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Jefferson Pilot Life Ins.#1
I F-1 ❑ A GROUP INSURANCE PROGRAM Designed Specially For CITY OF SUNNY ISLES Submitted By Brown & Brown Underwritten By 1 10 re. JEFFERSON PILOT FINANCIAL Keith L. Mueller, Marketing Associate Miami Regional Group Office 3107 Stirling Road Suite 206 Fort Lauderdale, FL 33312 Phone: (800) 279 -4598 Fax: (954) 894 -0905 November 12, 2001 Mr. Christopher Russo, City Manager City of Sunny Isles Beach 17070 Collins Avenue, Suite 250 Sunny Isles Beach, FL 33160 Re: REQUEST FOR PROPOSALS NO. 01 -10 -01 Dear Mr. Russo, Brown & Brown, Inc. Spessard Holland Bldg. Suite 400 8000 Governors Square Blvd. Miami Lakes, FL 33016 -1588 305/364 -7800 • Toll Free 800/432 -8844 FAX 305/822 -5687 NO -V-1 6 2001 City ot Sunny IS,!Os Beach In accordance with the City of Sunny Isles Beach RFP No. 01- 10 -01, I am pleased to enclose our proposal for the Employee Dental, Life, Long Term disability and Vision Insurance. Brown & Brown Insurance, Inc., is a national independent insurance agency, with local offices at 8000 Governors Square Boulevard, Suite 400, Miami Lakes, FL 33016. Our agency has extensive experience in providing these forms of insurance and is currently the agent for the City's Group Health and Property and Casualty Insurance Programs. We look forward to continuing to service the insurance needs of the City of Sunny Isles Beach, Florida. Very truly yo L Robert P.uHollander Executive Vice President Encl. FLORIDA DEPARTMENT OF INSUR-kNCE ROBERT PAUL HOLLANDER License Number A121581 IS LICENSED TO TRAt3A4 V. FOLLOWING CLASSES *J URANCE: General Lines (Prop & Cas) Heafth Life Life & Health Variable Annuity This licensee must have an active appointment mth the insurer or employer for which oroducts or services are being marketed See reverse for additional -equireme,its 3056 NE 210 Street SS#265-68-9331 Aventura F1 33180 FL# A121581 DOB: 6/29/45 BP: New York, NY 7- 0 • JEFFERSON PILOT FINANCIAL BENEFIT PARTNERS Jefferson Pilot Financial Insurance Company � Excellence In Ratings AAA Highest rating from Standard & Poor's --",` AAA Highest rating from Fitcht A+ + (Superior) Highest rating from A. M. Best Company' *Standard & Poor's AAA rating reflects extremely strong financial security. A scale of AAA (Exceptionally strong financial security) to CC (Extremely weak financial security) is used. *Fitch ** rating reflects the highest insurer financial strength. Fitch rates the insurer's financial strength using a scale of AAA (Exceptionally strong financial security) to D (regulatory intervention). •A. A Best Company rates the overall financial condition of a company using a scale of A ++ (Superior) to F (In Liquidation). Jefferson Pilot Financial Insurance Company Benefit Partners 8801 Indian Hills Dr. Omaha, NE 68114 (800) 423 -2765 www.jpfinancial.com "Formerly known as Duff & Phelps A N C P 1 -: O S ASSOCIATION JEFFERSON PILOT FINANCIAL INSURANCE COMPANY GROUP ADMINISTRATIVE REFERENCE GUIDE • REGIONAL SALES OFFICE 3107 Stirling Road Suite 206 Fort Lauderdale, Florida 33312 Broward: (954) 894 -0077 Toll Free: (800) 279 -4598 Fax: (954) 894 -0905 Jeffrey P. Eilers - Regional Manager (Ext. 1) Keith L. Mueller - Marketing Representative (Ext. 5) Karen S. Plunkett, HIA, ACS, AIAA, AIRC - Sales Support Specialist (Ext. 2) Scott Leichter - Sales Support Specialist (Ext. 3) Kim Marschall - Administrative Assistant (Ext. 4) HOME OFFICE 8801 Indian Hills Drive Omaha, Nebraska 68114 CLIENT SERVICES Main: (800) 423 -2765 Fax: (877) 573 -6177 Contacts For Specific Issues: Heidi Dross - Team Leader (Ext. 7373) Stephanie Heyl - Client Service Representative (Ext. 7436) Jim Sichmiller - Client Service Rep (Ext. 2582) DENTAL CLAIM CLIENT SERVICES Main: (800) 842 -3729 Fax: (909) 974 -0257 Contacts For Specific Issues: Sharon Jones - Dental /Life Claims Manager (Ext. 7256) Tracy Linquist - Dental Technical (Ext. 2680) LIFE & DISABILITY CLAIM CLIENT SERVICES Main: (877) 843 -3948 Fax: (877) 843 -3950 Contacts For Specific Issues: Deby Johnson - Disability Claims Manager (Ext. 2886) Jill Graber - LTD Benefits Supervisor (Ext. 2763) Bob Vlasnik - STD Benefits Supervisor (Ext. 2806) JEFFERSON PILOT WEB SITE www.jpfinancial.com • Enrollment Forms • Conversion Applications (Life & Long -Term Disability) • Billing Adjustment Reports • Evidence of Insurability Forms • Change Request Forms • Portability Forms • COBRA Election Forms • Claims Administration Guidelines • Dental Claim Forms • Life Claim Forms • AD&D Claim Forms • Extension of Death Benefit (Waiver of Premium) Forms • Living Benefit Applications • Short -Term Disability Claim Forms • LINKS Disability Claim Forms • Authorization to Obtain Information Forms • Detailed descriptions of all Jefferson Pilot Financial Insurance Company products. • A Question & Answer section that shows you how to access forms, fax forms and download Adobe Acrobat Reader* free of charge. V, JEFFERSON PILOT *Noce: Adobe software is necessary to view all Jefferson Pilo[ Financial web Site Forms. FINANCIAL Helping you write the story of your life 8 8 0 1 I N D I A N H I L L S D R I V E - 0 M A H A, N E 6 8 1 1 4 •( 8 0 0) 4 2 3 - 2 7 6 5 11 /00 • • C7 JEFFERSON PILOT FINANCIAL LIFE CLAIM MANAGEMENT Life insurance provides a financial cushion to help offset the economic hardship caused by death or disability. We offer "no hassle" life claim management. Our claim specialists strive to make claim filing an uncomplicated process as they offer step -by -step assistance to customers. *Average of 2 -4 days for processing a death claim. *Flexible beneficiary designations *Assistance available for claim filing inquiries *Interest on death benefits paid according to state law *Standard for return phone calls is less than 2 hours 0 JEFFERSON PILOT FINANCIAL L' 0 IS LEADING THE WAY ON GETTING DISABLED EMPLOYEES "BACK ON TRACK" DISABILITY MANAGEMENT Disability management differs from claim management. Disability management refers to managing the disability while claims management refers to proper payment of a claim. Disability management can help: *Reduce direct and indirect costs of disability to the employer (lost productivity, increase in premiums, morale) *Proactively manage the claim by setting clear objectives *Determine reasonable accommodation for employee limitations and provide ergonomic assistance *Provide early intervention in determining an employee's ability to return to work *Provide rehabilitation services Our LTD contract is an industry leader in benefit innovation when it comes to getting disabled employees back on track. Look for these features in our contract: *Partial Disability Benefit *Return -to -Work Incentive *0 -Day Residual *Accumulation of Elimination Period *Reasonable Accommodation Benefit *Vocational Rehabilitation Benefit Our disability management philosophy and our "employee friendly" approach will earn employers the respect of their employees for being sensitive to their total family and financial needs. • 0 JEFFERSON PILOT FINANCIAL DENTAL CLAIM MANAGEMENT Dental insurance offers an added value to an employer's benefit plan. Jefferson Pilot offers comprehensive dental plans that are easy to administer and highly appreciated by many employees and their families. *Average of 5 -7 days for a processing a dental claim. *ID cards provided with helpful 800 number *Predetermination of benefits encouraged so employees know what is covered before dental treatment begins *Dedicated client representatives available to answer all inquiries including dental eligibility and claim processing status. GLM -01519 03/01 0 1 D rD. „JEFFERSON PILOT FINANCIAL D'irectory of } n Participating Dentists DentalGuardPreferredSelectNetwork State: FL Coun ties: Browa rd, Miami - Dad e November2,2001 • Ira�EFFERSON PILOT AARON,STEVEND 90ON MIAMI BEACHB LVD NORTH MIAMI BEACH, FL33162 (561)947 -9001 ABOLSKY,NORMAN 12534NKENDALLDR MIAMI, FL33186 (305)595 -2335 ACOSTA,LUISA 5585S W 8TH ST MIAMI, FL33134 (305)267 -8899 ADLER,ANDREW 3901 SOCEAN DR HOLLYWOOD,FL33019 (954)457 -7637 ALAWA,ABDULAZIZ 16770N W 67AVE MIAMI, FL33015 (305)558 -0388 ALEXANDER,LEEJ 113SW11THCOURT FTLAUDERDALE,FL33315 (954)463 -7972 ALLEN,HERMAN 2323NW 19THST FTLAUDERDALE, FL33311 • (954)484 -8780 November2, 2001 ABELLA- TORRENTE,ALICIA 9115S W 87AVE MIAMI,FL33176 (305)595 -9556 ABREU- KIRSCHNER,ALICIA 7755S W 87THAVE MIAMI,FL33173 (305)271 -0160 DENTIST,GENERAL ABERGEL- NAHON,SUZANNE 8780SW 92ST MIAMI,FL33176 (305)271 -8411 ACOSTA,FRANKA MILLENNIUMDENTALCONCEPTS 9275SW 152NDST MIAMI,FL33157 (305)233 -3922 ALFONSO,RAFAEL 2482SW27THTERRACE MIAMI,FL33133 (305)859 -7949 ALLEN,HUGHG DENTALHEALTHGROUPATNORTHD 17301 N W 27THAVE OPALOCKA, FL33056 (305)624 -1371 ALFONZO,FARAA 19151 SDIXIEHWY MIAMI, FL33157 (305)256 -1303 ALONSO,ERNESTOJ 7175SW8THST MIAMI,FL33144 (305)649 -6112 ADAMI,ROBERTA ADELMAN,DAVID 12129SHERIDANSTREET 16680NE10AVE COOPERCITY,FL33026 NORTHMIAMIBEACH,FL33162 (954)433 -1888 (561)944 -6669 AGREDA,ANGEL AGREDA,ANGEL CSMDENTAL CSMDENTAL 5171 S W 8THST 1124 W 29ST MIAMI,FL33134 HIALEAH,FL33012 (305)567 -0236 (305)885 -8044 ALBOTA- STOENESCU,GABRIELA ALEMAN,ALEXE 8720NKENDALLDR CAPLIN &GOBERDDSPA MIAMI,FL33176 660OW 12AVE (305)279 -7500 HIALEAH,FL33012 (305)821 -2611 ALFONSO,RAFAEL 2482SW27THTERRACE MIAMI,FL33133 (305)859 -7949 ALLEN,HUGHG DENTALHEALTHGROUPATNORTHD 17301 N W 27THAVE OPALOCKA, FL33056 (305)624 -1371 ALFONZO,FARAA 19151 SDIXIEHWY MIAMI, FL33157 (305)256 -1303 ALONSO,ERNESTOJ 7175SW8THST MIAMI,FL33144 (305)649 -6112 0 Ira JEFFEIRS N PILOT ARILL,ERNESTO 9115S W 87THAVE MIAMI,FL33176 (305)273 -1788 ARNOLD,GARYS 328E HALLAN DALE BLVD HALLANDALE,FL33009 (954)454 -5333 ASKOWITZ,RONALDL 26095THST MIAMI, FL33154 (305)866 -8290 • AVALOS,NICOLASG 34SWDOUGLASRD CORALGABLES,FL33134 (305)446 -6900 ARILL,ERNESTO 27501 S DIXIE HWY3RDFLOOR NARANJA,FL33032 (305)246 -1778 ARNOLD,JAMESL 1440E HALLANDALE BEACH BLVD HALLANDALE,FL33009 (954)458 -1133 ASKOWITZ,RONALDL 27501S DIXIE HWY3RDFLOOR NARANJA, FL33032 (305)246 -1778 AVILES,ANA 12297PEMBROKERD PEMBROKEPINES, FL33025 (954)430 -0308 BACHEIKOV,ZALMAN BAEK,KYUNG -JA 420LINCOLNRD BAYVIEWDENTALASSOCIATES,PA MIAMI BEACH,FL33139 2633ECOMMERICALBLVD (305) 532 -6795 FTLAU DE RDALE, F L33308 (954)776 -4720 BAJUELO,OSVALDO BAKALAR,MARTIN 8000WFLAGLERST DENTALHEALTHGROUPATDADELAN MIAMI,FL33144 740ONKENDALLDR (305)266 -5222 MIAMI, FL33156 (305)670 -4476 L - -- BALMIR-THEVENIN,JOELLE BANA,RAMON 10621NKENDALLDR 454NW22NDAVE MIAMI,FL33176 MIAMI,FL33125 (305)271 -0510 (305)644 -9375 November2, 2001 ARNOLD,RICHARDM 657DESOTODR MIAMI SPRINGS, FL33166 (305)887 -3061 ARWAS,RAPHAEL 1899961SCAYN E BLVD AVENTU RA, F L33180 (305)466 -1444 AUERBACH,JEFFREYJ 4294SUNIVERSITYDR DAVIE, FL33328 (954)475 -8809 AYALA,RITAC 9280HAMMOCKSBLVD MIAMI, FL33196 (305)387 -5700 BAILEY,DANIELL 19916NW2NDAVE MIAMI,FL33169 (305)652 -3131 BALICK,RICHARDL 4700SHERIDANST HOLLYWOOD,FL33021 (954)966 -1166 BANA,RAMON FAMILYDENTALGROUPOFMIAMI 3307 W 80TH HIALEAH,FL33018 (305)512 -3700 • C • irsE FFEftSO N PILOT BEN ENFELD,BRUCEJ BEN ITO,J UAN CARLOS BENMERGUI,YUDAHARI 2706N U NIVE RS ITYDR 2609W OAKLANDPK 26095THST SUNRISE,FL33322 FTLAUDERDALE,FL33311 SURFSIDE,FL33154 (954)741 -0700 (954)485 -1170 (305)865 -0453 BERGER,JOEL BERTNOLLI,ANDREWE BIENES,LISSETTEMA 189OUNIVERSITYDR 1507ECOMMERCIALBLVD 3411 SW 107THAVENUE CORALS PRI NGS, FL33071 FTLAU DE RDALE, FL33334 MIAMI, FL33165 (954)344 -4488 (954)771 -7100 (305)221 -0301 BIRD,OLGA BIRD,JUAN BIRNS,BRADLEY SUNSETDENTAL CALLEOCHODENTALCORPORATION 5121SW90THAVE 6491SUNSETSTRIP 1843SW8THSTREET COOPERCITY,FL33328 SUN RISE, FL33313 MIAMI, FL33135 (954)680 -2237 (954)572 -1801 (305)643 -3040 BISTRITZ,DAVID BLACK,EUGENE BLANCO,EDUARDO 18171BISCAYNEBLVD 3000UNIVERSITYDR 50NE26THAVENUE NORTH MIAMIBEACH,FL33160 CORALSPRINGS,FL33065 POMPANO BEACH, FL33062 (305)933 -2501 (954)752 -4900 (954)946 -6626 BLARDONIS,ARMANDO BLARDONIS,ARMANDO BLAY,MARINA 20533OLDCUTTERRD WESTON DENTALASSOC IATES 8729SW136THSTREET MIAMI,FL33189 46INDIANTRACERD MIAMI,FL33176 (305)252 -0088 WESTON,FL33326 (305)255 -5550 (954)217 -0288 BLISS,MONICA BLONDET,ENRIQUE BLUM,MARK THE DENTALTEAMOF DEERF IE LDB 525NW27THAVE 7800WOAKLANDPKBLVD 123NPOWERLINE MIAMI,FL33125 SUNRISE,FL33351 DEERFIELD BEACH, FL33442 (305)374 -4271 (954)748 -3448 (954)427 -2436 BLUMENTHAL,FRED BLUTH,SHERRIJ BLUTH,BARRYA 6805PE MB ROKE RD 4175S W 64THAVE 4175S W 64AVE WESTHOLLYWOOD,FL33023 DAVIE,FL33314 DAVIE,FL33314 (954)989 -6950 (954)792 -3800 (954)792 -3800 Novemb erg, 2001 JEFFERSON PILOT CABALLERO,MA 212SW 12THAVE MIAMI, FL33130 (305)541 -1894 CABRERA,MOISES 15450NEWBARNRD MIAMI LAKES, F L33014 (305)557 -7775 CALABRESE,RICHARDM 961 UNIVERSITYDR CO RALSPRINGS, FL33071 (954)753 -1600 • CALLEJAS,DANILOJ 