICIPANT'S RIGHTS
This Plan shall not be deemed to constitute a contract between the Company and any participant or to be
consideration or an inducement for the employment of any participant or employee. Nothing contained in this Plan
shall be deemed to give any participant or employee the right to be retained in the service of the Company or to
interfere with the right of the Company to discharge any participant or employee at any time regardless of the effect
which such discharge shall have upon him or her as a participant of this PIan.
* If this Plan is an ERISA plan, these ERISA provisions apply. However, your employer may issue a Summary Plan Description
("SPD"). If it does, and if there are any conflicts between the SPD and the EIS in regards to your ERISA rights, the SPD
provisions will always control.
FDL EIS Standard 4/2009 rev'd.
n
Deoxbofn W Nair iona4
l°
Administrative Office:
1020 31st Street • Downers Grove, IL 60515-5591
Products and services marketed under the Dearborn National® brand and the star logo are underwritten
and/or provided by Dearborn National® Life Insurance Company (Downers Grove, IL) in all states
(excluding New York), the District of Columbia, the United States Virgin Islands, the British Virgin
Islands, Guam and Puerto Rico.
(f)
Dearborn National® Life Insurance Administrative Office:
Company 1020 31st Street
Downers Grove IL 60515-5591
(A stock life insurance company, herein called the "we, ,us,, or ,Our,)
Policyholder:
SAMPLE TEXAS
Policy Number:
SAMPLE TX -0001
Policy Effective Date:
January 1, 2013
Anniversary Date:
January 1
We agree with the Policyholder to insure certain eligible Employees of the Policyholder. We promise to pay
benefits for loss covered by the Policy in accordance with its provisions. The Policyholder should read this
Policy carefully and contact Dearborn National® Life Insurance Company promptly with any questions.
Policyholder means the Employer to whom the Policy is issued and who sponsored the coverage for its
Employees.
Employer means the Policyholder and includes any division, subsidiary, or affiliated company named in the
Policy.
POLICY EFFECTIVE DA TE AND TERM
The Policy takes effect on the Policy Effective Date stated above subject to any participation requirement stated in
the Policy. All insurance periods will be computed from that date. The Policy remains in force for the period for
which premium has been paid. It may be renewed for further successive periods by payment of premium as stated
in the Policy.
All periods of insurance begin and end at 12:01 A.M., Standard Time, at the Policyholder's address as stated in
the Policy, and on the Application. :1
Signed for Dearborn National Life Insurance Company '4'V j , P
4.
Jj
:,Secretary k:=� President
f Voluntary Group Term We Insurance Policy
with
Accidental Death & Dismemberment and Dependent Life Insurance with Dependent Accidental Death and
,.,, Dismemberment Benefits
„Ylv Non -Participating
1 'w�`f.�
FDL1-504-412 TX
TABLE OF CONTENTS
PROVISION
PAGE
Premium
3 0
Premium Rate Guarantee
3
Policy Termination
4
Additional Provisions
4
Rate Addendum
S
Application
Attached
ATTACHMENTS:
• Master Application
• Certificate of Insurance
FDL 1-504-412 TX 2 '
PREMIUM
How is the lnAW premium calculated?
Initial life, AD&D and Dependent Life insurance premium is calculated in accordance with the rates set forth on
the attached Rate Addendum.
When is premium paid?
The Policy is issued in consideration of the payment in advance of premium on the premium due date indicated on
the Application. Payment must be made by the premium due date as shown on the Application.
If an addition, termination or change in insurance takes place other than on a regular due date, any premium
adjustment will take effect on the next due date.
Is premium payable while an Insured receives benefits?
We will waive premium for an insured Employee in accordance with the Waiveroi¢Premium provision of the
Policy. ��;.�/
Is there a grace periodfor premium payment?
We will allow a grace period of 31 days for the payment of any premiums due except the first. -In' surance
coverage shall continue in force during the grace period unless the Policyholder has givenP advance written
notice of cancellation in accordance with the terms of this Policy. If premium is not received by the end of the
grace period, this Policy will terminate as of the last date for which premium was paid.
V -v"M .� t
The Policyholder is liable for premium due on coverage p"rovided duiing the grace period.
If We receive written notice during the grace period that the is to be canceled, We will cancel it as of the
later of:' ?,'Y
1. the date requested in the cancellation noticed h]'tor�
h ti;Gln�l.
2. the date We receive such notice. The Policyholder must payya.pro rata premium for any coverage
provided during the grace period. ' 1A N{
J.{ N++�Yi .
,, PREMIUM RA,.TEGUARANTEE
What is the initial premium rate guarantee?%tirSr '
A change in premium rates will not take effect before January 1, 2015. However, We may change premium rates
if the risk assumed changes. Premium rates may change if the following occurs:
1. a change in the Policy design;
2. a change in the terms of the Policy;
3. addition or deletiori..of ardivision; subsidiary or affiliated company;
4. a change in the number of Insureds by 10% or more from the number of Insureds on the initial Effective
{fi3ate;
5 V�,�a change in the laws o'r,regulations or other government action which applies to the Policy;
6.��'�for reasons other.than'1''=5 above such as but not limited to a change in factors bearing on the risk
assumed.Y'y- -'441
The Policyholder must furnish notice and documentation satisfactory to Us within 31 days of the occurrence of
any event which would cause a change in rates as described above. If the Policyholder fails to provide such
timely notice, we will apply new rates retroactively to the date of the event.
We will notify the Policyholder in writing at least 31 days in advance of any premium rate changes. A change
may take effect on an earlier date if both the Policyholder and We agree.
FDL I-504-412 TX
POLICY TERMINATION
Who may cancel the Policy or a plan under the Policy? �
The Policy or a plan under the Policy can be canceled by the Policyholder with 31 days written notice delivered to `..!
Us. This Policy will terminate for any of the following reasons:
1. If the Policyholder fails to pay any premium within the 31 -day Grace Period, this Policy will terminate in
accordance with the terms set forth in the Grace Period provision.
2. We may terminate this Policy on any premium due date if:
a. coverage is Contributory and less than 25% of the eligible Employees participate; or
b. the Policyholder fails to perform any of its obligations that relate to the Policy; or
c. the Policyholder does not promptly provide Us with information that is reasonably required; or
d. fewer than 2 Employees are insured under the Policy.
If We cancel the Policy, for reasons other than the Policyholder's failure to pay premium, a written notice will be
delivered to the Policyholder at least 31 days prior to the cancellation date.
ADDITIONAL PROVISIONS
What happens if an inadvertent error occurs?
Clerical error or omission by Us to the Policyholder will not:
1. Prevent an Employee from receiving coverage, if he is entitled to coverage under the terms of the Policy;
or
2. Cause coverage to begin or coverage to continue for an Employee when the coverage would not otherwise
be effective.
If the Policyholder gives Us information about an Employee that is incorrect, We will: 0
1. Use the facts to decide whether the Employee has coverage under the Policy and in what amounts; and
2. Make a fair adjustment of the premium.
Will certijkates he issued?
We will deliver certificates of insurance to the Policyholder for issuance to each insured Employee. The
certificates will describe the benefits, to whom they are payable, the Policy limitations and where the Policy may
be inspected.
What is considered to be the entire contract?
This entire Policy consists of:
I . all Policy provisions and any amendments and/or attachments issued;
2. the Certificate of Coverage; and
3. the Policyholder's signed Application; and
4. the Employee's signed enrollment forms.
FDL1-504-412 TX 4
C)
RATE ADDENDUM
(All Rates Per $1,000 Per Month unless otherwise stated)
Class 01 Voluntary Term Life: $0.00
Class 01 Voluntary Accidental Death & Dismemberment: $0.00
Class 01 Voluntary Spouse Life: $0.00
Class 01 Voluntary Child Life: $0.00
Class 0
FDL 1-504-412 TX 5
STATE SUPPLEMENT
The following policies apply only to those individuals in your group insurance program who reside in the
referenced states.
Arizona and Maine
Except as otherwise permitted by law, we will not disclose collected personal information about an individual to a
nonaffiliated third party with whom we jointly offer products without giving the individual an opportunity to tell
us that he or she does not want us to share his or her personal information.
Minnesota and Montana
Except as otherwise permitted by law, we will not disclose collected personal information about an individual to a
nonaffiliated third party with whom we jointly offer products without obtaining the individual's written
authorization.
Montana
Upon written request, an individual who has authorized the collection of health information is entitled to receive a
record of Dearborn National's disclosures of any of his medical record information made within the preceding 3
years.
Oregon
An individual has the right to authorize disclosure of his or her personal information to an insurance company.
An Oregon resident can exercise this right by requesting an authorization form in writing. Our address is:
Dearborn National® Life Insurance Company
1020 31 st Street
Downers Grove, IL 60515
FDL1-504-412 TX
o
r�
ERISA INFORMATION STATEMENT*
The benefits described in your certificate are insured by a Policy issued by Dearborn National Life Insurance
Company ("Dearborn National"), pursuant to an Employee Welfare Benefit Plan (" the Plan") established by your
employer ("the Company"). This ERISA Information Statement ("ELS") describes some of the key provisions of the
Plan in effect as of the Effective Date of the Policy.
It is not the intention of the EIS to cover all situations that may arise, but to provide you with a general
understanding of your benefits. In the case of any item not covered by the EIS or in,the event of any conflict
between the EIS and the Policy, the Plan will always control. You should not relimon any oral explanation,
description, or interpretation of the Plan because the written terms of the Plan will gov ern. Your right to any benefit
depends on the actual facts and terms and conditions of the particular Plan; no rights accrue by reason of or arising
out of any statement shown in or omitted from this EIS. � � � .iv
A. ADMINISTRATION OF THE PLAN
The Plan Administrator is responsible for the administration of the Plan. The Plan Adm strator has full
discretionary authority and control over the Plan. This authority provides the Plan Administrator with the power
necessary to operate, manage and administer the Plan. This authority includes, but is not limited to, the power to
interpret the Plan and determine who is eligible to participate, jofdeterminehamount of benefits that may be paid
to a participant or his or her beneficiary, and the status and"rights�W participants and beneficiaries. The Plan
Administrator also has the authority to prescribe the rules and procedures underfwhich.tthe Plan shall operate, to
request information, and to employ or appoint persons toatd the Plan Administrator;m the administration of the
Plan.
Failure by the Plan or the Plan Administrator to }insist upon compliance with any provisions of the Plan at any time
or under any set of circumstances shall not operateito,waive or `modify the provision or in any manner render it
unenforceable as to any other time or as to any other occurrence, whether the` circumstances are or are not the same.
No waiver of any term or condition of the Plan shall be valid,unless contained in a written memorandum expressing
lk&,
the waiver and signed by the person authorized by the Plan•Administrator to sign the waiver,
The Plan may be amended, ter,ray,minated o6suspend ed -,in whole or in part, at any time without the consent of the
employees or beneficiaries. Any amendment, termination or suspension shall be in writing, and attached to the Plan.
Any amendment, termination or suspension shall lierezecuted according to the Employer's authorized procedures.
Any such authorization may be specific to the Plan or persons authorized to act on behalf of the Employer or may be
general as to duties of.s ich person. Except for termination or suspensions, any amendments affecting the Policy
and/or Certificate must, alsofbe,approved in writing by an officer of Dearborn National and shall be effective as of
the date agreed to, in writing by thePlan-Sponsor and Dearborn National. Notwithstanding anything to the contrary
in this document, the Policy. shall term nate. according to the provisions in the Policy.
AL -o
The Plan has ,other fiduciaries, advisors and service providers. The Plan Administrator may allocate fiduciary
responsibility among the Plan's fiduciaries and may delegate responsibilities to others. Any allocation or delegation
must be done in writing and kept with the records of the Plan. The Plan's life benefits are provided pursuant to an
insurance �policy'�issuedtto the Company. Dearborn National's (the Insurer's) services shall be limited to, and the
Plan Administrator has ige,full discretionary and final authority to:
vA
resolve all matters when a review pursuant to the claims procedures has been requested;
interpret, establish and enforce rules and procedures for the administration of the Policy and any claim
under it; and
determine eligibility of Employees and Dependents for benefits and their entitlement to and the amount of
benefits.
Each fiduciary is solely responsible for its own improper acts or omissions. Except to the extent required by ERISA,
no fiduciary has the duty to question whether any other fiduciary is fulfilling all of the responsibilities imposed upon
the other fiduciary by law. Nor is a fiduciary liable for a breach of fiduciary duty committed before it became, or
after it stopped being, a fiduciary. However, a fiduciary may be liable for a breach of fiduciary responsibility of any
Plan fiduciary, to the extent provided in ERISA Section 405(a). The Employer makes no promise to continue these
* If this Plan is an ERISA plan, these ERISA provisions apply. However, your employer may issue a Summary Plan Description
("SPD"). If it does, and if there are any conflicts between the SPD and the EIS in regards to your ERISA rights, the SPD
provisions will always control.
FDL EIS Standard 4/2009 rev'd.
benefits in the future and rights to future benefits will never vest. Retirement does not give any retiree any vested
right to continue to participate or receive Plan benefits. 0
B. CLAIMS PROCEDURE:
When you or your Beneficiary are eligible to receive benefits, you or your Beneficiary, or your authorized
representative (collectively, "you") must notify the Plan Administrator by submitting the proper form in writing.
You may do this by sending notice of your claim to the Plan Administrator who has been appointed to assist
Dearborn National in the claims processing for this Plan or by contacting Dearborn National directly at:
Claims Department
Dearborn National Life Insurance Company
1020 31 st Street
Downers Grove, IL. 60515-5591
1-800-778-2281
For the purpose of this Section, including Subsections 1 and 2 below, the terms "written" and "in writing"
include "electronic." Any action required to be "written" or "in writing," may be done electronically, where
available. If Dearborn National uses electronic notices, it will do so in accordance with 29 CFR 2520.104b -
10(i), (iii) and (iv).
1. Disability Insurance Plans
Dearborn National will give you a written response to your claim, usually within 45 days. The time for decision
may be extended for two additional 30 day periods provided that, prior to any extension period, Dearborn National
notifies you in writing that an extension is necessary due to matters beyond the control of the Plan, identifies those
matters and gives the date by which it expects to render its decision. If the extension is due to your failure to submit
information necessary to decide your claim, the time for decision shall be tolled from the date on which we send you
notice of the extension until the date we receive your response to our request. This period will be no longer than 45
days after we have requested the information. At that time we will decide your claim based on the information we
have at that time.
If the claim is denied, in whole or in part, you will receive a written notice giving the following:
- the reason for the denial;
- the Policy provisions on which the denial is based;
- an explanation of what other information, if any, may be needed to process the claim and why it is needed;
- the steps that you have to follow to have the claim reviewed;
- a statement that you have the right to bring a civil action under section 502(a) of ERISA after you appeal
- our decision and after you receive a written denial on appeal; and
if an internal rule, guideline, protocol, or other similar criterion was relied upon in making the denial, either
(i) the specific rule, guideline, protocol or other similar criterion; or (ii) a statement that such a rule,
guideline, protocol or other similar criterion was relied upon in making the denial and that a copy will be
provided free of charge to you upon request; and
- if denial is based on medical judgment, either (i) an explanation of the scientific or clinical judgment for the
determination, applying the terms of the Plan to your medical circumstances, or (ii) a statement that such
explanation will be provided to you free of charge upon request.
If the claim has been denied, in whole or in part, you can appeal the denial to us for a full and fair review. You have
at least 180 days to appeal from the claim denial.
You may:
a. request a review upon written application within 180 days of the claim denial;
b. request, free of charge, copies of all documents, records and other information relevant to your claim; and
• If this Plan is an ERISA plan, these ERISA provisions apply. However, your employer may issue a Summary Plan Description
("SPD"). If it does, and if there are any conflicts between the SPD and the EIS in regards to your ERISA rights, the SPD
provisions will always control.
FDL EIS Standard 412009 rev'd.
C. submit written comments, documents, records and other information relating to your claim, without regard
to whether such information was submitted or considered in the initial benefit determination.
Dearborn National will make a decision no more than 45 days after we receive your appeal. The time for decision
may be extended for one additional 45 day period provided that, prior to the extension, Dearborn National notifies
you in writing that an extension is necessary due to special circumstances, identifies those circumstances and gives
the date by which it expects to render its decision. If your claim is extended due to your failure to submit
information necessary to decide your claim on appeal, the time for your decision shall be tolled from the date on
which the notification of the extension is sent to you until the date we receive your response to the request. The
written decision will include specific references to the Plan provisions on which the decision is based and any other
notice(s), statement(s) or information required by applicable law.
2. Life Insurance Plans 4 a
Dearborn National will give you a decision no more than 90 days after receipt of due proof of loss, except in ;special
circumstances (such as the need to obtain further information), but in no case more than 180 days after the dueYproof
of loss is received. The written decision will include specific reasons for the decision and specific references to the
Plan provisions on which the decision is based.
If the claim is denied, in whole or in part, the claimant will receive a written notice giving the following:
the reason for the denial;
the Policy provisions on which the denial is based?�b
an explanation of what other information, if any,,gfay be needed to process they'Il im and why it is needed;
and
the steps that have to be followed to have the.claim reviewed.
Any denied claim may be appealed to the Insurer for a full,and fair revidWjhe claimant may:
a) request a review upon written application within 60 days of receipt of claim denial;
b) upon request and free of charge, review pertinent d"' uinents, records and other information relevant to the
claim and receive copies of samej nd, ' �F1Y
C) submit issues, comments, records, and other,.information in writing.
A decision will be made by the Insurer no more than 60 days after receipt of the request for review, except in special
circumstances (such as,the need to obtain additional evidence), but in no case more than 120 days after the request
for review is received. 4 e written decision will include specific reasons for the decision and specific references to
the Plan provisions on which the decision is based. The decision will advise you of any other appeal rights you have
under the Plan, as well as your right t&bring an action under Section 502(x) of ERISA.
C. ERISV,,,NOTICE OF YOUR RIGHTS
,� r••
Asa participant' in the Plan you are entitled to certain rights and protections under the Employee Retirement Income
Security Act of 1974 ("ERISA';). ERISA provides that all Plan participants shall be entitled to:
Exaniine,� wttK6ut.cfi*e, at the Plan Administrators office and at other locations, such as work sites and union
halls, all Plan documents, including insurance contracts, collective bargaining agreements and copies of all
documents filed with the.U.S. Department of Labor, such as detailed annual reports and Plan descriptions.
Obtain copies of all Plan documents and other Plan information upon written request to the Plan Administrator. The
Plan Administrator may make a reasonable charge for the copies. Receive a summary of the Plan's annual financial
report. The Plan Administrator is required to furnish each participant with a copy of this summary annual report.
In addition to creating rights for the Plan participants, ERISA imposes duties upon the people who are responsible
for the operation of the employee benefit Plan. The people who operate your Plan, called "fiduciaries" of the Plan,
have a duty to do so prudently and in the interest of you and other Plan participants and beneficiaries.
No one, including your employers, your union, or any other persons, may fire you or otherwise discriminate against
you in any way to prevent you from obtaining a welfare benefit or exercising your rights under ERISA. If your
claim for a welfare benefit is denied in whole or in part you must receive a written explanation of the reason for the
(D
* If this Plan is an ERISA plan, these ERISA provisions apply, However, your employer may issue a Summary Plan Description
("SPD"). If it does, and if there are any conflicts between the SPD and the EIS in regards to your ERISA rights, the SPD
provisions will always control.
FDL EIS Standard 412009 redd.
denial. You have the right to have the Plan review and reconsider your claim. Under ERISA, there are steps you
can take to enforce your rights. For instance, if you request materials from the plan and do not receive them within
30 days, you may file a suit in federal court. In such a case, the court may require the Plan Administrator to provide
the materials and pay you up to $110 a day until you receive the materials, unless the materials were not sent
because of reasons beyond the control of the Plan Administrator.
If you have a claim for benefits which is denied or ignored, in whole or in part, you may file suit in a state or federal
court. If it should happen that Plan fiduciaries misuse the Plan's money, or if you are discriminated against for
asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in federal
court. The court will decide who should pay costs and legal fees. If you are successful the court may order the
person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees,
for example, if it finds your claim is frivolous.
If you have any questions about this statement or about your rights under ERISA, you should contact the nearest
office of the Pension and Welfare Benefits Administration, United States Department of Labor, listed in your
telephone directory or the Division of Technical Assistance and Inquiries, Employee Benefit Security
Administration, United States Department of Labor, 200 Constitution Avenue, NW Washington DC 20210.
D. PARTICIPANT'S RIGHTS
This Plan shall not be deemed to constitute a contract between the Company and any participant or to be
consideration or an inducement for the employment of any participant or employee. Nothing contained in this Plan
shall be deemed to give any participant or employee the right to be retained in the service of the Company or to
interfere with the right of the Company to discharge any participant or employee at any time regardless of the effect
which such discharge shall have upon him or her as a participant of this Plan.
* If this Plan is an ERISA plan, these ERISA provisions apply. However, your employer may issue a Summary Plan Description
("SPD"). If it does, and if there are any conflicts between the SPD and the EIS in regards to your ERISA rights, the SPD
provisions will always control.
FDL EIS Standard 4/2009 rev'd.
Voluntary Long Term Disability
Insurance
Products and services marketed under the Dearborn National® brand and the star logo are underwritten
and/or provided by Dearborn National® Life Insurance Company (Downers Grove, IL) in all states
(excluding New York), the District of Columbia, the United States Virgin Islands, the British Virgin
Islands, Guam and Puerto Rico.
12/20/2012
Dearborn National® Life Insurance Company
P Y
Group Certificate
Dearborn National Life Insurance Company
Chicago, Illinois
Administrative Office: 1020 31st Street a Downers Grove, IL 60515
Having issued Group Policy No. SAMPLE TX -0001
(herein called the Policy or this Plan)
to
SAMPLE TEXAS
(herein called the Policyholder)
CERTIFIES that You are insured, provided that You qualify under the ELIGIBILITY AND EFFECTIVE DATES
provision, become insured and remain insured in accordance with the terms of the Policy. Your insurance is subject
to all the definitions, limitations and conditions of the Policy. It takes effect on the effective date stated in the
ELIGIBILITY AND EFFECTIVE DATES provision.
This certificate describes Your eligibility for benefits and the terms and provisions of the Policy. It replaces and
cancels any other certificate previously issued to You under the Policy.
If the terns and provisions of the Certificate of Coverage (issued to You) are different from the policy (issued to the
Policyholder), the Policy will govern. Your coverage may be canceled or changed in whole or in part under the
terms and provisions of the Policy.
READ YOUR CERTIFICATE CAREFULLY
Signed for Dearborn National Life Insurance Company
' M!"lij,�'7�tJ
16/X,M.._ oe&44, x4w - r
Secretary President
THE INSURANCE POLICY UNDER WHICH THIS CERTIFICATE IS ISSUED IS NOT A POLICY OF
WORKERS' COMPENSATION INSURANCE. YOU SHOULD CONSULT YOUR EMPLOYER TO
DETERMINE WHETHER YOUR EMPLOYER IS A SUBSCRIBER TO THE WORKERS'
COMPENSATION SYSTEM.
Group Voluntary Long Term Disability Certificate
Non -Participating
THIS IS NOT A WORKERS' COMPENSATION CERTIFICATE
2-LTDC-412
IMPORTANT NOTICE
To obtain information or make a complaint:
You may contact your (title)
at (telephone number).
You may call Dearborn National Life Insurance
Company's toll-free telephone number for infor-
mation or to make a complaint at:
1-800-348-4512
You may also write to Dearborn National Life
Insurance Company at:
1020 31st Street, Downers Grove, IL 60515-5591
You may contact the Texas Department of Insurance
to obtain information on companies, coverages, rights
or complaints at:
1-800-252-3439
You may write the Texas Department of Insurance:
P. O. Box 149104
In .tip
Austin, TX 78714-9104
FAX #(512) 475-1771
Web: http://www.tdi.state.tx.us
E-mail: ConsumerProtection@tdi.state.tx.us '}•
PREMIUM OR CLAIM DISPUTES: Should you'���rf,
have a dispute concerning your premium or about a
claim, you should contact the company first. If the
dispute is not resolved, you may contact the Texas -
Department of Insurance. --=-6 1� Y
ATTACH THIS NOTICE TO YOUR POLICY:
This notice is for information only and does not
become a part or condition of the attached document.
"�vhl�llY�fY•w,, �•rfY�
r
9-632-895
AVISO IMPORTANTE
Para informacion o para someter una queja:
Peude communicarse con su (title)
al (telephone number).
Usted puede Ilamar al numero de telefono gratis de
Dearborn National Life Insurance Company para
informacion o para someter una queja al:
1-800-3484512
Usted tambien escribir a Dearborn National Life
Insurance Company al:
1020 31st Street, Downers Grove, IL 60515-5591
Puede comunicarse con el Departamento de Seguros
de Texas para conseguir informacion acerca de
companias, coberturas, derechos o quejas al:
1-800-252-3439
Puede escribir al Departamento de Seguros de Texas:
P. O. Box 149104
Austin, TX 78714-9104
FAX #(512) 475-1771
Web: http:;' ,www.tdi.state.tx.us
E-mail: ConsumerProtection@tdi.state.tx.us
DISPUTAS SOBRE PRIMAS O RECLAMOS: Si
tiene una disputa concemiente a su prima o a un
reclamo, debe comunicarse con la compania primero.
Si no se resuelve la disputa, puede entonces
comunicarse con al Departamento de Seguros de
Texas.
UNA ESTE AVISO A SU POLIZA: Este aviso es
solo para proposito de informacion y no se convierte
en parte o condicion del documento adjunto.
TABLE OF CONTENTS
SCHEDULE OF BENEFITS
ELIGIBILITYAND EFFECTIVE DATES
LONG TERM DISABILITYBENEFITS
EXCLUSIONS AND LIMITATIONS
TERMINATION OF COVERAGE
SUPPLEMENTAL BENEFITS AND SERVICES
DAY CARE EXPENSE BENEFIT
SURVIVOR INCOME BENEFIT
WORKSITE MODIFICATION BENEFIT
CLAIMSERVICES
FILING A CLAIM
UNIFORM PROVISIONS
DEFINITIONS
Note: All terms in Italics are listed and defined in the Definitions section or within the certificate itself.
