HomeMy WebLinkAboutReso 98-110
RESOLUTION NO, 98- \ \0
A RESOLUTION OF THE CITY COMMISSION OF THE
CITY OF SUNNY ISLES BEACH, FLORIDA, APPROVING
AN AGREEMENT WITH STANDARD INSURANCE
COMPANY FOR EMPLOYEE LIFE AND ACCIDENTAL
DEATH AND DISABILITY INSURANCE, ATTACHED AS
EXHIBIT "A"; AUTHORIZING THE CITY MANAGER TO
EXECUTE SAME; PROVIDING FORAN EFFECTIVE DATE,
WHEREAS, the City Manager and the Finance Director have negotiated with several
insurance companies for employee life and accidental death and disability insurance; and
WHEREAS, the premiums quoted by Standard Insurance Company for this coverage are
approximately thirty percent (30%) less than the City now pays for employees life insurance;
NOW THEREFORE, BE IT RESOLVED BY THE CITY COMMISSION OF THE CITY
OF SUNNY ISLES BEACH, FLORIDA, AS FOLLOWS:
1. The City Commission hereby approves the agreement with Standard Insurance Company for
employee life and accidental death and disability insurance, attached hereto as Exhibit "A".
2. The City Manager be and is hereby authorized to execute the attached agreement.
3. This Resolution shall become effective upon adoption.
PASSED AND ADOPTED this 17th day of December, 1998.
David Samson,
ATTEST:
~vL~ ~~M~ ~~
Richard Brown-Morilla, City Clerk
Life Insurance Res,
-1-
APPROVED AS TO FORM
AND LEGAL SUFFICIENCY:
~~,--
u M. DannheIsser, CIty Attorney
Vote: l)-O
Mayor Samson
Vice Mayor Turetsky
Commissioner Iglesias
Commissioner Kauffman
Commissioner Morrow
Life Insurance Res,
~Yes)
----v (Yes)
~(Yes)
t!Y es)
_(Yes)
Moved by:
Seconded by:
~~k~
~S~\~ J.c.f '
_(No)
_(No)
_(No)
_(No)
_(No)
-2-
Table of Contents
COVERAGE F'EATURES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
GENERAL POLICY INFORMATION. . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
BECOMIN'G IN'SURED .,...........................................................,.,..,... 1
P~ CO~tr.rIONS ...............................,............................... 2
SC:ErED~ OF IN'SURANCE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . . . . . . . . . . . . 2
REDUCTIONS IN'IN'SURANCE .............................................................. 3
OT:EiER PROVISIONS ....................................................................... 3
P~ RATES AND RENEWAl..S ......................................................... 3
LIFE IN'SURAN'CE ....................... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
A Insuring Clause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
B. Amount Of Life Insurance ................................................................ 5
C. Changes In Life Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , . 5
D. When Life Insurance Becomes Effective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
E. When Life Insurance Ends. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
F. Reinstatement Of Life Insurance .......................................................... 6
ACCIDENTAl.. DEATH AND DISMEMBERMENT IN'SURANCE ..................................... 6
A Insuring Clause. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
B. Definition Of Loss For AD&D Insurance................................................... 6
C. Amount Payable ......................................................................... 6
D. Changes In AD&D Insurance ............................................................. 7
E. Seat Belt Benefit . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
F. AD&D Insurance Exclusions .............................................................. 7
G. When AD&D Insurance Becomes Effective ................................................. 7
H. When AD&D Insurance Ends ............................................................. 7
SlJPPI..EMENT.AI. :LIFE IN'SURANCE ............................................................. 7
A Insuring Clause. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
B. Amount Of Supplemental Life Insurance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
C. Increases In Supplemental Life Insurance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
D. Decreases In Supplemental Life Insurance ........................... ~ . . . . . . . . . . . . . . . . . . . . . 8
E. Suicide Exclusion: Supplemental Life Insurance ............................................ 8
F. Becoming Insured For Supplemental Life Insurance ........................................ 8
G. When Supplemental Life Insurance Ends .................................................. 8
DEPENDENTS I.IFE IN'SURANCE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
A Insuring Clause. . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
B. Amount Of Dependents Life Insurance. . . . . . . . . . . . . . . . . . . . . . . . . . . . , . . , . . . . . . . . , . . . . . . . . . . . . 9
C. Changes in Dependents Life Insurance ................,............,...................... 9
D. Definitions For Dependents Life Insurance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
E. Becoming Insured For Dependents Life Insurance .......................................... 9
F. When Dependents Life Insurance Ends .................................................... 10
ACTIVE WORK PRO'VISIONS .................................................................... 10
WAIVER OF PREMIUM .......................................................................... 11
ACCEI..ERATED BENEFIT ................................"..,....,............................. 12
RIG:ElT TO CONVERT ........ . .. . . , . . . . . . . , , . . . . . . . , . . . . . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . . . . . 13
CLAIMS .,.....,.........................,....................................................... 14
ASSIGNMENT. ... . . . . .... .. . . . .. . . . . . . . . . . . . . . . ... . . . . . . .. .. . .. ... . . . . .., . .,. . . . . . . . . . ,. , , . . . . , . 15
BENEFIT PAYMENT AND BENEFICIARY PROVISIONS ......."..,........,.,....."...,...."... 15
AlLOCATION OF AUTHORITY, . . , . . . . . . . . . . . . . . . . . . . , . . . . . , , . . . , . . . . . . . . . . , . . . . . . . . . . . . . . . . . . . . . 17
TlJ\.IE LIMITS ON :LEG~ ACTIONS .,..,..,.,..,......,.,....".....,...........,................ 18
. IN'CONTEST.ABILITY PROVISIONS. . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . , . . . . . . . . . . . . . . . . , . . . . . . . . , . . , 18
DEFINITIONS ,.......,.................. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . . . . . . . . . 18
'STANDARD INSURANCE COMPANY
A Mutual Life Insurance Company
900 SW Fifth Avenue
Portland, Oregon 97204-1282
(503) 321-7000
Dedicated to Excellence
GROUP LIFE INSURANCE POLICY
Policyowner:
Policy Number:
Effective Date:
ABC Company
SAMPLE - LI, AD&D, DLI, Sup. LI
Jtme 1, 1995
The consideration for this Group Policy is the application of the Policyowner and the payment by the Policyowner of
premiums as provided herein.
Subject to the Policyowner Provisions and the Incontestability Provisions, this Group Policy (a) is issued for
the Initial Rate Guarantee Period shown in the Coverage Features, and (b) may be renewed for successive
renewal periods by the payment of the premium set by us on each renewal date. The length of each renewal period
will be set by us, but will not be less than 12 months.
For purposes of effective dates and ending dates tmder this Group Policy, all days begin and end at 12:00 midnight
Standard Time at the Policyowner's address.
This policy includes an Accelerated Benefit. The receipt of this benefit may be taxable and may affect
your eligibility for Medicaid or other government benefits or entitlements. You should consult your
personal tax and/or legal advisor before you apply for an Accelerated Benefit. .
All provisions on this and the following pages are part of this Group Policy. "You" and "your" mean the Member.
"'We", "us", and "our" mean Standard Insurance Company. Other defined terms appear with their initial letters
capitalized. Section headings, and references to them, appear in bold face type.
STANDARD INSURANCE COMPANY
By
~~Z~
President
~w! d~
Secretary
GPl90-UFE
* Prinud on recycled paper.
POLICYOWNER PROVISIONS ,...............,......................,.........................., 19
Index of Defined Terms
The page number shown below is where the term is defined. For terms defined by an entire section, the
page number below is the page on which that section begins.