763WFLAGLERST MIAMI, FL33130 (305)324 -6312 ALZADILLA,ELDA 3OE49ST IALEAH, FL33013 05)557 -6722 CANIZALES,JACQUELINE 201NUNIVERSITYDR PLANTATION,FL33324 (954)472 -0099 CARDOUNEL,ALEX BAYVIEWDENTALASSOCIATES 2633ECOMMERCIALBLVD • FTLAUDERDALE,FL33308 (954)776 -4720 Novemb er2, 2001 CABEZA,ILIANA 157NW36ST MIAMI,FL33127 (305)576 -4387 CAKMIS,PETERJ 17301 N W 27THAVE OPALOCKA, FL33056 (305)624 -1371 CALIFF,RANDALLT 6890MIRAMARPARKWAY MIRAMAR, F L33023 (954)987 -4435 CALLEJO,CATALINA 5771 SW40TH STREET MIAMI,FL33155 (305)665 -1176 CAMPBELL,BETHAW 9937MIRAMARPKWY MIRAMAR, FL33025 (954)436 -0100 CAPLIN,HARVEYD CAPLIN &GOBERDDSP, 660OW 12THAVE HIALEAH, F L33012 (305)821 -2611 CARDOUNEL,ALEX 7420NW5THSTREET PLANTATION, F L33317 (954)791 -0330 DENTIST, GENERAL CABRERA,MOISES 14609SW 104THST MIAMI,FL33186 (305)388 -3725 CAKMIS,PETERJ 150SUNIVERSITYDR PEMBROKE PIN ES, FL33025 (954)431 -0004 CALIFF,RANDALLT 12578WSUNRISEBLVD SUNRISE,FL33323 (954)851 -9829 CALZADILLA,ELDA 37 -11 SW 107THAVE MIAMI,FL33165 (305)554 -7074 CAMPOS,FERNANDO CAMPCOINC 1855UNIVERSITYDR CORALS PRINGS, FL33071 (954)344 -4949 CARDENAS,CARLOSM 1050OW FLAGLERST MIAMI,FL33174 (305)223 -7766 CARRENO,JOSEA 3815SW8THST CORALGABLES,FL33134 (305)443 -7501 • • CJ JEFFERSON PILOT CHERRY,ROBERTA CHHADVA,RASHMI CHIOU,WUNSAN 7797NUNIVERSITYDR TAMARAC,FL33321 8964TAFTST PEMBROKE PINES,FL33024 104SE8THAVE FTLAUDERDALE,FL33301 (954)722 -9339 (954)431 -8300 (954)463 -3994 CHIU,GORDONB CHIU,GORDONB CHRISTOPH,VICTOR DENTALCENTERATBAPTIST DENTALASSOC IATESO F HOMESTEAD DENTALHEALTHGROUPATPEMBROK 8940NKENDALLDR 151NW11THST 140SUNIVERSITYDR MIAMI,FL33176 HOMESTEAD,FL33030 PE MBROKE PINES, FL33025 (305)271 -3001 (305)247 -0099 (954)431 -0004 CHRISTOPH,VICTOR CINCI,GEORGE CINKILIC,WILLIAM DENTALHEALTHGROUPATNORTHD 10071SUNSETSTRIP PALM - MEDBLDG 17301 NW27AVE SUNRISE,FL33322 715OW20THAVE OPALOCKA, F L33056 (954)742 -4600 HIALEAH, F L33016 (305)624 -1371 (305)556 -3313 CLARK,LEONV CLARK,LEONV CLARK,LEONV GENTLEDENTALOFPOMPANOBEACH GENTLE DE NTALOF PLANTATION CALIFORN IACLUB DENTISTRY POMPANOONECOMPLEX 1776N PINE ISLANDRD CALIFORNIACLUB MALL 1 NE23RDAVE PLANTATION,FL33322 8501VESDAIRYRD POMPANOBEACH,FL33062 (954)472 -8707 NORTH MIAMIB EACH, FL33179 (954)946 -4867 CLINE,JACKA (305)654 -9399 CLAXTON,JOH N PAUL COBELO,ARMANDOF 1605SCYPRESSRD DENTALHEALTHGRPCORALSPRING DENTALPLUS POMPANO BEACH,FL33060 1881 UNIVERSITYDR 11352QUAILROOSTDR (954)782 -2440 CORALS PRINGS, FL33071 MIAMI, FL33157 (954)755 -1014 (305)969 -2651 COGAN,MICHAEL COHEN,MYRONB COHEN,ROBERT 1717NBAYSHOREDR 1518W49THST 2925AVENTURABLVD MIAMI,FL33132 HIALEAH,FL33012 NORTH MIAMI BEACH,FL33180 (305)358 -0282 (305)823 -2661 COHN,BRUCER (561)932 -1214 COHEN,STANLEY CONCEPCION,CARLOS 10001 SW40ST 951 NE167THST 11880SW40ST MIAMI,FL33165 NORTH MIAMI BEACH,FL33162 MIAMI,FL33175 (305)559 -2929 (561)654 -0477 (305)552 -1553 Novemb erg, 2001 • • C JEFFERSON PILOT CUNNINGHAM, HOWARDR CUTINO,JUAN CYMER,RENATA 2020E OAKLANDPARK 7311 S W 62AVEN UE 18921 NW 2N DAVE #A FTLAUDERDALE,FL33306 MIAMI,FL33143 MIAMI,FL33176 (954)566 -9812 (305)667 -2633 (305)652 -7333 CYMER,RENATA DAMIAN,GIANNINA DAUSA- HERNANDEZ, MARIA 8752SW72ND SMILECAREDENTALINC 8512SW40THSTBIRDROAD MIAMI,FL33176 5632N W 167TH ST MIAMI, FL33155 (305)279 -7725 HIALEAH,FL33014 (305)223 -0072 (305)625 -9777 DEAGUIRRE,ELIZABETHM DECARDENAS,ADRIANO DECARDENAS,ADRIANO DENTALASSOCIATESOFKENDALL 1125NW22AVE DENTALPLUS,INC 8966SW87THCT MIAMI,FL33125 11352QUAILROOSTDR MIAMI, F L33173 (305) 649 -6112 MIAMI, FL33157 (305)271 -2254 (305)969 -2651 DECARDENAS,ANDRESS DELACAMARA,VIVIANNE DECARDENAS,ALBERTOA 9000SW 152ST 5376W 16AVE CAPLIN &GOBER MIAMI, FL33157 HIALEAH,FL33012 660OW 12AVE (305)251 -3334 (305)821 -2752 HIALEAH,FL33012 (305)821 -2611 DELACAMARA,VIVIANNE DESTEFANO,HENRY DELACRUZ,ALEJANDRO DENTALCTRBAPTISTME D PLAZA 2645SW37THAVE 1766NEMIAMIGARDENSDR 8750SW 144THST MIAMI,FL33133 NORTHMIAMIBEACH, FL33179 MIAMI,FL33176 (305)441 -2773 (561)945 -7435 (305)969 -3122 DEANNA,ABELO DEBS,PABLOR DELRIO,FRANKLIN 7105S W 8ST 220W EST49THST 916S W 67AVE MIAMI, F L33144 HIALEAH,FL33012 MIAMI, FL33144 (305)266 -3581 (305)556 -0016 (305)266 -4071 DELVALLE,JOSEM DELVALLE,JOSEM DELCASTILLO,DANIEL 10768SW24ST 3918W 12AVE 925ARTHURGODFREYRD MIAMI,FL33165 HIALEAH,FL33012 MIAMIBEACH,FL33140 (305)220 -3777 (305)556 -1770 (305)535 -3113 Novemb erg, 2001 :7 • JEFFERSON PILOT Ire EHRLICH,RONALDS ELLINS,KARLB ERRO,JUANC THEE MERALD HILLS ME DICALSQUA 1111ONKENDALLDR 1851NW125THAVE 4430SHERIDANST MIAMI,FL33176 PEMBROKEPINES, FL33028 HOLLYWOOD, FL33021 (305)596-7807 (954)437-2040 (954)962-4430 ESCARZA,ALBERTOC ESCOBAR, RICARDOE ESCOFET,ENRIQUE 910000RALWAY 180OW49ST 133000RALWAY MIAMI, FL33165 HIALEAH,FL33012 MIAMI,FL33145 (305)551-0068 (305)823-3882 FABELO,LUIS (305)858-6085 EZELL,STEPHENE FAHEY,DANAA 9000SW152ST 9420PARKDR SUN RISE-INTRACOASTALDENTALCE MIAMI,FL33157 MIAMISHORES,FI-33138 90ONE26THAVE (305)232-8515 (305)757-6991 FTLAU DE RDALE, F L33304 (954)566-4208 FAINE,ROBERT FALLAH,R FARHANGPOUR,AMIRN 6262SUNSETDR i ADVANCED DE NTALC ENTER 6971 WSU NRISE BLVD MIAMI,FL33143 710OWCOMMERCIALBLVD PLANTATION, FL33313 (305)661-9556 LAUDERHILL, FL33319 (954)791-6666 (954)741-6556 FASS,ERICKL FEDER,RICHARD FEIFER,ROYL 2076NUNIVERSITYDR 7311 SW62AVE 7608MARGATEBLVD PEMBROKEPINES, FL33024 MIAMI,FL33143 MARGATE,FL33063 (954)432-5700 (305)667-2633 (305)975-9700 FERGUSON,RICKH FERNANDEZ,CARLOSF FERNANDEZ,JESSICAM 9980NW6THCT 850OWFLAGLERST DENTALCARECTROF HOLLYWOOD PEMBROKE PINES, FL33024 MIAMI,FL33144 3900HOLLYWOODBLVD (954)438-0996 (305)226-0803 HOLLYWOOD, FL33021 (954)989-5500 FERNANDEZ,MARIAC FERNANDEZ,AURELIO IFERNANDEZ,CONCEPCION 4830SW8ST 850OWFLAGLERST 9724SW40ST CORALGABLES,FL33134 MIAMI,FL33144 MIAMI,FL33165 (305)446-1067 1 (305)552-5511 (305)221-3666 November2,2001 • IraJEFFERSON PILOT FRIEDMAN,CRAIG 1000NHIATUSRD PEMBROKEPINES, FL33026 (954)431 -9500 FRIEFELD,KEITH 21457NW2AVE MIAMI, FL33169 (305)652 -1234 FRIEFELD,JEFFREY 21457NW2AVE MIAMI, FL33169 (305)654 -1234 • GALIK,JACQUELINEX 3005SALZEDO CORALGABLES,FL33134 (305)444 -5926 GARCIA,RICARDO 8940NKENDALLDR MIAMI, FL33176 (305)271 -3001 GARCIA,JOHNM 351 NW42NDAVE MIAMI,FL33126 (305)643 -4455 GARCIA,LUISAF TLCDENTAL 435ESHERIDANST DANIA, FL33004 • (954)926 -5888 November2, 2001 FRIEDMAN,CARL 1724NUNIVERSITYDR PEMBROKE PINES, FL33024 (954)432 -7771 FRIEDMAN,ALAN 8235WATLANTICBLVD CORALSPRINGS, FL33071 (954)753 -6100 GARCIA,ANGEL 9101PARKDR MIAMISHORES,FL33138 (305)754 -0062 GARCIA,JOHNM 4450WESTONRD DAVIE,FL33331 (954)217 -1411 GARCIA,JUANM 1490W49PL HIALEAH,FL33012 (305)821 -2261 GARCIA,MARIOK 6641 ASOUTH DIXIE H IG HWAY MIAMI,FL33143 (305)667 -0306 FRIEFELD,JEFFREY FRIEFELD,KEITH 17792SWSECONDSTREET 17792SW2NDSTREET PEMBROKEPINES,FL33029 PEMBROKEPINES,FL33029 (954)435 -2999 (954)435 -2999 FUENTES,ISABELF GALGUERA,ERNESTO 9268SW40ST 130OW49ST MIAMI, FL33165 H IALEAH, F L33012 (305)553 -1304 (305)827 -3031 GALLUZZO,GEORGER GALIK,JACQUELINEX 12290N W 7TRAIL 320S E 18THST MIAMI, FL33182 FTLAU DERDALE, FL33316 (305)559 -2519 (954)467 -8138 GARCIA,RAULISAAC GARCIA,RICARDOA DENTAL HEALTH GROUPATIVES DA 9301MILLERDR 10011VESDAIRYRD MIAMI,FL33165 NORTH MIAMIBEACH, F L33179 (305) 595 -4616 (305)652 -3412 GARCIA,ANGEL 9101PARKDR MIAMISHORES,FL33138 (305)754 -0062 GARCIA,JOHNM 4450WESTONRD DAVIE,FL33331 (954)217 -1411 GARCIA,JUANM 1490W49PL HIALEAH,FL33012 (305)821 -2261 GARCIA,MARIOK 6641 ASOUTH DIXIE H IG HWAY MIAMI,FL33143 (305)667 -0306 D, JEFFERSON PILOT GONZALEZ,OSCAR DENTALHEALTHGRPPEMBROKE 140SUNIVERSITYDRIVE PEMBROKEPINES,FL33025 (954)431 -0001 GONZALEZ,MARIA 9055SW 87AVE MIAMI, FL33176 (305)595 -5655 GONZALEZ,CARMEN 6730TAFTST HOLLYWOOD, FL33024 (954)987 -3309 • GORDON,STCHRISTOPH 4956N PINE ISLANDRD LAUDERHILL, FL33351 (954)742 -5355 • GORFIEN,JOSEPHJ 4506NUNIVERSITYDR LAUDERHILL, FL33321 (954)742 -0201 GRAFF,BRADW 3220STIRLINGRD HOLLYWOOD,FL33021 (954)963 -3706 GREENSPAN- BIRNS,ROBIN 5121 S W 90AVE COO PERC ITY, FL33328 (954)680 -2237 Novemb er2, 2001 GONZALEZ,LILIAN CALLEOCHO DENTALCORPORATION 1843S W 8THSTREET MIAMI, FL33135 (305)643 -3040 GONZALEZ,LILIAN LAG UNADENTALCORPORATION 10721 WESTFLAGLERSTREET MIAMI,FL33174 (305)225 -3452 GOODMAN, RICHARDB 830WASH INGTO NAVE MIAMI BEACH,FL33139 (305)531 -0063 GORDON,ALEXANDRA DENTALAND - AVENTURA 19501BISCAYNEBLVD AVENTURA,FL33180 (305)935 -1400 GONZALEZ,MARIA 11865S W 26TH ST MIAMI, F L33175 (305)227 -0600 GONZALEZ,LILIAN DENTALAMERICANCLINICCORP 1246WEST68THSTREET HIALEAH,FL33014 (305)556 -6100 GOODMAN,HAROLD 127NE8ST HOMESTEAD,FL33030 (305)245 -0304 GORDON,LUCIEN 11395BIRDRD MIAMI, FL33165 (305)226 -7135 GORFINKEL,MICHAELS GOTTFRIED,BETTY 8251 W B RO WARDB LVD 1946W ILTON DR PLANTATION, F L33324 FTLAU DE RDALE, F L33: (954)473 -6500 (954)565 -7666 GRANT,RICHARDA 20215N W 2NDAVE MIAMI, FL33169 (305)652 -3001 GRIGOROPOULOS,MARIOS PLANTATION DENTALASSOCIATES 10080NW 1 COURT PLANTATION,FL33324 (954)474 -8977 GREEN,GEORGED 17000NIVERSITYDR CORALSPRINGS, FL33071 (954)344 -8800 GUERRA,EDYA 4011 WFLAGLERST MIAMI,FL33134 (305)854 -3731 • • • Irk J I rksON PILOT HERNANDEZ,LILIANAJ HERNANDEZ,JORGEO HERNANDEZ,NORBERTO 1330SOUTHEAST4THAVE 6080SW40THST 1470NW 107AVE FTLAUDERDALE,FL33316 MIAMI,FL33155 MIAMI,FL33172 (954)523 -0566 (305)665 -6564 (305)594 -8666 HERNANDEZ,MARIAA HERNANDEZ,GREGORIO HERNANDEZ,PETERM 2500SW 107AVE 10051 PINESBLVD 5924W 16THAVE MIAMI,FL33165 PEMBROKE PINES,FL33024 HIALEAH,FL33012 (305)223 -5439 (954)437 -2009 (305)558 -2133 HERNANDEZ- ABREU,LUIS HERNANDEZ- ABREU,LUIS HERNANDEZ- GARAY,MARIAA 13091 N KENDALLDR 7900S W 104ST 1250SW 27AVE MIAMI,FL33186 MIAMI,FL33156 MIAMI,FL33135 (305)386 -3377 (305)595 -4548 (305)643 -3800 HERRMANN,THEODORE HIBBERT,CONRADV HIRSCHBERG,GILBERT 9000SW87CT 164NUNIVERSITYDR 5644WATLANTICBLVD MIAMI,FL33176 PEMBROKEPINES,FL33024 MARGATE,FL33063 (305)274 -0047 (954)435 -6636 (954)971 -6115 HOFFMAN,BERNARD HOROWITZ,HOWARDS HOLSTON,JOHN 15450NEW BARNRD 2633ECOMMERCIALBLVD 866NFEDERALHWY MIAMILAKES, FL33014 FTLAU DERDALE, FL33308 POMPANOBEACH, FL33062 (305)557 -7775 (954)776 -4720 (954)781 -3382 HOSSEINI,H HUBER,LAURENCE HORTA,REINALDO 11645BISCAYNEBLVD 1040WESTONRD 8833SW107THAVE NORTH MIAMI, F L33181 FTLAU DERDALE, FL33326 MIAMI, F L33176 (305)891 -3221 (954)389 -9500 (305)271 -1421 HUI,TINHAROLD HUI,TINHAROLD HUI,TINHAROLD 16209NE13AVE 17901 NWSST SOUTH DADE DE NTALGROUP NORTH MIAMIBEACH,FL33162 PEMBROKEPINES,FL33029 7900SW 104THST (305)595 -4548 (954)430 -2188 MIAMI, FL33156 (305)940 -9888 Novemb er2, 2001 Ira JEFFERSON PILOT KALTER,SANFORD 9670GRIFFINRD COO PERCITY, F L33328 (954)434 -2700 KAPLAN,CATH ERIN ED FLAMINGO DENTALGROUP 12129SHERIDANST COOPERCITY,FL33026 (954)433 -1888 E- - KATZ,RONALDL GENTLE DENTALOF POMPANO BEACH POMPANOONECOMPLEX 1NE23RDAVE POMPANO BEACH, FL33062 4)946 -4867 • KESSLER, LEONARD P 2076NOUNIVERSITYDRIVE PEMBROKE PINES,FL33024 (954)432 -4800 KALTER,SANFORD DENTALTEAMOFCORALSPRINGS 987UNIVERSITYDR CORALSPRINGS, FL33071 (954)753 -4005 KATZ,RONALDL CALIFORN IACLUB DENTISTRY CALIFORNIACLUB MALL 8501VESDAIRYRD NORTH MIAMIBEACH,FL33179 (305)654 -9399 KEALY,JOHNJ 1399NW 17THAVE MIAMI,FL33125 (305)325 -0050 KILSHTOK,JOSEPH PORTOFMIAMIDEN7 1015NAMERICANWA MIAMI,FL33132 (305)530 -0706 KLAREICH,SCOTT KLEIN,PETERB 8197 -1 NUNIVERSITYDR 7351 WOAKLANDPARKBLVD TAMARAC, F L33321 LAUDERH ILL, FL33319 (954)720 -0006 (954)742 -5055 KLEIN,MITCHELLJ KLEINER,RENATA SUPERSMILES 9654SW72ST 7228W OAKLAND PARKBLVD MIAMI, F L33173 LAU DERH ILL, FL 33313 (305)598 -3704 (954)748 -4860 November2, 2001 KAMINSKY,ARTHURL 997ROCKISLANDRD NORTHLAUDERDALE,FL33068 (954)722 -1522 KATZ,RONALDL GENTLEDENTALOFPLANTATION 1776N PINE ISLANDRD PLANTATION,FL33322 (954)472 -8707 KEMENY,JOHN 11254SW137AVE MIAMI, FL33186 (305)386 -7337 KILSHTOK,JOSEPH 2100EHALLANDALEBEACHBLVD HALLANDALE, F L33009 (954)456 -2100 KLEIN,ELAINE DADELANDMEDICALBUILDING 7400NORTHKENDALLDR MIAMI, FL33156 (305)670 -0641 KLUG ERMAN, BETHANNE 12515NKENDALLDR MIAMI, FL33186 (305)274 -6500 KRAMER,RICHARDW 4673UNIVERSITYDR CORALS PRINGS,FL33 (954)755 -8877 KOLOVANI-TUMMINIA,KATHRYNE KOLOVANI- TUMMINIA,KATHRYNE GENTLE DENTALOF POMPANO BEACH CALIF ORNIACLUBDE NTISTRY POMPANOONECOMPLEX CALIFORNIACLUB MALL 1 NE23RDAVE 8501VESDAIRYRD POMPANOBEACH,FL33062 NORTH MIAMIBEACH,FL33179 (954)946 -4867 (305)654 -9399 November2, 2001 KAMINSKY,ARTHURL 997ROCKISLANDRD NORTHLAUDERDALE,FL33068 (954)722 -1522 KATZ,RONALDL GENTLEDENTALOFPLANTATION 1776N PINE ISLANDRD PLANTATION,FL33322 (954)472 -8707 KEMENY,JOHN 11254SW137AVE MIAMI, FL33186 (305)386 -7337 KILSHTOK,JOSEPH 2100EHALLANDALEBEACHBLVD HALLANDALE, F L33009 (954)456 -2100 KLEIN,ELAINE DADELANDMEDICALBUILDING 7400NORTHKENDALLDR MIAMI, FL33156 (305)670 -0641 KLUG ERMAN, BETHANNE 12515NKENDALLDR MIAMI, FL33186 (305)274 -6500 KRAMER,RICHARDW 4673UNIVERSITYDR CORALS PRINGS,FL33 (954)755 -8877 :7 irim; JEFFERSON PILOT LENS,ROBERTE LEON,KARLT LESSIN,NATHANR G E NTLEDENTALOF PLANTATION 127NW 12AVE 1900NUNIVERSITYDR 1776N PINE ISLANDRD MIAMI,FL33128 PEMBROKE PINES,FL33024 PLANTATION, F L33322 (305)324 -5500 (954)432 -8000 (954)472 -8707 LEVIN,LAWRENCE LEVINSON,LARRYA LEVY,NORMAN 1011 SFEDERALHWY 9SW 17THST 7000WOAKLAND PARK BLVD HOLLYWOOD,FL33020 FTLAUDERDALE,FL33315 SUNRISE,FL33313 (954)921 -1011 (305)524 -3117 (954)742 -8880 LEWIS,SONYAD LEWIS,BRAD LEWKOWICZ,ESTHER 475BILTMOREWAY 140ONEMIAMIGARDENSDR 665MOKENADR CORALGABLES,FL33134 NORTH MIAMI BEACH,FL33179 MIAMI SPRINGS,FL33166 (305)446 -3306 (305)944 -4373 (305)885 -9721 • LIAKHOVETSKI,ANATOL 6720HOLLYWOO D BLVD HOLLYWOOD,FL33024 (954)989 -2141 • LIVINGSTONE,ANTHONYC 7731 S W 62AVE MIAMI, FL33143 (305)661 -9603 LLORENS,JAVIERJ 717E9THST HIALEAH,FL33010 (305)888 -9807 LOPEZ,MANUELG W E STO N DE N TALAS S O C IATE S 461NDIANTRACERD WESTON, FL33326 (954)217 -0288 Novemb er2, 2001 LIEBLER,ROBERT 8100SW81 DRIVE MIAMI,FL33143 (305)224 -3730 LIZASO- RODRIGUEZ 4999W 8AVE HIALEAH, F L33012 (305)556 -6055 LOPEZ,JOSEA 13232SW8ST MIAMI,FL33184 (305)559 -5519 LOPEZ,MANUELG 4040ASW57THAVE SOUTHMIAMI, FL33155 (305)667 -5061 LIPPMAN,HAL 5740HOLLYWOO D BLVD HOLLYWOOD, FL33021 (954)961 -4300 LLERA,JA 2607DAVIEBLVD FTLAUDERDALE, FL33312 (954)587 -7111 LOPEZ,MARIAR 4689PONCEDELEONBLVD CORALGABLES,FL33146 (305)665 -1655 LUGER,MARKS 9145BIRDRD MIAMI,FL33165 (305)221 -1902 0 • IJEFFERSON PILOT films MARKMAN,NOEL 7550S W 57THAVEN L SOUTHMIAMI,FL331 (305)661 -8499 MARTINEZ,SUSANA 13419S W 56ST MIAMI, FL33175 (305)559 -2663 MARTINEZ,JESUS CHIDRENSDENTALCTRKENDALL 8966SW 87CT MIAMI,FL33173 (305)275 -6224 • MARTIN EZ- NEGRON,AXEL 2654NANDREWSAVE WILTON MANORS, FL 33311 (954)567 -3311 MAS,AQUILESE 320W49ST HIALEAH,FL33012 (305)558 -1411 MAZOR, DAN 3870SHERIDANST HOLLYWOOD, FL33021 (954)985 -1818 MEHLER,ERIC 7800WOAKLANDPARKB SUNRISE,FL33351 (954)741 -5006 November2, 2001 MARKS,STEWART 7351 W OAKLANDPARKBLVD LAUDERHILL, FL33319 (954)742 -5055 MARTINEZ,OSWALDO 8890SW24ST MIAMI,FL33165 (305)221 -3813 MARTINEZ,JESUS PALMETTOCENTERFORDENTALSPC 715OW20THAVE HIALEAH,FL33016 (305)556 -5600 MARTOS,GRISEL 780NW42AVE M IAMI, FL33126 (305)448 -3896 MATTHEWS,DENBY 4800SW 64AVE DAVIE,FL33314 (954)581 -0120 MAZOR,DAN 747PONCEDELEONBLVC CORALGABLES,FL33134 (305)444 -8591 MEHMI,SATYAP 831 WSAMPLERD PO MPANOBEACH, F L33064 (954)943 -6644 MARTIN,CIROA 8463BIRDRD MIAMI,FL33155 (305)551 -6714 MARTINEZ,JESUS DENTALCENTERATBAPTISTMED 8750S W 144TH ST MIAMI,FL33176 (305)969 -3122 MARTIN EZ,OSWALDO Z645SW37AVE AIAMI, FL33133 ;305)441 -2773 MARX,MARIAT 555BILTMOREWAY CORALGABLES,FL33134 (305)444 -8188 MAUTNER,STEVENG 5609NW29THSTREET MARGATE, F L33063 (954)978 -8866 MCSWEENEY,JAMES 2020E OAKLAND PARK BLVD FTLAUDERDALE, FL33306 (954)566 -9812 MEHTA,RAVIN LAU DERH ILLDENTALCE NTER 3796NW 19ST LAUDERHILL,FL33311 (954)739 -1430 • • • JEFFERSON IllLO -f MONTANO,HALINA 987UNIVERSITYDRIVE CORALSPRI NGS, FL33071 (954)753 -4005 MORALES,RONALDJ 715OW20THAVE MIAMI,FL33016 (305)556 -5600 MOSKOVITZ, ROBERT THE DENTALTEAMOF POMPANO BEA 1POMPANOSO POMPANO BEACH, FL33062 (954)782 -8620 MOUSHATI,JOHN 1749NE26ST FTLAUDERDALE,FL33305 (954)564 -3244 MURO,THOMAS 15724SW72NDST MIAMI,FL33193 (305)380 -7000 NAMOFF,DAVID 8500 W FLAG LE RST MIAMI, FL33144 (305)552 -5511 NARVAEZ,M 7532SW 117/ MIAMI, FL331 (305)273 -111 l Novemb er2, 2001 MOOSAVI,AZITA 2625EXECUTIVE WESTON,FL333 (954)384 -8484 MORALES,RONALDJ 1350SW 160THAVE SUNRISE,FL33326 (954)385 -9240 MOSKOWITZ,HARVEY 4900W OAKLAN D PARK LANDO LAKES, F L33313 (954)731 -0586 MOVILLA,PATRICIAI B370W FLAGLERST MAIMI, FL33144 (305)225 -1914 NAJARIAN,STEPHEN DENTALHEALTHGROUPATNORTHD 17301 N W 27AVE OPALOCKA, FL33056 (305)624 -1371 NAMOFF,DAVID 8975SW 152NDST MIAMI,FL33157 (305)235 -8912 MORALES,ENRIQUE 3009EAST4THAVE HIALEAH,FL33013 (305)691 -1616 MORAN,JAMESJ 973NNOBHILLROAD PLANTATION, FL33324 (954)452 -0800 MOUALLEM,ALFREDR 6610NUNIVERSITYDR TAMARAC, F L33321 (954)722 -2950 MURIAS,GERMANL 7000WEST12THAVE HIALEAH, F L33014 (305)821 -0231 NAJARIAN,STEPHEN DENTALHEALTHGROUPATCOUNTY 20911 N W 2N DAVE MIAMI,FL33169 (305)651 -7676 NAMOFF,ANTHONYV 8975SW 152ST MIAMI,FL33157 (305)251 -0620 NARVAEZ,ANTONIOV NASSERY,HAMI[ MANHATTAN DENTALINC 96041ST 68NE167TH MIAMIBEACH,FL3 NORTH MIAMI BEACH, F L33162 (305)672 -2847 (561)940 -9840 • • F--]L JEFFERSON PILOT OSTROVSKY,ANNA PALE NZUELA,MARYAN IN PALLEN,HARVEY DENTALAND PLANTATION DENTALASSOCIATES 1395NW167ST 9601 W ATLANTIC B LVD 1008ONW1 STCOURT MIAMI,FL33169 CORALSPRINGS,FI-33071 PLANTATION, F L33324 (305)625-5400 (954)753-7400 (954)474-8977 PANDEY,ANITA PANDEY,ANITA PASTURA,JOSEPHC CHILDRENSDENTALCTIRBAPTIST DENTALCENTERATBAPTIST 3051NFEDERALHWY 8750SW144ST 8940N KE NDALLDR FTLAU DERDALE, F L33306 MIAMI,FL33176 MIAMI,FL33176 (954)563-5800 (305)969-3122 (305)271-3001 PATEL, ROHITKUMAR PATEL,JITENDRAL PECORARO,WILLIAM 4651 NW 31 AVE 1401SSTATERD7 4601 HOLLYWOOD BLVD TAMARAC, F L33309 NORTH LAU DE RDALE, FL33068 HOLLYWOOD, FL33021 (954)733-9832 (954)979-2511 (954)989-8800 PELAEZ,MAGNOLIAM PELTON,IVANS PELTON,IVANS DE NTALHEALTHG RP DADE LAND CALIF ORNfACLU B DENTISTRY GENTLE DE NTALOF POMPANO BEACH 740ONKENDALLDR CALIF ORNIACLUB MALL POMPANOONECOMPLEX MIAMI,FL33156 8501VESDAIRYRD 1NE23RDAVE (305)670-4476 NORTHMIAMIB EACH, FL33179 POMPANO BEACH, F L33062 (305)654-9399 (954)946-4867 PELTON,IVANS PENA,DAVID PERALES,RICARDOJ GENTLEDENTALOF PLANTATION 8034NW154ST 5600SW135AVE 1776NPINEISLANDRD HIALEAH,FL33016 MIAMI,FL33183 PLANTATION, FL33322 (305)827-5557 (305)387-4274 (954)472-8707 PERALTA,JOSER PERALTA,JOSER PERELL0,110SANNA 1760SWCORALWAY 7532SW1 17AVE 6917MIRAMARPKY MIAMI,FL33145 MIAMI,FL33183 MIRAMAR, F L33023 (305)856-1488 (305)273-1115 (954)986-9351 PERELL0,1110SANNA PERETZ,DAVIDA PEREZ,JORGE 1843SW8THST 4801HOLLYWOODBLVD 2332SW82CT MIAMI,FL33135 HOLLYWOOD, FL33021 MIAMI,FL33155 (305)643-3040 (954) 981-4500 (305)267-8807 Novemb erg, 2001 • • JEFFERSON PILOT POULERIGUEN,ALAIN POULERIGUEN,ALAIN POVEROMO,MARCA DENTALTEAMOFCORALSPRINGS 100SMILITARYTRAIL 1160KANECONCOURSE 987U NIVERS ITY DRIVE DEERFIELDBEACH,FL33442 BAYHARBOR,FL33154 CORALS PRI NGS, F L33071 (954)725 -3717 (305)866 -7127 (954)753 -4005 POWELL,JORGEL PRESNER,DONALDI PRIMERO,PATRICIA 2438CORALWAY 12193SOUTH DIXIE HWY LESLIEPLAZA MIAMI,FL33145 MIAMI,FL33156 13323SW42NDST (305)854 -1721 (305)251 -4602 MIAMI, FL33175 (305)223 -2828 PUENTE,KATIA PYSER,DOUGLASN QUEIJA,JORGEI 963NKROMEAVE 3343NE33RDST 420LINCOLNRD HOMESTEAD,FL33033 FTLAUDERDALE,FL33308 MIAMI BEACH, FL33139 (305)245 -7974 (954)563 -1362 (305)534 -3088 QUEIJA,JORGEI TODAY'SFAMILYDENTISTRY 1314UNIVERSITYDR CORALSPRING S, FL33071 (954)796 -0310 QUILICHIN1,CARLOS ALLDENTAL 1869N66THAVE HOLLYWOOD,FL33024 (954)983 -3992 QUINTANA,RAFAEL 4841W4THAVENUE HIALEAH,FL33012 (305)558 -2261 QUILICHINI,CARLOS GENTLE DENTALOF POMPANO B EACH 1NE23RDAVE POMPANO BEACH, FL33062 (954)946 -4867 QUILICHINI,CARLOS GENTLEDENTALOF PLANTATION 1776NPINEISLANDRD PLANTATION, F L33322 (954)472 -8707 QUINTANA,RAFAELJ 2438CORALWAY MIAMI, FL33145 (305)854 -1721 QUILICHINI,CARLOS 15495EAGLESNESTLANE MIAMI LAKES,FL33014 (305)698 -7566 i QUILICHINI,CARLOS CALIF ORN IACLU B DENTISTRY CALIFORNIACLU B MALL 8501VESDAIRYRD NORTHMIAMIBEACH, FL33179 (305)654 -9399 QUINTERO,JUANF 17996S W 97THAVE MIAMI, FL33157 (305)235 -5954 QUIROS,ROBERTO RABASSA,ANTONIOL RAND,SUSAN 10554SW8ST 2510SW27THAVE 12333NW 18THST MIAMI,FL33174 MIAMI,FL33133 PEMBROKE PINES,FL33026 (305)223 -0026 (305)443 -3131 (954)433 -5610 Novemb er2, 2001 0 • irlJEFFERSON PILOT ial RING,CHRISTIAN ROBBINS,ALFRED ROBERTS,BRADLEY GENTLE DENTALOF POMPANO BEACH 3850SW87AVE 6130WATLANTICBLVD POMPANOONECOMPLEX MIAMI,FL33165 MARGATE,FL33063 1NE23RDAVE (305)226-0131 (954)973-0990 POMPANOBEACH,FL33062 (954)946-4867 ROBERTS,NORIVIAN ROBISON,JONC ROCA-GODIN EZ, LILIAN R 3038NFEDERALHWY DENTALHEALTHGROU PATKEN DALE 4999W8THAVE FTLAUDERDALE,FL33306 13876KENDALLDR HIALEAH,FL33012 (954)563-6155 MIAMI,FL33186 (305)821-7681 (305)385-4215 RODRIGUEZ,MARIAA RODRIGUEZ,JORGEALBERTO RODRIGUEZ,JULIOA 3934SW8THST CHILDRENSDENTALCTRBAPTIST DENTALARTSOFSLINSET CORALGABLES,FI-33134 8750SW144ST 7100SW99AVE (305)444-1842 MIAMI,FL33176 MIAMI,FL33173 (305)969-3122 (305)274-9656 RODRIGUEZ,VICKY RODRIGUEZ,VICKY RODRIGUEZ,GUILLERMO 4841WEST4THAVE 177SW42AVE 716OPEMBROKERD HIALEAH,FL33012 MIAMI, FL33134 MIRAMAR, F L33023 (305)558-2261 (305)445-8459 (954)987-6977 RODRIGUEZ,GUILLERIVIO RODRIGUEZ,PEDROE RODRIGUEZ,AMAURY FAMILYDENTISTRY11 4629NW199THST 3944WFLAGLERST 2625EXECUTIVEPARKDR MIAMI,FL33055 MIAMI,FL33134 WESTON,FL33331 (305)625-9411 (305)445-1405 (954)384-8484 RODRIGUEZ,JORGEALBERTO ROSADO,JULIOC RODRIGUEZ,JORGEALBERTO DENTALASSOCIATESOFHOMESTEAD, DENTALCENTEROF BAPTIST HIALEAH DENTALCARE 151NW11THST 8940NKENDALLDR 4999W8THAVE HOMESTEAD, FL33030 MIAMI,FL33176 HIALEAH,FL33012 (305)247-0099 (305)271-3001 (305)821-7681 ROSADO,JULIOC ROSEN,GARYR ROSENBERG, HOWARD 8763SW24THST 14115SDIXIEHWY 12404WDIXIEHWY MIAMI,FL33165 MIAMI,FL33176 NORTH MIAMI, FL33161 (305)223-4546 (305)251-4330 (305)893-4801 November2,2001 • • Ira", JEFFERSON PILO i DENTIST,GENERAL SALAS,CLAUDIAM SALGUEIRO,JOSE SALMON,DWIGHT 7861 PINESBLVD 7933NW2NDST 20320NW2NDAVENUE PEMBROKE PINES,FL33024 MIAMI,FL33126 MIAMI,FL33169 (954)967 -8280 (305)261 -5251 (305)652 -5455 SALVAT,JUANM SAMPSON,MICHAEL SANCHEZ,JAVIER 12193SDIXIEHWY 9055SW87AVE 14433SDIXIEHWY MIAMI, F L33156 MIAMI, FL33176 MIAMI, FL33176 (305)251 -4602 (305)270 -1343 (305)251 -4525 SANCHEZ,JULIOCESAR SANCHEZ,EDUARDO SANCHEZ,CARLOSA 3900HOLLYW0ODBLVD 78ONW42AVE 2510SW27THAVE HOLLYWO0D,FL33021 MIAMI,FL33126 MIAMI,FL33133 (954)989 -5500 (305)448 -3896 (305)443 -3131 SANCHEZ,RAMONA SANCHEZ-GARCIA,CONCEPCIONM SANCHEZ- GARCIA,CONCEPCIONM 130000RALWAY 1300C0RALWAY 9301 MILLERRD MIAMI,FL33145 MIAMI,FL33145 MIAMI,FL33165 (305)854 -7200 (305)854 -7200 (305)595 -4616 SANTAMARINA,LUISM SANDER,MARCA SANDS,GEORGEK 2323N E26THAVE 1001 N W 54ST 330S W 27AVE POMPANO BEACH, FL33062 MIAMI,FL33127 MIAMI,FL33135 (954)782 -3334 (305)754 -0695 (305)743 -9998 SANTANA,ESTHER SANTANA,GERMAN SANTEIRO,ALFREDO 1829NE 185ST 2303HOLLYW0ODBLVD 2555CELLINSAVE N0RTHMIAMI BEACH, FL33179 HOLLYWOOOD,FL33020 MIAMI BEACH,FL33140 (305)932 -6600 (954)927 -1717 (305)672 -9698 SANTOS,REMEDIOS SARDA,MARIAMILAGRO SARRIS,JOHN 140- 160SUNIVERSITYDR 299ALHAMBRACIRCLE GENTLE DE NTALOF POMPANO BEACH PEMBROKE PINES, FL33025 CORALGABLES,FL33134 POMPANOONECOMPLEX (954)431 -0004 (305)443 -4841 1 NE23RDAVE POMPANO BEACH, FL33062 (954)9464867 Novemb er2, 2001 • Irmag JEFFERSON PILOT SCHWARTZ,EDWARD 730OWMCNABRD TAMARAC,FL33321 (954)722 -0100 SEVEL,DENNISS SUNSETLAKESDNTL &ORTHOCTR 18431MIRAMARPKWY MIRAMAR, FL33029 (954)433 -4300 SHARMETT,MICHAEL CALIFORNIACLUBDENTISTRY CALIFORNIACLUB MALL 8501VESDAIRYRD NORTH MIAMI BEACH, FL33179 (305)654 -9399 • SHARMETT,MICHAEL DEERFIELDDENTALSERVICES 1800WESTH ILLS BO ROB LVD DEERFIELD BEACH, FL33442 (954)427 -4321 SHOFNOS,CHARLES 12129SHERIDANST COOPE RC ITY, F L33026 (954)433 -1888 SHRAGER,JOSEPHA DENTALCENTERATBAPTIST 8940NKENDALLDR MIAMI,FL33176 (305)271 -3001 SEIJAS,MIGDALIA 400WEST65THST HIALEAH,FL33012 (305)819 -4056 SEVEL,DENNISS 12651 WSUNRISEBLVD SUNRISE,FL33323 (954)846 -7000 SHARMETT,MICHAEL GENTLE DENTALOF PLANTATION 1776N PINE ISLANDRD PLANTATION, F L33322 (954)472 -8707 SHERMAN,STEPHEN SHERMANDENTALSERVICESINC 10FAIRWAYDR DEERFIELDBEACH,FL33441 (954)421 -6400 SHOWSTARK,STEPHEN 22771ST MIAMIBEACH,FL33141 (305)866 -2933 SHROFF,HITESH 10078MCNABRD TAMARAC,FL33321 (954)720 -9730 SILBER,ALBERTO SILVESTRY,ELVIN 10554SW8ST 1140ONKENDALLDR MIAMI, FL33174 MIAMI, F L33176 (305)228 -6633 (305)271 -7777 November2, 2001 SERRA-JOVENICH, MAN UEL 7171 CORALWAY MIAMI,FL33155 (305)264 -9191 SHAPIRO,DARI 9601 WATLANTICBLVD CORALSPRI NGS, FL33071 (954)753 -7400 SHARMETT,MICHAEL GENTLE DENTALOF POMPANO BEACH POMPANOONECOMPLEX 1NE23RDAVE POMPANO BEACH,FL33062 (954)946 -4867 SHIFFMAN,HARVEYS 6209WCOMMERCIALBLVD TAMARAC, FL33319 (954)726 -3200 SHRAGER,JOSEPHA 519ONW 167THST MIAMI, FL33014 (305)624 -4115 SHUGAR,IRVING 407LINCOLNRD MIAMI B EACH, FL33139 (305)672 -4444 SILVESTRY,ELVIN DENTALASSOCIATESOFHOMESTEAD 151NW11ST HOMESTEAD,FL33030 (305)247 -0099 �J 0 • JEFFERSON PILOT SOOTIN,JOHN 15450NEWBARNRD MIAMI LAKES, FL33014 (305)557 -7775 SOSA- ABELLA,NANCY PAL - MEDBLDG 7150 W 20AVE HIALEAH,FL33016 (305)556 -3313 SPELIOS,LOUISG 20335OLDCUTLERRD MIAMI, FL33189 (305)238 -6777 SOOTIN,JOHN 935W49ST HIALEAH, F L33012 (305)821 -7811 SOTO,ERNIE 100N W 82AVE PLANTATION, F L33324 (954)472 -3100 ;OOTIN,JOHN 851 NW 125THAVE 3EMBROKEPINES, FL33028 954)437 -2040 -PECTOR,LAWRENCEA 1132WILESRD 'ORALS P RINGS, FL33067 954)341 -9900 SPERLING,HANS SPINGARN,JOSEPH DENTALHEALTHGROUPATKENDALL 7797NORTHUNIVERSITYDR 13876KENDALLDRIVE TAMARAC,FL33321 