2-LTDC-412
SCHEDULE OF BENEFITS
Policyholder:
SAMPLE TEXAS
-Policy Number:
SAMPLE TX -0001
Effective Date:
January 1, 2013
Eligibility:
The following are eligible: All active full-time
Employees.
A full-time employee is one who regularly works a
minimum of 30 hours per week for the Policyholder.
Part-time, seasonal and temporary employees of the
Policyholder are not eligible.
Waiting Period:
If You are in a class eligible for insurance on or before
the Policy Effective Date: First of the month following
30 Days of continuous, full-time active work
If You enter a class eligible for insurance after the Policy
Effective Date: First of the month following 30 Days of
continuous full-time active work
Elimination Period:
90 Days
Rates Per $100 of Monthly Covered Payroll:
Age
Rate
XX to XX
$0.00
�k.
LTD Monthly Benefit:
60% of Monthly Earnings to a Maximum Gross Monthly
f•,,,,,,ffy. r�
Benefit of $5,000.00 per month subject to reduction by
;
deductible sources of income or Disability Earnin s
Social Security Offset Method:
w.,
Primary & Family
Minimum Monthly Benefit:
$100.00 or 10% of Your Gross LTD Monthly Benefit,
whichever is greater
Policyholder Contribution:
0% of premium
2-LTDC-412
Maximum Period Payable:
Age on Date Disability Commences
Maximum Period Payable
Less than 60
To SSNRA*
65 years
60
60 months or to SSNRA*,
years, 2 months
1939
65
whichever is greater
61
48 months or to SSNRA*,
years, 6 months
1941
65
whichever is greater
62
42 months or to SSNRA*,
10 months
1943-1954
whichever is greater
63
36 months or to SSNRA*,
years, 2 months
1956
66
whichever is greater
64
30 months or to SSNRA*,
years, 6 months
1958 1
66
whichever is greater
65
24 months
10 months
66
21 months
67 years
67
18 months
68
15 months
69 or over
12 months
* Social Security Normal Retirement Ages Based on the 1983 amendment to the Social Security Act, the following
are normal retirement aees by date of birth.
Year of Birth
Social Security
Normal Retirement Age
1937 or earlier
65 years
1938
65
years, 2 months
1939
65
years, 4 months
1940
65
years, 6 months
1941
65
years, 8 months
1942
65 years,
10 months
1943-1954
66 years
1955
66
years, 2 months
1956
66
years, 4 months
1957
66
years, 6 months
1958 1
66
years, 8 months
1959
66 years,
10 months
1960 or later 1
67 years
2 -LMC -412
0.,
OTHER FEATURES
The following other features are included:
• Waiver of Premium
• Work Incentive Benefit
• Rehabilitation Incentive Income
• Recurrent Disability
hen
• FNILA Coverage Extension
• Survivor Benefit
• Day Care Benefit��r,
• Worksite Modification Benefit
{
• Vocational Rehabilitation Service
{
• Social Security Assistance
• Continuity of Coverage'
THIS SCHEDULE OF BENEFITS CANCELS AND
REPLACES ALL OTHER SCHEDULES
PREVIOUSLY ISSUED TO YOU UNDER THE POLICY.
IT OUTLINES THE POLICY FEATURES.
THE FOLLOWING PAGES PROVIDE A COMPLETE DESCRIPTION OF THE PROVISIONS OF YOUR
CERTIFICATE.
2-LTDC-412 7
ELIGIBILITY AND EFFECTIVE DATES
Who is eligible for this insurance?
The following people are eligible: All active full-time employees.
The Waiting Period is shown in the Schedule of Benefits.
00001
When does Your Contributory Insurance become effective?
Your Contributory coverage will become effective on the latest of the following dates, provided You are Actively at
Work on that date:
1. If there is no Waiting Period, the date you are eligible for coverage, if You enroll for coverage on or before that
date;
2. If You sign the Enrollment Form after the end of the Waiting Period, but within 31 days after that day, Your
coverage will become effective on the first of the month that falls on or next follows the date You sign the
Enrollment Form.
3. If You sign the Enrollment Form following this 31 -day period, You are considered a late applicant and must
furnish Evidence Of Insurability satisfactory to Us before coverage can become effective. Coverage will
become effective on the date We determine that the Evidence of Insurability is satisfactory and We provide
written notice of approval.
You must be Actively at Work for coverage under the Policy to become effective. If, because of Injury or Sickness,
You are not Actively at Work on the date the insurance would otherwise take effect, it will take effect on the day You
return to Active Work.
Contributory means You pay all or a portion of the premium for this insurance coverage.
Enrollment Form means the application You complete to apply for coverage under the Policy.
00003
When is Evidence of Insurability required?
Evidence of Insurability is required if:
1. You area late applicant, which means You enroll for insurance more than 31 days after the date You are eligible
for insurance; or
2. You voluntarily canceled Your insurance and are reapplying; or
3. You apply for coverage amounts in excess of the Guaranteed Issue Benefit Limit as shown in the Schedule of
Benefits; or
4. You apply to increase Your coverage amount during an annual enrollment period; or You apply to increase Your
coverage amount during the Policy year.
You may obtain an Evidence of Insurability Form from the Policyholder,
00005
Changes to Your coverage
A change in Your coverage may occur if
L You enroll for a different coverage option; or
2. There is a Policy change.
If You are eligible for additional coverage due to a Policy change, the additional coverage will be effective on the
date the Policy change is effective, as requested by the Policyholder and agreed upon by Us.
2-LTDC-412
Additional coverage for reasons other than a Policy change will be effective the first of the month following the later
of:
1. The date You enroll for the additional coverage;
2. The date We approve Your coverage if Evidence of Insurability is required.
In order for Your additional coverage to begin, You must be in .fictively at Work. Additional coverage is subject to
payment of premium.
Additional coverage includes increases in Your Monthly Benefit amount and other benefit provisions that may
impact when or for how long benefits are payable. Additional coverage is subject to the Pre -Existing Condition
Exclusion. ,/ 11,
hY`"
Any decrease in coverage will take effect immediately. If the Date of Disability was prior to the decrease, any claim
resulting from that Disability will be paid at the amount in effect at the time the Disability was incurred.
00006
Evidence of Insurability means a statement of Your medical history which We will use to determine if You are
approved for coverage. Evidence of Insurability will be provided at Our expense.
Evidence of Insurability Form means a form provided or approved by Us on which you provide a statement of Your
medical history.
00007
Who pays for Your coverage? 'Sfy
You pay the entire cost of Your coverage. a ,r
00008
Do You have to pay premium while You receive benefits?
We will waive premium for You during a period of Disability for which the LTD Monthly Benefit is payable under
the Policy. Premium payment is required during Your Elimination Period or any other period when the LTD
Monthly Benefit is not payable under the Policy. } .O�1 "0"
00009 , :fi'. .err
.ea
What happens if We are replacing an existing Policy?
Effect on Actively at Work requirement
If You were insured under the Prior Policy on the day before the Policy Effective Date, You may be covered by the
Policy even if You do not satisfy the .fictively at Work requirement as stated in the When does insurance become
effective? provision and You would otherwise be eligible to become insured under the Policy, We will provide
limited coverage under this Plan. Coverage under this provision will begin on the Policy effective date and will
continue until the earliest of:
1. The end of the month following the date You become Actively at Work;
2. The end of any period of continuance or extension provided under the Prior Policy; or
3. The date coverage would otherwise end, according to the provisions of the Policy.
Your coverage under this provision is subject to payment of premium.
Effect on Benefits
If You do not satisfy the Actively at Work requirement, You may still be eligible for benefits under the Policy as
follows:
The benefits payable under the Policy will be the benefits which would have been payable under the terms of the
Prior Policy if it had remained in force; and the benefits payable under the Policy will be reduced by any benefits
payable under the Prior Policy for the same Disability for which the prior carrier is liable.
2-LTDC-412
The Prior Policy is the group disability insurance policy issued to the Policyholder by ABC Carrier whose coverage
terminated immediately prior to the Policy Effective Date.
Effect on Pre-existing Conditions
If You have a Disability due to a Pre -Existing Condition after the Prior Policy has been replaced by this Plan,
Benefits may be payable if.
1. You were insured under the Prior Policy at the time the Policyholder changed coverage from the Prior Policy to
the Policy; and
2. You have been continuously insured under this Plan from the effective date of this Plan until the date Your
Disability began.
In order for benefits to be paid, You must satisfy the Pre -Existing Condition exclusion under:
1. this Plan; or
2. the Prior Policy, if benefits would have been paid had the Prior Policy remained in force.
If You satisfy the Pre -Existing Condition exclusion of this Plan, We will determine Your payments according to this
Plan's provision.
If You do not satisfy the Pre -Existing Condition exclusion of this Plan, but You do satisfy the Pre -Existing Condition
provision under the Prior Policy:
1. Your Monthly Benefit will be the lesser of:
a. The Monthly Benefit that would have been payable under the terms of the Prior Policy if it had remained in
force; or
b. The Monthly Benefit under this Plan.
2. Benefits will end on the earlier of:
a. The date benefits end under the Policy, as described under the Maximum Period Payable; or
b. The date benefits would have ended under the Prior Policy if it had remained in force.
If You do not satisfy the Pre -Existing Condition exclusion under either this Plan or the Prior Policy, We will not
make any payments.
We will require proof that You were insured under the Prior Policy.
00010
2-LTDC-412 10
e I
LONG TERM DISABILITY BENEFITS
How do We define Total Disability?
Total Disability or Totally Disabled means that during the first 24 consecutive months of benefit payments due to
Sickness or Injury;
1. You are continuously unable to perform the Material and Substantial Duties of Your Regular Occupation, and
2. Your Disability Earnings, if any, are less than 20% of Your pre -disability Indexed Monthly Earnings.
00011
After the LTD Monthly Benefit has been paid for 24 consecutive months, Total Disability or Totally Disabled means
that due to Injury or Sickness: r
1. You are continuously unable to engage in any Gainful Occupation, and tee,
2. Your Disability Earnings, if any, are less than 20% of Your pre -disability Indexed Monthly Earnings.
00013
V
How do We define Partial Disability?
Partial Disability or Partially Disabled means that: rr .
1. During the Elimination Period You are unable to perform all of the Material and Substantial Duties of Your
Regular Occupation. NM& ,3/
2. During the first 24 consecutive months of benefit payments, due to Injury or Sickness You are unable to perform
all of the Material and Substantial Duties of Your Regular Occupation, and Your Disability Earnings, if any,
are at least 20% but less than or equal to 130% of Your pre -disability Indexed Monthly Earnings.
3. After the LTD Monthly Benefit has been paid for 24 consecutive months Partial Disability or Partially Disabled
means that due to Injury or Sickness, You are unable to engage in any Gainful Occupation; and Your Disability
Earnings, if any, are at least 20% but less than or equal to 60% of Your pre -disability Indexed Monthly
Earnings.
00014
Loss of Professional License or Certification
If You require a professional license or certification for Your occupation, loss of that professional license or
certification does not in and of itself constitute Disability.
00017
What is the Elimination Period and how is it satisfied?
The Elimination Period is a period of continuous Disability which must be satisfied before You are eligible to
receive benefits from Us. It is shown in the Schedule of Benefits and begins on Your Date of Disability.
If You temporarily recover and return to work, We will treat Your Disability as continuous if You return to work for a
period of less than or equal to one-half the Elimination Period rounded up to the next whole number, not to exceed
90 days. The days that You are not Disabled will not count toward Your Elimination Period.
If You return to work for a period greater than one-half the Elimination Period, or 90 days, whichever is less, and
become Disabled again, You will have to begin a new Elimination Period.
00018
Can You satisfy Your Elimination Period if You are working?
You can satisfy Your Elimination Period if You are working, provided You meet the definition of Disability.
00019
2-LTDC-412
What Disability Benefit are You eligible to receive?
If You are Disabled, You are eligible to receive one of the following at any given time:
1. an LTD Monthly Benefit;
2. a Work Incentive Benefit; or
3. Rehabilitation Incentive Income.
While You are Disabled, You might be eligible to receive one or the other of the above, but You cannot receive more
than one of these benefits at the same time.
00020
What is Your LTD Monthly Benefit and how is it calculated?
Your LTD Monthly Benefit will be based on Your Monthly Earnings as reported to Us by the Policyholder and for
which premium has been paid.
An LTD Monthly Benefit will be payable after the end of the Elimination Period if You are Disabled. We will
calculate Your Gross LTD Monthly Benefit amount as follows:
1. Multiply Your Monthly Earnings by 60%.
2. The maximum Gross LTD Monthly Benefit is $5,000.00.
3. Compare the answers from Item 1 and Item 2. The lesser of these two amounts is Your Gross LTD Monthly
Benefit.
4. Subtract the Deductible Sources of Income from Your Gross LTD Monthly Benefit. The resulting figure is Your
Net LTD Monthly Benefit.
5. Compare the answer from item 3 and 4.
The lesser amount figured in item 5 is Your Monthly Benefit.
If a benefit is payable for less than one month, it will be paid on the basis of 1/30s' of the Net LTD Monthly Benefit
for each day of Disability.
00021-A
Monthly Earnings means Your gross monthly income from Your Employer in effect just prior to Your Date of
Disability. It includes Your total income before taxes and any deductions made for pre-tax contributions to a
qualified deferred compensation plan, Section 125 plan, or flexible spending account. It includes income actually
received from commissions, but does not include bonuses, overtime pay, or any other extra compensation, or income
received from sources other than Your Employer.
Commissions will be averaged for the lesser of:
a. the 12 full calendar month period of Your employment with Your Employer just prior to the date Disability
begins; or
b. the period of actual employment with Your Employer.
Earnings, whether for a full year or partial year, will be converted to a monthly amount for the purpose of
calculating the Monthly Benefit,
00022
What are the Deductible Sources of Income?
1. Disability benefits paid, payable, or for which You are eligible under:
a. The Social Security Act, including any amounts for which Your dependents may qualify because of Your
Disability;
b. Any Workers' Compensation or Occupational Disease Act or Law, or any other law which provides
compensation for an occupational Injury or Sickness;
2-LTDC-412 12
` c. Occupational accident coverage provided by or through the Policyholder;
d. Any Statutory Disability Benefit Law;
e. The Railroad Retirement Act;
f. The Canada Pension Plan, Quebec Pension Plan, or any other similar disability or pension plan or act;
g. The Canada Old Age Security Act;
h. Any Public Employee Retirement System Plan, or any State Teachers' Retirement System Plan, or any plan
provided as an alternative to any of the above acts or plans;
i. Title 46, United States Code Section 688 et seq (The Jones Act);, rn
j. Title 33, United States Code Section 901 et seq (Longshore and Harbor Workers' Compensation Act).
2. Disability benefits paid, payable, or for which You are eligible under:
a. Any group insurance plan provided by or through the Policyholder, and {;
b. Any sick leave or salary continuance plan provided by or through the Policyholder which causes the Net
Monthly Benefit, plus Deductible Sources of Income and any salary continuation to exceed 100% of Your
pre -disability Indexed Monthly Earnings. The amount in excess of 100% of Your pre -disability Indexed
Monthly Earnings will be used to reduce Your Net Monthly Benefit.
rf
3. Retirement benefits paid under the Social Security Act including any amounts for which Your dependents may
qualify because of Your retirement; vl
4. Retirement and Disability benefits paid under a Retirement Plan provided by the Policyholder except for
amounts attributable to Your contributions;
5. Retirement and Disability retirement benefits paid under any Public Employee Retirement System Plan, or any
State Teachers' Retirement System Plan, or any plan provided as an alternative to any of the above acts or plans;
y 6. Disability benefits paid under any No Fault Auto Motor Vehicle coverage;
6. Amounts received from a third party after subtracting attorney's fees by judgment, settlement or otherwise, not
to exceed 50% of the net settlement.
Proration of Lump Sum Awards
If any Deductible Source of Income described above is paid in a single sum through compromise settlement or as an
advance on future liability, We will determine the amount of reduction to Your Gross LTD Monthly Benefit as
follows:
1. We will divide the amount; paid by the number of months for which the settlement or advance was provided; or
2. If the number of months for which the settlement or advance is made is not known, We will divide the amount
of the settlement or advance by the expected remaining number of months for which We will provide benefits
for Your Disability based on the Proof of Disability which We have, subject to a maximum of 60 months.
What other sources of income are not deductible?
We will not reduce Your Gross LTD Monthly Benefit by any of the following:
1. deferred compensation arrangements such as401(k), 403(b) or 457 plans;
2. credit disability insurance;
3. pension plans for partners;
4. military pension and disability income plans;
5. franchise disability income plans;
6. individual disability income plans;
7. a Retirement Plan from another Policyholder;
2-LTDC-412 13
8. profit sharing plans;
9. thrift or savings plans;
10. individual retirement account (IRA);
11. tax sheltered annuity (TSA);
12. stock ownership plan.
00023
Can You work and still receive benefits?
While Disabled, You may qualify for the Work Incentive Benefit or Rehabilitation Incentive Income, but not both.
Work Incentive Benefit
A Work Incentive Benefit will be payable if You are Disabled and Gainfully Employed after the end of the
Elimination Period, or after a period during which You received LTD Monthly Benefits.
The Work Incentive Benefit will be calculated during the first 12 months of disability payments while You are
Gainfully Employed as follows:
1. We will add together the Gross Monthly Benefit and Disability Earnings and compare to pre -disability Indexed
Monthly Earnings.
2. If the total amount in Item 1 exceeds 100% of pre -disability Indexed Monthly Earnings, the Work Incentive
Benefit will be equal to the LTD Monthly Benefit reduced by the amount of the excess.
3. If the total amount in Item l does not exceed 100% of pre -disability Indexed Monthly Earnings, the Work
Incentive Benefit will be equal to the LTD Monthly Benefit amount.
After the first 12 months of disability payments while You are Disabled and Gainfully Employed, the Work
Incentive Benefit will be equal to the Net Monthly Benefit multiplied by the Adjusted Loss of Salary Ratio.
The Work Incentive Benefit will cease on the earliest of the following:
1. the date You are no longer Disabled, • or
2. the end of the Maximum Period Payable.
Adjusted Loss of Salary Ratio is equal to: A divided by B
A Your pre -disability Indexed Monthly Earnings minus Your Disability Earnings
B— Your pre -disability Indexed Monthly Earnings
Rehabilitation Incentive Income
Rehabilitation Incentive Income will be payable after the end of the Elimination Period, or after a period during
which You received LTD Monthly Benefits. This benefit is payable if You are Disabled and Gainfully Employed in
an occupation that has been approved as part of a Rehabilitation Plan.
Rehabilitation Incentive Income will be calculated during the first 12 months of Gainful Employment as follows:
1. If Disability Earnings exceed I00% of pre -disability Indexed Monthly Earnings, Rehabilitation Incentive
Income will be equal to the Net Monthly Benefit reduced by the amount of the excess.
2. If Disability Earnings do not exceed 100% of pre -disability Indexed Monthly Earnings, Rehabilitation Incentive
Income will be equal to the Monthly Benefit.
After the first 12 months of Gainful Employment, Rehabilitation Incentive Income will be equal to the LTD Monthly
Benefit multiplied by the adjusted Loss of Salary Ratio.
Rehabilitation Incentive Income will cease on the earliest of the following:
1. as stated in the Rehabilitation Plan;
2. the date You fail to comply with the requirements of the Rehabilitation Plan;
2-LTDC-412 14
N
3. the date You are no longer Gainfully Employed; or
4. the end of the Maximum Period Payable.
Adjusted Loss of Salary Ratio is equal to: A divided by B
A= Your pre -disability Indexed Monthly Earnings minus Your Disability Earnings
B- Your pre -disability Indexed Monthly Earnings
00014-A
What is the minimum Net LTD Monthly Benefit payable under the Policy?
The Net LTD Monthly Benefit payable for Disability will not be less than $100.00 or 10% of Your Gross LTD
Monthly Benefit, whichever is greater. The minimum Net LTD Monthly Benefit does not apply if You are Gainfully
Employed.
00025
What happens if Your Deductible Sources of Income increase? f� � .
The Net LTD Monthly Benefit will not be further reduced for subsequent cost -of -living increases which are paid,
payable, or for which You or Your dependents are eligible under any Deductible Source of Income'.shown above.
00026+. r
iY'N�I !J LAY J /•�
How long will You receive benefits under the Policy? %Kx �f+r
We will send You a payment for each month of Disability,5up toe `Maximum'Reriod Payable as shown in the
Schedule of Benefits. Payment of benefits is also subject,to=Y.-benefit duration limitation pertaining to Your
Disability.
00027<r p
rr'P, °`•r��P
What happens if Your Disability recurs?
If Disability for which benefits were payable ends but recurs due to the same or related causes less than 6 months
after the end of a prior Disability, it will be considered a resumption of the prior Disability. Such recurrent
Disability shall be subject to the provisions of the Policy that were in effect at the time the prior Disability began.
Disability which recurs more than 6 months after the end of a prior Disability is subject to:
1. a new Elimination Period;;m,.
2. a new Maximum Period Payable; and
3. the other provisions of the Policy that are in effect on the date the Disability recurs.
Disability must recur while Your coverage is in force under the Policy.
00018
2-LTDC-412 15
EXCLUSIONS AND LIMITATIONS
What are the exclusions and limitations under the Policy?
The Policy does not cover any loss or Disability caused by, resulting from, arising out of or substantially
contributed, directly or indirectly, to by any one or more of the following:
• a Pre -Existing Condition;
• commission of, participation in, or an attempt to commit an assault or felony;
• Intentionally self-inflicted injuries;
• attempted suicide, regardless of mental capacity;
• participation in a war, declared or undeclared, or any act of war;
• active military duty;
• active Participation in a Riot;
The Policy has limitations on:
• Mental Disorder - Disability beyond 12 months after the Elimination Period if it is due to a Mental Disorder of
any type. Confinement in a Hospital or institution licensed to provide care and treatment for mental illness will
not be counted as part of the 12 -month limit.
• Substance Abuse A Substance Abuse (drug or alcohol) related Disability unless You are participating in a
Substance Abuse treatment program approved by the State where the treatment program is provided. The cost
of the treatment program must be borne by You or another group plan of the Policyholder (such as a group
health plan or Employee Assistance Program) if one is available and covers this type of treatment.
Except as specifically stated above, in no event will LTD Monthly Benefits for a Mental Disorder or Substance
Abuse be paid beyond the earliest of the date:
1. 12 LTD Monthly Benefit payments have been made; or
2. the Maximum Period Payable is reached; or
3. You refuse to participate in an appropriate, available treatment program, or You leave the treatment program
prior to completion; or
4. You are no longer following the requirements of Your treatment plan under the program; or
5. You complete the initial treatment plan, exclusive of any aftercare or follow-up services.
• Special Conditions - Disability beyond 12 months after the Elimination Period if it is due to a Special
Conditions related Disability. Confinement in a Hospital or institution licensed to provide care and treatment of
Special Conditions will not count toward the 12 month limit.
The lifetime cumulative Maximum Period Payable for all disabilities due to a Mental Disorder, Substance Abuse,
and Special Conditions is 12 months. Only 12 months of benefits will be paid for any combination of such
disabilities even if the disabilities:
1. are not continuous; and/or
2. are not related.
2-LTDC-412 16
C
Furthermore:
• Benefits are not payable for any period during which You are confined to a penal or correctional institution if
the period of confinement exceeds 30 days.
• Benefits are not payable during the first 24 months of LTD Monthly Benefits, when You are able to return to
work in Your Regular Occupation on a part-time basis but You do not.
• Benefits are not payable after 24 months of LTD Monthly Benefits, when You are able to work in any Gainful
Occupation on a part-time basis but You do not.
00024
2-LTDC-412 17
TERMINATION
OF OVERAGE
When will Your insurance terminate?
Your coverage will terminate on the earliest of the following dates:
1. the date on which the Policy is terminated;
2. the date You stop making any required contribution toward payment of premiums;
3. the date on which the Employer's participation under the Policy is terminated; or
4. the date You:
a. are no longer a member of a class eligible for this insurance,
b. request termination of coverage under the Policy,
c. are retired or pensioned, or
d. cease work because of a leave of absence, furlough, layoff, or temporary work stoppage due to a labor
dispute, unless We and the Policyholder have agreed in writing in advance of the leave to continue
insurance during such period.
Termination will not affect a covered loss which began while the coverage was in force.
00030
Will coverage be continued if You are eligible for leave under FMLA?
In the event You are eligible for and the Policyholder approves a leave under the Family and Medical Leave Act of
1993 (FMLA), or any applicable state family and medical leave law (State FML), provided the required premium
continues to be paid, Your insurance will continue for a period of up to the later of:
1. the leave period permitted by the federal Family and Medical Leave Act of 1993 and any amendments; or
2. the leave period permitted by applicable state law.
While granted a Family or Medical Leave of Absence:
1. The Policyholder must remit the required premium according to the terms of the Policy; and
2, coverage will terminate if You do not return to work as scheduled according to the terms of Your agreement
with the Policyholder.
00031
Will coverage be continued !f You are eligible for leave under USERRA?
If You are on a leave of absence for active military service as described under the Uniformed Services Employment
and Reemployment Rights Act of 1994 (USERRA) and applicable state law, Your coverage may be continued until
the end of the later of:
1. the length of time the coverage may be continued under the Certificate for an FMLA or State FML leave of
absence; or
2. the length of time the coverage may be continued under the Certificate of Coverage for a leave of absence other
than an FMLA or State FML leave of absence.
00032
HIM coverage be continued for other leaves of absence?
If You are on an approved leave of absence other than an FMLA or State FML leave of absence, and if premium is
paid, Your coverage will be continued through the end of the month that immediately follows the month in which
Your leave of absence begins.
2-LTDC-412 19
e
If the Policyholder has approved more than one type of leave of absence for You during any one period that You are
not Actively at Work We will consider such leaves to be concurrent for the purpose of determining how long Your
coverage may continue under the Policy.
If Your coverage is not continued during an FU LA or State FML leave of absence, and You become Actively at
Work immediately following the end of Your FMLA or State FML leave of absence, Your coverage will be
reinstated. We will not apply a new Waiting Period, require Evidence (f Insurability, or apply a new Pre-existing
Condition limitation.
If Your coverage is not continued during a leave of absence for active military service, and You return to active
employment, Your coverage may be reinstated in accordance with USERRA and applicable state law.