Accelerated Benefit, 12
Active Work, Actively At Work, 10
AD&D Insurance, 18
Annual Earnings, 18
Automobile, 7
Life Insurance, 19
Loss (for AD&D Insurance), 6
Beneficiary, 16
Maximum Conversion Amount, 3
Member, 1
Minimum Participation Number, 4
Minimum Participation Percentage, 4
Minimum Time Insured, 3
Child, 9
Class Definition, 1
Contributory, 19
Conversion Period, 13
Noncontributory, 19
Notice of Rate Change, 4
Earnings Period, 3
Eligibility Waiting Period, 19
Employer(s),1
Evidence Of Insurability, 19
Physician, 13
Policyowner,1
Pregnancy, 19
Premium Due Dates, 4
Premium Rates, 3
Prior Plan, 19
Proof Of Loss, 14
Dependent, 9
Dependents Life Insurance, 19
Disabled Child, 9
Qualifying Event, 13
Qualifying Medical Condition, 12
Initial Rate Guarantee Period, 4
Injury, 19
Insurance (for Accelerated Benefit), 13
Insurance (for Right To Convert), 13
Insurance (for Waiver of Premium), 11
Recipient, 17
Right To Convert, 13
Seat Belt, 7
Sickness, 19
Spouse, 19
Supplemental Life Insurance, 19
Grace Period, 4
Group Policy, 19
Group Policy Effective Date, 1
Group Policy Number, 1
Guarantee Issue Amount, 2
Totally Disabled, 11
Waiting Period (for Waiver of Premium), 11
Waiver Of Premium, 11
War, 7
Leave of Absence Period, 3
you, your (for Right To Convert), 14
COVERAGE FEATURES
This section contains many of the features of your group life insurance. Other provisions, including exclusions and
limitations, appear in other sections. Please refer to the text of each section for full details. The Table of Contents
and the Index of Defined Terms help locate sections and definitions.
GENERAL POLICY INFORMATION
Group Policy Number:
Type of Insurance Provided:
Life Insurance:
Accidental Death And
Dismemberment (AD&D)
Insurance:
Supplemental Life
Insurance:
Dependents Life
Insurance:
SAMPLE - LI, AD&D, DLI, Sup. LI
Yes
Yes
Yes
Yes
Policyowner:
Employer(s):
ABC Company
ABC Company
XYZ Affiliate
June 1, 1995
Oregon
Group Policy Effective Date:
Policy Issued In:
BECOMING INSURED
To become insured for Life Insurance you must: (a) Be a Member; (b) Complete your Eligibility Waiting Period; and
(c) Meet the requirements in Life Insurance and Active Work Provisions. The requirements for becoming
insured for coverages other than Life Insurance are set out in the text.
Definition of Member: You are a Member if you are:
1. .An active employee of the Employer; and
2. Regularly working at least 30 hours each week.
You are not a. Member if you are:
1. A temporary or seasonal employee; or
2. A full time member of the armed forces of any country.
Class Definition:
None
Eligibility Waiting Period:
You are eligible on the later of:
1. The Group Policy Effective Date; and
2. The first day of the calendar month coinciding with or next
following 30 consecutive days as a Member.
Printed 4196 Revised 4196
-1-
SAMPLE U, AD&D, DU, Sup, U
Evidence Of Insurability
Required:
a. For late application for Contributory insurance.
b. For reinstatements ifrequired.
c. For Members eligible but not insured under the Prior Plan.
d. For all Supplemental Life Insurance.
e. For Life and AD&D Insurance in excess of $xxx,xxx: (the
Guarantee Issue Amount).
f. For any increase in Life and AD&D Insurance to an amount
which is $50,000 greater than the last amount for which your '
Evidence Of Insurability was approved.
PREMIUM CONTRIBUTIONS
Life and AD&D Insurance:
Supplemental Life
Insurance:
Dependents Life Insurance:
Noncontributory
Contributory
Contributory
SCHEDULE OF INSURANCE
Life Insurance:
2 times your Annual Earnings, rounded to the next higher multiple
of $1,000, if not already a multiple of $1,000. The maximum
amount is $300,000.
AD&D Insurance:
2 times your Annual Earninc.as, rounded to the next higher multiple
of $1,000, if not already a multiple of $1,000. The maximum
amount is $300,000.
The amount payable for certain Losses will differ. See Accidental Death And Dismemberment
Insurance.
Seat Belt Benefit:
The amount of the Seat Belt Benefit is the lesserof(1) $10,000 or(2)
the amount of AD&D Insurance payable for loss of life.
Supplemental Life
Insurance:
You may apply for Supplemental Life Insurance for you and your
Spouse in multiples of $10,000, from $30,000 to $300,000.
Spouse: $ 10,000
Child: 5,000
The amount of Dependents Life Insurance for your Spouse or Child Dependent may not exceed X% of the
amount of your Life Insurance,
Dependents Life Insurance:
Printed 4196 Revised 4196
-2-
SAMPLE U, AD&D, DU, Sup. U
REDUCTIONS IN INSURANCE
If you or your Spouse reaches an age shown below, the amount of insurance will be the amount determined from the
Schedule of Insurance, multiplied by the appropriate percentage below.
Life and AD&D Insurance
Age
65 through 69
70 through 74
75 or over
Supplemental Life Insurance
Age
70 through 74
75 through 79
80 through 84
85 through 89
90 through 94
95 or over
Percentage
65%
50%
35%
Percentage
65%
45%
30%
20%
15%
10%
OTHER PROVISIONS
Waiver Of Premium:
Limits on Right To Convert if
Group Policy terminates or is
amended:
Minimum Time Insured:
Maximum Conversion Amount:
Yes
Suicide Exclusions:
5 years
$10,000
Apply to:
a. Supplemental Life Insurance; and
b. AD&D Insurance.
The first 60 days of a scheduled leave of absence.
Earnings in effect on your last full day of Active Work.
Leave of Absence Period:
AImual EarDings based on:
Earnings Period for Commissions
(see Definitions):
The preceding 12 calendar months.
PREMIUM RATES AND RENEWALS
Premium Rates
Life Insurance:
AD&D Insurance:
$.xx monthly per $1,000 of Life Insurance
$.xx monthly per $1,000 of AD&D Insurance
Printed 4196 Revised 4/96
-3-
SAMPLE U, AD&D, DU, Sup. U
Dependents Life Insurance:
$XXX monthly per Member electing Dependents Life Insurance,
regardless of the number of Dependents covered.
Supplemental Life Insurance:
Age of Insured On
Last January 1
Under 30
30 through 39
40 through 44
45 through 49
50 through 54
55 through 59
60 through 64,
65 through 69
70 through 74
75 through 79
80 through 84
85 through 89
90 through 94
95 or over
Monthly Rate Per
Multiple of$10,000
$ 1.00
1.10
2.20
3.90
6.40
9.90
14.80
22.30
34.30
49.55
74.35
111.50
148.65
223.00
Premium Due Dates:
Grace Period:
lDitial Rate Guarantee Period:
June 1, 1995 and the first day of each calendar month thereafter.
31 days
Supplemental Life Insurance: None
All other insurance: 1 year
31 days
Notice of Rate Change:
Minimum Participation
Life Insurance:
Number:
Percentage:
Supplemental Life Insurance:
Dependents Life Insurance:
10 iDsured Members
100% of eligible Members
Not applicable.
Not applicable.