MIAMI, FL33186 (954)722 -9339 (305)385 -4215 STAMBLER,SILVIA STRAUSS,THEODORE STURRUP,CHARLESW 2925AVENTURABLVD THE DENTALTEAMOF POMPANO BEA 4230WBROWARDBLVD AVENTURA, FL33180 1 POMPANOSQ PLANTATION, F L33317 (305)935 -4800 POMPANO BEACH,FL33062 (954)583 -1139 (954)782 -8620 SUMMERS,MARK 10071SUNSETSTRIP SUNRISE,FL33322 (954)742 -4600 SUTNICK,STEVENA 40041STST MIAMI BEACH,FL33140 (305)531 -6646 November2, 2001 SURI,ALBA 1370E4AVE HIALEAH,FL33010 (305)888 -1458 SUTNICK,STEVENA PALMDENTALCENTER 715OW20THAVE HIALEAH, F L33016 (305)556 -3313 SUMMERS,JEROME 17996S W 97AVE MIAMI, FL33157 (305)235 -5954 SUSKIN,ALAN 30ON W 70AVE PLANTATION,FL33317 (954)327 -8075 SUTNICK,STEVENA DENTALCENTERATBAPTIST 894ONKENDALLDR MIAMI,FL33176 (305)271 -3001 SUAREZ,ELISA PLANTATION DE NTALSE RVICES 314SUNIVERSITYDR PLANTATION, F L33324 (954)474 -8475 SUAREZ,ELISA PAL- MEDBLDG 715OW20THAVE HIALEAH, F L33016 (305)556 -5600 SUMMERS,MARK 10071SUNSETSTRIP SUNRISE,FL33322 (954)742 -4600 SUTNICK,STEVENA 40041STST MIAMI BEACH,FL33140 (305)531 -6646 November2, 2001 SURI,ALBA 1370E4AVE HIALEAH,FL33010 (305)888 -1458 SUTNICK,STEVENA PALMDENTALCENTER 715OW20THAVE HIALEAH, F L33016 (305)556 -3313 SUMMERS,JEROME 17996S W 97AVE MIAMI, FL33157 (305)235 -5954 SUSKIN,ALAN 30ON W 70AVE PLANTATION,FL33317 (954)327 -8075 SUTNICK,STEVENA DENTALCENTERATBAPTIST 894ONKENDALLDR MIAMI,FL33176 (305)271 -3001 • • 0 JEFFERSON PILOT VALDES- SUEIRAS,CARLOSM VALENCIA,ALBERTOV VALENCIA,ALBERTOV 1534VENERAAVE SWEETWATERHEALTHCENTER 9885NKENDALLDR CO RALGABLES, FL33146 320SW 109AVE MIAMI, FL33176 (305)661 -6061 MIAMI, FL33174 (305)271 -4876 (305)221 -8661 VALENCIA,NELLY VALLE,RAMON VALLE,RAMON 4011 W FLAGLERST 820E41 ST 4890W3AVIENDA MIAMI, FL33134 HIALEAH, FL33013 HIALEAH, FL33012 (305)649 -4249 (305)836 -3635 (305)826 -0906 VALLE,RAMON VALLEJO,FREDDY VALLES,NORA LUCAYAPLAZAI I 600S PINE ISLANDRD 7500N W 5THST 1191W37THST PLANTATION,FL33324 PLANTATION,FL33317 HIALEAH,FL33012 (954)382 -0110 (954)587 -1490 (305)826 -9642 VANDENEDES,WILLIAM VASALLO,FRANCISCO VASALLO,FRANCISCO 8163BIRDRD 24NW29ST 8782ASW8ST MIAMI, FL33155 MIAMI, FL33127 MIAMI, FL33174 (305)264 -4008 (305)573 -2260 (305)552 -5340 VAZANA,RAPHAEL VAZQUEZ,JORGEE VAZQUEZ,HUMBERTOH 4841 W4THAVE 330SW27THAVE 2742SW8THSTREET HIALEAH, F L33012 MIAMI, FL33135 MIAMI, FL33135 (305)558 -2261 (305)643 -6645 (305)541 -4677 VELAZQUEZ,ANGELL VELEZ- LEON,WALESKAI VELIS,LUISA 3735SEBTHST D &DDENTAL THEVELISBROTHERSDENTALTEAM CORALGABLES,FL33134 8353SW 124THST 10449NW41STSTREET (305)442 -4566 MIAMI, FL33156 MIAMI, FL33178 (305)253 -7227 (305)629 -9909 VERA,RAFAEL VERA,RAFAEL VERNE,MARIA 807SW 25THST 1851 N W 125THAVE 12297PEMBROKERD MIAMI,FL33135 PEMBROKEPINES,FL33028 PEMBROKEPINES,FL33025 (305)649 -6723 (954)437 -2040 (954)430 -0308 Novemb er2, 2001 • C. • IrlJEFFERSON PILOT ipm ZENGA,WILLIAM 2500NUNIVERSITYDR SUNRISE,FL33322 (954)741 -8580 November2, 2001 ZERULIK,JOSEPHALLAN 7420NW5THST PLANTATION,FL33317 (954)581 -4110 ZIEMBA,ALBERTJ WESTUNIVERSITYPROFBLDG 7500NW5THST PLANTATION,FL33317 (954)581 -7540 WEISSMAN,MARKL WELLIKOFF,MICHAEL WILDE,MARK 4320WBROWARDBLVD 8320WSUNRISEBLVD 5280NUNIVERSITYDR PLANTATION, FL33317 PLANTATION, FL33322 LAUDERH ILL, FL33351 (954)581 -1910 (954)475 -8100 (954)749 -4594 WILLIAMS,KEITH WOODLOCK,DM WITKOFF,SHARI SIMMONDS &WILLIAMSDENTAL DENTALASSOCOFKENDALL 901SE8THAVE 1724NUNIVERSITYDR 8966SW87CT DEERFIELDBEACH,FL33441 PEMBROKEPINES, FL33024 MIAMI, FL33173 (954)426 -2298 (954)432 -7771 (305)271 -2254 WYNNE,LARRY WOOLDRIDGE,MARIAE WOOLF,JAREDW 101071STST CALIFORNIACLUBDENTISTRY GORDON DENTALASSOC IATES MIAMI BEACH,FL33141 8501VESDAIRYRD 931 NORMANDYDR (305)868 -8500 NORTH MIAMIBEACH, FL33179 MIAMISEACH, FL33141 (305)654 -9399 (305)861 -7222 YANG,JAMEST YANOWITZ,GARY YATZKAN,MARIA 820OWSUNRISEBLVD 1000NHIATUSRD HIALEAHSQUAREDENTALASSOC PLANTATI0N,FL33322 PEMBROKEPINES,FL33026 4186W12AVE (954)472 -5500 (954)431 -9500 HIALEAH,FL33012 (305)556 -6291 YUSMAN- WIRTH,LINDA ZAMBRANO- RIVAS,DARYS ZAHLER,MARKH 8729SW 136THSTREET 10051 PINESBLVD 10666N W FONTB LVD MIAMI,FL33176 PEMBROKEPINES,FL33024 MIAMI,FL33172 (305)255 -5550 (954)432 -1900 (305)220 -8911 ZARDON,RAMON ZARDON,RAMON ZEKIND,IRVING RAZARDENTALGROUP 15940SW 137THAVE 711 0SOUTHGATE BLVD 5864NW 183ST MIAMI,FL33177 NORTHLAUDERDALE,FL33068 HIALEAH,FL33015 (305)259 -0080 (954)724 -8949 (305)827 -1700 ZENGA,WILLIAM 2500NUNIVERSITYDR SUNRISE,FL33322 (954)741 -8580 November2, 2001 ZERULIK,JOSEPHALLAN 7420NW5THST PLANTATION,FL33317 (954)581 -4110 ZIEMBA,ALBERTJ WESTUNIVERSITYPROFBLDG 7500NW5THST PLANTATION,FL33317 (954)581 -7540 • • • JEFFERSON PILOT COMORA,ROBERT EFFREN,ROBERTT EFFREN,ROBERTT DEERFIELDCENTERFORDENTALSP 15000NIVERSITYDR 317ONFEDERALHWY 1800WHILLSBOROBLVD CORALSPRINGS,FL33071 LIGHTHO USE POINT, FL33064 DEE RF IE LDBEACH, F L33442 (954)752 -4408 (954)943 -5640 (954)427 -4361 GITTESS,RONALDM GITTESS,ROBERTH GITTESS,ROBERTH 740ONKENDALLDR 7400NORTHKENDALLDR 1625NCOMMERCEPKY MIAMI, FL33156 MIAMI, FL33156 FTLAUDERDALE, FL33326 (305)670 -4144 (305)670 -4144 (954)389 -2345 GREENGARG,NANCYS GREENGARG,NANCYS HEINSEN,GRETCHEN 21110BISCAYNEBLVD 6130WATLANTICBLVD 817SUNIVERSITYDR AVE NTU RA, FL33180 MARGATE, FL33063 PLANTATION, F L33324 (305)932 -6336 (954)973 -0990 (954)476 -0010 KHARAZI,MEHBRODCAMERON KERMAN,KENNETHJ JIMENEZ,JOHNJ DENTALHEALTHGROUP 270ONE14THTCAUSEWAY ADVANCEDDENTALCENTER 140SUNIVERSITYDRIVE POMPANO BEACH,FL33062 710OWCOMMERCIALBLVD PEMBROKEPINES,FL33025 (954)783 -9959 LAUDERHILL,FL33319 (954)431 -0004 (954)741 -6556 KNIGHT,DAVID KNOPF,KENNETHH KNOPF,KENNETHH 817SUNIVERSITYDR 1545ONEWBARNRD 7311SW62AVE PLANTATION, FL33324 MIAMI LAKES, FL33014 MIAMI, F L33143 (954)476 -0010 (305)557 -7775 (305)667 -2633 LANDSBERG,JACK LE,FERNPHUONG LE,FERNPHUONG 2420SW27AVE DENTALHEALTHGROUP DENTALHEALTHGROUP MIAMI, FL33145 17301 NW27THAVE 140SLINIVERSITYDRIVE (305)441 -9128 OPALOCKA,FL33056 PEMBROKEPINES,FL33025 (305)620 -2440 (954)431 -0004 MAUTNER,RICHARD MCCANN,JOHNT MAUTNER,RICHARD 925ARTHURGODFREYRD 2999NE191ST 4000SHERIDANST MIAMI BEACH, FL33140 AVENTURA, FL33180 HOLLYWOOD,FL33021 (305)531 -0841 (305)531 -0841 (954)983 -6100 I Novemb er2, 2001 0 • JEFFERSON PILOT ARROYO,JUANC DEERFIELDCTRDNTLSPECIALTIES 1800WHILLSBOROBLVD DEERFIELD BEACH, FL33442 (954)427 -4361 ARROYO,JUANC PALMETTO CENTE RFO RDENTALS PE 715OW20THAVE HIALEAH,FL33016 (305)556 -5660 BRANITZ,MARLON 7305W SAMPLE RD CORALS PRINGS, FL33065 (305)753 -6340 CARDENAS,LUISE 21110BISCAYNEBLVD AVENTURA, FL33180 (305)932 -4955 CORO,CARLOSM 3299PONCEDELEONBLVD CORALGABLES,FL33134 (305)444 -5066 CROSBY,MARYCECILIA 10621 NKENDALLDR MIAMI,FL33176 (305)271 -0510 DEMICK,ROBERT THEDENTALTEAMOFCORALSPRIN 987UNIVERSITYDR CO RALSPRINGS, FL33071 (954)753 -4005 Novemb er2, 2001 ARROYO,JUANC MIAMI B EACHCTRDENTALS P EC 333ARTHURGODFREYRD MIAMI BEACH,FL33140 ;305)674 -0095 BISTRITZ,JEROME 960ARTHURGODFREYRD MIAMI BEACH,FL33140 (305)531 -6900 BROWN,LAWRENCE 7400NORTHKENDALLDR MIAMI,FL33156 (305)670 -7610 CARDENAS,LUISE 1 SO UTH W EST129THA\ PEMBROKE PINES,FL3: (954)432 -2080 CROSBY,MARYCECILIA 175NE96THST MIAMISHORES,FL33138 (305)757 -1564 CUSHING,ROBERTB 90OW49THST HIALEAH,FL33012 (305)558 -1211 DEMICK,ROBERT 9050PINESBLVD PEMBROKEPIN ES, FL33024 (954)432 -7025 ARROYO,JUANC AMERICASORALANDFACIALSURGE 302NW 179THAVE PEMBROKEPINES,FL33027 (954)438 -8448 BOATRIGHT,JERRY 3837HOLLYWOO D BLVD HOLLYWOOD,FL33021 ;954)981 -5161 CARDENAS,LUISE 10ONW82NDAVE PLANTATION, F L33324 (954)475 -9840 CARDENAS,LUISE 975ARTHURGODFREYRD MIAMI BEACH, FL33140 (305)672 -1611 CROSBY,MARYCECILIA 1245N W 119THST NORTH MIAMI, FL33167 (305)685 -7863 DEMICK,ROBERT 8320WSUNRISEBLVD PLANTATION, F L33322 (954)474 -9660 DIAZ,MARCOS 2239NCOMMERCEPKY WESTON,FL33326 (954)659 -9990 0 • IreJEFFERSON PILOT HIRSCH,STUART 7305WSAMPLERD CORALSPRINGS,FL33065 (954)753 -6340 JACKSON,JACKM 6130WATLANTICBLVD MARGATE,FL33063 (954)973 -0990 LIEBERMAN,MORTON DENTALHEALTHGROUPATPEMBROK 140- 160SUNlVERSITYDR PEMBROKE PINES, FL33025 (954)431 -0004 NOVAK,FRED 3837HOLLYWOODBLVD HOLLYWOOD,FL33021 (954)981 -5161 PASTRANA,MIGUELA PALMETTOCTRDNTLSPECIALTIES 715OW 20THAVE H IALEAH, F L33016 (305)556 -5600 PASTRANA,MIGUELA DEERFIELDCTRDNTLSPECIALTIES 1800HILLSBOROBLVD DEERFIELDBEACH, FL33442 (954)427 -4287 PAYTON,KEVIN 1SOUTHWEST129THAVE PEMBROKE PINES, FL33027 • (954)432 -2080 Novemb erg, 2001 ISRAEL,SALOMON 4410SHERIDANST HOLLYWOOD,FL33021 (954)981 -4896 KARPEL,JOEL 7193WOAKLANDPARKBLVD LAUDERHILL,FL33313 (954)741 -0102 LIEBERMAN,MORTON DENTALHEALTHGROUPATNORTHD 17301 N W 27AVE OPALOCKA, FL33056 (305)624 -1371 JACKSON,JACKM G &GDENTALASSOCIATES 703ONW57THSTREET TAMARAC, F L33319 (954)722 -1082 KROHN,MELR 7500N W 5TH ST PLANTATION, F L33317 (954)792 -5544 MCCAIN,JOSEPHP 8940NKENDALLDR MIAMI, FL33176 (305)595 -1905 (954)722 -1082 PASTRANA,MIGUELA PAYTON,KEVIN PASTRANA,MIGUELA AMERICASO RALAND IMPLANT PARNES,EDMUND DENTALSPECIALTYCTRBAPTIST PASTRANA,MIGUELA 870ONKENDALLDR 8940N KE N DALLDR G &GDENTALASSOCIATES MIAMI, FL33176 MIAMI,FL33176 703ON W 57TH ST (305) 595 -4122 (305)275 -2275 TAMARAC, F L33319 (954)722 -1082 PASTRANA,MIGUELA PAYTON,KEVIN PASTRANA,MIGUELA AMERICASO RALAND IMPLANT 975ARTHURGODFREYRD DENTALSPECIALTYCTRBAPTIST 302N W 179THAVE MIAMIBEACH, FL33140 8940N KE N DALLDR PEMBROKE PINES, FL33029 (305)672 -1611 MIAMI,FL33176 (954)438 -8448 (305)275 -2275 PASTRANA,MIGUELA MIAMI BEACHCENTE RFO RDENTAL 333ARTHURGODFREYRD MIAMI BEACH, FL33140 (305)674 -0095 PAYTON,KEVIN 10ONW82AVE PLANTATION, F L33324 (954)475 -9840 PAYTON,KEVIN PAYTON,KEVIN 975ARTHURGODFREYRD 21110BISCAYNEB MIAMIBEACH, FL33140 AVE NTU RA, FL331 (305)672 -1611 (305)932 -4955 • • JEFFERSON PILOT SULTAN,LESLIEH 2480ECOMMERCIALBOULEVARD FTLAU DE RDALE, F L33308 (954)476 -2014 TAYLOR,GREG 2221 NUNIVERSITY[ PEMBROKEPINES, (954)983 -1800 TORRES,LUISA DENTALHEALTHGROUPATDADELAN 740ONKENDALLDR MIAMI,FL33156 (305)670 -4476 ARAUZ,NESTORL 841OWFLAGLERST MIAMI,FL33144 (305)229 -7026 BETANCOURT 7856NW 178TH; MIAMI,FL33015 (305)826 -2758 CHAMORRO,JORGE FAMILYDENTALCAR 1990S W 27AVE MIAMI,FL33145 (305)443 -4456 November2, 2001 TAYLOR,GREG 4410SHERIDANSTREET HOLLYWOOD,FL33021 (954)981 -4896 TORRES,LUISA DENTALHEALTHGROUPATNORTHD 17301 NW27AVE OPALOCKA, FL33056 (305)624 -1371 VALENTINE, ROSEMARIE 3101 NOFEDERALHWY FTLAU DERDALE, FL33306 (954)566 -0300 AU RRECOECHEA, RAFAEL 5370PALMAVE HIALEAH, F L33012 (305)821 -9022 BETANCOURT,MAYRAG 7976SW8THST MIAMI,FL33144 (305)266 -4544 TAYLOR,GREG 1040WESTONRD FTLAUDERDALE,FL33326 (954)389 -7771 TORRES,LUISA DENTALHEALTHGROUPATPEMBROK 140- 160SUNIVERSITYDR PEMBROKE PINES,FL33025 (954)431 -0004 WRUBLE,LLOYDL 740ONKENDALLDR MIAMI, FL33156 (305)670 -7610 BERKOWITZ,SAMUEL 6601 S W 80ST SOUTHMIAMI,FL33143 (305)667 -3126 CARR,ELAINE DENTALCENTE RS OFAME RICA 15810 W STATE RD84 FTLAU DERDALE, F L33326 (954)384 -4322 CHIRON,DAVID CHIRON,DAVID 3512SUNIVERSITYDR 2740ECOMMERCIALBLVD DAVI E, FL33328 FTLAU DERDALE, FL33308 (954)474 -2422 (954)493 -8939 • • • JEFFERSON PC.LOT k Y GOMARA, FRANCISCO GOMARA, FRANCISCO GORBACK,NORMANR PALMETTOCENTERFORDENTALSPE 13706SW56THST 7420NW5THSTREET 715OW20THAVE MIAMI,FL33175 PLANTATION,FL33317 HIALEAH,FL33016 (305)387 -4954 (954)791 -6510 (305)556 -5600 HABER,ISAACB IRIGOYEN,KENNETH IRIGOYEN,KENNETH 8701 SW 137THAVE 8966SW87THCT 5965PONCEDE LEON BLVD MIAMI,FL33183 MIAMI,FL33176 CORALGABLES,FL33146 (305)386 -0068 (305)274 -4440 (305)669 -4422 KAUFMAN,WILLIAME KORNBLUTH,DAVIDH KORNBLUTH,DAVIDH 8966S W 87THCO U RT 1908ON E29THAVE 7000W 12THAVE MIAMI,FL33176 AVENTURA,FL33180 HIALEAH,FL33014 (305)374 -4440 (305)944 -1946 (305)821 -7080 LE,NHATM KROP,MICHAELM KROP,MICHAELM 19495BISCAYNEBLVD 975ARTHURGODFREYRD 2625EXECUTIVEPARKDR AVENTURA,FL33180 MIAMI BEACH, FL33140 WESTON,FL33331 (305)934 -4500 (305)673 -5504 (954)349 -0545 LE,NHATM LEE,CAUSEYC LEE,CAUSEYC 4841 W4THAVE 4640NFEDERALHWY 180OW49ST H IALEAH, F L33012 FTLAU DERDALE, FL33308 HIALEAH, FL33012 (306)558 -2261 (954)493 -9755 MARIANI,RICHARDC (305)558 -3384 LUCAS,ALBERT MITCHELL,BYRONL 8430WESTBROWARDBLVD 7600SW57THAVE DENTALHEALTH GROUP NORTH DADE PLANTATION,FL33324 MIAMI,FL33143 17301 NW27THAVENUE (954)475 -1177 (305)665 -2402 O PALOCKA, FL33056 (305)624 -1371 MITCHELL,BYRONL NORENA,FELIPE NORENA,FELIPE DENTALHEALTHGROUPPEMBROKEP 1825NE45THST 7532SW117AVE 140SUNIVERSITYDR FTLAUDERDALE,FL33308 MIAMI,FL33183 PEMBROKEPIN ES, FL33025 (305)772 -1600 (305)273 -1113 (954)431 -0004 November2, 2001 • i r1lmmpg EFFERSON PILOT STOLZENBERG,JOEL DENTALANDOFAVENTURA 19501 BISCAYNEBLVD AVENTURA,FL33180 (305)935 -1400 WARN ER,WM ELVILLE 20215NW2NDAVE MIAMI,FL33169 (305)652 -3103 YAFFEY,MARKA ORTHODONTICGROUP 8977SW 152NDST MIAMI, FL33157 (305)238 -9582 • YAZJI,MARIAE DENTALSPECIALTYCENTERATBAP 8940NKENDALLDR MIAMI,FL33176 (305)271 -3001 • YAZJI,MARIAE 2625EXECUTIVEPAF WESTON,FL33326 (954)217 -3737 