In no event will Your coverage under the policy be continued beyond the date Your coverage would otherwise end
according to the terms of the When will Your insurance terminate? provision.
00033 1119°,_
2-LTDC-412 19
0
DAY CARE EXPENSE BENEFIT
Are Day Care Expense Benefits available while You are Disabled?
While Disabled and receiving Rehabilitation Incentive Income, You will be reimbursed for Day Care Expenses for
each Eligible Child. You must supply satisfactory proof to Us that You incurred such charges.
Day Care Expenses mean monthly expenses, up to $350.00 per child per month, to a maximum total benefit of
$1,000.00 per month, charged by a licensed day care provider who is not a member of Your immediate family or
living in Your residence.
Eligible Child means Your Dependent Child under age 13 who lives with You.
Dependent Child(ren) means any unmarried child of Yours, whether natural, step, foster or adopted, who is primarily
dependent on You for financial support and maintenance.
The Day Care Expense Benefit payments will end the earliest of the following to occur:
1. the date You are no longer incurring Dory Care Expenses for your Eligible Child;
2. the date You are no longer receiving Rehabilitation Incentive Income;
3. after 12 monthly Day Care Expense Benefit payments have been made for each Eligible Child
00034
LN
2-LTDC-412 20
SURVIVOR INCOME BENEFIT
What happens if You die while receiving benefits?
We will pay a Survivor Income Benefit to an Eligible Survivor when proof is received that You died:
1. After the Disability had continued for 6 or more consecutive months; and
2. While receiving an LTD Monthly Benefit
The Survivor Income Benefit shall be payable on a lump sum basis immediately after We receive written proof of
Your death. The benefit will be equal to 3 times Your Last Monthly Benefit. The benefit shall accrue from Your date
of death.
Eligible Survivor means Your Spouse, if living, or if Your Spouse dies before the final monthly benefit is paid, then
Your children who are under age 23.
If payment becomes due to Your children, payment will be made to:
1. the children; or
2. a person named by Us to receive payments on the children's behalf. This payment will be valid and effective
against all claims by others representing or claiming to represent the children.
Last Monthly Benefit means the Monthly Benefit paid to You immediately prior to Your death, but not including any
reductions for Deductible Sources of Income.
If there is no Eligible Survivor, We will pay the Survivor Income Benefit to Your estate.
00036
2-LTDC-412
21
WORKSITE MODIFICATION BENEFIT C)
What is the Worksite Modification Benefit?
We will assist You and the Policyholder in identifying modifications We agree are likely to help You remain at work
or return to work. This agreement will be in writing and must be signed by You, the Policyholder and Us.
When this occurs, We will reimburse the Policyholder for the cost of the modification, up to the greater of:
1. $1,500.00; or
2. 2 times Your Last Monthly Benefit.
We will reimburse the Policyholder upon completion of the following:
1. agreed upon modifications made on Your behalf are completed;
2. written proof of expenses incurred by Your Policyholder have been provided to Us; and
3. You have returned to work and are an Actively at Work Employee.
Last Monthly Benefit means the monthly benefit paid to You immediately prior to Your request for benefits under the
Worksite Modification Benefit provision, but not including any reductions for Deductible Sources of Income.
00044
2-LTDC-412 22
6M
CLAIM SERVICES
What other services are available to You while You are Disabled?
If You are Disabled and eligible to receive Disability benefits under the Policy, We will evaluate You for eligibility
to receive any of the following. We will make the final determination for any of the following benefits or services.
Vocational Rehabilitation Service
Rehabilitation services are available when We determine that these services are reasonably required to assist in
returning You to Gainful Employment, Vocational rehabilitation services might include but are not limited to one or
more of the following:
1. job modification;
2. job retraining;
3. job placement;
4. other activities.
C
V4,
;`khy�
Eligibility for vocational rehabilitation services is based upon Your education, training, work experience and
physical and/or mental capacity. To be considered for rehabilitation services: �r
1. Your Disability must prevent You from performing Your Regular Occupation;
2. You must have the physical and/or mental capacities necessary for successful completion of a rehabilitation
program, and
3. there must be a reasonable expectation that rehabilitation services will help You return to Gainful Employment.
Social Security Disability Assistance,
When necessary, We will provide an advocate for You in applying for and securing Social Security Disability
awards. When We determine that Social Security Assistance is appropriate for You, it is provided at no additional
cost to You.
00047 r�� S;Gj;,
2-LTDC-412
21
FILING A CLAIM 0
What are the Claim Filing Requirements?
Initial Notice of Claim
We ask that You notify Us of Your claim as soon as possible, so that We may make a timely decision on Your claim.
The Policyholder can assist You with the appropriate telephone number and address of Our Claim Department. You
must send Us written notice of Your Disability within 30 days of the Date of Disability, or as soon as reasonably
possible. Notice may be sent to Our Claim Department at the address shown on the claim form or given to Our
Agent.
Written Proof of Loss
Within I5 days of Our being notified in writing of Your claim, We will supply You with the necessary claim forms.
The claim form is to be completed and signed by You, the Policyholder and Your Doctor. If You do not receive the
appropriate claim forms within 15 days, then You will be considered to have met the requirements for written proof
of loss if We receive written proof, which describes the occurrence, extent and nature of loss as stated in the Proof of
Disability provision.
Time Limit for Filing Your Claim
You must furnish Us with written proof of loss within 91 days after the end of Your Elimination Period. The length
of the Elimination Period is shown in the Schedule of Benefits. If it is not possible to give Us written proof within
91 days, the claim is not affected if the proof is given as soon as possible. However, unless You are legally
incapacitated, written proof of loss must be given no later than 1 year after the time proof is otherwise due.
No benefits are payable for claims submitted more than i year after the time proof is due. However, You can request
that benefits be paid for late claims if You can show that:
1. It was not reasonably possible to give written proof during the 1 year period, and
2. Proof of loss satisfactory to Us was given as soon as was reasonably possible.
Proof of Disability
The following items, supplied at Your expense, must be a part of Your proof of loss. Failure to provide complete
proof of loss may delay, suspend or terminate Your benefits.
1. The date Your Disability began;
2. The cause of Your Disability;
3. The prognosis of Your Disability;
4. Proof that You are receiving Appropriate and Regular Care for Your condition from a Doctor, who is someone
other than You or a member of Your immediate family, whose specialty or expertise is the most appropriate for
Your disabling condition(s) according to Generally Accepted Medical Practice.
5. Objective medical findings which support Your Disability. Objective medical findings include but are not
limited to tests, procedures, or clinical examinations standardly accepted in the practice of medicine, for Your
disabling condition(s).
6. The extent of Your Disability, including restrictions and limitations which are preventing You from performing
Your Regular Occupation.
7. Appropriate documentation of Your Monthly Earnings. If applicable, regular monthly documentation of Your
Disability Earnings.
S. If You were contributing to the premium cost, the Policyholder must supply proof of Your appropriate payroll
deductions.
2-LTDC-412 24
9. The name and address of any Hospital or Health Care Facility where You have been treated for Your Disability.
10. If applicable, proof of incurred costs covered under other benefit provisions in the Policy.
Continuing Proof of Disability
You may be asked to submit proof that You continue to be Disabled and are continuing to receive Appropriate and
Regular Care of a Doctor. Requests of this nature will only be made as often as reasonably necessary, but not more
frequently than once every 3 months. If required, this will be at Your expense and must be received within 45 days
of Our request. Failure to comply with such a request may delay, suspend or terminate Your benefits.
Examination
At Our expense, We have the right to have You examined as often as reasonably necessary while the claim
continues. Failure to comply with this examination may result in denial, suspension or termination of benefits,
unless We agree You have a valid and acceptable reason for not complying.
Authorization and Documentation You will be asked to supply t f {
1. You will be required to provide signed authorization for Us to obtain and release all reasonably necessary
medical, financial or other non-medical information in support of Your Disability claim. Failure to submit this
information may deny, suspend or terminate Your benefits.
2. You will be required to supply proof that You have applied for other Deductible Sources of Income such as
Workers' Compensation or Social Security Disability benefits, when applicable.
3. You will be required to notify Us when You receive or are awarded other Deductible Sources of Income. You
must tell Us the nature of the Deductible Source of Income, the amount received, the period to which the benefit
applies, and the duration of the benefit if it is being paid in installments.
00048 -TX
`firry'r.,
Time of Payment of Claim
As soon as We have all necessary substantiating documentation for Your Disability claim, We will pay Your benefit
on a monthly basis, so long as You continue to qualify for it.
We will pay benefits to You unless otherwise indicated. If You die while Your claim is open, any due and unpaid
Disability benefit will be paid, at Our option, to the surviving person or persons in the first of the following classes
of successive preference beneficiaries: Your: 1) Spouse; 2) children including legally adopted children; 3) parents;
or 4) Your estate.„.
If any benefit is payable to an estate, a minor or a person not competent to give a valid release, We may pay up to
$1,000 to any relative or beneficiary of Yours whom We deem to be entitled to this amount. We will be discharged
to the extent of such payment made by Us in good faith.
00049 !Zr”
Can You assign Your benefits?
Your benefits are not assignable, which means that You may not transfer Your benefits to anyone else.
What will happen if a claim is overpaid?
A claim overpayment can occur when You receive a retroactive payment from a Deductible Source of Income when
We inadvertently make an error in the calculation of Your claim; or if fraud occurs. The overpayment amount equals
the amount We paid in excess of the amount We should have paid under the Policy.
We have the right to recover from You any amount that is an overpayment of benefits under the Policy. You must
refund to us the overpaid amount. We may also, without forfeiting our right to collect an overpayment through any
means legally available to Us, recover all or any portion of an overpayment by reducing or withholding future
benefit payments, including the Minimum Monthly Benefit.
In an overpayment situation, We will determine the method by which the repayment is made. You will be required
to sign an agreement with Us which details the source of the overpayment, the total amount We will recover and the
2-LTDC-412 25
method of recovery. If LTD Monthly Benefits are suspended while recovery of the overpayment is being made,
suspension will also apply to the minimum LTD Monthly Benefits payable under the Policy. 0
Subrogation —Right of Reimbursement
When any claim payment is made, We reserve any and all rights to subrogation and/or reimbursement to the fullest
extent allowed by statute and customary practice. Any party to this contract shall not perform any act that will
prejudice such rights without prior agreement with Us. We will bear any expenses associated with Our pursuit of
subrogation or recovery.
00050
O
2-LTDC412 26
.A—�
UNIFORM PROVISIONS
Entire Contrad; Changes
The Policy, the Policyholder's application, the employee's certificate of coverage, and Your application, if any, and
any other attached papers, form the entire contract between the parties. Coverage under the Policy can be amended
by mutual consent between the Policyholder and Us. No change in the Policy is valid unless approved in writing by
one of Our officers. No agent has the right to change the Policy or W waive any of its provisions.
Statements on the Application
All
In the absence of fraud, all statements made in any signed application are considered representations and not
warranties (absolute guarantees). No representation by:
1. the Policyholder in applying for the Policy will make it void unless the representation is contained in the signed
application; or
2. any Employee in applying for insurance under the Policy will be used in defense to a claim under the Policy
unless it is contained in a written application signed by the Insured and a copy of such application is or has been
given to him or to his personal representative.
Legal Actions,
Unless otherwise provided by federal law, no legal action of any kind may be filed against Us:
1. until 60 days after proof of claim has been given; or "W,
2. more than 3 years after proof of Disability must be filed, unless the law in the state where You live allows a
longer period of time. .,
Clerical Error
Clerical error or omission by Us to the Policyholder will not: /,y.
1. Prevent You from receiving coverage, if You are entitled to coverage under the terms of the Policy; or
2. Cause coverage to begin or coverage to continue for You when the coverage would not otherwise be effective.
If the Policyholder gives Us information about You that is incorrect, We will:
1. Use the facts to decidewhether You have coverage under the Policy and in what amounts; and
4
2. Make a fair adjustment of the premium.
Misstatement of Age
If Your age has been misstated, an equitable adjustment will be made in the premium. If the amount of the benefit is
dependent upon Your age, as shown in the Benefit Duration Schedule, the amount of the benefit will be the amount
You would have been entitled to if Your correct age were known.
Note: A refund of premium will not be made for a period more than twelve months before the date
the Company is advised of the error.
Incontestability
The validity of the Policy shall not be contested, except for non-payment of premiums, after it has been in force for
two years from the date of issue. The validity of the Policy shall not be contested on the basis of a statement made
relating to insurability by any person covered under the Policy after such insurance has been in force for two years
during such person's lifetime, and shall not be contested unless the statement is contained in a written instrument
signed by the person making such statement.
Conformity with State Statutes and Regulations
If any provision of the Policy conflicts with the statutes and regulations of the state in which the Policy was issued
or delivered, it is automatically changed to meet the minimum requirements of the statute.
2-LTDC-412 27
Workers' Compensation or State Disability Insurance 0
The Policy is not in place of, and does not affect the requirements for coverage by any workers' compensation or
state disability insurance.
Agency
Neither the Policyholder, any employer, any associated company, nor any administrator appointed by the foregoing
is Our agent.
General Provisions
We have the right to inspect all of the Policyholder's records on the Policy at any reasonable time. This right will
extend until:
L 2 years after termination of the Policy; or
2. all claims under the Policy have been settled,
whichever is later.
The Policy is in the Policyholder's possession and may be inspected by You at any time during normal business
hours at the Policyholder's office.
0005! -TX
l�
2-LTDC-412 29
DEFINITIONS
The following are key words and phrases used in this certificate. When these words and phrases, or forms of them,
are used, they are capitalized and italicized in the text. As You read this certificate, refer back to these definitions.
Accident or Accidental means a sudden, unexpected event that was not reasonably foreseeable.
00052
Actively at Work or Active Work means that You must be:
I . working for the Policyholder on a full-time active basis; or ,0
2. working at least the minimum number of hours shown in the Schedule of Benefits: and either:
a. working at the Policyholder's usual place of business; or���,
l� v
b. working at a location to which the Policyholder's business requires You to travel, PF S
3. a legal citizen or resident of the United States of America;`„i
t�.
4. are paid regular earnings by the Policyholder, and
5. not a temporary or seasonal Employee.
You will be considered Actively at Work if You were actually at work on the day immediately preceding:
1. a weekend (except for one or both of these days if they are scheduled days of work);
2. holidays (except when such holiday is a scheduled work day);
3.aid vacations;
P
4. any non-scheduled work day; hf�^
5. excused leave of absence (except medical leave and lay -oft); and '
6. emergency leave of absence (except emergency medical leave).
00053
Appropriate and Regular Care means that You are regularly visiting a Doctor as frequently as medically required to
meet Your basic health needs. The effect of the care should be of demonstrable medical value for Your disabling
condition(s) to effectively attain and/or maintain maximum medical improvement.
00055 r f,:
Date of Disability is the date We determine that You are Disabled.
00057
Disability or Disabled means that You satisfy the definition of either Total Disability or Partial Disability.
00058
Disability Earnings is the wage or salary You earn from Gainful Employment after a Disability begins. It includes
any earnings You could receive if You were working to Your Maximum Capacity. Any lump sum payment will be
prorated, based on the time over which it accrued or the period for which it was paid.
If Your Disability Earnings routinely fluctuate widely from month to month, We may average Your Disability
Earnings over the most recent three months to determine if Your claim should continue. If We average Your
Disability Earnings, We will not terminate Your claim unless the average of Your Disability Earnings from the last
three months exceeds 800/6 of Your Indexed Monthly Earnings.
00054
2-LTDC- 412 29
Domestic Partner means an adult of the same or opposite gender who has an emotional, physical and financial
relationship to You, similar to that of a Spouse, as evidenced by the following:
1. You and Your Domestic Partner share financial responsibility for a joint household and intend to continue an
exclusive relationship indefinitely;
2. You and Your Domestic Partner each are at least eighteen (18) years of age;
3. You and Your Domestic Partner are both mentally competent to enter into a binding contract;
4. You and Your Domestic Partner share a residence and have done so for at least 12 months;
5. Neither You nor Your Domestic Partner are married to or legally separated from anyone else;
6. You and Your Domestic Partner are not related to one another by blood closer than would bar marriage; and
Neither You nor Your Domestic Partner is a Domestic Partner of anyone else.
Where the laws of the governing jurisdiction mandate a definition of Domestic Partner other than shown
above, that definition will be used in the Policy.
00060
Doctor means a person legally licensed to practice medicine, psychiatry, psychology or psychotherapy, who is
neither You nor a member of Your immediate family. A licensed medical practitioner is a Doctor if applicable state
law requires that such practitioners be recognized for purposes of certification of Disability, and the treatment
provided by the practitioner is within the scope of his or her license.
00061
Elimination Period means the number of calendar days at the beginning of a continuous period of Disability for
which no benefits are payable. The Elimination Period is shown in the Schedule of Benefits.
00062
Employee means an Actively at Work full-time Employee whose principal employment is with the Policyholder, at
the Policyholder's usual place of business or such place(s) that the Policyholder's normal course of business may
require, who is Actively at Work for at least the number of hours per week as stated in the Application and is
reported on the Policyholder's records for Social Security and withholding tax purposes.
00069
Gainful Occupation, Gainful Employment or Gainfully Employed means the performance of any occupation for
wages, remuneration or profit, for which You are qualified by education, training or experience on a full-time or
part-time basis.
00063
Generally Accepted Medical Practice or Generally Accepted in the Practice of Medicine means care and treatment
which is consistent with relevant guidelines of national medical, research and health care coverage organizations and
governmental agencies.
00064
Gross LTD Monthly Benefit means that benefit shown in the Schedule of Benef is which applies to You.
00065
Hospital or Health Care Facility is a legally operated, accredited facility licensed to provide full-time care and
treatment for the condition(s) causing Your Disability. It is operated by a full-time staff of licensed physicians and
registered nurses. It does not include facilities which primarily provide custodial, educational or rehabilitative care.
00066
Indexed Monthly Earnings means Your Monthly Earnings adjusted on each anniversary of benefit payment by the
lesser of 3% or the current annual percentage increase in the Consumer Price Index. Your Indexed Monthly
Earnings may increase or remain the same, but will never decrease.
2-LTDG- 412 10
Consumer Price Index (CPI -VL) means the Consumer Price Index for all urban wage earners and clerical workers
in the United States as published by the Bureau of Labor Statistics of the United States Department of Labor or its
successors. If the CPL -W is discontinued or changed, We may use another index that most closely reflects the cost
of living in the United States.
Indexing is only used as a factor in the determination of the percentage of lost earnings while You are Disabled and
working in a Gainful Occupation.
00067
Injury means bodily injury that is the direct result of an ,occident and not related to any other cause.
must occur, and Disability resulting from the Injury must begin while You are covered under the Policy.
occurs before You are covered under the Policy will be treated as a Sickness.
00068
LTD means Long Term Disability.
00070
Male pronoun, whenever used, includes the female.
00071
The Injury
Injury that
Material and Substantial Duties means duties that:
rf
1. are normally required for the performance of Your Regular Occupation; and y A�, '
2. cannot be reasonably omitted or modified, except that if You are required to work on average in excess of 40
hours per week, We will consider You able to perform that requirement if You have the capacity to work 40
hours.
00072
x Maximum Capacity means, based on Your restrictions and limitations:
1. During the first 24 consecutive months of monthly payments, the greatest extent of work You are able to do in
Your Regular Occupation; and
2. Beyond 24 consecutive months of monthly payments, the greatest extent of work You are able to do in any
Gainful Occupation.
00073
Maximum Medical Improvement is the level at which, based on reasonable medical probability, further material
recovery from, or lasting improvement to, an Injury or Sickness can no longer be reasonably anticipated.
00074
Maximum Period Payable, as shown in the Schedule of Benefits, means the longest period of time that We will
make payments to You for any one period of Disability.
00075
Mental Disorder means a disorder found in the current diagnostic standards of the American Psychiatric
Association.
00076
Monthly Benefit means the LTD Monthly Benefit shown in the Schedule of Benefits which applies to You.
00077
2-LTDC- 412 31
Monthly Earnings means Your gross monthly income from Your Employer in effect just prior to Your Date of
Disability. It includes Your total income before taxes and any deductions made for pre-tax contributions to a
qualified deferred compensation plan, Section 125 plan, or flexible spending account. It includes income actually
received from commissions, but does not include bonuses, overtime pay, or any other extra compensation, or income
received from sources other than Your Employer.
Commissions will be averaged for the lesser of.
c. the 12 full calendar month period of Your employment with Your Employer just prior to the date Disability
begins; or
d. the period of actual employment with Your Employer.
00078
Net LTD Monthly Benefit means the Gross LTD Monthly Benefit less the Deductible Sources of Income.
00079
Participation in a Riot shall include promoting, inciting, conspiring to promote or incite, aiding, abetting, and all
forms of taking part in, but shall not include actions taken in defense of public or private property, or actions taken
in defense of the person of the insured, if such actions of defense are not taken against persons seeking to maintain
or restore law and order including but not limited to police officers and firemen.
00080
Pre-existing Condition means a condition which;
was caused by, or results from a Sickness or Injury for which You received medical treatment, or advice was
rendered, prescribed or recommended whether or not the Sickness was diagnosed at all or was misdiagnosed
within 12 months prior to Your effective date; and
2. results in a Disability which begins in the first 12 months after Your effective date.
00081 0
Regular Occupation means the occupation that You are routinely performing when Your Disability begins. We will
look at Your occupation as it is normally performed in the national economy, instead of how the work tasks are
performed for a specific Policyholder or at a specific location.
00081
Rehabilitation Plan means a written agreement between You and Us. Its purpose is to assist You in returning to
Gainful Employment. The Rehabilitation Plan will outline the time and dates of the vocational rehabilitation
services, Our responsibilities, Your responsibilities and the responsibilities of any third party which might be
involved. The Rehabilitation Plan will be at Our expense, at the expense of the third parry, or a shared expense of
Ours and a third party. The Rehabilitation Plan may include the Day Care Expense Benefit.
00083
Riot shall include all forms of public violence, disorder or disturbance of the public peace, by three or more persons
assembled together, whether or not acting with common intent and whether or not damage to persons or property or
unlawful act or acts is the intent or the consequence of such disorder.
00085
Schedule of Benefits means the schedule which is a part of this certificate.
00086
Sickness means sickness or disease causing Disability which begins while You are covered under the Policy.
00087
2-LTDC- 412 32
Special Conditions means
1. muscoskeletal and connective tissue disorders of the neck and back including any disease or disorder of the
cervical, thoracic and lumbosacral back and its surrounding soft tissue including sprains and strains of joints
and adjacent muscles, except:
a. Arthritis;
b. Herniated Invertebrate Discs;
C. scoliosis;
d. spinal fractures;
e. osteopathies;
f. spinal tumors, malignancy, or vascular
g. radiculopathies, documented by elkectr
h. spondylolosthesis, grade lI or higher;
i. myelopathies and myelitis;
j. demyelinating disease;
k. traumatic spinal cord neurosis;
!. myofacial air syndrome;
P
2. chronic fatigue syndrome;
3. fibromyalgia; '��r J�Jr
4. carpal tunnel syndrome, or
5. environmental allergic illness, including but not limited to sick building syndrome and multiple chemical
sensitivity.
00088
Spouse means lawful spouse in the jurisdiction in which You reside. Spouse will include Your Domestic Partner.
00091
Substance Abuse means a pattern of pathological use of alcohol or other psychoactive drugs resulting in impairment
of social and or occupational functioning; debilitating physical condition; inability to abstain from or reduce
consumption of the substance; or the need for daily substance use for adequate functioning.
00092
Waiting Period as shown in the Schedule of benefit means the continuous length of time immediately before Your
Effective Date during which You must be in an Eligible Class. Any period of time prior to the Policy Effective Date
You were Actively at Work for Your Employer will count towards completion of the Waiting Period.
00093
We, Our and Us mean the Dearborn National Life Insurance Company, Chicago, Illinois.
00094
You, Your and Yours means the employee to whom this certificate is issued and whose insurance is in force under
the terms of the Policy.
00095
2-LTDC- 412 33
Administrative Office: 1020 3V Street
Downers Grove, Illinois 60515
n
DEARBORN NATIONAL® LIFE INSURANCE COMPANY
Chicago, Illinois
RIDER
This Rider is made a part of the Policy or Certificate (hereafter "the Policy") to which it is attached. It
takes effect and ends at the same time as the Policy. All provisions of the Policy, including any other
Riders or Amendatory Endorsements will apply to this Rider, except that in the event of a conflict, the
specific provisions of this Rider will govern.
Disability Resource Services
What is Disability Resource Services?
Disability Resource Services is a noninsurance benefit made available to You which provides access at no
additional cost to the following services:
• Access to Guidance Resources® Online, a secure, password -protected interactive website that
contains self -assessments, search tools, extensive content on personal health, relational, legal,
health and financial concerns for You.
Access to unlimited telephonic counseling service. This service provides access to experts to
provide You with assessment, counseling and referral advice.
+ Up to three face-to-face counseling sessions.
How Do You Access Disability Resource Services?
Guidance Resources is accessed online. Your employer will provide You with a password to use on the
website. The website URL is www.GuidanceResources.com. Telephonic and face to face counseling is
available if you qualify as stated above. To contact a counselor, please call 1-866-899-1363.
Guidance Resources and telephonic counseling is provided by ComPsych" Corporation. We do not
underwrite or administer this program.
When do Disability Resource Services Terminate?
Disability Resource Services terminate if Your coverage is terminated under the section on When
does Your coverage under the Policy end? located in the Termination Provision of the contract;
or,
When you are no longer qualify for Total Disability or Partial Disability benefits under the
Policy.
" .1444��
President
Nothing contained in this Rider shall be held to alter or affect any provision or condition of the Policy other than as
stated above.
FDL2-NIB-DRS (5/2012)
NOTICE
to
the Policyholder and Certifkate holder Insured under
the Group Long Term Disability Insurance Policy
Provided by Dearborn National Life Insurance Company
Regarding the Disability Resource Services Noninsurance Benefit
This notice is to advise you that Your Group Disability Insurance program also provides a non -
insurance benefit: Disability Resource Services.
Noninsurance Benefit Descriation and How the Benefit May Be Obtained
Disability Resource Services is a noninsurance benefit that provides you with a link to Guidance
Resources® Online, a secure, password -protected interactive website that contains self -assessments,
search tools, and extensive content on personal health, relational, legal, health and financial concerns for
insured persons and their family.