Printed 4196 Revised 4196
-4-
SAMPLE U,AD&D, DU, Sup. U
LIFE INSURANCE
A. Insuring Clause
If you die while insured for Life Insurance, we will pay benefits according to the terms of the Group Policy after
we receive satisfactory Proof Of Loss.
B. Amount Of Life Insurance
See the Coverage Features for the amount of your Life Insurance.
C. Changes In Life Insurance
Subject to 1 and 2 below, a change in your Life Insurance will become effective on the first day of the calendar
month coinciding with or next followiDg the date of change in classification, age, Annual Earnings, or other
factor shown in the Coverage Features.
1. All increases in your Life Insurance are subject to the Active Work Provisions.
2. Insurance which exceeds any Guarantee Issue Amount shown in the Coverage Features will become
effective on the date we approve your Evidence Of Insurability.
D. When Life Insurance Becomes Effective
The Coverage Features states whether your Life Insurance is Contributory or Noncontributory.
1. Noncontributory Life Insurance
Subject to the Active Work Provisions, your Noncontributory Life Insurance becomes effective on the
date you become eligible.
2. Contributory Life Insurance
You must apply in writing for Contributory Life Insurance and agree to pay premiums. Subject to the
Active Work Provisions, your Life Insurance becomes effective on:
a. The date you become eligible, if you apply on or before that date;
b. The date you apply, if you apply within 31 days after you become eligible; or
c. The date we approve your Evidence Of Insurability, if you apply more than 31 days after you become
eligible (late application).
3. Insurance Subject To Evidence Of Insurability
Subject to the Active Work Provisions, insurance subject to Evidence Of Insurability becomes effective
on the date we approve Evidence Of Insurability.
4. Takeover Provisions
a. If you were insured under the Prior Plan on the day before the effective date of your Employer's
coverage under the Group Policy, your Eligibility Waiting Period is waived on the effective date of
your Employer's coverage under the Group Policy.
b. You must submit satisfactory Evidence Of Insurability to become insured for Life Insurance if you
were eligible under the Prior Plan for more than 31 days but were not insured.
E. When Life Insurance Ends
Your Life Insurance ends automatically on the earliest of:
1. The date the last period ends for which you made a premium contribution, if your insurance is
Contributory;
2. The date the Group Policy terminates;
3. The date your employment terminates; and
4. The date you cease to be a Member. However, your Life Insurance will be continued with premium
payment duringthefollowingperiods while you are not a Member because you are regularly working less
than the minimum number of hours, unless your insurance ends under 1 through 3 above.
Printed 4196 Revised 4196
-5-
SAMPLE U,AD&D, DU, Sup. U
a. While your Employer is paying you at least the same Annual Earnings paid to you immediately
before you ceased to be a Member.
b. While your ability to work is limited because of Sickness, Injury, or Pregnancy.
c. During the first 60 days of:
(1) A temporary layoff; or
(2) A strike, lockout, or other general work stoppage caused by a labor dispute between your
collective bargaining unit and your Employer.
d. During a leave of absence if continuation of your insurance under the Group Policy is required by a
state-mandated family or medical leave act or law.
e. During any other scheduled leave of absence approved by your Employer in advance and in writing
and lasting the Leave Of Absence Period shown in the Coverage Features.
F. Reinstatement Of Life Insurance
If your Life Insurance ends, you may become insured again as a new Member. However, 1 through 4 below will
apply.
1. If your Life Insurance ends because you cease to be a Member, and if you become a Member again within
90 days, the Eligibility Waiting Period will be waived. '
2. If your Life Insurance ends because you fail to make a required premium contribution, you must provide
Evidence Of Insurability to become insured again.
3. If you exercised your Right To Convert, you must provide Evidence Of Insurability to become insured
again.
4. If your insurance ends because you are on a federal or state-mandated family or medical leave of absence,
and you become a Member again immediately following the period allowed, your insurance will be
reinstated pursuant to the federal or state-mandated family or medical leave act or law.
U.LF.l38
ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE
A InsuriDg Clause
If you have an accident while insured for AD&D Insurance, and the accident results in a Loss, we will pay
benefits according to the terms of the Group Policy after we receive satisfactory Proof Of Loss.
B. Definition Of Loss For AD&D Insurance
Loss means loss of life, hand, foot, or sight which:
1. Is caused solely and directly by an accident;
2. Occurs independently of all other causes; and
3. Occurs within 365 days after the accident.
With respect to a hand or foot, Loss means actual and permanent severance from the body at or above the wrist
or ankle joint. With respect to sight, Loss means entire and irrecoverable loss of sight.
C. Amount Payable
The amount payable is equal to a percentage of your AD&D Insurance in effect on the date of the accident (See
Coverage Features). The percentage is shown below.
Loss: Percentage
Life 100%
One hand, one foot, or sight of one eye 50%
Two or more of the above Losses 100%
Printed 4196 Revised 4196
-6-
SAMPLE U. AD&D. DU, Sup. U
No more than 100% of your AD&D Insurance will be paid for all Losses resulting from one accident.
D. Changes In AD&D Insurance
Subject to 1 and 2 below, a change in your AD&D Insurance will become effective on the first day of the
calendar month coinci.dingwith or next followingthe date of change in c1ac:.sincation, age, Annual Earnings, or
other factor shown in the Coverage Features.
1. All increases in your AD&D Insurance are subject to the Active Work Provisions.
2. Insurance which exceeds any Guarantee Issue Amount shown in the Coverage Features will become
effective on the date we approve your Evidence Of Insurability.
E. Seat Belt Benefit
See the Coverage Features for the amount of the Seat Belt Benefit.
We will pay a Seat Belt Benefit if:
1. You die as a result of an Automobile accident for which an AD&D Insurance benefit is payable; and
2. You were wearing a Seat Belt at the time of the accident, as evidenced by a police accident report.
Seat Belt means a properly installed seat belt, lap and shoulder restraint, or other restraint approved by the
National Highway Traffic Safety Administration.
Automobile means a motor vehicle licensed for use on public highways.
F. AD&D Insurance Exclusions
No AD&D Insurance benefit is payable if the Loss is caused or contributed to by any of 1 through 7 below.
1. War or act of War. War means declared or undeclared war, whether civil or international, and any
substantial armed conflict between organized forces of a military nature.
2. Suicide or other intentionally self-inflicted Injury, while sane or insane.
3. Committing or attempting to commit an assault or felony, or actively participating in a violent disorder or
riot. Actively participating does not include being at the scene of a violent disorder or riot while
performing your official duties.
4. The voluntary use or consumption of any poison, chemical compound or drug, unless used or consumed
according to the directions of a physician.
5. Sickness or Pregnancy existing at the time of the accident.
6. Heart attack or stroke.
7. Medical or surgical treatment for any of the above.
G. When AD&D Insurance Becomes Effective
Your AD&D Insurance becomes effective on the date your Life Insurance becomes effective.
H. When AD&D Insurance Ends
Your AD&D Insurance ends automatically on the earlier of:
1. The date your Life Insurance ends; and
2. The date your Waiver Of Premium begins.
u.AO.25
SUPPLEMENTAL LIFE INSURANCE
A. Insuring Clause
If you die, or if your Spouse dies, while insured for Supplemental Life Insurance, we will pay benefits according
to the terms of the Group Policy after we receive satisfactory Proof Of Loss.
Printed 4196 Revised 4196
-7-
SAMPLE U, AD&D, DU, Sup. U
B. Amount Of Supplemental Life Insurance
See the Coverage Features for the schedule of Supplemental Life Insurance. If we approve Evidence Of
Insurability, we will issue a notice showing the amount of Supplemental Life Insurance we have approved.