STOLZENBERG,JOEL 4410SHERIDANST HOLLYWOOD,FL33021 (954)962 -7200 WEINBERG,HARRY 11634NKENDALLDR MIAMI,FL33176 (305)270 -2020 YAFFEY,MARKA ORTHODONTICGROUP 2700S W 87THAVE MIAMI,FL33165 (305)226 -1837 YAZJI,MARIAE 3811 S W 107AVE MIAMI, FL33165 (305)227 -9927 ARNOLD,PATRICK AZAR,XAVIERFRAN( 480ONE20THTERRACE 1048KANECONCOUF FTLAUDERDALE,FL33308 BAYHARBOR,FL3315 (954)771 -8891 (305)866 -3030 Novemb er2, 2001 WARN ER,WMELVILLE 330SOUTHSTATEROAD7 PLANTATION, FL33317 (954)321 -0217 WEINBERG,HARRY 11254SW 137AVE MIAMI,FL33186 (305)386 -7337 YANG,JAMES DENTALHEALTH GROUP 17301 N W 27AVE MIAMI, FL33056 (305)624 -1371 YAZJI,MARIAE 1350SW 160AVE WESTON,FL33326 (954)217 -3737 PEDIATRIMENTIST BENNETT,JAMESG SFLDENTISTRYFORCHILDREN 9327WSAMPLERD CORALS PRINGS, FL33065 (954)752 -7651 0 0 C] , JEFFERSON PILOT MARTINEZ,MARIOJ MARTINEZ,AICMEE ROMASAN,OANA DENTALHEALTHGROUPATKENDALE PALMETTO CENTER-DENTALSPCLTY SMILEYKIDZDENTALCARE 13876KENDALLDR 715OW20THAVE 1749NE26THST MIAMI, FL33186 H IALEAH, F L33016 WILTON MANORS, F L33305 (305)385 -4215 (305)556 -5600 (954)564 -5540 SOBEL,PETERB STEPHENS,ROBERTC STEPHENS,ROBERTC 15495EAGLENESTLANE SOFLDENTISTRYFORCHILDREN 1930NE34THCOURT MIAMI LAKES,FL33014 9327WSAMPLERD POMPANO BEACH,FL33064 (305)698 -7566 CO RALSPRI NGS, FL33065 (954)781 -1855 (954)752 -7651 THOMAS,CHRISTIANM WALTERS,EDWARDR 3471 NFEDERALHWY 8313WATLANTICBLVD FTLAUDERDALE,FL33306 CORALSPRINGS,FL33071 (954)565 -0000 (954)753 -7822 AL- JOBURI,WESAMA 817SUNIVERSITYDR PLANTATION,FL33324 (954)424 -6500 ALLEN,JOSEPHA 1141ONKENDALLDR MIAMI,FL33176 (305)595 -4117 AMAR,HERMAN SOUTHDADEDENTALGROUP 7900S W 104TH ST MIAMI, FL33156 (305)595 -4548 Novemb erg, 2001 AL- JOBURI,WESAMA CORALDENTALCARE 2123UNIVERSITYDRIVE CORALSPRINGS, F L33071 (954)344 -6266 ALLEN,JOSEPHA 2420SW27THAVE MIAMI, FL33145 (305)445 -1790 AMAR,HERMAN 16209NE13THAVE NORTHMIAMIBEACH, FL33162 (305)940 -9888 PERIDnnNTRT ALLEN,JOSEPHA 7311SW62NDAVE SOUTH MIAMI, FL33143 (305)667 -2633 AMAR,HERMAN CROSSROADS DENTALCENTER 11634NKENDALLDR MIAMI,FL33176 (305)270 -2020 AMAR,HERMAN DENTALASSOCIATESOFHOMESTEAD 151NW11ST HOMESTEAD,FL33030 (305)247 -0099 • • • Ira JEFF RSON PILOT GUTT,MARKI GUZMAN,AIXA HOROWITZ,ALLEN 975ARTHURG0DFREYRD 12251TAFTSTREET 7000W 12AVE MIAMIBEACH,FL33140 PEMBR0KEPINES,FL33026 HIALEAH,FL33014 (305)538 -2112 (954)441 -8778 (305)557 -5888 KLIGERMAN,BARRY HOROWITZ,ALLEN LEI DERMAN, RICHARD 5000H0LLYW00DBLVD 2480EC0MMERCIALBLVD 8251 W BROWARDBLVD HOLLYWO0D,FL33021 FTLAUDERDALE,FL33308 PLANTATION,FL33324 (954)963 -4700 (954)771 -9090 (954)475 -1574 LEI DERMAN, RICHARD MAIZ,CARLOSYAMIL MAIZ,CARLOSYAMIL 960ARTHURG0DFREYRD 10000SW65THST DENTALHEALTHGROUPATKENDALE MIAMI BEACH,FL33140 MIAMI,FL33165 13876KENDALLDR (305)672 -7339 (305)279 -9005 MIAMI,FL33186 (305)385 -4215 MARFINO,NICHOLASROBERT MELLADO,JOSER MELLADO,JOSER 961 UNIVERSITYDRIVE 180OW49THST 15450NEWBARNRD C0RALSPRINGS,FL33071 HIALEAH,FL33012 MIAMI LAKES,FL33014 (954)753 -1600 (305)558 -2200 (305)557 -7775 MELLADO,JOSER MONTAMARTA,FRANCISCOT MONTAMARTA,FRANCISCOT 299ALHAMBRACIRCLE DENTALTEAMO F POMPANO PALMETTOCENTERFORDENTALSPE CO RALGAB LES, F L33134 1 PO MPANOSQUARE 715OW 20THAVE (305)441 -0302 POMPANOBEACH, FL33062 HIALEAH, F L33016 (954)782 -8620 (305)556 -5600 MONTAMARTA,FRANCISCOT MONTAMARTA,FRANCISCOT MYONES,WILLIAM DEERFIELDCENTERFORDENTALSP DE NTALSPECIALTYCENTE RO F BAP 0NESW129THAVE 1800WHILLSBOROBLVD 8940NKENDALLDR PE MBR0KEPINES,FL33027 DEERFIE LID BEACH, FL33442 MIAMI, FL33176 (954)431 -4000 (954)407 -4287 (305)275 -8875 OSTROFF,LEONARD OSTROFF,LEONARD PEARLMAN,ALLEND DENTALHEALTHGROUPATPEMBROK DENTALHEALTHGROUPATNORTHD 9050PINESBLVD 140- 160SUNIVERSITYDR 17301 NW27AVE PEMBROKEPINES, FL33024 PE MBROKE P I NES, FL33025 OPALOCKA, FL33056 (954)432 -7025 (954)431 -0004 (305)624 -1371 Novemb erg, 2001 0 0 CANELA- PICHARDO,DALINDA COGAN,JACQUELINE FONTE,FRANCISCOE 603NFEDERALHWY ADVANCEDDENTALCENTER 9933PINESBLVD HOLLYWOOD,FL33020 7100WESTCOMMERCIALBLVD PEMBROKEPINES,FL33024 (954)920 -6616 LAUDERH ILL, FL33319 (954)433 -5230 (954)741 -6556 VILLA,ROLOLFO WOHLSTEIN,DIANA WOHLSTEIN,DIANA BAYVIEWDENTALASSOCIATES,PA GENTLEDENTALGROUPOFPLANTAT GENTLEDENTALOFPOMPANOBEACH 2633ECOMMERCIALBLVD 1776NPINEISLANDRD POMPANOONECOMPLEX FTLAUDERDALE,FL33308 PLANTATION,FL33322 1NE23RDAVE (954)776 -4720 (954)472 -8707 POMPANOBEACH,FL33062 (954)946-4867 --- - - - - -- -- - - -- WOHLSTEIN,DIANA CALIFORNIACLUB DENTISTRY CALIFORNIACLUB MALL 8501VESDAIRYRD NORTH MIAMI,FL33179 (305)654 -9399 Novemb er2, 2001 0 • • A GROUP INSURANCE PROGRAM Designed for CITY OF SUNNY ISLES BEACH Submitted by Brown & Brown Inc Miami Lakes, FL Underwritten by JEFFERSON PILOT FINANCIAL INSURANCE COMPANY 8801 Indian Hills Drive Omaha, Nebraska 68114 SUNNYISLES 1703779 City of Sunny Isles Beach SCHEDULE OF INSURANCE Option 2.01 Proposed Effective Date: January 01, 2002 CLASSIFICATION AMOUNT OF BENEFIT Life Accidental Death Insurance and Dismemberment Class 1 All Active Full Time Employees Except Department Managers, City Manager, & Attorney Class 2 Department Managers & City Attorney Class 3 City Manager (24 Hour) 1.00 times annual salary, rounded to the next higher 1,000, subject to a maximum of 300,000 2.00 times annual salary, rounded to the next higher 1,000, subject to a maximum of 300,000 300,000 The amount of Life Insurance and AD &D for Class 1, 2, 3 will reduce: -35% upon the Person's attainment of age 65 -an additional 25% of the original amount at age 70 -an additional 15% of the original amount at age 75 Benefits will terminate upon retirement. 300,000 Annual Salary means only the salary or wage an Insured Person receives for services rendered to the Group Policyholder. It does not include bonuses, overtime pay or other extra compensation other than commissions. Commissions will be averaged over the 12 month period prior to the date disability begins. Guarantee Issue Amount: 250,000 0 Jefferson Pilot Financial Insurance Company 3 11/16/2001 SUNNYISLES 1703779 City of Sunny Isles Beach • SCHEDULE OF RATES AND COSTS Number of Monthly Coverage Employees Volume Rate Premium Life Insurance 95 4,992,500 $.24 /per $1,000 of benefit $1,198.20 AD &D 95 4,992,500 $.040 /per $1,000 of benefit $199.70 Total Premium $1,397.90 The above rates assume the Life coverage is on a non - contributory basis and 100% participation is required. The above rates are guaranteed for Two Years from the effective date of coverage. This proposal describes certain insurance coverages available from Jefferson Pilot Financial and should under no circumstances be construed as a contract or offer to contract for such coverages. An application must be completed and submitted to our Omaha Office, before a group will be considered for coverage. If the proposed policy qualifies as a replacement plan, then coverage for an otherwise eligible person who is disabled on the policy effective date will be administered in accord with any applicable state discontinuance and replacement law. The proposal is based on preliminary census data received by Jefferson Pilot Financial. Actual costs will be leased on the final enrollment data of employees insured under the plan on its effective date. Rates quoted for the proposed benefits shown are effective for 90 days from the date shown on the proposal. A complete listing of the terms, conditions, and limitations, that will apply to your coverage, if issued, is available upon request. • Jefferson Pilot Financial Insurance Company L.30A.050 4 11/16/2001 SUNNYISLES 1703779 City of Sunny Isles Beach • PROPOSAL CONDITIONS This proposal has been prepared on the premise: - there are no known uninsurable individuals in the group to be covered; - no employee is absent from work because of sickness or injury. If any individual to be insured falls into the above categories, we will require full disclosure of all necessary information to evaluate the risk. After reviewing this information, we reserve the right to revise or withdraw our quotation. To become insured, an eligible employee must be an active, full -time employee who: - is a member of an eligible class of employees; - has completed the eligibility waiting period established by the employer; - is not a temporary or seasonal employee; - is performing all customary duties of his /her occupation at his /her usual place of business on the policy effective date (or on the effective date of his /her coverage); and - is regularly scheduled to work at least 30 hours per week, unless otherwise agreed upon by Jefferson Pilot Financial Insurance Company. If included, any eligible dependents must satisfy a nonconfinement requirement on the policy effective date (or on the date coverage becomes effective). This proposal is based on the assumption that the current insurance carrier will continue coverage on any insured individual who is disabled on the date the existing contract terminates (even if it terminates while a 4 Isabled person is satisfying any applicable waiting period). The rates quoted in this proposal are a function of the characteristics of the group (i.e.: Policyholder contributions, occupations, age, gender, etc.) and the benefits requested at the time of proposal submission. If the plan is non - contributory, 100% of the eligible employees must enroll; and if the plan is contributory, 75% of the eligible employees must enroll on the effective date. We reserve the right to re- evaluate the risk, and revise or withdraw our quotation if necessary, based upon the characteristics of the group and the benefits provided on the effective date of the plan. This proposal is a description of insurance coverages available from Jefferson Pilot Financial and is not an offer to contract. An application must be completed before a group will be considered for coverage. This proposal outlines in general some of the important features of the proposed Group Insurance Program. The controlling provisions will be in the Group Insurance Policy, and this proposal is not intended in any way to modify the provisions or their meanings. This proposal will remain in effect until withdrawn or a new proposal is issued by Jefferson Pilot Financial, but in no event will this proposal remain in effect beyond 90 days from November 16, 2001. is FL Jefferson Pilot Financial Insurance Company 5 11/16/2001 SUNNYISLES 1703779 City of Sunny Isles Beach • EMPLOYEE GROUP LIFE INSURANCE BENEFIT: The Life Insurance Benefit is payable to the Insured Person's beneficiary upon death from any cause; except if employees contribute towards the premium, a suicide exclusion will apply to any medically underwritten amount during the first two years of coverage. The beneficiary may be changed at any time by written notice to Jefferson Pilot Financial. If no beneficiary survives the Insured Person, the death benefit will be payable to: the Insured Person's surviving spouse, children, parents or siblings; or the Insured Person's estate (as specified in the policy). CONVERSION PRIVILEGE: Conversion is available when anyone's group life insurance terminates due to: - the Insured Person's termination of employment or membership in an eligible class; or - a covered Dependent's ceasing to be an eligible dependent. That person has the option to convert all or part of the terminated insurance without Evidence of Insurability. The conversion may be made to any Individual Life Policy then provided by Jefferson Pilot Financial (except term insurance). To purchase a conversion policy, application and the first premium payment must be made within the time period specified in the policy. it XTENSION OF DEATH BENEFIT: An Insured Person's Life Insurance (and any Dependent Life Insurance) will be continued without payment of premium, if the Insured Person: - becomes Totally Disabled while insured under the policy and before age 70; - remains Totally Disabled for at least 6 months; and - submits satisfactory proof within the time period specified in the policy. Total Disability shall be defined as shown in the policy. The continued life insurance will be subject to the age reductions shown in the Schedule of Insurance. The continued life insurance will terminate when the Insured Person: - ceases to be Totally Disabled; - fails to take a required medical exam or to submit additional proof requested by Jefferson Pilot Financial; - becomes insured under an individual conversion policy; or - attains age 70 (whichever occurs first). • FL Jefferson Pilot Financial Insurance Company 6 11/16/2001 SUNNYISLES 1703779 City of Sunny Isles Beach GIVING BENEFIT: An Accelerated Death Benefit is available when the Insured Person's life insurance benefit is $2,000 or more. If the Insured Person: - is diagnosed terminally ill due to a sickness or injury at least 12 