In addition You have access to telephonic counseling by calling 1-866-899-1363, and up.l jo,three face-to-
face counseling sessions.
This noninsurance benefit is available at the option of,the/S�7.1hPolicyholder,without any=tion required on the
part of an insured person to either acceptor decline,the service'f
ixry "df. I 'N
There is no charge for this noninsurance benefit.�?f•
.11� fir,
The service is currently administered and provided by Com syc ho Corporation.
Dearborn National Life Insurance Company{,(sometimes referred to as "We" or "Our") makes this
program available, but it does not underwrite of.administer the Disability Resource Services program.
Why This Service is Beine Made Availablep
We are making this service available to provide�s�zpport and assistance to insureds who have suffered a
loss that is covered by the group disability insurance policy. Living with a disability can be difficult, and
this program provides counseling, and assistance with locating services to support the insured and their
family members.
Termination of the Nodinsuranee'Benefit
This noninsurance benefit is provided free of charge It is subject to termination at our option or at the
optiont'of the program administrator.
rf� `A O;
If We discontinue thisservice We will notify the Policyholder not less than thirty (30) days in advance of
the discontinuance of this service.
1
. 14-
If the current program administrator discontinues the program and we are unable to find a replacement,
we will notify the Policyholder as soon as is reasonable under the circumstances. If discontinued, the
services available under this noninsurance benefit will no longer be available.
Unless terminated by Us or by the Program administrator, the Disability Resource Services noninsurance
benefit is available following a covered loss for as long as you remain covered under the group disability
insurance policy and such policy remains in effect.
NIB -DRS -Notice (512012)
ERISA INFORMATION STATEMENT'
The benefits described in your certificate are insured by a Policy issued by Dearborn National Life Insurance
Company ("Dearborn National"), pursuant to an Employee Welfare Benefit Plan (" the Plan") established by your
employer ("the Company"). This ERISA Information Statement ("EIS") describes some of the key provisions of the
Plan in effect as of the Effective Date of the Policy.
It is not the intention of the EIS to cover all situations that may arise, but to provide you with a general
understanding of your benefits. In the case of any item not covered by the EIS or in the event of any conflict
between the EIS and the Policy, the Plan will always control. You should not rely on any oral explanation,
description, or interpretation of the Plan because the written terms of the Plan will govern. Your right to any benefit
depends on the actual facts and terms and conditions of the particular Plan; no rights accrue by reason of or arising
out of any statement shown in or omitted from this EIS.
A. ADMINISTRATION OF THE PLAN
The Plan Administrator is responsible for the administration of the Plan. The Plan Administrator has full
discretionary authority and control over the Plan. This authority provides the Plan Administrator with the power
necessary to operate, manage and administer the Plan. This authority includes, but is not limited to, the power to
interpret the Plan and determine who is eligible to participate, to determine the amount of benefits that may be paid
to a participant or his or her beneficiary, and the status and rights of participants and beneficiaries. The Plan
Administrator also has the authority to prescribe the rules and procedures under which the Plan shall operate, to
request information, and to employ or appoint persons to aid the Plan Administrator in the administration of the
Plan.
Failure by the Plan or the Plan Administrator to insist upon compliance with any provisions of the Plan at any time
or under any set of circumstances shall not operate to waive or modify the provision or in any manner render it
unenforceable as to any other time or as to any other occurrence, whether the circumstances are or are not the same.
No waiver of any term or condition of the Plan shall be valid unless contained in a written memorandum expressing
the waiver and signed by the person authorized by the Plan Administrator to sign the waiver.
The Plan may be amended, terminated or suspended in whole or in part, at any time without the consent of the
employees or beneficiaries. Any amendment, termination or suspension shall be in writing, and attached to the Plan.
Any amendment, termination or suspension shall be executed according to the Employer's authorized procedures.
Any such authorization may be specific to the Plan or persons authorized to act on behalf of the Employer or may be
general as to duties of such person. Except for termination or suspensions, any amendments affecting the Policy
and/or Certificate must also be approved in writing by an officer of Dearborn National and shall be effective as of
the date agreed to, in writing by the Plan Sponsor and Dearborn National. Notwithstanding anything to the contrary
in this document, the Policy shall terminate according to the provisions in the Policy.
The Plan has other fiduciaries, advisors and service providers. The Plan Administrator may allocate fiduciary
responsibility among the Plan's fiduciaries and may delegate responsibilities to others. Any allocation or delegation
must be done in writing and kept with the records of the Plan. The Plan's life benefits are provided pursuant to an
insurance policy issued to the Company. Dearborn National's (the Insurer's) services shall be limited to, and the
Plan Administrator has the full discretionary and final authority to:
resolve all matters when a review pursuant to the claims procedures has been requested;
interpret, establish and enforce rules and procedures for the administration of the Policy and any claim
under it; and
determine eligibility of Employees and Dependents for benefits and their entitlement to and the amount of
benefits.
Each fiduciary is solely responsible for its own improper acts or omissions. Except to the extent required by ERISA,
no fiduciary has the duty to question whether any other fiduciary is fulfilling all of the responsibilities imposed upon
the other fiduciary by law. Nor is a fiduciary liable for a breach of fiduciary duty committed before it became, or
after it stopped being, a fiduciary. However, a fiduciary may be liable for a breach of fiduciary responsibility of any
Plan fiduciary, to the extent provided in ERISA Section 405(a). The Employer makes no promise to continue these
' If this Plan is an ERISA plan, these ERISA provisions apply. However, your employer may issue a Summary Plan Description
("SPD"). If it does, and if there are any conflicts between the SPD and the EIS in regards to your ERISA rights, the SPD
provisions will always control.
FDL FIS Standard 4/2009 rev'd.
benefits in the future and rights to future benefits will never vest. Retirement does not give any retiree any vested
right to continue to participate or receive Plan benefits.
B. CLAIMS PROCEDURE;
When you or your Beneficiary are eligible to receive benefits, you or your Beneficiary, or your authorized
representative (collectively, "you") must notify the Plan Administrator by submitting the proper form in writing.
You may do this by sending notice of your claim to the Plan Administrator who has been appointed to assist
Dearborn National in the claims processing for this Plan or by contacting Dearborn National directly at:
Claims Department
Dearborn National Life Insurance Company
1020 31 st Street
Downers Grove, IL. 60515-5591 A. �yti
1-800-778-2281+.,
For the purpose of this Section, including Subsections 1 and 2 below, the terms "written" and "in writing"
include "electronic." Any action required to be "written" or "in writing," may be done electronically, where
available. If Dearborn National uses electronic notices, it will do so in accordance with 29 CFR 2520.104b -
10(i), (iii) and (iv).
1. Disability Insurance Plans rx�pi ,,
Dearborn National will give you a written response to yo r clam,, V ally within; 45 days The time for decision
may be extended for two additional 30 day periods provided that, prior to any extension period, Dearborn National
notifies you in writing that an extension is necessary due tor'mattersplieyond the control of the Plan, identifies those
s•.u:n.tr.
matters and gives the date by which it expects to render its decision. If the extension is due to your failure to submit
information necessary to decide your claim, the time for decision shall be tolled from the date on which we send you
notice of the extension until the date we receive your response to ourrequest. This period will be no longer than 45
days after we have requested the information. At that tune we will decide your claim based on the information we
have at that time.
Fi•..' ?}'r tir
If the claim is denied, in whole or in part, you;.wil l receive a writttetA notice giving the following:
the reason for the denial;kr�,
the Policy provisions on which the denial is based;
an explanation of i6it other information cif any, may be needed to process the claim and why it is needed;
- the steps that you have to follow to,have the claim reviewed;
r
UP
- a statement that you have the right iii bring a civil action under section 502(a) of ERISA after you appeal
,r
- our decision and after you receive a written denial on appeal; and
rr ,'r
- if an internalrr:: ru!e,,.guideline, protocol, or other similar criterion was relied upon in making the denial, either
(i) the specificrule, guideline, protocol or other similar criterion; or (ii) a statement that such a rule,
guideline, protocol;or other similar criterion was relied upon in making the denial and that a copy will be
provided free of charge to you upon request; and
if denial is based on medical judgment, either (i) an explanation of the scientific or clinical judgment for the
determination, applying the terms of the Plan to your medical circumstances, or (ii) a statement that such
explanation will be provided to you free of charge upon request.
If the claim has been denied, in whole or in part, you can appeal the denial to us for a full and fair review. You have
at least 180 days to appeal from the claim denial.
You may:
a. request a review upon written application within 180 days of the claim denial;
b. request, free of charge, copies of all documents, records and other information relevant to your claim; and
* If this Plan is an ERISA plan, these ERISA provisions apply. However, your employer may issue a Summary Plan Description
("SPD"). If it does, and if there are any conflicts between the SPD and the EIS in regards to your ERISA rights, the SPD
provisions will always control.
FDI, EIS Standard 412009 rev'd.
C. submit written comments, documents, records and other information relating to your claim, without regard
to whether such information was submitted or considered in the initial benefit determination.
Dearborn National will make a decision no more than 45 days after we receive your appeal. The time for decision
may be extended for one additional 45 day period provided that, prior to the extension, Dearborn National notifies
you in writing that an extension is necessary due to special circumstances, identifies those circumstances and gives
the date by which it expects to render its decision. If your claim is extended due to your failure to submit
information necessary to decide your claim on appeal, the time for your decision shall be tolled from the date on
which the notification of the extension is sent to you until the date we receive your response to the request. The
written decision will include specific references to the Plan provisions on which the decision is based and any other
notice(s), statement(s) or information required by applicable law.
2. Life Insurance Plans
Dearborn National will give you a decision no more than 90 days after receipt of due proof of loss, except in special
circumstances (such as the need to obtain further information), but in no case more than 180 days after the due proof
of loss is received. The written decision will include specific reasons for the decision and specific references to the
Plan provisions on which the decision is based.
If the claim is denied, in whole or in part, the claimant will receive a written notice giving the following:
- the reason for the denial;
- the Policy provisions on which the denial is based;
- an explanation of what other information, if any, may be needed to process the claim and why it is needed;
and
- the steps that have to be followed to have the claim reviewed.
Any denied claim may be appealed to the Insurer for a full and fair review. The claimant may:
a) request a review upon written application within 60 days of receipt of claim denial;
b) upon request and free of charge, review pertinent documents, records and other information relevant to the
claim and receive copies of same; and
C) submit issues, comments, records, and other information in writing.
A decision will be made by the Insurer no more than 60 days after receipt of the request for review, except in special
circumstances (such as the need to obtain additional evidence), but in no case more than 120 days after the request
for review is received. The written decision will include specific reasons for the decision and specific references to
the Plan provisions on which the decision is based. The decision will advise you of any other appeal rights you have
under the Plan, as well as your right to bring an action under Section 502(a) of ERISA.
C. ERISA NOTICE OF YOUR RIGHTS
As a participant in the Plan you are entitled to certain rights and protections under the Employee Retirement Income
Security Act of 1974 ("ERISA"). ERISA provides that all Plan participants shall be entitled to:
Examine, without charge, at the Plan Administrator's office and at other locations, such as work sites and union
halls, all Plan documents, including insurance contracts, collective bargaining agreements and copies of all
documents filed with the U.S. Department of Labor, such as detailed annual reports and Plan descriptions.
Obtain copies of all Plan documents and other Plan information upon written request to the Plan Administrator. The
Plan Administrator may make a reasonable charge for the copies. Receive a summary of the Plan's annual financial
report. The Plan Administrator is required to furnish each participant with a copy of this summary annual report.
In addition to creating rights for the Plan participants, ERISA imposes duties upon the people who are responsible
for the operation of the employee benefit Plan. The people who operate your Plan, called "fiduciaries" of the Plan,
have a duty to do so prudently and in the interest of you and other Plan participants and beneficiaries.
No one, including your employers, your union, or any other persons, may fire you or otherwise discriminate against
you in any way to prevent you from obtaining a welfare benefit or exercising your rights under ERISA. If your
claim for a welfare benefit is denied in whole or in part you must receive a written explanation of the reason for the
*
If this Plan is an ERISA plan, these ERISA provisions apply. However, your employer may issue a Summary Plan Description
( J
("SPD"). If it does, and if there are any conflicts between the SPD and the EIS in regards to your ERISA rights, the SPD
provisions will always control.
FDL EIS Standard 412009 rev'd.
denial. You have the right to have the Plan review and reconsider your claim. Under ERISA, there are steps you
can take to enforce your rights. For instance, if you request materials from the plan and do not receive them within
30 days, you may file a suit in federal court. In such a case, the court may require the Plan Administrator to provide
the materials and pay you up to $110 a day until you receive the materials, unless the materials were not sent
because of reasons beyond the control of the Plan Administrator.
If you have a claim for benefits which is denied or ignored, in whole or in part, you may file suit in a state or federal
court. If it should happen that Plan fiduciaries misuse the Plan's money, or if you are discriminated against for
asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in federal
court. The court will decide who should pay costs and legal fees. If you are successful the court may order the
person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees,
for example, if it finds your claim is frivolous.
If you have any questions about this statement or about your rights under ERISA, you should contact the nearest
office of the Pension and Welfare Benefits Administration, United States Department of Labor, listed in your
telephone directory or the Division of Technical Assistance and Inquiries, Employee Benefit Security
Administration, United States Department of Labor, 200 Constitution Avenue, NW Washington DC 20210.
D. PARTICIPANT'S RIGHTS
This Plan shall not be deemed to constitute a contract between the Company and any participant or to be
consideration or an inducement for the employment of any participant or employee. Nothing contained in this Plan
shall be deemed to give any participant or employee the right to be retained in the service of the Company or to
interfere with the right of the Company to discharge any participant or employee at any time regardless of the effect
which such discharge shall have upon him or her as a participant of this Plan.
* If this Plan is an ERISA plan, these ERISA provisions apply_ However, your employer may issue a Summary Plan Description
("SPD"), If it does, and if there are any conflicts between the SPD and the EIS in regards to your ERISA rights, the SPD
provisions will always control.
FDL EIS Standard 4/2009 rev'd.
Deoxborn National0r
Administrative Office:
1O20 31st Street • Downers Grove, IL 60515-5591
Products and services marketed under the Dearborn National® brand and the star logo are underwritten
and/or provided by Dearborn National® Life Insurance Company (Downers Grove, IL) in all states
(excluding New York), the District of Columbia, the United States Virgin Islands, the British Virgin
Islands, Guam and Puerto Rico.
Dearborn National® Life Insurance Company
(A stock life insurance company herein called "We", "Us", "Our")
Chicago, Illinois
Administrative Office: 1020 31st Street • Downers Grove, IL 60515-5591
Policyholder: SAMPLE TEXAS
Policy Number: SAMPLE TX -0001
Policy Effective Date: January 1, 20130
Anniversary Date: January 1, 2014 :
We agree with the Policyholder to insure certain eligible Employees of the Policyholder. We roml ise-to a benefits
g Y gcY P p.Y
for loss covered by the Policy in accordance with its provisions.
The Policyholder should read this Policy carefully and contact Dearborn National Life Insurance Company
promptly with any questions. r.
Policyholder means the Employer to whom the Policy is issued and96sponsored the coverage for its Employees.
If the Policyholder is a trust or Organization, the term Participating Employer shall be substituted for Policyholder.
Employer means the Policyholder and includes any division, subsidiary, or affiliated company named in the Policy.
W.
Employee means a person who is a citizen or legai,iesiddnt of the°United States and Actively at Work with the
Employer.
POLICY EFFECTIVE DATE&AND TERM
The Policy takes effect on the Policy Effective Date.stakabove sulbjcct'to any participation requirement stated in
the Policy. All insurance periods will be computeefrom thai date. Th'e Policy remains in force for the period for
s- d
which premium has been paid. It may be renewed for further successive periods by payment as stated in the Policy.
All periods of insurance begin and end'at-12:01 A',M.i,Standard'Time, at the Policyholder's address as stated in the
Policy, and on the Application. �'N„
Signed for Dearborn National Life Insurance Company @v
l"Frti,'
�I ,,JAS
•�{' Secretary President
THIS IS NOT A POLICY, OF WORKERS' COMPENSATION INSURANCE, THE EMPLOYER DOES NOT BECOME A
SUBSCRIBER'%.i0� 711E WORKERS' COMPENSATION SYSTEM BY PURCHASING THIS POLICY, AND IF THE
EMPLOYER51SykW I -SUBSCRIBER, THE EMPLOYER LOSES THOSE BENEFITS WHICH WOULD OTHERWISE
ACCRUE UNDER THE WORKERS' COMPENSATION LAWS. THE EMPLOYER MUST COMPLY WITH THE
WORKERS' COMPENSATION LAW AS IT PERTAINS TO NON -SUBSCRIBERS AND THE REQUIRED
NOTIFICATIONS THAT MUST BE FILED AND POSTED.
Group Voluntary Long Term Disability Policy
Non -Participating
THIS IS NOT A WORKERS' COMPENSATION POLICY
2-LTDP-412 (TX)
IMPORTANT NOTICE
To obtain information or make a complaint:
You may contact your (title)
at (telephone number).
You may call Dearborn National Life Insurance
Company's toll-free telephone number for infor-
mation or to make a complaint at:
1-800-348-4512
You may also write to Dearborn National Life
Insurance Company at:
1020 31st Street, Downers Grove, IL 60515-5591
You may contact the Texas Department of Insurance
to obtain information on companies, coverages, rights
or complaints at:
1-800-252-3439
You may write the Texas Department of Insurance:
P. O. Box 149104
Austin, TX 78714-9104
FAX #(512) 475-1771
Web: http://www.tdi.state.tx.us
E-mail: ConsumerProtection@tdi.state.tx.us
PREMIUM OR CLAIM DISPUTES: Should you
have a dispute concerning your premium or about a
claim, you should contact the company first. If the
dispute is not resolved, you may contact the Texas
Department of Insurance.
ATTACH THIS NOTICE TO YOUR POLICY:
This notice is for information only and does not
become a part or condition of the attached document.
9-632-895
DISPUTAS SOBRE PRIMAS O RECLAMOS: Si
tiene una disputa concemiente a su prima o a un
reclamo, debe comunicarse con la compania primero.
Si no se resuelve la disputa, puede entonces
comunicarse con al Departamento de Seguros de
Texas.
UNA ESTE AVISO A SU POLIZA: Este aviso es
solo para proposito de information y no se convierte
en parte o condition del documento adjunto.
AVISO IMPORTANTE
Para information o para someter una queja:
Peude communicarse con su (title)
al (telephone number).
Usted puede Ilamar al numero de telefono gratis de
Dearborn National Life Insurance Company para
informacion o para someter una queja al:
1-800-348-4512
Usted tambien escribir a Dearborn National Life
Insurance Company al:
1020 31st Street, Downers Grove, IL 60515-5591
Puede comunicarse con el Departamento de Seguros
de Texas para conseguir information acerca de
companias, coberturas, derechos o quejas al:
1-800-252-3439
Puede escribir al Departamento de Seguros de Texas:
P. O. Box 149104
Austin, TX 78714-9104
FAX #(512) 475-1771
Web: http://www.tdi.statc.tx.us
E-mail: ConsumerProtection@tdi.state.tx.us
DISPUTAS SOBRE PRIMAS O RECLAMOS: Si
tiene una disputa concemiente a su prima o a un
reclamo, debe comunicarse con la compania primero.
Si no se resuelve la disputa, puede entonces
comunicarse con al Departamento de Seguros de
Texas.
UNA ESTE AVISO A SU POLIZA: Este aviso es
solo para proposito de information y no se convierte
en parte o condition del documento adjunto.
IMPORTANT INFORALMONABOUT COVERAGE UNDER THE
TEXAS LIFE, ACCIDENT, HEALTHAND HOSPITAL SERVICE INSURANCE GUARANTYASSOCIATION
eft(For Insurers declared Insolvent or impaired on or after September I, 2005)
--t Texas law establishes a system, administered by the Texas Life, Accident, Health and Hospital Service
Insurance Guaranty Association (the "Association"), to protect Texas policyholders if their life or health
insurance company fails. Only the policyholders of insurance companies which are members of the
Association are eligible for this protection which is subject to the terms, limitations, and conditions of the
Association law. (The law is found in the Texas Insurance Code, Chapter 463.)
It is possible that the Association may not cover your policy in full or in part due to statutory
limitations.
Eligibility for Protection by the Association
When a member insurance company is found to be insolvent and placed under an order of liquidation by a
court or designated as impaired by the Texas Commissioner of Insurance, the Association provides coverage
to policyholders who are:
• Residents of Texas at that time (irrespective of the policyholder's residency at policy issue)
• Residents of other states, ONLY if the following conditions are met:
1. The policyholder has a policy with a company domiciled in Texas;
2. The policyholder's state of residence has a similar guaranty association; and
3. The policyholder is not eligible for coverage by the guaranty association of the'policyholder's state
of residence. 1014 ,/r
Limits of Protection by�.tbe_Association;
Accident, Accident and Health, or Health Insurance:,,.
• For each individual covered under one or morel policies: up to a total of $500,000 for basic hospital,
medical -surgical, and major medical insurance, $300,000 for disability or long term care insurance, and
$200,000 for other types of health insurance.
Life Insurance:yf{
• Net cash surrender value or net cash withdrawalrtvalue up td' a total of $100,000 under one or more
policies on any one life; or
• Death benefits up to a total of $300,000junder one or morepolicies on any one life; or
• Total benefits up to a total of $5,000,000to,,any, owner of multiple non -group life policies.
w ,. .
Individual Annuities: rAf`
• Present value of benefits up to a total of $100,000 under one or more contracts on any one life.
Group Annuities:r:,
• Present value of allocated benefitsupao a#otal of $100,000 on any one life; or
2r ir. �Ile,
• Present value of unallocated'bene i'' ;up to a total of $5,000,000 for one contractholder regardless of the
number of contracts. �n
Aggregate Limit-�;�
• $300;000 onany one.life with the exception of the $500,000 health insurance limit, the $5,000,000
multiple owner life insance limit, and the $5,000,000 unallocated group annuity limit.
Insurance companies andVagents 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. When you are
electing an insurance company, you should not rely on Association coverage.
Texas Life, Accident, Health and Hospital
Service Insurance Guaranty Association
6504 Bridge Point Parkway, Suite 450
Austin, Texas 78730
800-982-6362 or www.txlifega.org
FDL Notice 09
Texas Department of Insurance
P.O. Box 149104
Austin, Texas 78714-9104
800-252-3439 or www.tdi.state.tx.us
TABLE OF CONTENTS
PROVISION PAGE
f'remau114. .... ........................................................................................................... S
PremiumRateGuanvxw.......................................................,.........,......................... 6
PolicyTerminalon .............................. . . ............................ . ......................... .. ... . 7
AddinowiPnwWom.................................................................................................. 8
ATTACHMMNTS,
• Mwter Application
• Certificate of Insurance
2-LTDP-412 (TX)
}-�
v
PREMIUM
How is the initial premium calculated?
Initial Premium is calculated by multiplying the total insured Monthly Earnings, divided by 100, by *. Do not
include Monthly Earnings for any individual in excess of $8,333.33 per month in the premium calculation.
*See "Rates" section within Schedule of Benefits page
When is premium paid?
The Policy is issued in consideration of the payment in advance of premium on the billing mode indicated on the
Application. The initial premium is calculated at the premium rate stated above. Payment must be made by the
premium due date as shown on the Application. rr 7111
If an addition, termination or change in insurance takes place other than on a regular due date, any premium
adjustment will take effect on the next due date.
Is premium payable while an Insured receives benefits?
We will waive premium for an Insured Employee during the period of Disability for which the LTD Monthly Benefit
is payable under the Policy. Premium payment is required during the Insured Employee's Elimination Period.
During this period, the Insured Employee's insurance will remain in force.
Is there a grace period for premium payment? �`�Y/4• "?Y/
We will allow a grace period of 31 days for the payment of any premiums due except the first. Insurance coverage
shall continue in force during the grace period unless the Policyholder has given Us advance written notice of
cancellation in accordance with the terms of this Policy. If premium is not received by the end of the grace period,
this Policy will terminate as of the last date for which premium was paid.
The Policyholder is liable for premium due on coverage provided during the grace period.
If We receive written notice during the grace period that the Policy is to be canceled, We will cancel it as of the later
of:
1. the date requested in the cancellation notice; or
2. the date We receive such notice. The Policyholder must pay a pro rata premium for any coverage provided
during the grace period.
2-LTDP- 705 (TX)
rREMIUM RATE GUARANTEE
What is the initial premium rate guarantee?
A change in premium rates will not take effect before January 1, 2014. However, We may change premium rates if
the risk assumed changes. Premium rates may change if the following occurs:
1. a change in the policy design;
2. a change in the terms of the Policy;
3. addition or deletion of a division, subsidiary or affiliated company;
4. a change in the number of Insureds by 10% or more from the number of Insureds on the initial Effective Date;
5. a change in the laws or regulations or other government action which applies to the Policy;
6. for reasons other than 1-5 above such as but not limited to a change in factors bearing on the risk assumed.
The Policyholder must furnish notice and documentation satisfactory to Us within 31 days of the occurrence of any
event which would cause a change in rates as described above. If the Policyholder fails to provide such timely
notice, we will apply new rates retroactively to the date of the event.
We will notify the Policyholder in writing at least 31 days in advance of any premium rate changes. A change may
take effect on an earlier date if both the Policyholder and We agree.
2-LTDP- 705 (TX)
C
6
L. POLICY TERMINATION
Who may cancel the Policy or a plan under the Policy?
The Policy or a plan under the Policy can be canceled by the Policyholder with 31 days written notice delivered to
Us. This Policy will terminate for any of the following reasons:
1. If the Policyholder fails to pay any premium within the 31 -day Grace Period, this Policy will terminate in
accordance with the terms set forth in the Grace Period provision.
2. We may terminate this Policy on any premium due date if.-
a.
f:
a. coverage is Contributory and less than 25% of the eligible Employees participate; or Al 1 �..
b. the Policyholder fails to perform any of its obligations that relate to the Policy; or ,�' , '`x
c. the Policyholder does not promptly provide Us with information that is reasonably required; or ,
d. fewer than 10 Employees are insured under the Policy.
If We cancel the Policy, for reasons other than the Policyholder's failure to pay premium, a written notice will be
delivered to the Policyholder at least 31 days prior to the cancellation date.