C. Increases In Supplemental Life Insurance
You must apply in writingfor any increase in Supplemental Life Insurance on your life or on your Spouse's life.
Subject to the Active Work Provisions, an increase in your Supplemental Life Insurance becomes effective
on the date we approve your Evidence Of Insurability.
An increase in your Spouse's Supplemental Life Insurance becomes effective on the date we approve your
Spouse's Evidence Of Insurability.
D. Decreases In Supplemental Life Insurance
A decrease in Supplemental Life Insurance because of a change in age becomes effective on the first day of the
calendar month coinciding with or next following the change in age.
Any other decrease in Supplemental Life Insurance becomes effective on the first day of the calendar month
coinciding with or next following the date the Policyowner or Employer receives your written request for the
decrease.
E. Suicide Exclusion: Supplemental Life Insurance
If death results from suicide or other intentionally self- inflicted Injury, while sane or insane, 1 and 2 below
will apply.
1. The amount payable will exclude the amount of Supplemental Life Insurance which has not been
continuously in effect for at least 2 years on the date of death.
2. . We will refund all premiums paid for Supplemental Life Insurance which is excluded from payment
under this suicide exclusion.
F. Becoming Insured For Supplemental Life Insurance
1. Eligibility
You and your Spouse are eligible if you are insured for Life Insurance.
2. Effective Date
You must apply in writing for Supplemental Life Insurance on your life or on your Spouse's life and agree
to pay premiums.
Subject to the Active Work Provisions, your Supplemental Life Insurance becomes effective on the
date we approve your Evidence Of Insurability.
Your Spouse's Supplemental Life Insurance becomes effective on the date we approve your Spouse's
Evidence Of Insurability.
G. When Supplemental Life Insurance Ends
Supplemental Life Insurance ends automatically on the earliest of:
1. The date all your Life Insurance ends;
2. The date the last period ends for which you made a premium contribution for the Supplemental Life
Insurance;
3. The date you die; and
4. For your Spouse, the date of your divorce.
U.Sl...01
Printed 4196 Revised 4196
-8-
SAMPLE U. AD&D. DUo Sup, U
DEPENDENTS LIFE INSURANCE
A. Insuring Clause
If your Dependent dies while insured for Dependents Life Insurance, we will pay benefits according to the
terms of the Group Policy after we receive satisfacto:ry Proof Of Loss.
B. Amount Of Dependents Life Insurance
See the Coverage Features for the amount of your Dependents Life Insurance.
C. Changes in Dependents Life Insurance
A change in your Dependents Life Insurance will become effective on the first day of the calendar month
coinciding with or next following the date of change in factors shown in the Coverage Features. Insurance
which exceeds any Guarantee Issue Amount shown in the Coverage Features will become effective on the
date we approve your Dependent's Evidence Of Insurability.
D. DefinitioDS For Dependents Life Insurance
Dependent means your Spouse or Child. Dependent does not include a person who is afull-time member of the
armed forces of any country.
Child means your unmarried child from live birth through age 20 (through age 24 if a registered student in full
time attendance at an accredited educational institution). Child includes a stepchild living in your home and
an adopted child. .
Disabled Child means your unmarried child who, on and after the date on which Dependents Life Insurance
would end because of the child's age, is continuously:
1. Incapable of self-sustaining employment because of mental retardation or physical handicap; and
2. Chiefly dependent upon you for support and maintenance, or institutionalized because of mental
retardation or physical handicap.
Disabled Child includes your unmarried child over age 20 (or over age 24 and a registered student in full-time
attendance at an accredited educational institution) who:
a. On the day before the effective date of your Employer's coverage under the Group Policy was insured
under the Prior Plan; and
b. On and after the effective date of your Employer's coverage under the Group Policy continuously meets
the requirements of 1 and 2 above.
You must give us proof of Disabled Child status on our forms and within 31 days after a) the date on which
insurance would otherwise end because of the Child's age or b) the effective date of your Employer's coverage
under the Group Policy if your child is a Disabled Child on that date. At reasonable intervals thereafter, we
may require further proof, and have your Disabled Child PYl'1m;ned at our expense.
E. Becoming Insured For Dependents Life Insurance
1. Eligibility
You become eligible to insure your Dependents on the later of:
a. The date your Life Insurance becomes effective; and
b. The date you first acquire a Dependent.
2. Effective Date
The Coverage Features states whether your Dependents Life Insurance is Contributory or
Noncontributory.
a. Noncontributory Dependents Life Insurance
Subject to the Active Work Provisions, Noncontributory Dependents Life Insurance becomes
effective on the date you become eligible to insure your Dependents.
b. Contributory Dependents Life Insurance
Printed 4196 Revised 4/96
-9-
SAMPLE U.AD&D, DU. Sup. U
You must apply in writing for Contributory Dependents Life Insurance and agree to pay premiums.
Subject to the Active Work ProvisioDS, your Dependents Life Insurance becomes effective on:
i The date you become eligible, if you apply on or before that date.
ii. The date you apply, if you apply within 31 days after you become eligible.
ill. The date we approve each Dependent's Evidence Of Insurability, if you apply more than 31
days after you become eligible Qate application).
While your Dependents Life Insurance is in effect, each new Dependent becomes insured immediately.
c. Dependents Life Insurance Subject To Evidence Of Insurability
Insurance subject to Evidence of Insurability becomes effective on the date we approve Evidence Of
Insurability.
F. When Dependents Life Insurance Ends
Dependents Life Insurance ends automatically on the earliest of:
1. Five months after you die (no premiums will be charged for your Dependents Life Insurance during this
time);
2. The date your Life Insurance ends for reasons other than your death;
3. The date the Group Policy terminates, unless: (a) your Dependents Life Insurance continues under 1.
. above; or (b) you qualify for Waiver Of Premium;
4. The date the last period ends for which you made a premium contribution, if your Dependents Life
Insurance is Contributory;
5. For your Spouse, the date of your divorce;
6. For any Dependent, the date the Dependent ceases to be a Dependent; and
7. For a Disabled Cbild, 90 days after we mail you a request for proof of Disabled Child status, ifproofis not
given.
WoOL-01
ACTIVE WORK PROVISIONS
If you are incapable of Active Work because of Sickness, Injury or Pregnancy on the day before the scheduled
effective date of your insurance or an increase in your insurance, your insurance or increase will not become
effective until the day after you complete one full day of Active Work as an eligible Member.
Active Work and Actively At Work mean performing the material duties of your own occupation at your Employer's
usual place of business. .
Printed 4196 Revised 4196
-10-
SAMPLE U, AD&D, DU Sup. U
You will also meet the Active Work requirement if:
1. You were absent from Active Work because of a regularly scheduled day off, holiday, or vacation day;
2. You were Actively At Work on your last scheduled work day before the date of your absence; and
3. You were capable of Active Work on the day before the scheduled effective date of your insurance or increase in
your insurance.
U..AW.02
WAIVER OF PREMIUM
A. Waiver Of Premium Benefit
Insurance will be continued without payment of premiums while you are Totally Disabled if:
1. You become Totally Disabled while insured under the Group Policy and under age 60;
2. You complete your Waiting Period; and
3. You give us satisfactory Proof Of Loss.
B. Definitions For Waiver Of Premium
1. Insurance means all your insurance under the Group Policy, except AD&D Insurance.
2. Totally Disabled means that, as a result of Sickness, accidental Injury, or Pregnancy, you are unable to
perform with reasonable continuity the material duties of any gainful occupation for which you are
reasonably fitted by education, training and experience.