months after life insurance takes effect; and - qualifies for the Extension of Death Benefit; then part of his or her life insurance benefit can be paid prior to death (subject to state law). Terminally ill means the Insured Person's medical condition is expected to result in death within 12 months, despite appropriate medical treatment. The amount of the Accelerated Death Benefit is subject to: - a minimum of $1,000 or 10% of the Insured Person's life insurance coverage, whichever is more; and - a maximum of $250,000 or 75% of the Insured Person's life insurance coverage, whichever is less. An Accelerated Death Benefit payment will be subject to an interest charge, and the amount of the Death Benefit payable upon that Insured Person's death will be reduced accordingly. NOTE: This is not a Long Term Care benefit. Before requesting an Accelerated Death Benefit payment, Insured Persons should seek their own tax or legal counsel concerning the effect upon taxable income or eligibility for government benefits. •OTHER FEATURES: Our LINKS PROGRAM provides integrated disability management when an insured is covered under Jefferson Pilot Financial's STD and LTD plans. LINKS helps to provide a smooth transition from STD to LTD without claim filing, while helping the employee return to work in the most efficient and effective manner possible. Furthermore, the LINKS program identifies those claimants with life insurance coverage through Jefferson Pilot Financial to determine whether they're eligible for Life Waiver. As of January 1, 2000, a FICA MATCH SERVICE is included on all new and existing LTD business at no additional charge. With this service, Jefferson Pilot Financial matches the policyholder's share of FICA taxes on payments made to disabled employees; generates monthly reports summarizing what has been paid and withheld; and prepares W -2 forms at year -end for LTD benefits paid to each disabled employee. • Jefferson Pilot Financial Insurance Company 7 11/16/2001 SUNNYISLES 1703779 City of Sunny Isles Beach • GROUP ACCIDENTAL DEATH & DISMEMBERMENT INSURANCE BENEFITS: If an Insured Person sustains an accidental bodily injury which directly causes one of the following losses within 365 days following the injury, Jefferson Pilot Financial will pay the benefit listed below: LOSS Loss of one hand by severance at or above the wrist Loss of one foot by severance at or above the ankle Irrecoverable loss of the sight in one eye Any combination of two or more of the losses listed above Loss of life BENEFIT One -half the Principal Sum One -half the Principal Sum One -half the Principal Sum Principal Sum Principal Sum The total benefit for all losses resulting from the same accident may not exceed the Principal Sum. The •Principal Sum for the Insured Person's class is shown in the Schedule of Insurance. Benefits for loss of life will be paid in accord with the Beneficiary Section. All other benefits will be paid to the Insured Person. LIMITATIONS: Benefits are not payable for any loss to which a contributing cause is: - intentional self - inflicted injury or self- destruction; - disease, bodily or mental infirmity, or medical or surgical treatment of these; - the Insured Person's participation in riot; - duty as a member of any military, naval or air force; - war or any act of war, declared or undeclared; - the Insured Person's participation in the commission of a felony; - use of drugs except where prescribed by a physician; - voluntary inhalation of gas; including carbon monoxide; - travel or flight in any aircraft, including balloons and gliders, except as a fare paying passenger on a regularly scheduled flight; or - the Insured Person driving a vehicle while having an alcohol concentration of .10 grams of alcohol or more per 100 milliliters of blood. r� 24 Hour Jefferson Pilot Financial Insurance Company 8 11/16/2001 SUNNYISLES 1703779 City of Sunny Isles Beach • SAFE DRIVER BENEFIT If an Insured Person dies as a direct result of a covered auto accident, for which Accidental Death and Dismemberment Benefits are payable; then: (1) an additional Seat Belt Benefit will be payable (2) provided the Insured Person was wearing a properly fastened seat belt at the time of the accident. The Seat Belt Benefit equals $10,000 or 10% of the Principal Sum, whichever is less. It will not be less than $1,000 per Insured Person. The Principal Sum is the amount payable because of the Insured Person's accidental death. A copy of the police report must be submitted with the claim. The position of the seat belt must be certified by: (1) the official accident report; or (2) the coroner, traffic officer or other investigating officer. Upon receipt of satisfactory written proof, the additional benefit will be paid in accord with the Beneficiary section. DEFINITIONS. As used in this provision: "Auto" means a 4 -wheel passenger car, station wagon, jeep, pick -up truck or van -type car. It must be licensed for use on public highways. It includes a car owned or leased by the Group Policyholder. "Intoxicated," "Impaired," or "Under the Influence of Drugs" shall be defined as by the jurisdiction where the accident occurs. Beat Belt" means a properly installed: (1) seat belt or lap and shoulder restraint; or (2) other restraint approved by the National Highway Traffic Safety Administration. LIMITATIONS. Safe Driver Benefits will not be paid if (1) the Accidental Death and Dismemberment Benefits is not paid under the Policy for the Insured Person's death; or (2) at the time of the accident, the Insured Person or any other person who was driving the auto in which the Insured Person was traveling: (a) was driving without a valid drivers' license; (b) was driving in excess of the legal speed limit; or (c) was driving while intoxicated, impaired, or under the influence of drugs (except for drugs taken as prescribed by a Physician for the driver's use). The above limitations will apply, whether or not the driver is convicted. • Jefferson Pilot Financial Insurance Company Seat Belt 9 11/16/2001 SUNNYISLES Not Included same 1703779 City of Sunny Isles Beach same Long -Term Disability (LTD) Benefits & Cost Summary Wroposed MANDATORY Survivor Income Benefit Effective Date: October 01, 2001 Option 1.00 Class 1: Executives /All Other Active Full -time Employees SCHEDULE of BENEFITS PREMIER Plan VALUE Plan Benefit Percentage 60% same Maximum Monthly Benefit $10,000 same - Social Security Integration Primary & Family same - Minimum Monthly Benefit $100 same Elimination Period 90 Days same - Accumulation of Elimination Period 2X Elimination Period same Maximum Benefit Period 65 /SSNRA same Pre - existing Condition Exclusion 3/12 same Specified Illness/ Injury Limits - Mental /Nervous & Substance Abuse 24 Months same - Other Limits (see 24 Mo. Ben. Limits) Not Applicable 24 MONTHS Premium Contributions Non - Contributory same Minimum Participation 100% same DEFINITION OF DISABILITY *Own Occupation Coverage Period To Age 65/24 Months same Following Own Occupation Period Any Occupation ANY GAINFUL OCCUPATION Zero Day Residual Included same weturn to Work Incentive SSNRA same rtial Disability Formula Residual w/ Progressive same - Income Test first 24 Months 99% same - Income Test after 24 Months 85% 60% ADDITIONAL FEATURES Progressive Income Benefit Not Included same Reasonable Accommodation Included same Vocational Rehabilitation Voluntary MANDATORY Survivor Income Benefit 3 Months same Subrogation / Third Party Reimburs. Not Applicable INCLUDED Conversion Option Not Included same Prior Insurance Credit Included same PLAN ASSUMPTIONS & COST Number of Covered Employees 100 same Monthly Covered Payroll $412,220 $412,220 Rate, as a Percent of Payroll .48% .41% MONTHLY PREMIUM $1,978.66 $1,690.10 Rate Guarantee Two Years same The proposed rates for this LTD plan may be reduced by 5% if a Short Term Disability plan is purchased with the LTD coverage or is currently inforce with Jefferson Pilot Financial for the employees to be covered by the •proposed plan. Jefferson Pilot Financial Insurance Company T1 .49 T2.42 11 11/02/01 SUNNYISLES 1703779 City of Sunny Isles Beach • Beginning at end of elimination period and ending at end of Maximum Benefit Period for an executive or administrator; or 24 months later for all other employees. • • (continued on next page) Jefferson Pilot Financial Insurance Company 12 11/02/01 SUNNYISLES 1703779 City of Sunny Isles Beach LTD Benefits & Cost Summary (continued) SPROPOSAL ASSUMPTIONS & CONDITIONS This proposal assumes that: - there are no known uninsurable individuals in the group to be covered; and - no employee is absent from work because of sickness or injury. If any individual to be insured falls into either of these categories, Jefferson Pilot Financial requires full disclosure of all information needed to evaluate the risk. After reviewing this information, we reserve the right to revise or withdraw our proposal. If the proposed policy qualifies as a replacement plan, then coverage for an otherwise eligible person who is disabled on the policy effective date will be administered in accord with any applicable state discontinuance and replacement law. The proposal also assumes current and continued employer and employee participation in Workers' Compensation or an equivalent plan, which would be used as a source of integration (offset) for the LTD plan of benefits. If the employer's LTD plan is currently insured by another carrier, this proposal assumes that the current carrier will continue coverage on any insured employee who is disabled on the date the existing contract terminates — even if the contract terminates before the disabled employee has satisfied the Elimination Period. �uoted rates were developed based on the information contained in the Request for Proposal. Final rates will be calculated based on: - the agreed -upon plan; - amount & tax status of employer and employee contributions; - enrolled census; - employee location(s); - correct industry code (SIC); and - other pertinent underwriting factors. Jefferson Pilot Financial reserves the right to re -rate or refuse to issue coverage if there are changes in these factors. THIS IS NOT A CONTRACT: This illustration was prepared based on the information provided in the Request for Proposal. It is a description of the Long Term Disability Insurance coverage available from Jefferson Pilot Financial and not an offer to contract. More detailed information is available upon request concerning the terms, conditions and limitations contained in the master policy, if issued. If there are discrepancies between the information contained in this proposal and the master policy, the terms of the master policy will control. An Application for Group Insurance must be completed by the employer and approved by Jefferson Pilot Financial before coverage can become effective. This proposal is subject to revision if not accepted within 90 days of November 02, 2001. L� (continued on next page) Jefferson Pilot Financial Insurance Company FL 13 11/02/01 SUNNYISLES 1703779 City of Sunny Isles Beach LTD Benefits & Cost Summary (continued) *Our VALUE PLAN Option includes the following provisions: PROGRESSIVE PARTIAL DISABILITY BENEFIT with RETURN TO WORK INCENTIVE: The plan includes our BACK ON TRACK° partial disability benefit. BACK ON TRACK' encourages employees to try to return to work by allowing them to receive an overall higher level of income than they would receive from their total disability benefit. For the first 24 months of partial disability benefits — even if the claimant has received total disability benefits for several years — a partially disabled employee can receive up to 99% of predisability earnings from partial disability employment, LTD Plan benefits and other sources of income ... while still satisfying the earnings test. After 24 months, Jefferson Pilot Financial's BACK ON TRACK® provision will continue to pay partial disability benefits until the employee receives: - 85% of predisability earnings, if the Premier Plan is purchased. - 60% of predisability earnings, if the Value Plan is selected. VOCATIONAL REHABILITATION: Jefferson Pilot Financial offers vocational rehabilitation programs that focus on job modification, retraining and job placement. With the help of these services, many disabled employees are able to return to productive employment. Participation in vocational rehabilitation is voluntary under our Premier Plan; it is mandatory for qualifying claimants covered by the Value Plan. ANY GAINFUL OCCUPATION: The Value Plan includes an 'any gainful occupation' definition of disability after the 24 month own occupation period, which reduces disability benefits if the employee is able to earn 00% of predisability earnings. • FULL EARNING CAPACITY: The Value Plan provides that, disability benefits may be reduced or terminated if an employee is able to return to work, but chooses not to, or chooses not to work to the extent allowed by his /her condition. 