Termination of this Policy under any conditions will not prejudice any claim for a loss which is incurred while this
Policy is in force. ; ;. r J;
rk "Mfk.�
2-LTDP- 705 (TX)
7
ADDITIONAL PROVISIONS
What happens if an inadvertent error occurs?
Clerical error or omission by Us to the Policyholder will not:
1. Prevent You from receiving coverage, if You are entitled to coverage under the terms of the Policy; or
2. Cause coverage to begin or coverage to continue for You when the coverage would not otherwise be effective.
If the Policyholder gives Us information about You that is incorrect, We will:
I. Use the facts to decide whether You have coverage under the Policy and in what amounts; and
2. Make a fair adjustment ofthe premium.
Will certificates be issued?
We will deliver certificates of insurance to the Policyholder for issuance to each Insured Employee. The certificates
will describe the benefits, to whom they are payable, the Policy limitations and where the Policy may be inspected.
What is considered to be the entire contract?
This entire Policy consists of:
1. all Policy provisions and any amendments and/or attachments issued;
2. the Certificate of Coverage; and
3. the Policyholder's signed Application
4. the Employee's signed enrollment forms.
IN
C,J
2-LTDP- 705 (TX) 8
STATE SUPPLEMENT
The following policies apply only to those individuals in your group insurance program who reside in the referenced
states.
Arizona and Maine
Except as otherwise permitted by law, we will not disclose collected personal information about an individual to a
nonaffiliated third party with whom we jointly offer products without giving the individual an opportunity to tell us
that he or she does not want us to share his or her personal information.
Minnesota and Montana
Except as otherwise permitted by law, we will not disclose collected personal information about an individual to a
nonaffiliated third party with whom we jointly offer products without obtaining the individual's written
authorization.
Montana
Upon written request, an individual who has authorized the collection of health information is entitled to receive a
record of Dearborn National's disclosures of any of his medical record information made within the preceding 3
years.„
Oregon
An individual has the right to authorize disclosure of his or her personal information to an insurance company. An
Oregon resident can exercise this right by requesting an authorisation form in writing. Our address is:
Dearborn National Life Insurance Company
1,&D— Administrative Office:
1020 31st Street • Downers Grove, IL 60515
9
C
PRIVACY NOTICE
THIS NOTICE REQUIRES NO ACTION ON YOUR PART. IT IS DESIGNED TO HELP YOU
UNDERSTAND HOW WE PROTECT YOUR PERSONAL INFORMATION.
Insured's private records and those of their covered family members are safe with us. We have a longstanding
policy that maintains the confidentiality of your personal data necessary to administer insurance and to provide
service.
It is widely known that many companies sell the names of customers to others. We do not sell or rent the name or
records of our insureds to any other organization or business concern.
Confidentiality and Security
We implemented policies and procedures to protect the confidentiality of personal information. We maintain
physical, electronic, and procedural safeguards to protect personal data from unauthorized access and unanticipated
threats or hazards.
Information That May Be Collected
We receive personal information on insurance applications, claim forms, and other forms. In addition, we may
receive information from health care providers through the course of managing insurance transactions. We also
have personal information from transactions with us, our affiliates, and certain third parties with whom we have
service or joint marketing agreements. These third parties may include our reinsurers, insurance administrators,
consultants, medical information bureaus, and other insurers with whom we do business.
Generally, we receive personal information by telephone, in writing or through a computer. This includes
information about policies, premiums, and claims. If we need more information from medical professionals or
consumer reporting agencies, it must be authorize by the insured.
Independent Insurance Agents
The independent insurance agents authorized to sell our products are not our employees. Since these agents are
subject to the same privacy laws that govern us, these agents may have privacy obligations that are independent of
ours.
Information We May Disclose
We regard all personal information as confidential. We will not disclose personal information unless we are allowed
or required by law or if we are told we can by the insured. We only make those disclosures that are necessary to
administer insurance products, to effect transactions made in the ordinary course of our business and to pay claims.
We may provide personal information only to our affiliates, agents, joint marketing partners, and certain third parties
such as insurance administrators, reinsurers, consultants, and regulatory or governmental authorities.
We work with our affiliates and outside firms to help with administrative and other insurance services and
marketing. As permitted bylaw, these affiliates and firms may use certain identifying and non-medical information.
Our affiliates are subject to the same policies regarding privacy of your information as we are. Our policy is to
require our vendors and third party administrators to pledge to maintain the confidentiality of personal information
and abide by all applicable privacy laws. These firms are prohibited from using or disclosing personal information
given to us for any purpose other than the work they are performing or as required by law.
Further Information
Insureds have the right to obtain access to recorded personal information in our possession or control, to request
correction if it is believed the information may be inaccurate and to add a rebuttal statement to the file if there is a
dispute. Each insured has the right to know the reasons for an adverse underwriting decision. Previous adverse
underwriting decisions may not be used as the basis for subsequent underwriting decisions unless we make an
independent evaluation of the underlying facts. Further, each insured has the right, with very narrow exceptions, not
to be subjected to pretext interviews.
Even if our relationship ends, we pledge to maintain our privacy policy and practices.
If you have any questions about our privacy policy, please write us at....
Dearborn National Life
Administrative Office:
1020 31 st Street
Downers Grove, IL 60515-5591
The following is a list of entities that this notice applies to, as
Dearborn National Life Insurance Company
Colorado Bankers Life Insurance Company
And their offillates:
Dental Network of America
Medical Life Insurance Agency
Industry Savings Plans, Inc.
Combined Services, LLC
Health Care Service Corporation, a Mutual Legal Reserve Company
1"n
ERISA INFORMATION STATEMENT* 0
The benefits described in your certificate are insured by a Policy issued by Dearborn National Life Insurance
Company ("Dearborn National"), pursuant to an Employee Welfare Benefit Plan (" the Plan") established by your
employer ("the Company"). This ERISA Information Statement ("EIS") describes some of the key provisions of the
Plan in effect as of the Effective Date of the Policy.
It is not the intention of the EIS to cover all situations that may arise, but to provide you with a general
understanding of your benefits. In the case of any item not covered by the EIS or in the event of any conflict
between the EIS and the Policy, the Plan will always control. You should not rely on any oral explanation,
description, or interpretation of the Plan because the written terms of the Plan will govern. Your right to any benefit
depends on the actual facts and terms and conditions of the particular Plan; no rights accrue by reason of or arising
out of any statement shown in or omitted from this EIS.
A. ADMINISTRATION OF THE PLAN
The Plan Administrator is responsible for the administration of the Plan. The Plan Administrator has full
discretionary authority and control over the Plan. This authority provides the Plan Administrator with the power
necessary to operate, manage and administer the Plan. This authority includes, but is not limited to, the power to
interpret the Plan and determine who is eligible to participate, to determine the amount of benefits that may be paid
to a participant or his or her beneficiary, and the status and rights of participants and beneficiaries. The Plan
Administrator also has the authority to prescribe the rules and procedures under which the Plan shall operate, to
request information, and to employ or appoint persons to aid the Plan Administrator in the administration of the
Plan.
Failure by the Plan or the Plan Administrator to insist upon compliance with any provisions of the Plan at any time
or under any set of circumstances shall not operate to waive or modify the provision or in any manner render it
unenforceable as to any other time or as to any other occurrence, whether the circumstances are or are not the same.
No waiver of any term or condition of the Plan shall be valid unless contained in a written memorandum expressing
the waiver and signed by the person authorized by the Plan Administrator to sign the waiver.
The Plan may be amended, terminated or suspended in whole or in part, at any time without the consent of the
employees or beneficiaries. Any amendment, termination or suspension shall be in writing, and attached to the Plan.
Any amendment, termination or suspension shall be executed according to the Employer's authorized procedures.
Any such authorization may be specific to the Plan or persons authorized to act on behalf of the Employer or may be
general as to duties of such person. Except for termination or suspensions, any amendments affecting the Policy
and/or Certificate must also be approved in writing by an officer of Dearborn National and shall be effective as of
the date agreed to, in writing by the Plan Sponsor and Dearborn National. Notwithstanding anything to the contrary
in this document, the Policy shall terminate according to the provisions in the Policy.
The Plan has other fiduciaries, advisors and service providers. The Plan Administrator may allocate fiduciary
responsibility among the Plan's fiduciaries and may delegate responsibilities to others. Any allocation or delegation
must be done in writing and kept with the records of the Plan. The Plan's life benefits are provided pursuant to an
insurance policy issued to the Company. Dearborn National's (the Insurer's) services shall be limited to, and the
Plan Administrator has the full discretionary and final authority to:
resolve all matters when a review pursuant to the claims procedures has been requested;
interpret, establish and enforce rules and procedures for the administration of the Policy and any claim
under it; and
determine eligibility of Employees and Dependents for benefits and their entitlement to and the amount of
benefits.
Each fiduciary is solely responsible for its own improper acts or omissions. Except to the extent required by ERISA,
no fiduciary has the duty to question whether any other fiduciary is fulfilling all of the responsibilities imposed upon
the other fiduciary by law. Nor is a fiduciary liable for a breach of fiduciary duty committed before it became, or
after it stopped being, a fiduciary. However, a fiduciary may be liable for a breach of fiduciary responsibility of any
Plan fiduciary, to the extent provided in ERISA Section 405(a). The Employer makes no promise to continue these
• If this Plan is an ERISA plan, these ERISA provisions apply. However, your employer may issue a Summary Plan Description
("SPD"). If it does, and if there are any conflicts between the SPD and the EIS in regards to your ERISA rights, the SPD
provisions will always control.
FDL EIS Standard 412009 rev'd.
benefits in the future and rights to future benefits will never vest. Retirement does not give any retiree any vested
right to continue to participate or receive Plan benefits.
B. CLAIMS PROCEDURE:
When you or your Beneficiary are eligible to receive benefits, you or your Beneficiary, or your authorized
representative (collectively, "you") must notify the Plan Administrator by submitting the proper form in writing.
You may do this by sending notice of your claim to the Plan Administrator who has been appointed to assist
Dearborn National in the claims processing for this Plan or by contacting Dearborn National directly at:
Claims Department '(f��•.
Dearborn National Life Insurance Company r
1020 31 st Street ,�� j `.�
Downers Grove, IL. 60515-5591 t��r
1-800-778-2281
For the purpose of this Section, including Subsections l and 2 below, the terms "w ltten" and "in writing"
include "electronic." Any action required to be "written" or "in writing," may be done"�electronically, where
available. If Dearborn National uses electronic notices, it will do so in accordance with'29 CFR 2520.104b-
IC(i), (iii) and (iv). i
1. Disability Insurance Plans fry *�
fir Yr..* r
Dearborn National will give you a written response to your claim;jusually withiit,45 days. The time for decision
may be extended for two additional 30 day periods provided.that, prior to any extension period, Dearborn National
notifies you in writing that an extension is necessary due tomatters;beyond the control of the Plan, identifies those
matters and gives the date by which it expects to render its decision. If the extension is due to your failure to submit
information necessary to decide your claim, the time for decision "I.,
hall. be tolled from the date on which we send you
notice of the extension until the date we receive your response to our request. This period will be no longer than 45
days after we have requested the information. At that tiiiieywe will decide your claim based on the information we
have at that time. `(t
' If the claim is denied in whole or in�4 S � � �
part, you;wilhreceive a written notice giving the following:
the reason for the denial;,4r.,
the Policy provisions on which the denial is based;
an explanation of Whitt`other information, if any, may be needed to process the claim and why it is needed;
U",
the steps that you liaye to follow,to; have the claim reviewed;
a statement that you Have the right to bring a civil action under section 502(a) of ERISA after you appeal
our decision and after you receive a written denial on appeal; and
if an internal, rule guideline, protocol, or other similar criterion was relied upon in making the denial, either
i the -sr c fe rule guideline, protocol or other similar criterion' or (ii) a statement that such a rule
C) P , 8 , P � C•) ,
guideline, protocol or other similar criterion was relied upon in making the denial and that a copy will be
provided free of charge to you upon request; and
if denial is based on medical judgment, either (i) an explanation of the scientific or clinical judgment for the
determination, applying the terms of the Plan to your medical circumstances, or (ii) a statement that such
explanation will be provided to you free of charge upon request.
If the claim has been denied, in whole or in part, you can appeal the denial to us for a full and fair review. You have
at least 180 days to appeal from the claim denial.
You may:
a. request a review upon written application within 180 days of the claim denial;
b. request, free of charge, copies of all documents, records and other information relevant to your claim; and
* If this Plan is an ERISA plan, these ERISA provisions apply. However, your employer may issue a Summary Plan Description
("SPD"), If it does, and if there are any conflicts between the SPD and the EIS in regards to your ERISA rights, the SPD
provisions will always control.
FDL EIS Standard 4/2009 rev'd.
C. submit written comments, documents, records and other information relating to your claim, without regard
to whether such information was submitted or considered in the initial benefit determination.
Dearborn National will make a decision no more than 45 days after we receive your appeal. The time for decision
may be extended for one additional 45 day period provided that, prior to the extension, Dearborn National notifies
you in writing that an extension is necessary due to special circumstances, identifies those circumstances and gives
the date by which it expects to render its decision. If your claim is extended due to your failure to submit
information necessary to decide your claim on appeal, the time for your decision shall be tolled from the date on
which the notification of the extension is sent to you until the date we receive your response to the request. The
written decision will include specific references to the Plan provisions on which the decision is based and any other
notice(s), statement(s) or information required by applicable law.
2. Life Insurance Plans
Dearborn National will give you a decision no more than 90 days after receipt of due proof of loss, except in special
circumstances (such as the need to obtain further information), but in no case more than 180 days after the due proof
of loss is received. The written decision will include specific reasons for the decision and specific references to the
Plan provisions on which the decision is based.
If the claim is denied, in whole or in part, the claimant will receive a written notice giving the following:
- the reason for the denial;
- the Policy provisions on which the denial is based;
- an explanation of what other information, if any, may be needed to process the claim and why it is needed;
and
- the steps that have to be followed to have the claim reviewed.
Any denied claim may be appealed to the Insurer for a full and fair review. The claimant may:
a) request a review upon written application within 60 days of receipt of claim denial;
b) upon request and free of charge, review pertinent documents, records and other information relevant to the
claim and receive copies of same; and
C) submit issues, comments, records, and other information in writing.
A decision will be made by the Insurer no more than 60 days after receipt of the request for review, except in special
circumstances (such as the need to obtain additional evidence), but in no case more than 120 days after the request
for review is received. The written decision will include specific reasons for the decision and specific references to
the Plan provisions on which the decision is based. The decision will advise you of any other appeal rights you have
under the Plan, as well as your right to bring an action under Section 502(a) of ERISA.
C. ERISA NOTICE OF YOUR RIGHTS
As a participant in the Plan you are entitled to certain rights and protections under the Employee Retirement Income
Security Act of 1974 ("ERISA"). ERISA provides that all Plan participants shall be entitled to:
Examine, without charge, at the Plan Administrator's office and at other locations, such as work sites and union
halls, all Plan documents, including insurance contracts, collective bargaining agreements and copies of all
documents filed with the U.S. Department of Labor, such as detailed annual reports and Plan descriptions.
Obtain copies of all Plan documents and other Plan information upon written request to the Plan Administrator. The
Plan Administrator may make a reasonable charge for the copies. Receive a summary of the Plan's annual financial
report. The Plan Administrator is required to furnish each participant with a copy of this summary annual report.
In addition to creating rights for the Plan participants, ERISA imposes duties upon the people who are responsible
for the operation of the employee benefit Plan. The people who operate your Plan, called "fiduciaries" of the Plan,
have a duty to do so prudently and in the interest of you and other Plan participants and beneficiaries.
No one, including your employers, your union, or any other persons, may fire you or otherwise discriminate against
you in any way to prevent you from obtaining a welfare benefit or exercising your rights under ERISA. If your
claim for a welfare benefit is denied in whole or in part you must receive a written explanation of the reason for the
• If this Plan is an ERISA plan, these ERISA provisions apply. However, your employer may issue a Summary Plan Description
("SPD"). If it does, and if there are any conflicts between the SPD and the EIS in regards to your ERISA rights, the SPD
provisions will always control.
FDL EIS Standard 412009 redd
e
denial. You have the right to have the Plan review and reconsider your claim. Under ERISA, there are steps you
can take to enforce your rights. For instance, if you request materials from the plan and do not receive them within
30 days, you may file a suit in federal court. In such a case, the court may require the Plan Administrator to provide
the materials and pay you up to $110 a day until you receive the materials, unless the materials were not sent
because of reasons beyond the control of the Plan Administrator.
If you have a claim for benefits which is denied or ignored, in whole or in part, you may file suit in a state or federal
court. If it should happen that Plan fiduciaries misuse the Plan's money, or if you are discriminated against for
asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in federal
court. The court will decide who should pay costs and legal fees. If you are successful the court may order the
person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees,
for example, if it finds your claim is frivolous.
If you have any questions about this statement or about your rights under ERISA, you should contact the nearest
office of the Pension and Welfare Benefits Administration, United States Department of Labor, listed in your
telephone directory or the Division of Technical Assistance and Inquiries, Employee Benefit Security
Administration, United States Department of Labor, 200 Constitution Avenue, NW Washington DC 20210.
D. PARTICIPANT'S RIGHTS "W". .,o
This Plan shall not be deemed to constitute a contract between the Company and any participant or to be
consideration or an inducement for the employment of any participant or employee. Nothing contained in this Plan
shall be deemed to give any participant or employee the right to be retained in the service of the Company or to
interfere with the right of the Company to discharge any participant or employee at any time regardless of the effect
which such discharge shall have upon him or her as a participant of this Plan.
* if this Plan is an ERISA plan, these ERISA provisions apply. However, your employer may issue a Summary Plan Description
("SPD"). If it does, and if there are any conflicts between the SPD and the EIS in regards to your ERISA rights, the SPD
provisions will always control.
FDL EIS Standard 412009 rev'd
N
Voluntary Accident
Insurance
Employee Benefit Booklet
Dearborn 1 National®
SAMPLE IL
F01234-0001
Class 1-01
Plan 2
Products and services marketed under the Dearborn National* brand and the star logo are underwritten and/
or provided by Dearborn National* Life Insurance Company (Downers Grove, IL) in all states (excluding
New York), the District of Columbia, the United States Virgin Islands, the British Virgin Islands, Guam and
Puerto Rico.
01/02/2018
This plan is an "employee welfare benefit plan," ("Plan") as defined in Section 3(l) of the Employee Retirement Income
Security Act of 1974, as amended ("ERISA"). 0
This document serves to provide important information about the Plan. It is not the entire Plan document, but a summary of
important information about the Plan. In addition to this summary plan description ("SPD"), ERISA requires that you receive a
Statement of ERISA Rights, a description of Claim Procedures, and other specific information about the Plan. Your employer
or Plan Administrator maintains the full Plan Document. If there is a conflict between the Plan Document and this SPD, the
Plan Document controls. A copy of the Plan Document is available for review during normal working hours in the office of the
Plan Administrator.
The benefits described in your Plan document are provided under a group Plan sponsored by the Employer and insured by
Dearborn National Life Insurance Company.
SPD 712013 Revised
K
SUMMARY PLAN DESCRIPTION
1.
PLAN NAME:
EMPLOYEE WELFARE PLAN
If different, the name by which the plan is commonly known.
2.
PLAN TYPE:
Welfare Benefit Plan providing a Group
Accident Insurance Policy and Certificate
3.
PLAN SPONSORIEMPLOYER'S NAME AND ADDRESS:
ABC COMPANY
Name and address of employer sponsoring the Plan or employee
organization maintaining the Plan
4.
EMPLOYER IDENTIFICATION NUMBER (EIN):
36-4284078
Employer identification number assigned by the IRS to the Plan
Sponsor
5.
PLAN NUMBER:
501
Number assigned by the Plan Sponsor. This number is used for
Form 5500 reporting. Each Plan should be assigned a unique
number that is not used more than once.
6.
ERISA PLAN YEAR ENDS ON EACH:
DECEMBER 31
This is the end of the Plan Year for maintaining the Plan's fiscal
records and may be different from she insurance policy year.
7.
PLAN ADMINISTRATOR'S NAME, ADDRESS, AND
ABC COMPANY
TELEPHONE NUMBER:
8.
AGENT FOR SERVICE OF LEGAL PROCESS ON THE
SAMPLE, INC.
PLAN:
9.
SOURCES OF FUNDING AND CONTRIBUTIONS:
The Plan is funded as an insured plan under
Contributions are, for example, employer, employee organization
policy number F012345 issued by Dearborn
or employee contributions and the method by which the amount of
National Life Insurance Company. Contributions
the contributions is calculated.
to the Plan are made as stated on the Schedule of
Funding is the medium by which the Plan is funded. For example,
Benefits in the Group Insurance Certificate. The
the identity of the insurance company or trust fund through which
employer determines the method of funding and
the Plan is funded or benefits are provided.
contributions, if any, to be made by the
participants.
SPD 712013 Revised
K
N-1
10. TYPE OF ADMINISTRATION:
This plan is administrated by insurer
administration.
11. CLAIM ADMINISTRATION:
The Claim Administrator is not the "plan
administrator" of your Plan, as defined in Section
3(16)(A) of ERISA. The Plan Administrator
has selected Dearborn National Life Insurance
Company ("Dearborn National") as the claims
administrator of your Plan and has delegated to
Dearborn National the authority and discretion
to administer the terms of the applicable group
policy provisions such as making initial claim
determinations concerning the availability
of benefits, and the final review and benefit
determinations for appealed claims.
12. EACH TRUSTEE'S NAME, TITLE, AND ADDRESS OF
PRINCIPAL PLACE OF BUSINESS:
This is only applicable if the Plan has trustees.
13. LABOR ORGANIZATION:
This is applicable if the Plan is subject to a CBA.
14. PLAN AMENDMENT AND TERMINATION PROCEDURE:
The Employer reserves full authority, at its sole
discretion, to terminate, suspend, withdraw, reduce,
amend or modify the Plan (including any related
documents and underlying policies), in whole
or in part, at any time, without prior notice. Any
amendment, modification, or termination must be
in writing and endorsed on or attached to the Plan.
The Employer also reserves the right to adjust your
share of the cost to continue coverage by the same
procedures. Rights with respect to termination
of insurance benefits are stated in the Policy and
Certificate. The employer can request a Policy
change, including a change to benefits, rights and
obligations under the Policy but only an officer of
Dearborn National Life Insurance Company can
approve a change to the Policy. The change must
be in writing and endorsed on or attached to the
Policy
15. ELIGIBILITY FOR PARTICIPATION AND BENEFITS:
These requirements are found in the Policy and
Certificate incorporated herein by reference.
16. CIRCUMSTANCES CONCERNING INELIGIBILITY,
These requirements are found in the Policy and
DISQUALIFICATION, OR DENIAL OR LOSS OF
Certificate incorporated herein by reference.
BENEFITS:
17. CLAIMS PROCEDURES:
The Plan's claims procedures are furnished
The procedures which govern claims for benefits and requests for
automatically, without charge, as a separate
review of denied claims.
document. Refer to the ERISA Information
Statement incorporated herein by reference.
SPD 112013 Revised
• ® Administrative Office:
COAG � National 1024 31st Street
Downers Grove, IL 60515
(A stock life insurance company, herein called "We" "Us" or "Our")
Having issued Group Policy No. F021902
(herein called the Policy)
to
SAMPLE
(herein called the Policyholder)
GROUP ACCIDENT INSURANCE CERTIFICATE
CERTIFIES that You are insured, if You qualify under the ELIGIBILITY AND EFFECTIVE DATES provision, and remain
insured in accordance with the terms of the Policy. Your insurance is subject to all the definitions, exclusions, limitations and
conditions of the Policy, and it takes effect as stated in the ELIGIBILITY AND EFFECTIVE DATES provision.
This Certificate describes Your eligibility for benefits and the terms and provisions of the Policy. It replaces and cancels any
other Certificate previously issued to You under the Policy.
If the terms and provisions of this Group Insurance Certificate (issued to You) are different from the Policy (issued to the
Policyholder), the Policy will govern. Your coverage may be canceled or changed under the terms and provisions of the Policy
READ THIS CERTIFICATE CAREFULLY
Signed for Dearborn National Life Insurance Company
1616441.- Q4*VAK--
Secretary President
Voluntary Group Accident Insurance Certificate
with Dependent Accident Benefits
Non -Participating
THIS IS AN ACCIDENT ONLY CERTIFICATE
THIS IS NOT A WORKERS' COMPENSATION POLICY
DNL2-604AIC-0316 IL
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DNL2-604AIC-0316 IL
POLICYHOLDER:
POLICY NUMBER:
POLICY EFFECTIVE DATE:
ANNUAL ENROLLMENT PERIOD:
SCHEDULE OF BENEFITS
SAMPLE
F012345-0001
01/01/2018
November 1 - November 30
O
ELIGIBILITY:
All Active Employees of the Policyholder working in the United States of America who
Class 01
are Actively at Work for the Policyholder and who have completed the Eligibility Waiting
Period are eligible for the insurance. A full-time Employee is one who regularly works a
minimum of 30 hours per week for the Policyholder. Part-time, seasonal and temporary
Employees of the Policyholder are not eligible.
Eligibility Waiting Period:
Current Employees: First of the month following 60 Days of continuous, full-time
Active Work
New Employees: First of the month following 60 Days of continuous, full-time
Active Work
Policyholder Contribution:
Voluntary Accident 0% of premium
Coverage For:
Employee, Spouse, and Dependent Child
Dependent Benefit amounts
unless otherwise stated:
0
Spouse Benefits
100% of the Employee's benefit amount
Dependent Child Benefits
100% of the Employee's benefit amount
Live birth to age 26
Coverage Type: Group Accident Insurance On and off the job coverage
Reduction of Benefits: Benefits terminate at age 70, or retirement whichever comes first.
Portability:
Benefit Eligibility Voluntary
Insured Eligibility Employee, Spouse, Dependent Child(ren)
Portability Benefit Duration To Age 65
DNL2-604AIC-03 l6 IL 1
C.