3. Waiting Period means the 180 consecutive day period beg;",,;ng on the date you become Totally Disabled.
Waiver Of Premium begins when you complete the Waiting Period.
C. Premium Payment
Premium payment must continue until the later of:
1. The date you complete your Waiting Period; and
2. The date we approve your claim for Waiver Of Premium.
D. Refund Of Premiums
We will refund up to 12 months of the premiums that were paid for Insurance after the date you become Totally
Disabled.
E. Amount Of Insurance
The amount of Insurance continued without payment of premium is the amount in effect on the day before you
become Totally Disabled, subject to the following:
1. Insurance will be reduced or terminated according to the Group Policy provisions in effect on the day
before you become Totally Disabled.
2. The amount of Supplemental Life Insurance on your Spouse will be the lesser of:
a. The amount in effect on the day before you become Totally Disabled; and
b. The amount in effect one year before the date you become Totally Disabled.
3. If you receive an Accelerated Benefit, Insurance will be reduced according to the Accelerated Benefit
provision.
F. Effect Of Death During The Waiting Period
If you die during the Waiting Period and are otherwise eligible for Waiver Of Premium, the Waiting Period will
be waived.
Printed 4196 Revised 4196
-11-
SAMPLE LI, AD&D, DLI, Sup. U
G. Termination Or Amendment Of The Group Policy
Insurance will not be affected by termination or amendment of the Group Policy after you become Totally
Disabled.
H. When Waiver Of Premium Ends
Waiver of Premium ends on the earliest of:
1. The date you cease to be Totally Disabled;
2. 90 days after the date we mail you a request for additional Proof Of Loss, if it is not given;
3. The date you fail to attend an ~l'Imin8tion or cooperate with the eYl'Iminer;
4. With respect to the amount of Insurance wbich an insured has converted, the effective date of the
individual life insurance policy issued to the insured; and
5. The date you reach age 65.
U.WP.46
ACCELERATED BENEFIT
A. Accelerated Benefit
If you qualify for Waiver Of Premium and incur a Qualifying Medical Condition while you are insured under
the Group Policy, we will pay anAccelerated Benefit to you according to the terms of the Group Policy after we
receive satisfactory Proof Of Loss.
Qualifying Medical Condition means you are terminally ill, with a life expectancy of less than 12 months.
We may have you ~l'Im;ned at our expense in connection with your claim for an Accelerated Benefit. Any such
I"Yl'Im;ns:l:ti.on will be conducted by one or more Physicians of our choice.
B. Application For Accelerated Benefit
You must have at least $10,000 of Insurance in effect to be eligible.
You must apply for an Accelerated Benefit. To apply you must give us satisfactory Proof Of Loss on our forms.
Proof Of Loss must include a statement from a Physician that you have a Qualifying Medical Condition.
C. Amount Of Accelerated Benefit
You may receive an Accelerated Benefit ofup to 50% of your Insurance. The J11l'1Yimum Accelerated Benefit is
$250,000. The minimum Accelerated Benefit is $5,000 or 10% of your Insurance, whichever is greater.
If the amount of your Insurance is scheduled to reduce within 24 months following the date you apply for the
Accelerated Benefit, your Accelerated Benefit will be based on the reduced amount.
If your Insurance is scheduled to end within 24 months following the date you apply for the Accelerated
Benefit, you will not be eligible for the Accelerated Benefit.
You may elect an Accelerated Benefit once in your lifetime. The Accelerated Benefit will be paid to you in a
lump sum. If you recover from your Qualifying Medical Condition after receiving an Accelerated Benefit, we
will not ask you for a refund.
D. Effect On Insurance And Other Benefits
The amount of your Insurance after payment of the Accelerated Benefit will be:
1. The amount of your Insurance as if no Accelerated Benefit had been paid; minus
2. The amount of the Accelerated Benefit; minus
Printed 4196 Revised 4/96
-12-
SAMPLE U. AD&D. DU. Sup. U
3. An interest charge calculated as follows:
A times B times C divided by 365 = interest charge.
A = The amount of the Accelerated Benefit.
B = The monthly average of our variable policy loan interest rate.
C = The number of days from payment of the Accelerated Benefit to the earlier of(l) the date you die,
and (2) the date you have a Right To Convert.
Your AD&D Insurance, if any, is not affected by payment of the Accelerated Benefit.
E. Exclusions
No Accelerated Benefit will be paid if:
1. .All or part of your Insurance must be paid to your Cbild(ren), or your Spouse or former Spouse as part of a
court approved divorce decree, separate maintenance agreement, or property settlement agreement.
2. You are married and live in a community property state unless you give us a signed written consent from
your Spouse.
3. You have made an assignment of all or part of your Insurance unless you give us a signed written consent
from the assignee.
4. You have filed for bankruptcy, unless you give us written approval from the Bankruptcy Court for
payment of the Accelerated Benefit.
5. You are required by a government agency to use the Accelerated Benefit to apply for, receive, or continue
a government benefit or entitlement.
6. You have previously received an Accelerated Benefit under the Group Policy.
F. Definitions For Accelerated Benefit
Insurance means your Life Insurance and Supplemental Life Insurance, if any, under the Group Policy.
Physician means a licensed M.D. or D.O., other than yourself, acting within the scope of the license.
LU\B.110
RIGHT TO CONVERT
A. Right To Convert
You may buy an individual policy of life insurance without Evidence Of Insurability if:
1. Your Insurance ends or is reduced due to a Qualifying Event; and
2. You apply in writing and pay us the first premium during the Conversion Period.
Except as limited under C. Limits On Right To Convert, the ml'lYimum amount you have a Right To Convert is
the amount of your Insurance which ended. .
B. Definitions For Right To Convert
1. Conversion Period means the 31-day period after the date of any Qualifying Event.
2. Insurance means all your insurance under the Group Policy, including insurance continued under
Waiver Of Premium, but excluding AD&D Insurance.
3. Qualifying Event means termination or reduction of your Insurance for any reason except:
a. The Member's failure to make a required premium contribution.
b. Payment of an Accelerated Benefit.
Printed 4196 Revised 4196
-13-
SAMPLE LI.AD&D. DLI, Sup. U
4. You and your mean any person insured under the Group Policy.
C. Limits On Right To Convert
If your Insurance ends or is reduced because of termination or amendment of the Group Policy, 1 and 2 below
will apply.
1. You may not convert Insurance which has been in effect for less than the Minimum Time Insured. See
Coverage Features.
2. The ml'lYimum amount you have a Right To Convert is the lesser of:
a. The amount of your Insurance which ended, minus any other group life insurance for which you
become eligible during the Conversion Period; and
b. The Maximum Conversion Amount. See Coverage Features.
D. The Individual Policy
You may select any form of individual life insurance policy we issue to persons of your age, except:
1. A term insurance policy;
2. A umversallife policy;
3. A policy with disability, accidental death, or other additional benefits; or
4. A policy in an amount less than the minimum amount we issue for the form of life insurance you select.
The individual policy of life insurance will become effective on the day after the end of the Conversion Period.
We will use our published rates for standard risks to determine the premium.
E. Death During The Conversion Period
If you die during the Conversion Period, we will pay a death benefit equal to the maximum amount you had a
Right To Convert, whether or not you applied for an individual policy. The benefit will be paid according to the
Benefit Payment And Beneficiary ProvisiODS.