24 MONTH BENEFIT LIMITATIONS: Jefferson Pilot Financial's Premier LTD Plan can include maximum benefit duration limits for disabilities caused by mental sickness and /or substance abuse. The Value Plan automatically includes benefit duration limitations for disabilities related to: - mental sickness - substance abuse - environmental sicknesses (e.g. Sick Building Syndrome) - chronic fatigue sicknesses (e.g. Epstein -Barr syndrome) - certain musculoskeietal or connective tissue injuries/ conditions SUBROGATION/THIRD PARTY REIMBURSEMENT - Benefit for claimants covered by the Value Plan will be offset income replacement benefits received from auto liability or other third party payors. Jefferson Pilot Financial Insurance Company 14 11/02/01 SUNNYISLES 1703779 City of Sunny Isles Beach 40 HOUR WORK WEEK - The Value Plan's definition of full -time employment provides that a claimant is Wonsidered to have returned to work full time, if he /she is able to work 40 hours per week, regardless of the number of hours worked per week prior to the disability. ZERO DAY RESIDUAL: The elimination period can be satisfied by either days of total and /or partial disability and requires no loss of earnings. 1 31%/$247,332 • Jefferson Pilot Financial Insurance Company 15 11102/01 SUNNYISLES 1703779 City of Sunny Isles Beach Group Long Term Disability Insurance OELIGIBLE EMPLOYEE is an active, full -time employee who: - is a member of an eligible class of employees; - has completed the eligibility waiting period established by the employer; - is not a temporary or seasonal employee; - is at work on the effective date of his /her coverage; - is regularly scheduled to work at least 30 hours per week, unless otherwise agreed upon by Jefferson Pilot Financial; and - is a citizen of or legally works in the United States. ELIMINATION PERIOD is the period of disability during which no benefit is payable. It is shown on the Benefits & Cost Summary page of this proposal. The elimination period begins on the first day of disability. Only days of total or partial disability will count towards the satisfaction of the elimination period. Accumulation of Elimination Period: With this feature, the elimination period is satisfied when the required number of days is accumulated within a period up to two times the length of the elimination period. For example, a 90 day elimination period must be satisfied within 180 consecutive days. PREDISABILITY INCOME means the employee's monthly rate of earnings from the employer in effect: 1. just prior to the date the Elimination Period begins; or 2. just prior to the date an approved leave of absence begins, if the Elimination Period begins while the employee is continuing coverage during a leave of absence. �t includes commissions averaged over the most recent 12 months before the disability begins. Predisability Income does not include overtime pay, bonuses or other forms of compensation. It is also referred to as 'BASIC MONTHLY EARNINGS'. Other 'earnings' definitions may be available upon request. • Jefferson Pilot Financial Insurance Company 16 11/02/01 SUNNYISLES 1703779 City of Sunny Isles Beach TOTAL DISABILITY *or the Premier Plan, Total Disability means that, due to an injury or sickness, an employee is unable: 1. During the ELIMINATION PERIOD and the "OWN OCCUPATION" Period, to perform each of the material and substantial duties of his or her own occupation; and 2. After the "OWN OCCUPATION" Period, to perform each of the material and substantial duties of any occupation which his or her training, education or experience will reasonably allow. The loss of a professional license, an occupational license or certification or a driver's license for any reason does not, by itself, constitute total disability. For the Value Plan, Total Disability means that, due to an injury or sickness, an employee is unable: 1. During the ELIMINATION PERIOD and the "OWN OCCUPATION" Period, to perform each of the material and substantial duties of his or her own occupation; and 2. After the "OWN OCCUPATION" Period, to perform each of the substantial and material duties of any gainful occupation. A gainful occupation is any occupation in which the employee: a) is or reasonably could become qualified, considering his /her education, training, experience, physical and mental abilities; b) could reasonably find employment, considering the demands of the national labor force; and c) could earn, or reasonably expect to earn, a before tax income of at least 60% of his /her predisability income within 12 months of returning to work. The loss of a professional license, an occupational license or certification or a driver's license for any reason does not, by itself, constitute total disability. aA p" WN OCCUPATION PERIOD: To Age 65/24 Months (Option 1.00) period beginning at the end of the elimination period and ending: 1. at the end of the maximum benefit period for an employee who is an executive or administrator; or 2. 24 months later for all other employees. The loss of a professional license, an occupational license or certification, or a driver's license does not, by itself, constitute total disability. MONTHLY TOTAL DISABILITY BENEFIT: After the Elimination Period is satisfied, the LTD policy provides a monthly benefit for an employee who is totally disabled and under a physician's regular care. This monthly total disability benefit equals: - the benefit percentage times the insured's predisability income, up to the maximum monthly benefit; - minus other income benefits. This benefit amount will not be less than the minimum monthly benefit. The policy also provides a monthly benefit for an employee who is partially disabled, under a physician's regular care, and sustaining a specified percentage of lost earnings. See the Partial Disability Benefit section of this proposal. RECURRENT DISABILITY means a disability which is related to or due to the same cause or causes of a prior disability for which a monthly benefit was payable. A recurrent disability: - will be treated as part of the prior disability if, after receiving policy benefits, the employee returns to his or her regular occupation full -time for less than 6 months. will be treated as a new period of disability if, after receiving policy benefits, an employee returns to his or her regular occupation full -time for 6 months or more. A new elimination period must be completed before benefits become payable. Jefferson Pilot Financial Insurance Company FL 17 11/02/01 SUNNYISLES 1703779 City of Sunny Isles Beach BACK ON TRACK® PARTIAL DISABILITY BENEFIT - Residual with Progressive (Option 1.00) *An employee may qualify for a partial disability benefit if he or she is partially disabled, is earning at least 20% of his or her predisability income, and is under the regular care of a physician. During the first 24 months of Partial Disability Benefit payments, an earnings test will not be applied until the employee's earnings reach 99% of his or her predisability income. After 24 months, the employee must earn at least 85% (60% for the Value Plan) of predisability earnings before the earnings test is applied. • Partially Disabled for the Premier Plan will be defined as follows: 1. During the Elimination Period and Own Occupation Period, it means that due to an Injury or Sickness the Insured Employee: a) is unable to perform one or more of the substantial and material duties of his or her regular occupation, or is unable to perform such duties full -time; and b) is engaged in Partial Disability Employment. 2. After the Own Occupation Period, it means that due to an Injury or Sickness the Insured Employee: a) is unable to perform one or more of the substantial and material duties of any gainful occupation which his or her training, education or experience will reasonably allow; or is unable to perform such duties full -time; and b) is engaged in Partial Disability Employment. Partially Disabled for the Value Plan will be defined as follows: 1. During the Elimination Period and Own Occupation Period, it means that due to an Injury or Sickness the Insured Employee: a) is unable to perform one or more of the substantial and material duties of his or her regular occupation, or is unable to perform such duties full -time; and b) is engaged in Partial Disability Employment. 2. After the Own Occupation Period, it means that due to an Injury or Sickness the Insured Employee: a) is unable to perform one or more of the substantial and material duties of any gainful occupation, or is unable to perform such duties full -time; and b) is engaged in Partial Disability Employment. The Partial Disability Monthly Benefit will cease on the earliest of: 1. the date the employee ceases to be Partially Disabled or dies; 2. the date the Maximum Benefit Period ends; 3. the date the employee earns more than 99% of predisability income, until partial disability benefits have been paid for 24 months; 4. the date the employee's current earnings exceed 85% (60% for the Value Plan) of the predisability income, after partial disability benefits have been paid for 24 months; 5. the date the employee is able, but chooses not to work full -time: a) in his or her regular occupation, during the Own Occupation Period; b) in any gainful occupation, after the Own Occupation Period; 6. the date the employee fails to take a required medical exam, without good cause; or 7. the 60' day after the Company mails a request for additional proof, if not given. Jefferson Pilot Financial Insurance Company 18 11/02/01 SUNNYISLES 1703779 City of Sunny Isles Beach The Partial Disability Monthly Benefit equals the lesser of A, B or C below: • A) The total disability benefit which would be payable if the employee I disability employment: predisability income (times) benefit percentage; B) The employee's predisability income minus other income benefits, a earnings from partial disability employment. C) The plan's maximum benefit. Example: Benefit Percentage: 60% Maximum Monthly Benefit: $5,000 Predisability Income: $3,000 Partial Disability Employment Earnings: $1,450 Other Income Benefits: $0 The partial disability benefit payable is the lesser of: A) 60% of Predisability Income B) Predisability Income less less Other Income Benefits: Partial Disability Employment Earnings and Other Income Benefits: $3,000 $3,000 x 60% - $1,450 $1,800 $1,550 �ceived no earnings from partial minus other income benefits. defined in the policy, including C) Maximum Monthly Benefit: $5,000 With Back On Track ®, income the employee receives from all sources would equal $3,000. (The LTD Plan's monthly partial disability benefit payment would equal $1,550, the lesser of A, B and C. Partial disability employment earnings of $1,450 + partial disability benefit of $1,550 = $3,000.) The partial disability benefit payable will never be more than the total disability monthly benefit or less than the minimum monthly benefit payable under the policy. C Jefferson Pilot Financial Insurance Company FL 19 11/02/01 SUNNYISLES 1703779 City of Sunny Isles Beach MAXIMUM BENEFIT PERIOD - Social Security Normal Retirement Age ( SSNRA) (Option 1.00) �enefits for a disabled employee are payable to the employee's Social Security Normal Retirement Age, or the Maximum Benefit Period shown below (whichever is later): Age at Disability Maximum Benefit Period Less than age 60 SSNRA 60 60 months 61 48 months 62 42 months 63 36 months 64 30 months 65 24 months 66 21 months 67 18 months 68 15 months 69 and over 12 months SOCIAL SECURITY INTEGRATION: Primary and Family Social Security Integration (Option 1.00) The Group Long Term Disability Benefit will be reduced by: - Social Security disability and unreduced retirement benefits which the employee and spouse receives; and - reduced Social Security benefits which the employee and spouse receive. BENEFIT REDUCTIONS from OTHER INCOME: LTD benefits will be reduced by disability or retirement benefits from the following sources. • Social Security benefits, described above Disability benefits for which the employee receives under: - State - mandated temporary income plans - Any employer- sponsored group disability, sick leave or formal salary continuance plans - Any public retirement system due to employment with policyholder • Disability benefits which the employee receives under Workers' Compensation, occupational disease or similar law • Disability