Accident Insurance Benefits
Burn Benefit
Square Centimeters of the body surface 2nd Degree Burn 2nd or 3rd Degree Burn
burned
Less than 20 $125 $250
DNL2-604AIC-0316 IL 2
Emergency Treatment Benefits
Accident Emergency Treatment Benefit
Emergency Room
$150
Urgent Care Center
$150
Physician's Office
$50
X -Ray Benefit
$50
Accident Follow -Up Treatment Benefit
$50
Hospital Admission Benefit
$1,200
Intensive Care Unit (ICU) Admission Benefit
$2,000
Hospital Confinement Benefit
$250
Intensive Care Unit (ICU) Confinement Benefit
$500
Accident Injury Benefits
Dislocation Benefit
Open Reduction
Closed Reduction
Hip
$4,000
$1,500
Knee
$2,000
$1,500
Shoulder
$2,000
$1,500
Collar bone
$1,700
$500
Ankle or foot (excluding toes)
$1,500
$500
Lower jaw
$1,000
$500
Wrist
$750
$500
Elbow
$750
$500
Toe
$300
$100
Finger
$300
$100
Local or no anesthesia (percent of closed reduction)
25%
Burn Benefit
Square Centimeters of the body surface 2nd Degree Burn 2nd or 3rd Degree Burn
burned
Less than 20 $125 $250
DNL2-604AIC-0316 IL 2
At least 20 but less than 40
$250
$625
At least 40 but less than 65
$500
$1,250
At least 65 but less than 160
$750
$3,750
At least 160 but less than 225
$1,000
$8,750
225 or more
$1,250
$12,500
Skin Grafi Benefit as percentage of Bum
50%
50%
Benefit
$1,500
$500
Eye Injury Benefit
Surgical Repair $300
Removal of foreign body $65
Laceration Benefit
Laceration with no repair $35
Total of all lacerations with repair:
Less than 5 cm $65
5 cm 15 cm $250
Greater than 15 cm $500
Fracture Benefit
Open Reduction
Closed Reduction
Hip
$5,000
$2,000
Leg
$3,000
$1,000
Hand (excluding fingers)
$1,500
$500
Foot (excluding toestheel)
$1,500
$500
wrist
$1,500
$500
Elbow
$1,500
$500
Ankle
$1,500
$500
Kneecap
$1,500
$500
Shoulder blade
$1,500
$500
Forearm
$1,500
$500
Lower jaw
$1,500
$500 {
DNL2-604AIC-0316 IL 3
Vertebrae (body of)
Pelvis
Sternum
Upper jaw or face (excluding nose)
Upper arm
Rib
Nose
Heel
Finger
Coccyx
Toes
Vertebral Processes
Skull - depressed
Skull - simple
Chip Fracture (% of Closed Reduction)
Concussion Benefit
Dental Benefit
Broken tooth repaired with crown
Broken tooth resulting in extraction
Coma Benefit
Paralysis Benefit
Quadriplegia
Paraplegia
Hemiplegia
Surgical Procedure Benefit
Arthroscopy
Open abdominal
DNL2-604AIC-03161L
$2,000
$2,000
$2,000
$1,200
$1,200
$2,200
$1,000
$1,000
$1,000
$500
$500
$3,000
$3,500
$1,800
Surgical Benefits
4
$700
$700
$700
$375
$375
$500
$250
$250
$250
$250
$250
$400
$1,875
$800
25%
5150
$400
$130
$12,500
$12,500
$6,250
$4,750
$300
$1,250
Cranial
Hernia
Thoracic Surgery
Repair of Tendon and/or Ligament
Repair of Torn Rotator Cuff
Repair of Ruptured Disc
Repair of Torn Knee Cartilage
Miscellaneous Surgical Procedure Benefit
Surgery with General Anesthesia
Surgery with Conscious Sedation
Outpatient Ambulatory Surgical Center Benefit
Increase to applicable Surgical or Miscellaneous Surgical benefit
Additional Accident Benefits
Major Diagnostic Exam Benefits
Epidural Pain Management Benefit
Physical Therapy Benefit
Rehabilitation Unit Benefit
Appliance Benefit
Prosthesis Benefit
One prosthetic device
More than one prosthetic device
Blood/Plasma/Platelets Benefit
Ambulance Benefit
$1,250
$1,250
$1,250
$625
$625
$625
$625
$300
$120
20%
$200
$100
$35
$150
$125
$750
$1,500
$200
Ground Ambulance
$200
Air Ambulance
$1,500
Transportation Benefit
$600
Lodging Benefit
$125
Accidental Death and Dismemberment Benefits
Accidental Death Benefit
Employee
$40,000
Spouse
$40,000
Child(ren)
$12,500
DNL2-604AiC-0316 IL 5
0
AO
Accidental Death Common Carrier Benefit
DNL2-604AIC-03 l6 IL 6
$150,000
$150,000
$25,000
$40,000
$40,000
$12,500
$40,000
$40,000
$12,500
$10,000
$10,000
$3,750
$2,000
$2,000
$625
Employee
Spouse
Child(ren)
Accidental Dismemberment Benefit
Loss of both arms and both legs
Employee
Spouse
Child(ren)
Loss of bath eyes, or both feet
Employee
or, both hands, or both arms or
both legs
Spouse
Child(ren)
Loss of one eye, or one foot, or
Employee
one hand, or one arm or one leg
Spouse
Child(ren)
Loss of one or more fingers and/ Employee
or one or more toes
Spouse
Child(ren)
DNL2-604AIC-03 l6 IL 6
$150,000
$150,000
$25,000
$40,000
$40,000
$12,500
$40,000
$40,000
$12,500
$10,000
$10,000
$3,750
$2,000
$2,000
$625
ELIGIBILITY AND EFFECTIVE DATE PROVISIONS
Who is eligible for this insurance?
The eligibility for this insurance is as indicated in the Schedule of Benefits.
The Eligibility Waiting Period is further defined in the Schedule of Benefits.
00001
When does Your Contributory insurance become effective?
You may enroll for coverage during the Annual Enrollment Period, unless You qualify because of a Change in Family Status.
Your Contributory coverage will become effective on the latest of the following dates:
1. If You enroll for coverage prior to the Policy Effective Date, the Policy Effective Date; or
2. If You enroll for coverage after the Policy Effective Date on the first of the month that falls on or next follows the date You
sign the Enrollment Form; or
3. If You enroll during an Annual Enrollment Period, the next Anniversary Date following the Annual Enrollment Period.
Coverage requested because of a Change in Family Status will become effective on the first of the month that falls on or next
follows the date You sign the Enrollment Form.
00003
Change in Family Status
If You experience a Change in Family Status, You may enroll for coverage, apply for additional coverage, or request changes
to Your current insurance coverage, provided the change is consistent with the Change in Family Status. For Your coverage to
become effective, We must receive a completed Enrollment Form within 31 days of the Change in Family Status.
Change in Family Status means:
I. You get married; or
2. You have a Dependent Child, or You adopt or become the legal guardian of a Dependent Child; or
3. Your Spouse dies or You become divorced; or
4. Your Dependent Child becomes emancipated or dies; or
5. Your Spouse is no longer employed, resulting in a loss of group insurance; or
6. You have a change in employment classification which results in You changing from part-time to full-time, or full-
time to part-time employment.
00004A
When does Dependent coverage become effective?
Your Dependent's coverage will become effective on the latest of:
1. The date Your coverage becomes effective under the Policy, if You have enrolled for Dependent coverage on or before that
date; or
2. The first day of the month following the date You enroll for Dependent coverage.
When does coverage for a new Spouse become effective?
Coverage for a new Spouse starts automatically on Your marriage. Your new Spouse will be a Covered Person for 31 days.
Your Spouse will cease to be a Covered Person unless:
L You request, in writing within those 31 days continuation of such Dependent coverage; and
2. The required premium is paid. Premium will be charged from the date of marriage.
When does coverage jar a newborn Child become effective?
DNL2-604AIC-0316 IL
M
If You have not previously elected Dependent Child coverage, coverage for a newborn Child starts automatically from the
moment of birth if a Child is born to You. The newborn Child will be a Covered Person for 31 days. The newborn Child will
cease to be a Covered Person after 31 days, unless:
1. You request in writing within those 31 days continuation of such Dependent Child coverage; and
2. The required premium is paid. Premium will be charged from the date of birth.
If You currently have Dependent Child coverage, Your newborn Child will be automatically added to Your coverage.
Dependent Child coverage will also be extended to newly adopted, foster or step Children, as of the date they become
financially dependent on You for support, provided they otherwise meet the definition of a Dependent Child.
00005
What is an Annual Enrollment Period?
Unless otherwise specified, Annual Enrollment Period means a period of time during which Employees may enroll for
coverage or request changes to their benefit plan. The Annual Enrollment Period is shown on the Schedule of Benefits.
Initial requests for coverage or requests for changes to existing coverage made during the Annual Enrollment Period will
become effective on the next Policy Anniversary Date.
0000-7
Eligibility after You Terminate Employment
If Your coverage ends due to termination of employment and You do not elect continued coverage under the Portability Benefit
provision, You must meet all the requirements of a new Employee if You are rehired by the Policyholder at a later date.
Exception: If Your coverage ends due to termination of employment and You return to Active Work for the Policyholder in an
eligible class within 60 days, We will not apply a new Eligibility Waiting Period as defined in the Schedule of Benefits.
00009
Changes to Your coverage
A change in Your coverage may occur if.
1. You enroll for a different benefit amount; or
2. there is a Policy change; or
3. You enter another class and become eligible for a change in benefits.
If You are eligible for additional coverage due to a Policy change, the additional coverage will be effective on the date the
Policy change is effective, as requested by the Policyholder and agreed upon by Us.
If a change results in additional coverage, for reasons other than a Policy change, the change will be effective the first of the
month following the later of -
1.
f1. The date You enroll for the additional coverage; or
2. The date You become eligible for the additional coverage, if enrollment is not required.
Additional Contributory coverage is subject to Our receipt of premium.
If a change results in a decrease in coverage the change will take effect immediately.
00010
DNL2-604AIC-0316 IL
ACCIDENT INSURANCE BENEFITS
Emergency Treatment Benefits
What is the Accident Emergency Treatment Benefit?
The Accident Emergency Treatment Benefit is payable if a Covered Person receives treatment for an Injury. For purposes of
this benefit, Accident Emergency Treatment means treatment received in a Hospital Emergency Room, or Urgent Care Center
or a Physician's office within 72 hours of the Accident. This benefit is payable once per Accident, per Covered Person.
We will pay either the Hospital Emergency Room benefit, or Urgent Care Center benefit or Physician's office benefit. If
treatment is received at more than one location, We will pay the highest level benefit.
00011
What is the X -Ray Benefit?
The X -Ray Benefit is payable if a Covered Person receives an x-ray while receiving emergency treatment for an Injury. The
x-ray must be taken within 72 hours of the Accident. This benefit is limited to one payment per Accident, per Covered Person.
The X -Ray Benefit is not payable for exams listed in the Major Diagnostic Exams Benefit.
00012
What is the Accident Follow-up Treatment Benefit?
The Accident Follow-up Treatment Benefit is payable if a Covered Person receives emergency treatment for an Injury
and later requires additional treatment for an Injury sustained in the same Accident, over and above emergency treatment
administered in the first 72 hours following the Accident. We will pay for one treatment per day for up to 6 treatments per
Accident, per Covered Person. The treatment must begin within 30 days of the Accident or discharge from the Hospital.
Treatments must be furnished by a Physician in a Physician's office or in a Hospital on an outpatient basis. The Accident
Follow-up Benefit is not payable for the same days that the Physical Therapy Benefit is paid.
00013
What is the Hospital Admission Benefit?
The Hospital Admission Benefit is payable if a Covered Person is admitted for a Hospital Confinement of at least 18 hours for
treatment of an Injury. This benefit is payable only once per Hospital Confinement and only once per Accident, per Covered
Person. Hospital Confinements must start within 30 days of the Accident.
We will only pay the Hospital Admission Benefit or the Intensive Care Unit Admission Benefit. We will not pay both benefits
for a Covered Person for the same Accident.
00014
What is the Intensive Care Unit (ICU) Admission Benefit?
The ICU Admission Benefit is payable if a Covered Person is admitted directly to an ICU of a Hospital for at Ieast 18 hours of
treatment for an Injury. This benefit is payable only once per period of Hospital Confinement and only once per Accident, per
Covered Person. The ICU confinement must start within 30 days of the Accident.
We will only pay the Hospital Admission Benefit or the Intensive Care Unit Admission Benefit. We will not pay both benefits
for a Covered Person for the same Accident.
00015
What is the Hospital Confinement Benefit?
The Hospital Confinement Benefit is payable if a Covered Person is admitted for a Hospital Confinement of at least 18 hours
for treatment of an Injury. We will pay this benefit up to 365 days per Accident, per Covered Person. Hospital Confinements
must start within 30 days of the Accident. The Hospital Confinement Benefit and the Rehabilitation Unit Benefit are not paid
for the same date of service. The highest eligible benefit will be paid.
If a Covered Person is confined in an ICU for more than 15 days, We will pay the Hospital Confinement Benefit beginning on
the 16th day. The total amount payable per Accident will not exceed 365 days for Hospital Confinement and 15 days for ICU.
We will not pay both benefits for the same date of service.
00016 0
DNL2-604AIC-0316 IL
What is the Intensive Care Unit (ICU) Confinement Benef a
The Intensive Care Unit Confinement Benefit is payable if a Covered Person is confined to a Hospital Intensive Care Unit for
treatment of an Injury. This Intensive Care Unit Confinement Benefit is payable for up to 15 days per Accident, per Covered
Person. ICU confinement must start within 30 days of the Accident.
If a Covered Person is confined in an ICU for more than 15 days, We will pay the Hospital Confinement Benefit beginning on
the 16th day. The total amount payable per Accident will not exceed 365 days for Hospital Confinement and 15 days for ICU.
We will not pay both benefits for the same date of service.
00017
Accident Injury Benefits
What are the Accident Injury Benejits7
The Accident Injury Benefits are payable when a Covered Person receives treatment for an Injury sustained in an Accident.
00018
Dislocation Benefit:
The Dislocation Benefit is payable for a Covered Person who sustains a Dislocation as the result of an Injury. The Dislocation
must be diagnosed by a Physician within 90 days after the date of the Accident. The treatment of the Dislocation must require
anesthesia by a Physician. It can be corrected by open (surgical) or closed (non-surgical) Reduction. The applicable amount
payable is listed in the Schedule of Benefits.
We will pay for no more than two Dislocations per Accident, per Covered Person. We will pay for the first Dislocation of any
individual joint per Accident.
00019
Burn Benefit
The Burn Benefit is payable for a Covered Person who sustains bums as the result of Injuries received in an Accident. The
.- Covered Person must be treated by a Physician within 72 hours after the Accident. If the Covered Person meets more than one
of the bum classifications, as shown in the Schedule of Benefits, We will pay for only one burn at the highest amount. We will
pay this benefit once per Covered Person per Accident. The applicable amount payable is listed on the Schedule of Benefits.
00020
Skin Graft Benefit
The Skin Graft Benefit is payable for a Covered Person who receives a skin graft for a bum for which a benefit was received
under the Burn Benefit. This benefit is not payable for elective procedures and/or cosmetic surgery that are not the result of the
Accident. This benefit is payable once per Covered Person per Accident.
00021
Eye Injury Benefit
The Eye Injury Benefit is payable for a Covered Person who requires eye surgery or the removal of a foreign object from the
eye by a Physician as a result of an Injury. The surgery or the removal must occur within 90 days after the date of the Accident.
This benefit is payable once per Covered Person per Accident.
00022
Laceration Benefit
The Laceration Benefit is payable for a Covered Person who sustains Lacerations as the result of an Injury. A Laceration is
a cut. The Laceration must be repaired by a Physician within 72 hours after the Accident. We will pay the applicable amount
listed on the Schedule of Benefits. The benefit payable will be based on the total length of all Lacerations received in any
one .occident which require repair. If the Laceration is severe enough to require stitches but the Physician chooses to repair it
another way, We will pay it as if the Laceration was repaired with stitches.
If a Covered Person sustains a Laceration on a finger, toe, hand, foot or eye and later loses that finger, toe, hand, foot or
eye as a result of the same Accident, We will subtract the amount We paid under the Laceration Benefit from the Accidental
Dismemberment Benefit for loss of Finger, Toe, Hand, Foot or Eye benefit.
00023
DNL2-604AIC-03 l6 IL 10
Fracture Benefit
The Fracture Benefit is payable for a Covered Person who sustains a Fracture as the result of an Injury. The Fracture must be
diagnosed by a Physician within 14 days after the Accident and must require open (surgical) or closed (non-surgical) Reduction
by a Physician. The applicable amount payable is listed on the Schedule of Benefits.
We will pay no more than one Fracture Benefit per bone, per Accident.
If multiple bones are Fractured in an Accident, We will pay no more than two times the highest Fracture Benefit that would
otherwise be payable for any one of the bones involved.
We will pay the benefit amount shown in the Schedule of Benefits for the closed Reduction for Chip Fractures.
00024
Concussion Benefit
The Concussion Benefit is payable for a Covered Person who sustains a concussion as the result of an Injury. The Covered
Person must be diagnosed by a Physician within 72 hours after the date of the Accident using any type of medical imaging
procedures. This benefit is payable once per Covered Person per Accident.
00025
Dental Benefit
The Dental Benefit is payable for a Covered Person who requires dental work as the result of an Injury. This benefit is payable
for newly broken teeth repaired with a crown or resulting in extraction. The dental services must begin within 60 days of the
Accident. We will pay for no more than one crown and one extraction per Accident, per Covered Person, regardless of the
number of teeth involved.
00026
Coma Benefit
The Coma Benefit is payable for a Covered Person who sustains a Coma as the result of an Injury. The Coma must occur
within 14 days of the Accident and last for a period of seven or more consecutive days. Medically induced Comas are not
covered under the Coma Benefit. For the purpose of this benefit, Coma means a continuous state of profound unconsciousness
characterized by the absence of purposeful response to commands, including:
• Eye opening;
• Verbal responses; and
• Motor responses.
The Coma must require intubation for respiratory assistance.
00027
Paralysis Benefit
The Paralysis Benefit is payable for a Covered Person who becomes Paralyzed as a result of spinal cord Injuries sustained in
an Accident. The Paralysis must be confirmed by a Physician and be continuous for a period of at least 30 days. The Paralysis
Benefit is listed in the Schedule of Benefits and will be paid according to the number of paralyzed limbs. This benefit will be
payable once per Covered Person,
00028
Surgical Benefits
Surgical Procedure Benefit
The Surgical Procedure Benefit is payable for a surgery performed within 180 days of an Accident which resulted in an Injury.
Two or more surgical procedures performed through the same incision will be considered one operation, and benefits will be
paid based upon the surgery with the highest benefit amount. The covered surgeries are listed in the Schedule of Benefits.
40024
Miscellaneous Surgical Procedure Benefit
DNL2-604AIC-0316 IL 1 l
The Miscellaneous Surgical Procedures Benefit is payable for any other surgery to a Covered Person as the result of an Injury
sustained in an Accident that is not covered by any other surgical benefit. The surgery must be performed within 180 days of
the Accident. Only one Miscellaneous Surgical Procedures Benefit is payable per 24-hour period even though more than one
surgical procedures may be performed.
00030
Outpatient Ambulatory Surgical Center Benefit
The Outpatient Ambulatory Surgical Center Benefit is payable when a Covered Person undergoes a surgery listed in the
Surgical Procedures Benefit or the Miscellaneous Surgical Procedures Benefit and the surgery is performed at an Outpatient
Ambulatory Surgical Center. The Outpatient Surgical Center benefit will increase the Surgical Procedures Benefit or
Miscellaneous Surgical Procedures Benefit payable by the amount listed in the Schedule of Benefits.
00031
Additional Accident Benefits
What is the Major Diagnostic Exams Benefit?
The Major Diagnostic Exams Benefit is payable when a Covered Person requires one of the following exams for an Injury:
computerized tomography (CT scan), computerized axial tomography (CAT), magnetic resonance imaging (MRI), or
electroencephalography (EEG). These exams must be performed in a Hospital or a Physician's office and performed within 90
days of the Accident. This benefit is limited to one payment per Accident. Exams listed in the Major Diagnostic Exams Benefit
are not payable under the X -Ray Benefit.
00032
What is the Epidural Pain Management Beneft?
The Epidural Pain Management Benefit is payable when a Covered Person receives an epidural administered for pain
management in a Hospital or a Physician's office for an Injury. The epidural anesthesia must be administered within 60 days
after the Accident. This benefit is not payable for an epidural administered during a surgical procedure. This benefit is payable
no more than once per covered Accident, per Covered Person.
00033
What is the Physical Therapy Benefit?
The Physical Therapy Benefit is payable when a Covered Person receives emergency treatment for an Injury and later receives
physical therapy from a licensed Physical Therapist. The physical therapy must be on the advice of a Physician. Physical
therapy must be for Injuries sustained in an Accident and must start within 30 days of the Accident or discharge from a
Hospital Confinement due to an Injury. We will pay for one treatment per day for up to a maximum of ten treatments per
Accident, per Covered Person. The treatment must be completed within six months after the Accident. The Physical Therapy
Benefit is not payable for the same days that the Accident Follow -Up Treatment Benefit is paid.
00034
What is the Rehabilitation Unit Benefit?
The Rehabilitation Unit Benefit is payable when a Covered Person is admitted for a Hospital Confinement and is immediately
transferred to a bed in a Rehabilitation Unit of a Hospital for treatment of an Injury. This benefit is limited to 30 days for each
Covered Person per Accident. The Rehabilitation Unit Benefit will not be payable for the same days the Hospital Confinement
Benefit is paid. The highest eligible benefit will be paid.
00035
What is the Appliance Benefit?
The Appliance Benefit is payable when a Covered Person receives a medical appliance, prescribed by a Physician, as an aid
in personal locomotion, for an Injury. The appliance must be prescribed by a Physician within 90 days after the date of the
Accident. Benefits are payable for the following types of appliances: wheelchair, cane, leg brace, back brace, walker, and a pair
of crutches. This benefit is payable once per Accident, per Covered Person.
00036
DNL2-604AIC-0316 IL 12
What is the Prosthesis Benefit?
The Prosthesis Benefit is payable when a Covered Person requires use of one or more Prosthetic Devices as a result of an
Injury. The prosthetic(s) must be prescribed by a Physician and received within 365 days of the Accident. This benefit is not
payable for repair or replacement of existing Prosthetic Devices, even if the Prosthetic Device is damaged as a result of the
Accident. Prosthetic Devices do not include hearing aids, wigs, or dental aids to include false teeth. We will not pay this benefit
for a joint replacement. This benefit is payable once per Accident, per Covered Person.
00037
What is the Blood/Plasma/Platelets Benefit?
The Blood/Plasma/Platelets Benefit is payable when a Covered Person receives blood/plasma and/or platelets for the treatment
of an Injury. The blood/plasma and/or platelets must be administered within 90 days of the Accident. This benefit does not pay
for immunoglobulins. It is payable only one time per Accident, per Covered Person,
00036
What is the Ambulance Benefit?
The Ambulance Benefit is payable when a Covered Person requires ambulance transportation to a Hospital for an Injury.
Ambulance transportation must be within 72 hours of the Accident. A licensed professional ambulance company must provide
the ambulance service.
1:-0039
What is the Transportation Benefit?
The Transportation Benefit is payable when a Covered Person requires transportation from his residence to a facility for
medical treatment due to an Injury sustained in an Accident. The location of the treatment must be on the advice of the local
Physician for a Hospital Confinement, outpatient surgery or a Physician's office visit.
This benefit is not payable for transportation when the facility is located within a 50 -mile radius of the residence of the
Covered Person or for transportation by ambulance or air ambulance. This benefit is payable for up to three round trips per
Accident, per Covered Person. 0
We will also pay a Transportation Benefit for a companion to travel commercially (plane, train or bus) if accompanying a
covered Dependent Child who requires medical treatment due to an Injury sustained in an Accident.
00040
What is the Lodging Benefit?
The Lodging Benefit is payable if a companion accompanies a Covered Person who is admitted for a Hospital Confinement for
the treatment of an Injury and requires overnight lodging. This benefit is payable only for the same period of time the injured
Covered Person is confined to the Hospital. The Hospital and lodge motel/hotel must be more than 50 miles from the residence
of the Covered Person. This benefit is limited to one lodge room per night and is payable up to 30 days per covered Accident.
The companion must incur an expense for the lodging.
For the purposes of this benefit, Lodging means an establishment licensed under the laws where it is located, such as a motel,
hotel or other facility that provides sleeping accommodations to the general public in exchange for a fee.
00041
DNL2-604AIC-0316 IL 13
ACCIDENTAL DEATH and DISMEMBERMENT BENEFITS
What is the Accidental Death Benefit?
The Accidental Death Benefit is payable if a Covered Person dies within 90 days of the date of an Accident as a result of
Injuries received from that Accident. If We pay this benefit for a Covered Person, We will not pay the Accidental Death
Common Carrier Benefit for the same Covered Person.
00044
What is the Accidental Death Common Carrier Benefit?
The Accidental Death Common Carrier Benefit is payable if a Covered Person dies within 90 days of the date of an Accident
as a result of Injuries received from that Accident, while a fare paying passenger on a Common Carrier.
A Common Carrier means commercial airplanes, trains, buses, trolleys, subways, ferries and boats that operate on a regularly
scheduled basis between predetermined points. A Common Carrier operates under a license to transport passengers for hire. A
Common Carrier does not include private, on demand, or chartered transportation in which a Covered Person is a passenger at
the time of the Accident.
If We pay this benefit for a Covered Person, We will not pay the Accidental Death Benefit for the same Covered Person.
00045
What is the Accidental Dismemberment Benefit?
The Accidental Dismemberment Benefit is payable if a Covered Person suffers a loss listed in the Schedule of Benefits due
to Injuries sustained in an Accident. The loss must occur within 90 days of the Accident. We will pay only one loss and the
highest single benefit per Covered Person for Dismemberment. Benefits will be paid only once per Covered Person, per
Accident. If death and Dismemberment result from the same Accident, We will pay only the applicable Accidental Death
Benefit.