U.RC.14
CLAIMS
A. Filing A Claim
Claims should be filed on our forms.lfwe do not provide our forms within 15 days after they are requested, the
claim. may be submitted in a letter to us.
B. Time Limits On Filing Proof Of Loss
Proof Of Loss must be provided within 90 days after the date of the loss. If that is not possible, it must be
provided as soon as reasonably possible, but not later than one year after that 9o-day period.
Proof Of Loss for Waiver Of Premium must be provided within 12 months after the end of the Waiting Period.
We will require further Proof Of Loss at reasonable intervals, but not more often than once a year after you
have been continuously Totally Disabled for two years.
IfProofOfLoss is filed outside these time limits, the claim will be denied. These limits will not apply while the
Member or Beneficiary lacks legal capacity.
C. ProofOfLoss
Proof Of Loss means written proof that a loss occurred:
1. For which the Group Policy provides benefits;
2. Which is not subject to any exclusions; and
Printed 4196 Revised 4/96
-14-
SAMPLE U,AD&D, DU, Sup. U
3. Which meets all other conditions for benefits.
Proof Of Loss includes any other information we may reasonably require in support of a claim. Proof Of Loss
must be in writing and must be provided at the expense of the claimant. No benefits will be provided until we
receive Proof Of Loss.
D. Investigation Of Claim
We may have you l"Y~m;ned at our expense at reasonable intervals. Any such €'Y~min~tion will be conducted by
specialists of our choice.
We may have an autopsy performed at our expense, except where prohibited by law.
E. Time Of Payment
We will pay benefits within 60 days after Proof Of Loss is satisfied.
F. Notice Of Decision On Claim
The claimant will receive a written decision on a claim within a reasonable time after we receive the claim.
If the ,.l~imant does not receive our decision within 90 days after we receive the claim, the cl~imant will have
an immediate right to request a review as if the claim had been denied.
If we deny any part of the claim, the claimant will receive a written notice of denial cont~;ning:
1. The reasons for our decision;
2. Reference to the parts of the Group Policy on which our decision is based;
3. A description of any additional information needed to support the claim; and
4. Information concerning the claimant's right to a review of our decision.
G. Review Procedure
If all or part of a claim is denied, the claimant must request a review in writing within 60 days after receiving
notice of the denial.
The cll'lim~nt may send us written comments or other items to support the claim, and may review any
non privileged information that relates to the request for review.
We will review the claim promptly after we receive the request. We will send notice of our decision within 60
days after we receive the request, or within 120 days if special circumstances require an extension. We will
state the reasons for our decision and refer to the relevant parts of the Group Policy.
U.CLOl
ASSIGNMENT
The rights and benefits under the Group Policy caDIlot be assigned.
U.AS.Ol
BENEFIT PAYMENT AND BENEFICIARY PROVISIONS
A Payment Of Benefits
Benefits payable because of your death will be paid to the Beneficiary you name. See B through E of this
section.
The benefits below will be paid to you if you are living.
1. AD&D Insurance dismemberment benefits.
Printed 4196 Revised 4196
-15-
SAMPLE U,AD&D, DU, Sup. U
2. Dependents Life Insurance benefits.
3. Supplemental Life Insurance benefits payable because of the death of your insured Spouse.
4. Accelerated Benefits.
Any AD&D Insurance dismemberment benefits which are unpaid at your death will be paid to the Beneficiary
you name to receive Life Insurance benefits.
Dependents Life Insurance benefits which are unpaid at your death will be paid in equal shares to the first
surviving class of the classes below.
1. The children of the Dependent.
2. The parents of the Dependent.
3. The brothers and sisters of the Dependent.
4. Your estate.
. Supplemental Life Insurance benefits payable because of the death of your Spouse which are unpaid at your
death will be paid in equal shares to the :first surviving class of the classes below.
1. The children of your Spouse.
2. The parents of your Spouse.
3. The brothers and sisters of your Spouse.
4. Your estate.
B. Naming A Beneficiary
Beneficiary means a person you name to receive death benefits.
You may name one or more Beneficiaries. Two or more surviving Beneficiaries will share equally, UDless you
specify otherwise. You may name or change Beneficiaries at any time without the consent of a Beneficiary.
Your Beneficiary designation must be the same for Life Insurance and AD&D Insurance death benefits. Your
Beneficiary designations for Life Insurance and your Supplemental Life Insurance may be different.
You must name or change Beneficiaries in writing. Your designation:
1. Must be dated and signed by you;
2. Must be delivered to the Policyowner or Employer during your lifetime;
3. Must relate to the insurance provided under the Group Policy; and
4. Will take effect on the date it is delivered to the Policyowner or Employer.
Ifwe approve it, a written designation signed and dated by you under the Prior Plan will be accepted as your
Beneficiary designation under the Group Policy.
C. Simultaneous Death Provision
If a Beneficiary dies on the same day you die, or within 15 days thereafter, benefits will be paid as if that
Beneficiary had died before you, UDless Proof Of Loss with respect to your death is delivered to us before the
date of the Beneficiary's death.
D. No Surviving Beneficiary
If you do not name a Beneficiary, or if you are not survived by one, benefits will be paid in equal shares to the
first surviving class of the classes below.
1. Your spouse.
2. Your children.
3. Your parents.
Printed 4196 Revised 4196
-16-
SAMPLE U, AD&D. DU, Sup. U
4. Your brothers and sisters.
5. Your estate.
E. Methods Of Payment
Recipient means a person who is entitled to benefits under this Benefit Payment and Beneficiary
Provisions section.
1. Lump Sum
If the amount payable to a Recipient is less than $25,000, we will pay it in a lump sum.
2. Standard Secure Access Checking Account
If the amount payable to a Recipient is $25,000 or more, we will deposit it into a Standard Secure Access
checking account which:
a. Bears interest;
b. Is owned by the Recipient;
c. Is subject to the terms and conditions of a confirmation certificate which will be given to the
Recipient; and
d. Is fully guaranteed by us.
3. Installments
Payment to a Recipient may be made in installments if:
a. The amount payable is $25,000 or more;
b. The Recipient chooses; and
c. We agree.
To the extent permitted by law, the amount payable to the Recipient will not be subject to any legal process orto
the claims of any creditor or creditor's representative.
U.Ba09
ALLOCATION OF AUTHORITY
Except for those functions which the Group Policy specifically reserves to the Policyowner, we have full and
exclusive authority to control and manage the Group Policy, to anm;n;~ claims, and to interpret the Group Policy
and resolve all questions arising in the anmin;~ation, interpretation, and application of the Group Policy.
Our authority includes, but is not limited to:
1. The right to resolve all matters when a review bas been requested;
2. The right to establish and enforce rules and procedures for the anmin;~tration of the Group Policy and
any claim under it;
3. The right to determine:
a. Eligibility for insurance;
b. Entitlement to benefits;
c. Amount of benefits payable;
d. Sufficiency and the amount of information we may reasonably require to determine a., b., or c.,
above.
Printed 4196 Revised 4196
-17-
SAMPLE U,AD&D, DU, Sup. U
Subject to the review procedu~'es of the Group Policy, any decision we make in the exercise of our authority is
conclusive and binding.
U.ALOl
TIME LIMITS ON LEGAL ACTIONS
No action at law or in equity may be brought until 60 days after we have been given Proof Of Loss. No such action
may be brought more than three years after the earlier of:
1. The date we receive Proof Of Loss; and
2. The time within which Proof Of Loss is required to be given.
U.Tl..Ol
INCONTESTABILITY PROVISIONS
A Incontestability Of Insurance
Any statement made to obtain insurance is a representation and not a warranty.