00047
DNL2-604AIC-0316 IL 14
LIMITATIONS AND EXCLUSIONS
Limitations:
In additions to the limitations and exclusions listed in the individual benefits, We will not pay any benefit for an Injury
resulting from or caused by:
1. any disease, Illness or infirmity of mind or body, and any medical or surgical treatment thereof; or
2. any error, mishap or malpractice during a medical, diagnostic or surgical treatment or procedure for any Illness; or
3. cosmetic surgery or other elective procedure that is not medically necessary; or
4. suicide or attempted suicide, while sane or insane; or
5. any intentionally self-inflicted Injury; or
6. war, declared or undeclared, whether or not a member of any armed forces; or
7. travel or flight in any aircraft while a member of the crew, or while engaged in the operation of the aircraft, or giving or
receiving training or instruction in such aircraft; or
8. commission of, participation in, or an attempt to commit an assault or felony as defined by state or federal law; or
9. The Covered Person being under the influence of any narcotic, hallucinogen, barbiturate, amphetamine, gas or fumes,
poison or any other controlled substance as defined in Title 1I of the Comprehensive Drug Abuse Prevention and Control
Act of 1970, as now or hereafter amended, unless prescribed by a Physician and used in the manner prescribed. Conviction
is not necessary for a determination of being under the influence; or
10. The Covered Person being intoxicated as defined by the laws of the jurisdiction in which the Accident occurred or .08%
blood alcohol content if the jurisdiction in which the Accident occurred does not define intoxication. Conviction is not
necessary for a determination of being intoxicated; or
11. active participation in a Riot. Riot means all forms of public violence, disorder, or disturbance of the public peace, by three
or more persons assembled together, whether with or without a common intent and whether or not damage to person or
property or unlawful act is the intent or the consequence of such disorder; or
12. driving or riding in any vehicle used in a race, speed or endurance test or for acrobatic or stunt driving.
Exclusions:
We will not pay any benefits for an Accident that occurred while the Covered Person was operating a motor vehicle and was
either:
1. under the influence of any narcotic, hallucinogen, barbiturate, amphetamine, gas or fumes, poison or any other controlled
substance as defined in Title 11 of the Comprehensive Drug Abuse Prevention and Control Act of 1970, as now or
hereafter amended, unless prescribed by a Physician and used in the manner prescribed. Conviction is not necessary for a
determination of being under the influence; or
2. intoxicated as defined by the laws of the jurisdiction in which the Accident occurred or .08% blood alcohol content if such
jurisdiction does not define intoxication. Conviction is not necessary for a determination of being intoxicated.
00056
DNL2-604AIC-0316 IL 15
O
PORTABILITYBENEFIT
What is the Portability Benefit?
If Your Voluntary group Accident Insurance terminates, You may elect to continue Your insurance in accordance with the terms
of the Policy by paying premiums directly to Us. If You elect Portability, You may also elect to continue Dependent coverage
under the conditions set forth below, but You may not enroll for Dependent coverage at the time You elect Portability. The
coverages eligible for Portability and the Portability Benefit Duration are in the Schedule of Benefits.
The premiums for the coverage continued under the Portability Benefit will not be the same as the premium You are charged
for Your group insurance under the Policy. Portability premium will be based on:
1. Our current rates for the applicant's age and class of risk at the time he elects Portability; and
2. the amount of insurance continued under Portability.
The maximum amount of insurance which may be continued under Portability is the amount of insurance You had in force
under the Policy at the time the Portability Benefit is elected, not to exceed the Portability Benefit amount as set forth in the
Schedule of Benefits.
What are Eligibility Requirements for Employee Portability?
To be eligible for Portability, You must meet the following conditions:
1. You must have been insured under the Policy or the Policy it replaced for at least one year prior to electing Portability; and
2. Your insurance, or a portion of it, must have terminated for reasons other than Illness, Injury, retirement or termination of
the Policy; and
3. You must be less than 60 years of age.
You must submit a Portability Request Form and the first premium within 31 days after the date Your insurance terminated.
We reserve the right to rescind any coverage amounts continued under Portability if it can be shown that You misrepresented
any of the information provided to support eligibility for Portability.
Can Dependent Insurance be Ported if Your Eligibility Terminates or if Your Spouse's Coverage Terminates?
If Dependent coverage ceases, You or Your covered Spouse may elect Portability of Dependent coverage as follows:
1. You may elect Portability of Dependent coverage if You meet the eligibility requirements to port Your insurance as shown
above and You are covered for Dependent coverage on the date Your coverage ceases.
2. Your Spouse may elect Portability of his group insurance, and/or insurance on covered Dependent Child(ren) if:
a. Your Spouse's insurance terminates because You die or Your eligibility for Dependent coverage ceases for reasons
other than retirement or termination of the Policy and Your Spouse is less than 60 years of age, and
b. Your Spouse had elected Dependent coverage on Eligible Dependent Child(ren) and such coverage is still in force
when Your eligibility for Dependent coverage ceased for reasons other than retirement or termination of the Policy.
Your Spouse must have been insured for such coverage(s) under the Policy for at least one year prior to electing Portability.
Exception: Portability is not available if Your Spouse's insurance terminates because he no longer meets the Policy definition
of a Dependent Spouse.
If these criteria are met, You or Your Spouse, must submit a Portability Request Form and pay the first premium within 31 days
after the date such Dependent coverage terminated.
We reserve the right to rescind any coverage amounts continued under Portability if it can be shown that You or Your Spouse
misrepresented any information provided to support eligibility for Portability of Dependent insurance.
A Portability Request Form means a form acceptable to Us which You complete and submit to elect coverage under the
Portability Benefit.
When will Portable Coverage Terminate?
Coverage continued under the Portability Benefit will terminate at the earliest of the following:
DNL2-604A1C-03161L 16
1. the date You return to .fictive Work with the Policyholder while the Policy is still in force; or
2. the date required premiums are not paid when due; or
3. the end of the Portability Benefit Duration in the Schedule of Benefits; or
4. the premium due date following the date a Dependent ceases to meet the definition of an eligible Dependent.
00057
DNL2-604AIC-0316 IL 17
TERMINATION PROVISIONS
When does Your coverage under the Policy end?
Unless coverage is continued under the Portability Benefit, Your coverage terminates on the earliest of the following dates:
1. the date on which the Policy is terminated; or
2. the date You stop making any required contribution toward payment of premiums; or
3. the effective date of an amendment to the Policy which terminates insurance for the class to which You belong; or
4. the earliest of:
a. the date You die; or
b. the date You are no longer a member of a class eligible for this insurance; or
c. the date You request termination of coverage under the Policy; or
d. the first of the month following the date You reach age 70; or
e. the date You are no longer Actively at Work as a result of a Disability, layoff, or leave of absence, or military leave.
Termination will not affect an eligible claim for Injuries the Covered Person sustained in an .occident which occurred while the
coverage was in force.
You may continue to be eligible for coverage, as follows:
Disability Until the end of the twelfth week following the week in which the Disability began, if all premiums are
paid when due.
Layoff Until the end of the thirtieth (30) day which the layoff began, if all premiums are paid when due.
Leave of Until the end of the thirtieth (30) day which the leave of absence began, if all premiums are paid when due,
Absence as governed by the Policyholder's Human Resource policy on family and medical leaves of absence or in
accordance with the FMLA provision below.
Military Leave Until the end of the thirtieth (30) day in which the military leave began, if all premiums are paid when due.
If coverage terminates due to termination of employment, group insurance shall terminate at 12:00 midnight on the last day for
which premium was paid.
For the purposes of this provision, Disability means You are unable to perform all of the Material and Substantial Duties of
Your Regular Occupation.
00058 IL
Will coverage be continued if You are eligible for leave under FMLA?
In the event You are eligible for and the Policyholder approves a leave of absence under the Family and Medical Leave Act of
1993 and its amendments (FMLA), or any applicable state family and medical leave law provided the Policyholder continues
to pay Your required premium, Your coverage will continue for a period of up to the later of:
1. the leave period permitted by the federal FMLA; or
2. the leave period permitted by applicable state law.
You are eligible for leave under this Act in order to provide care:
L After the birth of a Child; or
2. After the legal adoption of a Child; or
3. After the placement of a foster Child in Your home; or
4. To a Spouse, Child or parent due to their serious Illness; or
5. For Your serious health condition; or
6. For any event later added by amendment to the Act.
During Your FMLA period:
1. The Policyholder must remit the premium required by the Policy; and
DNL2-604AIC-0316 IL 18
2. Coverage will terminate if You do not return to work as scheduled according to the terms of Your leave of absence
agreement with the Policyholder.
00059
When does Dependent coverage end?
Unless insurance is continued under the Portability Benefit provision, Dependent coverage will end on the earliest of:
I . the first premium due date You are no longer an Employee (except in the case of Disability, layoff, or leave of absence, or
military leave as set forth above); or
2. the date on which the Policy is terminated; or
3. the first premium due date You stop making any required contribution toward payment of premiums; or
4. the effective date of an amendment to the Policy which terminates insurance for the class to which You belong; or
5. the first premium due date You:
a. are no longer a Member of a class eligible for this insurance; or
b. request termination of coverage under the Policy; or
c. reach age 70; or
d. are retired or pensioned; or
6. the date a Dependent Child or Spouse no longer meets the Policy definition of Dependent; or
7. the first of the month following 90 days after the date of Your death. Premium will not be payable during this period.
Coverage will continue past the age limit for Dependent Children who are primarily dependent on You for support and who
cannot work to support themselves due to a physical or mental incapacity which began before the age limit was reached.
Written proof of such incapacity must be provided to Us on request.
00060
O
DNL2-604AIC-0316 IL 19
GENERAL PROVISIONS
Entire Contract; Changes
The Entire Contract consists of.
1. The Group Insurance Policy;
2. The Application;
3. This Certificate;
4. The Enrollment Forms of the persons insured, including any individual statements; and
5. Any riders; endorsements; or amendments to the Policy or the Certificate.
Coverage under the Policy can be amended by mutual consent of the Policyholder and Us. No change in the Policy is valid
unless approved in writing by one of Our officers. No agent has the right to change the Policy or to waive any of its provisions.
Statements on the Application
All statements made in any signed Application, or other written and signed statement, are considered representations and not
warranties (absolute guarantees). No representation by:
1. the Policyholder in applying for the Policy will make it void unless the representation is contained in the signed
Application or other written and signed statement; or
2. any Employee in enrolling for insurance under the Policy will be used to reduce or deny a claim unless a copy of the
Application for Insurance or other written and signed statement, if applicable, has been signed by the Employee and has
been given to the Employee.
Legal Actions
Unless otherwise provided by federal law, no legal action brought to recover on the Policy of any kind may be filed against Us:
1. until 60 days after proof of claim has been given; or
2. more than 3 years after proof of the Accident must be filed, unless the law in the state where You live allows a longer
period of time.
Clerical Error
Clerical error or omission by Us to the Policyholder will not:
1. Prevent You from receiving coverage, if You are entitled to coverage under the terms of the Policy; or
2. Cause coverage to begin or coverage to continue for You when the coverage would not otherwise be effective.
If the Policyholder gives Us information about You that is incorrect, We will:
1. Use the facts to decide whether You have coverage under the Policy and in what amounts; and
2. Make a fair adjustment of the premium.
Incontestability
The validity of the Policy shall not be contested, except for non-payment of premiums, after it has been in force for two years
from the date of issue. No statement You made relating to Your insurability under the Policy will be used to contest the validity
of the insurance with respect to which such statement was made after such insurance has been in force for two years during
Your lifetime, and in no event unless the statement is contained in a written instrument signed by You and a copy is given to
You or to Your beneficiary.
Premium Provisions
Premiums are payable in United States dollars on or before their due dates. The Policyholder has agreed to deduct from Your
pay any premiums payable for Your Contributory coverage. The Policyholder agrees to and is responsible for remitting such
premiums for the entire time coverage under the Policy is in effect.
Premium charges for increases in insurance amounts becoming effective during a Policy month will begin on the next premium
due date. Premium charges for insurance terminating during a Policy month will cease at the end of the month in which such
insurance terminates. This method of charging premium is for accounting purposes only. It will not extend any insurance
coverage beyond the date it would otherwise have become effective or terminated.
DNL2-604AIC-0316 IL 20
Misstatement of Age
If You have misstated Your age or the age of a Dependent, the true age will be used to determine:
1. the effective date or termination date of insurance; and
2. the amount of insurance; and
3. any other rights or benefits.
Premiums will be adjusted to reflect the premiums that You should have been paid if the true age had been known.
Conformity with State Statutes and Regulations
If any provision of the Policy conflicts with the statutes and regulations of the state in which the Policy was issued or delivered,
it is automatically changed to meet the minimum requirements of the statute.
Assignment
Insurance, if any, on Your Spouse or Child is not assignable. You have the right to make an absolute assignment of all rights
and interest under the Policy to any person permitted by law, subject to all of the following terms and conditions:
1. The assignment must transfer rights and interest of all insurance under the Policy. You may not make a collateral or partial
assignment.
2. Your rights and interest under the Policy include, but are not limited to the following:
3.
4. a. the right to make contributions required to keep the insurance in force;
b. the right to change the beneficiary; and
c. the right to convert.
The assignment will apply to all insurance under the Policy in effect on the date of the assignment or which becomes
effective after that date. The assignment will have no effect unless it is made in writing, signed by You, and delivered to
the Policyholder during Your lifetime. The assignment will take effect on the date You signed the assignment, provided the
Policyholder receives it before benefits are paid or any other action is taken by Us. If We have paid benefits or taken any
other action before the Policyholder receives Your designation, the assignment will not go into effect. Neither We, nor the
Policyholder are responsible for the validity, sufficiency or effect of the assignment.
All insurance benefits will be paid in accordance with the beneficiary designation on file with the Policyholder, and the
beneficiary provisions of the Policy (not to the assignee unless the assignee is also the beneficiary). Any payment made
by Us in accordance with the beneficiary designation on file with the Policyholder and the beneficiary provisions of the
Policy will fully discharge Us to the extent to the payment.
You may only change an absolute assignment made by You with written consent of the absolute beneficiary(s), and a copy
of the written consent must be on file with the Policyholder.
You may not make any assignment which is inconsistent with these requirements.
On Your death, Your beneficiary may make an assignment of benefits to a funeral home provided that We receive written
notice of the assignment prior to payment of any benefits. Any payment made by Us to a beneficiary prior to receiving notice
of the assignment will fully discharge Us to the extent of the payment.
Retention of Discretion
We shall have the exclusive right to interpret the terms of the Policy. The decision about whether to pay any claim, is within
Our sole discretion and such decisions shall be final and conclusive.
00061 IL
0
DNL2-604AIC-0316 IL 21
UNIFORM CLAIM PROVISIONS
Initial Notice of Claim
We must receive written notice of the Accident within 30 days of the date of the Accident, or as soon as reasonably possible.
The Policyholder can assist with the appropriate telephone number and address of Our Claim Department. Notice may be sent
to Our Claim Department at the address shown on the claim form or given to any authorized agent of Ours.
Telephonic Claim Notification
In lieu of written Proof, We may accept telephonic notice and Proof. All time limits in the Policy applicable to the filing of
Proof and commencement of Legal Actions shall apply to notice and Proof filed by telephone or other means acceptable to Us.
Claim Forms
Within 15 days of Our being notified in writing of a claim, We will supply the claimant with the necessary claim forms. The
claim form must be completed and signed by the claimant, the Policyholder and the claimant's Physician. If the appropriate
claim forms are not received within 15 days, then the claimant will be considered to have met the requirements for written
Proof only if We receive written Proof, which describes the occurrence, extent and nature of the Accident and Injuries.
77me Limitfor Filing Your Claim
We must receive written Proof within 90 days after the date of the Accident. If it is not possible to give Us written Proof
within 90 days, the claim is not affected if the Proof is given as soon as possible. However, unless the claimant is legally
incapacitated, written Proof must be given no later than one year after the time Proof is otherwise due.
No benefits are payable for claims submitted more than 1 year after the time Proof is due. However, benefits may be paid if it
can be shown that:
1. It was not reasonably possible to give written Proof during the one year period, and
2. Proof was given as soon as was reasonably possible.
We will give You written response to Your claim, usually within 45 days. The time for decision may be extended for two
additional 30 day periods provided that, prior to any extension period, We notify You in writing that an extension is necessary
due to matters beyond Our control, identify those matters and gives the date by which We expect to render a decision. If the
extension is due to Your failure to submit information necessary to decide Your claim, the time for decision shall be tolled from
the date on which We send You notice of the extension until the date We receive Your response to Our request. This period
will be no longer than 45 days after We have requested the information. At that time We will decide Your claim based on the
information We have at that time.
Physical Examinadon/Autopsy
On receipt of a claim, We may have a Covered Person examined, at Our expense, at any reasonable time. We may have an
autopsy performed, at Our expense, if it is not prohibited by any applicable local law(s).
Who will receive Your Insurance Benefits?
Insurance benefits are payable to You unless such benefits have been assigned. The Policyholder may not be named as
beneficiary. In the event of Your death prior to insurance benefits being paid, benefits will be paid according to the Facility of
Payment provision.
Facility of Payment
If no named beneficiary survives You or if You do not name a beneficiary, We will pay the amount of insurance:
1. to Your Spouse, if living; if not,
2. in equal shares to Your then living natural or legally adopted Children, if any; if none,
3. in equal shares to Your father and mother, if living; if not,
4. in equal shares to Your brothers and/or sisters, if living; if not,
5. to Your estate.
00062
DNL2-604AIC-0316 IL 22
Do I have the Right to Appeal a Claim Denial?
If Your claim is denied, You will receive a written notice giving the following:
the reason or reasons for the denial;
. the Policy provisions on which the denial is based;
- an explanation of what other material or information, if any, may be needed to process the claim and why it is needed;
- the steps that You have to follow to have the claim reviewed;
- a statement that You have the right to bring a civil action under section 502(a) of ERISA after You appeal Our decision and
after You receive a written denial on appeal; and
- if an internal rule, guideline, protocol, or other similar criterion was relied upon in making the denial, either (i) the specific
rule, guideline, protocol or other similar criterion; or (ii) a statement that such a rule, guideline, protocol or other similar
criterion was relied upon in making the denial and that a copy will be provided free of charge to You upon request; and
if denial is based on medical judgment, either (i) an explanation of the scientific or clinical judgment for the determination,
applying the terms of the Plan to Your medical circumstances, or (ii) a statement that such explanation will be provided to
You free of charge upon request.
If the claim has been denied, You can appeal the denial to Us for a full and fair review. You have at least 180 days to appeal
from the claim denial.
You may:
a. request a review upon written application within 180 days of the claim denial;
b. request, free of charge, copies of all documents, records and other information relevant to Your claim; and
r. submit written comments, documents, records and other information relating to Your claim, without regard to whether
such information was submitted or considered in the initial benefit determination.
O
We will make a decision no more than 45 days after We receive Your appeal. The time for decision may be extended for one
additional 45 day period provided that, prior to the extension, We notify You in writing that an extension is necessary due to
special circumstances, identifies those circumstances and gives the date by which it expects to render its decision. If Your claim
is extended due to Your failure to submit information necessary to decide Your claim on appeal, the time for Your decision
shall be tolled from the date on which the notification of the extension is sent to You until the date We receive Your response to
the request. 0
The decision on appeal will provide the following:
- the reason or reasons for the decision;
- the Plan provision on which the decision is based;
- a statement that You are entitled to receive, upon request and free of charge, reasonable access to, and copies of, all
documents, records, and other information relevant to Your claim for benefits;
- a statement of the claimant's right to bring an action under section 502(a) of ERISA;
- if an internal rule, guideline, protocol, or other similar criterion was relied upon in making the decision either (i) the
specific rule, guideline, protocol or other similar criterion; or (ii) a statement that such a rule, guideline, protocol or other
similar criterion was relied upon in making the decision and that a copy will be provided free of charge to You upon
request;
if the decision is based on medical judgment, either (i) an explanation of the scientific or clinical judgment for the
determination, applying the terms of the Plan to Your medical circumstances, or (ii) a statement that such explanation will
be provided to You free of charge upon request; and
the following statement: "You and Your plan may have other voluntary alternative dispute resolution options, such as
mediation. One way to find out what may be available is to contact Your local U.S. Department of Labor Office and Your
State insurance regulatory agency."
000631L
DNL2-604AIC-0316 IL 23
.__ GENERAL DEFINITIONS
Accident or Accidental means an unexpected event that was not reasonably foreseeable which occurs while the Covered
Person's insurance is in effect.
00064 IL
Actively at Work or Active Work means that You must:
I. work for the Policyholder on a full-time active basis; or
2. work at least the minimum number of hours set forth in the Schedule of Benefits: and either:
a. work at the Policyholder's usual place of business; or
b. work at a location to which the Policyholder's business requires You to travel; and
3. not be a temporary or seasonal Employee; and.
4. be paid regular earnings by the Policyholder.
00065
Anniversary Date means the annual month and day that corresponds with the Policy Effective Date.
00066
Annual Enrollment Period means the annual timeframe defined in the Schedule of Benefits when Employees can make benefit
changes.
00067
Application means the document which sets forth the eligible classes, the amounts of insurance, and other relevant information
pertaining to the plan of insurance for which the Policyholder applied.
00068
Certif cate means this Accident Insurance Certificate.
00069
Child(ren) means:
L Your natural or step Child under the age stated in the Schedule of Benefits; or
2. a Child under the age stated in the Schedule of Benefits placed with You for adoption from the date of placement or the
date You are party in a suit in which You seek the adoption of the Child, or a child who is in Your custody, pursuant to an
interim court order of adoption. Eligibility will continue unless the Child is removed from placement; or
3. a Child of Your Child who is Your dependent for federal income tax purposes at the time application for coverage of the
Child of Your Child is made.
000701L
Chip Fracture means a Fracture in which a piece of the bone is broken off near a joint at a place where a ligament is usually
attached. A Chip Fracture must be diagnosed by a Physician by an x-ray.
00071
Contributory means You pay all or a portion of the premium for this insurance coverage.
00072
Covered Person means an Employee or Eligible Dependent covered under the Policy.
00073
Dependent means:
1. Your lawful Spouse; and/or
2. Your Child(ren) who are not in active military service; and are within the age limits set forth in the Schedule of Benefits.
00074
Dislocation means a completely separated joint due to an Injury. The Dislocation must be diagnosed by a Physician within 90
days after the date of the Injury and require correction by a Physician. It can be corrected by open or closed Reduction.
00075
Dismemberment means the loss, with or without reattachment, of one or more of the following body parts as the result of an
Injury sustained within 90 days of a covered Accident.
• Arm: actual severance above the elbow
DNL2-604AIC-0316 IL 24
• Leg: actual severance above the knee
• Hand: actual severance above the wrist
• Foot: actual severance above the ankle
• Finger: actual severance at the joint (proximate to the first interphalangeal joint) where it is attached to the hand
• Toe: actual severance at the joint (proximate to the first interphalangeal joint) where it is attached to the foot
• Eye: loss of the eye or permanent loss of vision such that central visual acuity cannot be corrected to better than
201200.
Loss of use does not constitute Dismemberment except as described in the loss of vision for the Eye.
00076
Enrollment Form means a form acceptable to Us that You complete to enroll for coverage under the Policy.
00077
Emergency Room means a specified area within a Hospital that is designated for the emergency care of Accidental Injuries.
An Emergency Room is staffed and equipped to handle trauma, is supervised and provides treatment by Physicians and
provides care 24 hours per day, seven days a week.
00078
Employee or Eligible Employee means an ,fictively at Work full-time Employee working in the United States of America
as shown in the Schedule of Benefits whose principal employment is with the Policyholder and who is reported on the
Policyholder's records for Social Security and withholding tax purposes.
00079
Fracture means a break in a bone due to an Injury that can be seen by x-ray. The Fracture must be diagnosed by a Physician
within 14 days after the date of the Injury and require correction by a Physician. It can be corrected by open or closed
Reduction.
00080
Hospital means either of the following:
1. A licensed facility which 0
a. maintains on the premises everything necessary for major surgical treatment; and
b. provides such treatment on an inpatient basis for compensation under the full-time supervision of licensed
Physicians; and
c. provides 24-hour service by registered graduate nurses.
2. A free-standing surgical facility which maintains on the premises everything necessary for major surgical treatment
available to the Hospital on a prearranged basis.
The term Hospital does not include an institution which is primarily a place for rest or convalescence, a place for the aged, a
nursing home, a place for the treatment of alcohol or drug abuse or any facility primarily affording custodial, educational, or
rehabilitative care.
00081
Hospital Confinement or Confinement means the assignment to a bed as an inpatient in a Hospital on the advice of a
Physician or confinement in an observation unit within a Hospital for a period of no less than 20 continuous hours on the
advice of a Physician.
00082
Illness means sickness, disease, pregnancy or complications of pregnancy.
00083
Intensive Care Unit or ICU means a place which:
• Is a specially designated area of the Hospital called an Intensive Care Unit that provides the highest level of medical
care and is restricted to patients who are critically ill or injured and who require intensive comprehensive observation
and care; and
• Is separate and apart from the surgical recovery room and from rooms, beds, and wards customarily used for patient
confinement; and
• Is permanently equipped with special lifesaving equipment for the care of the critically ill or injured; and
DNL2-604AIC-0316 IL 25
• Is under constant and continuous observation by a specially trained nursing staff assigned exclusively to the Intensive
Care Unit on a 24-hour basis; and
• Has a Physician assigned to the Intensive Care Unit on a full-time basis.
An Intensive Care Unit is not a progressive care unit, an intermediate care unit, a private monitored room, sub -acute Intensive
Care Unit, an observation unit or any facility not meeting the definition of an Intensive Care Unit as defined above.
An Intensive Care Unit that meets the definition above includes Hospital units with the following names:
- Intensive Care Unit;
- Coronary Care Unit;
- Neonatal Intensive Care Unit;
- Pulmonary Care Unit;
- Burn Unit; or
Transplant Unit.
00085
Injury means bodily injury resulting directly from an Accident and independently of disease or bodily infirmity.
00086 IL
Insured means an Employee or Dependent covered under the Policy.
00087
Male Pronoun whenever used includes the female.
00088
Material and Substantial Duties means duties that are normally required for the performance of Your Regular Occupation
which cannot be reasonably omitted or modified.
00089
On and off the job coverage means benefits are payable for a Injuries sustained on the job and off the job, even if the Injury or
treatment is covered by a Workers' Compensation or occupational disease law.
00093
Outpatient Ambulatory Surgical Center means a facility mainly engaged in performing outpatient surgery. It must:
• be accredited as an ambulatory surgery facility by either the Joint Commission or the Accreditation Association for
Ambulatory Care;
• be approved as an ambulatory surgery facility by Medicare; or
• meet all of the following criteria:
o maintains all appropriate licensing for a facility that provides ambulatory surgery; and
o is staffed by Physicians and nurses, under the supervision of a Physician; and
o has permanent operating and recover rooms; and
o is staffed and equipped to provide emergency care; and
o has written back-up arrangements with a local Hospital for emergency care.
00094
Paralysis means complete and total loss of use of two or more limbs (paraplegia -four limbs, quadriplegia -lower limbs, or
hemiplegia -one side of the body) as the result of a spinal cord Injury for a continuous period of at least 34 days. The Paralysis
must be confirmed by a Physician and be expected to be permanent.
00095
Physical Therapist means a person other than a Covered Person, a member of a Covered Person's immediate family or a
Covered Person's business associate who is licensed by the state to practice physical therapy, performs services which are
allowed by his license and for which benefits are provided by this Certificate and practices according to the Code of Ethics of
the American Physical Therapy Association.
00099
DNL2-604A1C-0316 IL 26
Physician means a person other than a Covered Person, a member of a Covered Person's immediate family or a Covered
Person's business associate, who is licensed to and actively practicing medicine in the United States, and is licensed to treat
Illness and Injury. 0
00100
Policy means the contract between the Policyholder and Us including the Application, this Certificate and any amendments,
riders or endorsements.
00101
Policy Effective Date or Effective Date means the date stated on the Schedule of Benefits.
00102
Policyholder means the person, firm, or institution to whom the Policy was issued. Policyholder also means any covered
subsidiaries or affiliates set forth on the face of the Policy. If the Policyholder is an association the term Participating
Employer shall be substituted for Policyholder.
00103
Proof means evidence satisfactory to Us that the Covered Person has sustained an Injury or treatment listed in the Schedule of
Benefits. We reserve the right to determine, at Our sole discretion, if Proof is acceptable under the terms of the Policy.
00104
Prosthetic Device /Prosthesis means an artificial device designed to replace a missing part of the body.
00105
Reduction means an open (surgical) or closed (manipulative) repair of a Fracture or Dislocation.
00106
Regular Occupation means the occupation that You are routinely performing when Your insurance terminates due to
Disability. We will look at Your occupation as it is normally performed in the national economy, instead of how the work tasks
are performed for Your Policyholder or at Your specific location.
00108
Rehabilitation Unit means an appropriately licensed facility that provides rehabilitation care on an inpatient basis.
Rehabilitation care services consist of the combined use of medical, social, educational and vocational services to enable
patients disabled by an Injury to achieve the highest possible functional ability. Services provided by or under the supervision
of an organized staff of Physicians.
A Rehabilitation Unit is not:
• a nursing home;
• an extended care facility;
• a skilled nursing facility;
• a rest home or home for the aged;
• a hospice care facility;
• a place for alcoholics or drug addicts; or
• an assisted living facility.
00109
Spouse means lawful Spouse, which includes couples of same sex or different sex that enter into a civil union with all the
obligations, protections and legal rights that Illinois provides to married heterosexual couples.
001101L
Urgent Care Center means a health care facility that is separate from a Hospital or a separate unit of a Hospital and whose
primary purpose is the offering and provision of immediate, short term medical care, without an appointment, for urgent care.
00111
Voluntary means coverage for which You pay 100% of the premium.
00112
We, Our and Us means Dearborn National Life Insurance Company.
00113
DNL2-604AIC-0316 IL 27
0
N
You, Your and Yours means the Employee to whom this Certificate is issued and whose insurance is in force under the terms
of the Policy.
00114
DNL2-604AIC-0316 IL 28
NOTICE OF
PROTECTION PROVIDED BY
ILLINOIS LIFE AND HEALTH INSURANCE GUARANTY ASSOCIATION
This notice provides a brief summary description ofthe Illinois Life and Health Insurance Guaranty Association (the Association)
and the protection it provides for policyholders. This safety net was created under Illinois law that 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 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 and
pay claims, in accordance with Illinois law, with funding from assessments paid by other insurance companies.
The basic protections provided by the Association per insolvency are:
• Life Insurance
$300,000 in death benefits
1 $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, except
special rules apply to hospital, medical and surgical insurance 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 Illinois Department of Insurance
Insurance Guaranty Association 41h Floor
1520 Kensington Road, Suite 112 320 West Washington Street
Oak Brook Illinois 60523-2140 Springfield, Illinois 62767
(773) 714-8050 (217) 782-4515
Insurance companies 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, you should not rely on
Association coverage. If there is any inconsistency between this notice and Illinois law, then Illinois law will control.
GEN -56-1013
END OF CERTIFICATE
e
rej
STATEMENT OF ERISA RIGHTS
As a participant in the plan You are entitled to certain rights and protections under the Employee Retirement Income Security
Act of 1974, as amended ("ERISA"). ERISA provides that all plan participants shall be entitled to:
1. Receive Information about Your Plan and Benefits
a. Examine, without charge, at the plan administrator's office and at other specified locations, such as worksites and
union halls, all documents governing the plan, including insurance contracts and collective bargaining agreements,
and a copy of the latest annual report (Form 5500 Series) filed by the plan with the U.S. Department of Labor and
available at the Public Disclosure Room of the Pension and Welfare Benefit Administration.
b. Obtain, upon written request to the plan administrator, copies of documents governing the operation of the plan,
including insurance contracts and collective bargaining agreements, and copies of the latest annual report (Form
5500 Series) and updated summary plan description. The administrator may make a reasonable charge for the copies.
c. Receive a summary of the plan's annual financial report. The plan administrator is required by law to furnish each
participant with a copy of this summary annual report.
2. Prudent Actions by Plan Fiduciaries
In addition to creating rights for plan participants, ERISA imposes duties upon the people who are responsible for
the operation of the Employee benefit plan. The people who operate Your plan, called "fiduciaries" of the plan, have
a duty to do so prudently and in the interest of You and other plan participants and beneficiaries. No one, including
Your employer, Your union, or any other person, may fire You or otherwise discriminate against You in any way to
prevent You from obtaining a welfare benefit or exercising Your rights under ERISA.
3. Enforce Your Rights
If Your claim for a welfare benefit is denied or ignored, in whole or in part, You have a right to know why this was
done, to obtain copies of documents relating to the decision without charge, and to appeal any denial, all within certain
time schedules. 0
Under ERISA, there are steps You can take to enforce the above rights. For instance, if You request a copy of plan
documents or the latest annual report from the plan and do not receive them within 30 days, You may file suit in federal
court. In such case, the court may require the plan administrator to provide the materials and pay You up to $110 a
day until You receive the materials, unless the materials were not sent because of reasons beyond the control of the
administrator.
If You have a claim for benefits which is denied or ignored, in whole or in part, You may file suit in a state or federal
court. If it should happen that plan fiduciaries misuse the plan's money, or if You are discriminated against for asserting
Your rights, You may seek assistance from the U.S. Department of Labor, or You may file suit in a federal court. The
court will decide who should pay court costs and legal fees. If You are successful the court may order the person You
have sued to pay these costs and fees. If You lose, the court may order You to pay these costs and fees if, for example,
it finds Your claims are frivolous.
4. Assistance with Your Questions
If You have any questions about Your plan, You should contact the plan administrator. If You have questions about this
statement or about rights under ERISA, or if You need assistance in obtaining documents from the plan administrator,
You should contact the nearest office of the Employee Benefit Security Administration, U.S. Department of Labor,
listed in Your telephone directory or the Division of Technical Assistance and Inquiries, Employee Benefits Security
Administration, U.S. Department of Labor, 200 Constitution Avenue, Washington, D.C. 20210. You may obtain certain
publications about Your rights and responsibilities under ERISA by calling the publication hotline of the Employee
Benefits Security Administration.
v
FDL EIS 712013 rev'd.
? ERISA INFORMATION STATEMENT
The benefits described in Your certificate are insured by an Accident insurance Policy ("Policy") issued by Dearbom National
Life Insurance Company ("Dearborn National" or "Insurer"), pursuant to an "Employee welfare benefit plan" ("the Plan") as
defined in Section 3(1) of the Employee Retirement Income Security Act of 1974, as amended ("ERISA") established by Your
employer ("the Company").
Every Employee welfare benefit plan must be established and maintained pursuant to a written instrument that provides for a plan
administrator. Your plan administrator has delegated the authority to administer claims under the Policy to Dearborn National.
As claims administrator, Dearborn National will make decisions concerning eligibility and benefit determinations in accordance
with the Policy provisions.
A. ADMINISTRATION OF THE PLAN
The plan administrator is the person or entity responsible for the administration of the Plan. The plan administrator has full
discretionary authority and control over the Plan. This authority provides the Plan Administrator with the power necessary to
operate, manage and administerthe Plan. This authority includes, but is not limited to, the powerto interpret the Plan and determine
who is eligible to participate, to determine the amount of benefits that may be paid to a participant or his or her beneficiary,
and the status and rights of participants and beneficiaries. The Plan Administrator also has the authority to prescribe the rules
and procedures under which the Plan shall operate, to request information, and to employ or appoint persons to aid the plan
administrator in the administration of the Plan.
Failure by the Plan or the plan administrator to insist upon compliance with any provisions of the Plan at any time or under any
set of circumstances shall not operate to waive or modify the provision or in any manner render it unenforceable as to any other
time or as to any other occurrence, whether the circumstances are or are not the same. No waiver of any term or condition of
the Plan shall be valid unless contained in a written memorandum expressing the waiver and signed by the person authorized
by the plan administrator to sign the waiver.
The Plan may be amended, terminated or suspended in whole or in part, at any time without the consent of the Employees
or beneficiaries. Any amendment, termination or suspension shall be in writing, and attached to the Plan. Any amendment,
termination or suspension shall be executed according to the Employer's authorized procedures. Any such authorization may be
specific to the Plan or persons authorized to act on behalf of the Employer or may be general as to duties of such person. Except
for termination or suspensions, any amendments affecting the Policy and/or Certificate must also be approved in writing by an
officer of Dearbom National and shall be effective as of the date agreed to, in writing by the Plan Sponsor and Dearbom National.
Notwithstanding anything to the contrary in this document, the Policy shall terminate according to the provisions in the Policy.
The Plan has other fiduciaries, advisors and service providers. The plan administrator may allocate fiduciary responsibility among
the Plan's fiduciaries and may delegate responsibilities to others. Any allocation or delegation must be done in writing and kept
with the records of the Plan. As stated above, the Plan's benefits are provided to You pursuant to an insurance Policy issued to
the Company. The Insurer shall, with respect to the Policy:
- resolve all matters when a review pursuant to the claims procedures has been requested;
- interpret, establish and enforce rules and procedures for the administration of the Policy and any claim under it; and
- determine eligibility of Employees and dependents for benefits and their entitlement to and the amount of benefits.
Each fiduciary is solely responsible for its own improper acts or omissions. Except to the extent required by ERISA, no fiduciary
has the duty to question whether any other fiduciary is fulfilling all of the responsibilities imposed upon the other fiduciary by
law. Nor is a fiduciary liable for a breach of fiduciary duty committed before it became, or after it stopped being, a fiduciary.
However, a fiduciary may be liable for a breach of fiduciary responsibility of any Plan fiduciary, to the extent provided in ERISA
Section 405(a). The Employer makes no promise to continue these benefits in the future and rights to future benefits will never
vest. Retirement does not give any retiree any vested right to continue to participate or receive Plan benefits, except as provided
in the Plan.
FDL EIS 712013 rev'd.
B. CLAIMS PROCEDURE:
When You or Your Beneficiary are eligible to receive benefits, You or Your Beneficiary, or Your authorized representative
(collectively, "You") must follow the claim procedures described in Your Group Insurance Certificate by submitting the proper
form in writing to Dearborn National at:
Claims Department
Dearborn National Life Insurance Company
1020 31 st Street
Downers Grove, IL. 60515-5591
1-800-348-4512
For the purpose of this Section, the terms "written" and "in writing" include "electronic." Any action required to be "written" or
"in writing," may be done electronically, where available. If Dearborn National uses electronic notices, it will do so in accordance
with 29 GFR 2520.104b-1c(i), (iii) and (iv).
0
FDL EIS 712013 rev'd.
c
Dearborn *National 0
Administrative Office:
1020 31st Street
Downers Grove Illinois 60515
Principal Office:
300 E. Randolph Street
Chicago Illinois 60601
Products and services marketed under the Dearborn Nationale brand and the star logo are underwritten and/
or provided by Dearborn Nationale Life Insurance Company (Downers Grove, IL) in all states (excluding
New York), the District of Columbia, the United States Virgin Islands, the British Virgin Islands, Guam and
Puerto Rico.
DEARBORN NATIONAL® LIFE INSURANCE COMPANY
jo_� (A stock life insurance company, herein called "We" "Us" or "Our")
K
Administrative Office Address: 1020 31st Street, Downers Grove IL 60515
Policyholder: SAMPLE INC.
Policy Number: F012345
Policy Effective Date: January 1, 2018
Anniversary Date: January 1
We agree with the Policyholder to insure certain eligible Employees of the Policyholder. We promise to pay benefits for
loss covered by the Policy in accordance with its provisions. The Policyholder should read this Policy carefully and contact
Dearborn National Life Insurance Company promptly with any questions.
Policyholder means the Employer to whom the Policy is issued and who sponsored the coverage for its Employees.
Employer means the Policyholder and includes any division, subsidiary, or affiliated company if named in the Policy.
Employee means a person who is a citizen or legal resident of the United States and .fictively at Work with the Employer.
POLICY EFFECTIVE DA TE AND TERM
The Policy takes effect on the Policy Effective Date stated above subject to any participation requirement stated in the Policy.
All insurance periods will be computed from that date. The Policy remains in force for the period for which premium has been
paid. It may be renewed for further successive periods by payment of premium as stated in the Policy.
All periods of insurance begin and end at 12:01 A.M., Standard Time, at the Policyholder's address as stated in the Policy, and
on the Application.
Signed for Dearborn National Life Insurance Company
IfIXA.— Z&4� -1 `1_e�
Secretary President
THIS IS AN ACCIDENT ONLY POLICY
DNL2-504-AEP-0316
Voluntary Group Accident Insurance Policy
with Dependent Accident Benefits
Non -Participating
THIS IS NOT A WORKERS' COMPENSATION POLICY
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PREMIUM
How is the initial premium calculated?
The monthly premium is calculated in accordance with the rates set forth on the attached Rate Addendum.
When is premium paid?
The Policy is issued in consideration of the payment in advance of premium on the premium due date indicated on the
Application. Payment must be made by the premium due date as shown on the Application.
If an addition, termination or change in insurance takes place other than on a regular due date, any premium adjustment will
take effect on the next due date.
Is there a grace period for premium payment?
We will allow a grace period of 31 days for the payment of any premiums due except the first. Insurance coverage shall
continue in force during the grace period unless the Policyholder has given Us advance written notice of cancellation in
accordance with the terms of this Policy. We will not be liable for claims incurred during a grace period unless all premiums
have been received by Us before the end of the grace period. If premium is not received by the end of the grace period, the
effective date of the Policy termination will be the last date for which premium was paid.
If We receive written notice during the grace period that the Policy is to be canceled, We will cancel it as of the later of-
t. the date requested in the cancellation notice; or
2. the date We receive such notice. The Policyholder must pay a pro rata premium for any coverage provided during the
grace period.
PREMIUM RATE GUARANTEE
What is the initial premium rate guarantee?
A change in premium rates will not take effect before January 1, 2021. However, We may change premium rates if the risk
assumed changes. Premium rates may change if the following occurs:
1. a change in the Policy design; or
2. a change in the terms of the Policy; or
3. addition or deletion of a division, subsidiary or affiliated company; or
4. a change in the number of Insureds by 10% or more from the number of Insureds on the initial Effective Date; or
5. a change in the laws or regulations or other government action which applies to the Policy; or
6. for reasons other than 1-5 above such as but not limited to a change in factors bearing on the risk assumed.
The Policyholder must furnish notice and documentation satisfactory to Us within 31 days of the occurrence of any event
which would cause a change in rates as described above. If the Policyholder fails to provide such timely notice, we will apply
new rates retroactively to the date of the event.
We will notify the Policyholder in writing at least 31 days in advance of any premium rate changes. A change may take effect
on an earlier date if both the Policyholder and We agree.
DNL2-504-AEP-0316
POLICY TERMINATION
Who may cancel the Policy or a plan under the Policy?
The Policy or a plan under the Policy can be canceled by the Policyholder with 31 days written notice delivered to Us.
When does this Policy terminate?
This Policy will terminate for any of the following reasons:
1. If the Policyholder fails to pay any premium within the 31 -day Grace Period, this Policy will terminate in accordance with
the terms set forth in the Grace Period provision.
2. We may terminate this Policy on any premium due date if:
a. coverage is Contributory and less than 25% of the eligible Employees participate; or
b. the Policyholder fails to perform any of its obligations that relate to the Policy; or
c. the Policyholder does not promptly provide Us with information that is reasonably required; or
d. fewer than 10 Employees are insured under the Policy.
If We terminate the Policy, for reasons other than the Policyholder's failure to pay premium, a written notice will be delivered
to the Policyholder at least 30 days prior to the effective date of termination.
ADDITIONAL PROVISIONS
What happens If an inadvertent error occurs?
Clerical error or omission by Us to the Policyholder will not:
1. Prevent the Employee -from receiving coverage, if he is entitled to coverage under the terms of the Policy; or
2. Cause coverage to begin or coverage to continue for the Employee when the coverage would not otherwise be effective.
If the Policyholder gives Us information about the Employee that is incorrect, We will:
1. Use the facts to decide whether the Employee has coverage under the Policy and in what amounts; and
2. Make a fair adjustment of the premium.
Will certificates be issued?
We will deliver certificates of insurance to the Policyholder for issuance to each insured Employee. The certificates will
describe the benefits, to whom they are payable, the Policy limitations and where the Policy may be inspected.
What is considered to be the entire contract?
Entire Contract {Contract)
The Entire Contract consists of:
1. The Group Insurance Policy, and
2. The Application; and
3. The Certificate; and
4. The Enrollment Forms of the persons insured, including any individual statements; and
5. Any riders, endorsements, inserts, attachments or amendments to the Policy, Application or the Certificate.
Coverage under the Policy can be amended by mutual consent between the Policyholder and Us. No change to the Policy is
valid unless approved in writing by one of Our officers. No agent or third party has the right to change the Policy or to waive
any of its provisions.
Statement on the Application
All statements made on the Application are considered representations and not warranties (absolute guarantees). No
representation by:
1. The Policyholder in applying for the Policy will make it void unless the representation is contained in the signed
Application, or other written and signed statement; or
DNL2-504-AIP-0316
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2. Any Employee, in applying for insurance under the Policy will be used to reduce or deny a claim unless a copy of the
., application for insurance, signed by the Employee, or other written and signed statement, is or has been given to the
Employee.
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New Employees
All new Employees in the classes eligible for insurance will be added to such class for which they are eligible.
DNL2-504-AIP-0316
RATE ADDENDUM
Initial Monthly Rates
Class: 01, 02
Employee $17.98
Employee and Spouse $33.89
Employee and Child $33.97
Employee and Family $44.03
DNL2-504-AEP-0316
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C -)
STATE SUPPLEMENT
The following policies apply only to those individuals in Your group insurance program who reside in the referenced states.
Arizona and Maine
Except as otherwise permitted by law, We will not disclose collected personal information about an individual to a
nonaffiliated third party with whom We jointly offer products without giving the individual an opportunity to tell us that he or
she does not want Us to share his or her personal information.
Minnesota and Montana
Except as otherwise permitted by law, We will not disclose collected personal information about an individual to a
nonaffiliated third party with whom We jointly offer products without obtaining the individual's written authorization.
Montana
Upon written request, an individual who has authorized the collection of health information is entitled to receive a record of
Dearborn National's disclosures of any of his medical record information made within the preceding 3 years.
Oregon
An individual has the right to authorize disclosure of his or her personal information to an insurance company. An Oregon
resident can exercise this right by requesting an authorization form in writing. Our address is:
Dearborn National* Life Insurance Company
Administrative Office:
1020 31st Street
Downers Grove, IL 60515
N
Dearborn NQtioml' Rev. 1212015
WHAT DOES DEARBORN NATIONAO
DO WITH YOUR PERSONAL INFORMATION?
Financial companies choose how they share your personal information. Federal law gives consumers the right
to limit some but not all sharing. Federal law also requires us to tell you how we collect, share, and protect your
personal information. Please read this notice carefully to understand what we do.
The types of personal information we collect and share depend on the product or service you have with us. This
information can include:
■ Social Security number and payment history
■ Transaction history and employment information
■ Medical information and insurance claim history
When you are no longer our customer, we continue to share your information as described in this notice.
All financial companies need to share customers' personal information to run their everyday business. In the section
below, we list the reasons financial companies can share their customers' personal information; the reasons Dearborn
National chooses to share; and whether you can limit this sharing.
.01 1 E 1 7 "Im"llumm
For our everyday business purposes-- such as to process your transactions, maintain Yes No
your acwunt(s), respond to court orders and legal investigations, or report to credit
bureaus
For our marketing purposes— to offer our products and services to you Yes No
For joint marketing with other financial companies Yes No
For our affiliates' everyday business purposes-- information about your transactions Yes No
and experiences
For our affiliates' everyday business purposes— information about your No We don't share
creditworthiness
For our affiliates to market to you No We don't share
For nonaffiliates to market to you No We don't share
Go to www.dearbornnational.com
Who is providing this notice?
Dearborn National brand companies:
■ Dental Network of Americae, LLC
■ Dearborn Nationale Life Insurance Company
■ Dearborn Nationale Life Insurance Company of New York
Products and services marketed under the Dearborn National® brand and the star logo are underwritten and/or provided by Dearborn Nation Life Insurance Company
(Downers Grove. Illinois) which is not licensed in and does not solicit business in New York; in New York, the company is Dearborn National® Life Insurance Company of
New York (Pittsford. New York), Dental Network oftmericam, LLC is an administratorfor oup dental claims. DenleMaxe, LLC is a dental provider network. Products
amt services and availability vary by state and company, and are solely the responsibility a each affiliate.
v
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Dearborn National'
Who is providing this
The Dearborn National brand companies. (See "Other important information" below for the list of
iotice?
companies.)
How does Dearborn
To protect your personal information from unauthorized access and use, we use security measures that
National protect my
comply with federal law. These measures include computer safeguards and secured files and buildings.
personal information?
Access to your information is limited to employees who need it in their jobs. If a company working for
us has access, it is required to protect it.
How does Dearborn
We collect your personal information, for example, when you
National collect my
■ apply for insurance or pay insurance premiums
personal information?
■ file an insurance claim or provide employment information
■ give us your contact information
■ We also collect your personal information from others, such as credit bureaus, affiliates, or other
companies.
Why can't I limit all
Federal law gives you the right to limit only
sharing?
+ sharing for affiliates' everyday business purposes—information about your creditworthiness
■ affiliates from using your information to market to you
■ sharing for nonaffiliates to market to you
State laws and individual companies may give you additional rights to limit sharing.
Affiliates
Companies related by common ownership or control. They can be financial and nonfinancial companies.
■ Health Care Service Corporation, a Mutual Legal Reserve Company
■ DenteMae, LLC
Companies not related by common ownership or control. They can be financial and nonfinancial
,Nonaffiliates
companies.
■ Dearborn National does not share with nonaffiliates so they can market to you
Joint marketing
A formal agreement between nonaffiliated financial companies that together market financial products
or services to you.
+ Our joint marketing partners include categories of companies such as insurance companies and
brokers.
IME
For Insurance Customers in AZ, CA, CT, GA, IL, ME, MA, MN, MT, NC, NJ, NV, OH, OR and VA only: The term "information" as
used in this part means personal information that is obtained in an insurance transaction. We may give your information to government
officials, including insurance officials, law enforcement, and to group policy holders about claim experience, or to auditors, or as you
may authorize, or as the law allows or requires. We may give your information to insurance support entities that may keep it or give it
to others. We may share medical information and other information so we can learn if you qualify for coverage, to process claims, or to
prevent fraud, or if you authorize us to do so.
To see your information, write to Dearborn National, Administrative Office, 1020 31st Street, Downers Grove, IL 60515. You must
state your full name, address, the name of the insurance company, policy number (if applicable) and the information you want. If you
think any information we have is wrong, you may ask us to correct it. We then will let you know what actions we will take. If you do
not agree with the actions we take, you may send us a concise statement explaining the basis for your concern or dispute about the
information, and we will place that statement in our file with the information.
For California Insurance Customers only: We will share information about you only as permitted by California law. We will not share
personal information we collect about you with affiliated or nonaffiliated third parties except if permitted by law, or with your consent,
or to the extent necessary to administer your insurance coverage.
r'or MA Insurance Customers only: You may ask in writing for the specific reasons we made an adverse underwriting decision.
For VT Insurance Customers only: We will share information about you only as permitted by Vermont law. We will not share personal
information we collect about you with affiliated or nonaffiliated third parties except if permitted by law, or with your consent, or to the
extent necessary to administer your insurance coverage.
NOTICE OF
PROTECTION PROVIDED BY
ILLINOIS LIFE AND HEALTH INSURANCE GUARANTY ASSOCIATION
This notice provides a brief summary description ofthe Illinois Life and Health Insurance Guaranty Association (the Association)
and the protection it provides for policyholders. This safety net was created under Illinois law that 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 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 and
pay claims, in accordance with Illinois law, with funding from assessments paid by other insurance companies.
The basic protections provided by the Association per insolvency are:
• Life Insurance
A $300,000 in death benefits
$100,000 in cash surrender or withdrawal values
• Health Insurance
s $500,000 in hospital, medical and surgical insurance benefits*
1 $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, except
special rules apply to hospital, medical and surgical insurance 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.ora or contact:
Illinois Life and Health Illinois Department of Insurance
Insurance Guaranty Association 4th Floor
1520 Kensington Road, Suite 112 320 West Washington Street
Oak Brook Illinois 60523-2140 Springleld, Illinois 62767
(773) 714-8050 (217) 781-4515
Insurance companies 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, you should not rely on
Association coverage. If there is any inconsistency between this notice and Illinois law, then Illinois law will control.
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