No misrepresentation will be used to reduce or deny a claim unless:
1. The insurance would not have been approved if we had known the truth; and
2. We have given you or any other person d ~;m;ng benefits a copy of the signed written instrument which
contains the misrepresentation.
We will not use a misrepresentation to reduce or deny a claim after the insured's insurance has been in effect
for two years.
B. Incontestability Of Group Policy
Any statement made by the Policyowner or Employer to obtain the Group Policy is a representation and not a
warranty.
No misrepresentation by the Policyowner or Employer will be used to deny a claim or to deny the validity of the
Group Policy unless:
1. The Group Policy would not have been issued if we had known the truth; and
2. We have given the Policyowner or Employer a copy of a written instrument signed by the Policyowner or
Employer which contains the misrepresentation.
The validity of the Group Policy will not be contested after it has been in force for two years, except for
nonpayment of premiums.
UJN.Ol
DEFINITIONS
AD&D Insurance means accidental death and dismemberment insurance, if any, under the Group Policy.
Annual Earnings means your annual rate of earnings from your Employer. Your Annual Earnings will be based on
your earnings in effect on your last full day of Active Work unless a different date applies (see Coverage Features).
Annual Earnings includes:
1. Contributions you make through a salary reduction agreement with your Employer to:
a. An mc Section 401(k), 403(b), 408(k) or 457 deferred compensation arrangement; or
Printed 4/96 Revised 4/96
-18-
SAMPLE U,AD&D, DU, Sup. U
b. An executive nonqu.a1ified deferred compensation arrangement.
2. Commissions for the Earnings Period shown in the Coverage Features or for the period of your employment
ifless than the Earnings Period.
3. Shift differential pay.
4. Amounts contributed to your fringe benefits according to a salary reduction agreement under an mc Section
125 plan.
Annual Earnings does not include:
1. Bonuses.
2. Overtime pay.
3. Your Employer's contributions on your behalf to any deferred compensation arrangement or pension plan.
4. Any other extra compensation.
Contributory means you pay all or part of the premium for insurance.
Dependents Life Insurance means dependents life insurance, if any, under the Group Policy.
Eligibility Waiting Period means the period you must be a Member before you become eligible for insurance. See
Coverage Features.
Evidence Of Insurability means an applicant must:
1. Complete and sign our medical history statement;
2. Sign our form authorizing us to obtain. information about the applicant's health;
3. Undergo a physical PTl'Im;nl'ltion, if required by us, wbich may include blood testing; and
4. Provide any additional information about the applicant's insurability that we may reasonably require.
Group Policy means the group life insurance policy issued by us to the Policyowner and identified by the Group
Policy Number.
Injury means an injury to your body.
Life Insurance means life insurance under the Group Policy.
Noncontributory means the Policyowner or Employer pays the entire premium for insurance.
Pregnancy means your pregnancy, childbi.rth, or related medical conditions, including complications of pregnancy.
Prior Plan means your Employer's group life insurance plan in effect on the day before the effective date of your
Employer's coverage under the Group Policy and wbich is replaced by the Group Policy.
Sickness means your sickness, illness, or disease.
Spouse means a person to whom you are legally manied. Spouse does not include a person who is a full-time
member of the armed forces of any country.
Supplemental Life Insurance means supplemental life insurance, if any, under the Group Policy.
UOF.16
POUCYOWNER PROVISIONS
A Premiums
The premium due on each Premium Due Date is the sum of the premiums for all persons then insured.
Premium Rates are shown in the Coverage Features.
Printed 4196 Revised 4196
-19-
SAMPLE LI, AD&D, DU, Sup, U
B. Contributions From Members
The Policyowner determines the amount, if any, of each Member's contribution toward the cost of insurance
under the Group Policy.
C. Changes In Premium Rates
We may change Premium Rates for Supplemental Life Insurance upon 31 days written notice, but not more
often than once in any calendar year.
We may change any other Premium Rates when:
1. A change or clarification in law or governmental regulation affects the amount payable under the Group
Policy. Any such change in Premium Rates will reflect only the change in our obligations; or
2. The number of insured Members changes by 25% or more; or
3. We and the Policyowner mutually agree to change Premium Rates.
Except as provided above, Premium Rates will not be changed duringthe Initial Rate Guarantee Period shown
in the Coverage Features. Thereafter, except as provided above, we may ~o-e Premium Rates upon
advance written notice to the Policyowner. The minimum advance notice is shown in the Coverage Features
as Notice of Rate Change. Any such change in Premium Rates may be made effective on any Premium Due
Date, but no such change will be made more than once in any contract year. Contract years are successive 12
month periods computed from the end of the Initial Rate Guarantee Period.
D. Payment Of Premiums
All premiums are due on the Premium Due Dates shown in the Coverage Features.
Each premium is payable on or before its Premium Due Date directly to us at our home office. The payment of
each premium as it becomes due will maintain the Group Policy in force until the next Premium Due Date.
E. Grace Period And Termination For Nonpayment
If a premium is not paid on or before its Premium Due Date, it may be paid during the following Grace Period.
The length of the Grace Period is shown in the Coverage Features. The Group Policy will remain in force
during the Grace Period.
If the premium is not paid during the Grace Period, the Group Policy will terminate automatically at the end of
the Grace Period.
The Policyowner is liable for premium for insurance under the Group Policy during the Grace Period. We may
charge interest at the legal rate for any premium which is not paid during the Grace Period, beginning-with the
:first day after the Grace Period. .
F. Termination For Other Reasons
The Policyownermay terminate the Group Policy by givingus written notice. The effective date of termination
will be the later of:
1. The date stated in the notice; and
2. The date we receive the notice.
We may terminate the Group Policy as follows:
1. On any Premium Due Date if the number of persons insured is less than the Minimum Participation
Number or less than the Minimum Participation Percentage shown in th~ Coverage Features.
2. On any Premium Due Date if we determine that the Policyowner has failed to promptly furDish any
necessary information requested by us, or has failed to perform any other obligations relating to the
Group Policy.
The minimum advance notice of such termination by us is the same as the Notice ofRate Change stated in the
Coverage Features.
Printed 4/96 Revised 4/96
-20-
SAMPLE U, AD&D, DU, Sup. U
G. Premium Adjustments
Premium adjustments involving a return of unearned premiums to the Policyowner will be limited to the 12
months just before the date we receive a request for premium adjustment.
H. Dividends
While the Group Policy is in force, it will be credited with its share, if any, of the divisible surplus in the form of
dividends we may declare.
If required by state law, the Policyowner will use, for the sole benefit of the insured Members, the amount of
such dividends or rate reductions which exceeds the Policyowner's expenditures for the insurance under the
Group Policy.
1. Certificates
We will issue certificates to the Policyowner showing the coverage under the Group Policy. The Policyowner
will distribute a certificate to each insured Member.
J, Records And Reports
The Policyowner or Employer will fumish on our forms all information reasonably necessary to anm;n;~erthe
Group Policy. .We have the right at all reasonable times to inspect the payroll and other records of the
Policyowner or Employer which relate to insurance under the Group Policy.
Clerical error by the Policyowner will not:
1. Cause a person to become insured;
2. Invalidate insurance otherwise validly in force; or
3. Continue insurance otherwise validly terminated.
K. Misstatement Of Age
If a person's age has been misstated, we will make an equitable adjustment of premiums, benefits, or both. The
adjustment will be based on:
1. The amount of insurance based on the correct age; and
2. The difference between the premiums paid and the premiums which would have been paid if the age had
been correctly stated.
L. Entire Contract, Changes
The Group Policy and the application of the Policyowner constitute the entire contract between the parties. A
copy of the Policyowner's application is attached to the Group Policy when issued.
The Group Policy may be changed in whole or in part. No change in the Group Policy will be valid unless it is
approved in writing by one of our executive officers and given to the Policyowner for attacbment to the Group
Policy. No agent has authority to change the Group Policy or to waive any ofits provisions.
M, Effect On Workers' Compensation, State Disability Insurance
The coverage provided under the Group Policy is not a substitute for coverage under a workers' compensation
or state disability income benefit law and does not relieve the Employer of any obligation to provide such
coverage.
U.PO.01
Printed 4196 Revised 4'96
-21-
SAMPLE LIt AD&D, DU. Sup. U
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City of Sunny Isles Beach
17070 Collins Avenue, Suite 250
Sunny Isles Beach, Florida 33160
(305) 947-0606 phone (305) 949-3113 fax
David Samson
Mayor
Irving Thretsky
Vice Mayor
Commissioners
Danny Iglesias
Lila Kauffman
Connie Morrow
James DiPietro
City Manager
Lynn M. Dannheisser
City Attorney
To:
City Commission
From:
Finance Director
Date:
December 17, 1998
Subject:
Employee Life Insurance
RECOMMENDATION
It is recommended that the City Commission authorize the City Manager by
resolution to execute an agreement with Standard Insurance Company for
Employee Life and Accidental Death and Disability Insurance in accordance with
the attached proposal for Basic coverage provided by the City for all employees
and voluntary increased coverage of up to a similar amount subject to a minimum
participation and paid by the employees who chose such additional coverage.
REASONS
The premiums quoted for this coverage are approximately 30% less than the City
now pays for employee life insurance.
ADDITIONAL INFORMATION
The initial policy for the year from January through December 1998 covered less
than 20 employees prior to the 42 additional employees in the Police department
who started in late July, The policy that has been in effect until the end of the
calendar year was reasonable for the small size of the original number of
employees covered and could not be appropriately changed during the initial policy
year. The larger number of employees at this time enabled the City to obtain six
responsive bids ranging from 30 cents per month per $1,000 of coverage to
43 cents per month per $1,000 of coverage.
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LIFE INSURANCE
There were six proposals for life insurance.
In order of premium levels the proposals are:
Rates per month per thousand dollars of coverage
LIFE AD&D
- Standard (Howard) $.26 $.04
-BMA $.31 $.03
- Reliastar $.35 $.03
- Hartford (Sedgwick) $.36 $,03
- Humana (Friedman) $.37 $.06
- Florida League Of Cities Combined
TOTAL
$.30
$.34
$.38
$.39
$.43
$.43
CITY OF SUNNY ISLES BEACH
Presented By:
MICHAEL HAYES
STANDARD INSURANCB COMPANY
November 12, 1998
582028-0-981202
STUDARD Dl'suaurCB COIIPAHY
LtPB AND AD5D IH8URAHcB
PLAN A
SCBBDULB 0.. XH81JRAHCB
Class: All Bligible
Life Amount
$25,000
AD&O Amount
$25,000
COST
No. of Benefit Rate Monthly
Lives Volume X Der SlOOO - Premium
LIFE 53 $J.,292,500 $.26 $336
AD&:!> 53 $1,292,500 $.04 $52
TOTAL $388
PLAN PBATtJRJlS
*
*
*
All benefits are Guarantee Issue.
Plan reflects 100% Employer contribution.
Proposal assumes all known health risks have been disclosed
to Standard's field personnel.
Waiver Of Premium if disabled prior to age 60: will
terminate at age 65.
No benefit termination due to age.
Benefits reduce to 65% at age 65, to 50% at age 70, to 35%
at age 75.
Rates reflect combined purchase of Basic and Additional
Life.
An Accelerated Benefit, which allows up to 7S% of a Member's
Life Insurance benefit to be paid while still living, is
available to Members with a Qualifying Medical Condition,
Certain minimums and maximums apply, subject to state
statute. Waiver of Premium must be included for this
provision to be available,
Notice of Rate Change is 60 days.
Final rates will be guaranteed until 8-1-2001.
J. DiPietro and Lynn Dannheiser are eligible for basic and
additional benefits in the amount of $50,000.
AD&D includes an additional Seat Belt Benefit equal to the
lesser of $10,000 and the amount of AD&D payable for loss
of life.
AD&D provides coverage for private flying.
*
*
*
*
*
*
*
*
*
*
582028-1-981202
STAH!)UJ) DfSUltDCB COIIPUY
ADDITIOHAL LID IHSUlWICB
PLAN A
SCBBDULB or DIS1JRAHCB
Class: All Bnrolled in Additional Life
Life Amount
$25,000
COST
- Rate 'Der 51000
Under 30 $.10
30 - 39 $.13
40 - 44 $.22
45 - 49 $.39
50 - S4 $.60
S5 - 59 $1.00
60 - 64 $1.13
65 - 69 $1.98
70 - 74 $3.25
75 or more $5.61
582028-1-981202
STAImARD XITSURUCI: COMPANY
ADDI'l'IORAL ACCmD'l'AL DRAm AHD DISICBIIl'DIIJDI'l' INS1JltARCB
PLAN A
8CIDIDtJLB 0. msuaD'C.
Class: All Enrolled in Additional Life
AD&!) Amount
$25,000
COST
No. of
Lives
Benefit
Volume
x
Rate
per SlOOO
s
Monthly
Premium
27
$646,250
$.04
$26
PLAN I'BATURBS
* Number of live. and volume were adjusted to reflect assumed
enrollment in this contributory plan.
* Proposal assumes all known health risks have been disclosed
to Standard's field personnel.
· No benefit termination due to age.
. Benefits reduce to 65% at age 65, to sot at age 70, to 35%
at age 75.
* Rates reflect combined purchase of Basic and Additional
Life.
* AD&D includes an additional Seat Belt Benefit equal to the
lesser of $10,000 and the amount of AD&O payable for loss
of life.
582028-1-981202
TOTAL P.06
STAND.un DfSURAlfCB COMPANY
PLAN PBATtJRBS
* Evidence Of Insurability will be required for all amounts
for Members enrolling more than 31 days after becoming
eligible.
* Plan reflects at Employer contribution.
* Rates assume sot of the eligible Members will enroll. 35t
of the eligible Members must enroll. Pinal rates will
be based on actual Member composition and enrollment.
* Proposal assumes all known health risks have been disclosed
to Standard's field personnel.
* Waiver Of Premium if disabled prior to age 60: will
terminate at age 65.
* No benefit termination due to age.
* Benefits reduce to 65t at age 65, to SOt at age 70, to 35%
at age 75.
* Rates reflect combined purchase of Basic and Additional
Life.
* An Accelerated Benefit, which allows up to 7St of a Member's
Life Insurance benefit to be paid while still living, is
available to Members with a Qualifying Medical Condition.
Certain minimums and maximums apply, subject to state
statute. Waiver of Premium must be included for this
provision to be available.
* Until coverage has been in force for 2 years, death which
results from suicide or other intentional self-inflicted
injury is not covered (in force for 1 year in co, NO; no
exclusion in WA).
* Notice of Rate Change is 60 days.
582028-1-981202