or retirement benefits received under a retirement plan VALUE PLAN benefits will also be reduced by disability income benefits from auto or other third party liability payments. • LTD Benefits are not reduced by: - Distributions from profit sharing, 401(k), IRA, TSA or stock ownership plans - Non qualified deferred compensation plans - Military disability benefits Cost -Of- Living Freeze: After the initial reduction for other income benefits, the monthly LTD benefit will not be further reduced due to any cost -of- living increases payable under any of these other income benefits. MINIMUM MONTHLY BENEFIT: A disabled employee will not receive less than the minimum monthly benefit shown in the Benefits & Cost Summary page, regardless of income received from other sources. WAIVER OF PREMIUM: Premium payments for a disabled employee are waived during any period for which •total or partial disability benefits are payable. Jefferson Pilot Financial Insurance Company FL 20 11/02/01 SUNNYISLES 1703779 City of Sunny Isles Beach SURVIVOR INCOME BENEFIT: 3 Months (Option 1.00) If an employee dies after having been disabled for a minimum of 180 consecutive days and the employee was receiving a monthly benefit under the policy, Jefferson Pilot Financial will pay the eligible survivor a lump sum benefit equal to three times the employee's last gross monthly LTD Benefit. If there are no eligible survivors, payment will be made to the employee's estate. REASONABLE ACCOMMODATION BENEFIT enhances the return to work possibilities for an employee by assisting the employer in complying with the reasonable accommodation section of the Americans with Disabilities Act (ADA). The benefit is designed to reimburse the policyholder for any "reasonable accommodations" made to the workplace to allow an employee currently receiving disability benefits to return to work. Examples of such accommodations could be more accessible parking spaces or entrances, removal of barriers or hazards from the worksite, installation of special seating, furniture or equipment for the employee's workstation, or the provision of special training materials or other services necessary to help the employee return to work. The benefit reimburses the employer for 50% of the expense incurred for reasonable accommodation services (as described above) up to a maximum of $5,000 on any one employee. In order for a policyholder /employer to be eligible for this benefit, the employer must have an employee: 1. whose disability prevents the performance of his or her regular occupation at the employer's worksite; 2. who has the physical and mental abilities needed to perform his or herown or another occupation at the employer's worksite; but only with the help of the proposed accommodation; and 3. who is reasonably expected to return to work with the help of the proposed accommodation. •Once an employer is considered eligible, a written proposal is developed with input from the employer, employee and attending physician, which states the purpose of the proposed accommodation. Upon receipt of proof that the employer has provided the services for the employee and paid the provider for the services, the employer will be reimbursed. n U OTHER FEATURES: Our LINKS PROGRAM provides integrated disability management when an insured is covered under Jefferson Pilot Financial's STD and LTD plans. LINKS helps to provide a smooth transition from STD to LTD without claim filing, while helping the employee return to work in the most efficient and effective manner possible. Furthermore, the LINKS program identifies those claimants with life insurance coverage through Jefferson Pilot Financial to determine whether they're eligible for Life Waiver. As of January 1, 2000, a FICA MATCH SERVICE is included on all new and existing LTD business at no additional charge. With this service, Jefferson Pilot Financial matches the policyholder's share of FICA taxes on payments made to disabled employees; generates monthly reports summarizing what has been paid and withheld; and prepares W -2 forms at year -end for LTD benefits paid to each disabled employee. Jefferson Pilot Financial Insurance Company 21 11/02/01 SUNNYISLES 1703779 City of Sunny Isles Beach VOCATIONAL REHABILITATION BENEFIT • Premier Plan - VOLUNTARY Value Plan - MANDATORY With the assistance of vocational rehabilitation programs that focus on job modifications, job placement and retraining, many disabled employees can return to productive employment. Services such as these are available to employees unable to perform their regular occupation, and who do not currently have the skills to return to work at another occupation. These employees must have the physical and mental capability for the successful completion of a rehabilitation program. In addition, there must be reasonable expectation that these services will assist the employee in returning to work. If the employee is eligible for rehabilitation services, a written program will be developed with input from the employee, physician and employer outlining the goals, responsibilities, services, and all applicable costs of the program. Rehabilitation efforts only take place if the patient's physician endorses the program. Consideration for participation in such a program can be proposed by the employee, attending physician or Jefferson Pilot Financial. In the Premier Plan contract, participation in a vocational rehabilitation program is recommended, but not required. If a claimant elects to participate, LTD benefits will be reduced if the claimant, without good cause, fails to complete or follow the program. In the Value Plan contract, participation in a vocational rehabilitation program is required for claimants who qualify. If a qualified claimant refuses to participate without good cause, LTD benefits will be reduced. "Good Cause" means that an employee will not be required to participate if physical or mental impairments Would prevent rehabilitation, or if the rehabilitation program would interfere with any medical program in which he or she is currently participating. PRE - EXISTING CONDITION EXCLUSION: 3/12 (Option 1.00) The policy will not cover any total or partial disability which: 1. is contributed to, caused by or results from a pre- existing condition; and 2. begins in the first 12 months after the employee's effective date of coverage under the employer's long term disability plan. A pre- existing condition is a sickness or injury: - for which medical advice, diagnosis, care or treatment was recommended or received during the 3 months prior to his or her effective date. It also means a pregnancy existing on the effective date. "Treatment" means consultation, care or services provided by a physician, including diagnostic measures and the prescription and /or taking of drugs and medicines. Jefferson Pilot Financial Insurance Company 22 11/02/01 SUNNYISLES 1703779 City of Sunny Isles Beach SPECIFIED INJURIES OR SICKNESSES LIMITATION: Benefits for disability due to certain disorders will be 40 imited to 24 months. The following conditions contain this limitation: Plan Mental Disorders Substance Abuse Environmental Sicknesses (e.g. sick building syndrome) Musculoskeletal or Connective Tissue Disorders Premier Plan Value Plan 24 Month Limitation 24 Month Limitation 24 Month Limitation 24 Month Limitation Maximum Benefit Duration 24 Month Limitation Maximum Benefit Duration 24 Month Limitation If the claimant is confined to a hospital or other appropriate treatment facility at the end of the first 24 months of receiving total and /or partial disability benefits for one of these conditions, the monthly benefit will continue to be paid until discharge. The monthly benefit will not be payable beyond the policy's Maximum Benefit Period. PRIOR INSURANCE CREDIT UPON TRANSFER OF INSURANCE CARRIERS: Option 1.00 To prevent loss of coverage for an employee because of a transfer of insurance carriers, this policy will provide prior insurance credit for employees insured under the prior carriers' policy on its termination date as follows: Disability Due To A Pre - Existing Condition: Benefits may be payable for a disability due to a pre- existing condition for an employee who: 1. was insured by the prior carrier at the time of transfer; and 2. was actively -at -work and insured under this policy on its effective date. Whe level of benefits will be the lesser of as follows: 1. If the employee is eligible for benefits under this policy, such employee will be paid according to this policy's benefit schedule. 2. If the employee is not eligible for benefits under this policy, such employee will be paid according to the prior carrier's benefit schedule, if eligible for benefits under that plan; or 3. If the employee is not eligible for benefits under this policy or the prior carrier's plan, no benefit will be paid. Failure To Be Active -At -Work Due To Injury Or Sickness: Subject to premium payments, the policy will provide coverage to any employee: 1. who was insured by the carrier's policy at the time of transfer; and 2. who was not actively -at -work due to injury or sickness on the policy's effective date. The coverage will be that provided by the prior carrier's policy, had it remained inforce. The Company will pay: 1. the benefit that the prior carrier would have paid; minus 2. any amount for which the prior carrier is liable. EXCLUSIONS: Disabilities which arise from intentionally self - inflicted injuries, war or participation in a riot, committing a felony, any type of assault or battery or during which the employee is not under the regular care of a Physician, or is incarcerated, are excluded from coverage. n LJ Jefferson Pilot Financial Insurance Company FL 23 11/02/01 SUNNYISLES 1703779 City of Sunny Isles Beach BENEFITS AND COST SUMMARY FOR DENTAL PROPOSAL • Option 1.03 Proposed Effective Date: October 01, 2001 PROPOSED SCHEDULE OF BENEFITS for Class 1 Class 1: All Active Full -time Employees (Retired, temporary and seasonal employees are not eligible) CALENDAR YEAR DEDUCTIBLE: In Network Deductible applies to: Type II and III INDIVIDUAL $50 FAMILY $150 BENEFITS LEVELS PPO Plan TYPE I - Diagnostic & Preventive 100% TYPE II - Basic Services 80% TYPE III - Major Services 50% TYPE IV - Orthodontia for Children 50% Out of Network UCR - 90th percentile MAXIMUM BENEFIT per covered person: isTYPES I, II and III combined, per calendar year $1000 TYPE IV, while covered by the plan $1000 BENEFIT WAITING PERIOD Waived For: TYPE II Expenses None TYPE III Expenses 6 Months Current Participants TYPE IV Expenses 12 Months Current Participants Terms of the Prior Carrier Credit Provision may apply. Out of Network Type II and III $50 $150 100% 80% 50% 50% $1000 $1000 COST SUMMARY Rates shown are monthly and are guaranteed for one year from the program effective date. Eligible For PPO Plan Employees with child ortho Employee Only 62 $28.70 Family 45 $71.10 MONTHLY COST $4,979.28 • Jefferson Pilot Financial Insurance Company 2 11/05/01 SUNNYISLES 1703779 COVERED SERVICES 4P.TYPE I - Diagnostic & Preventive YPE II - Basic Services TYPE III - Major Services TYPE IV - Orthodontia* City of Sunny Isles Beach oral exams, cleanings & x -rays fillings, extractions, sealants, endodontics & periodontics crowns & dentures for Children *To include Orthodontic Coverage for children in your Jefferson Pilot Financial Group Dental Policy, the policyholder must meet the following dependent enrollment criteria: On the Policy's Effective Date and at each annual Renewal Date, 8 dependent units must be enrolled. A'dependent unit' is a'spouse' or 'child (ren)' or 'spouse and child(ren)' covered by the dental plan. If dependent enrollment in the group policy does not meet this minimum requirement, Orthodontic Coverage (Type IV Services) will not be issued or continued. This requirement does not change Jefferson Pilot Financial's minimum participation requirements, described below. PROPOSAL ASSUMPTIONS: Quoted rates are based on the following assumptions adjusted or the proposal may be withdrawn. If these assumptions are not correct, the rates may be Employer contribution to employee premium - 100% Employer contribution to dependent premium - 50% Minimum employee participation - 100% (A minimum of 10 employees must be enrolled) Minimum dependent participation - 60% (A minimum of 8 dependent units must be enrolled in order to include orthodontic benefits in the policy) •Employees covered by another dental plan may be excluded from participation calculations, as long as they do not exceed 30% of eligible employees. Final rates will be calculated based on: - the agreed -upon plan; - employer contribution (changing the percentage of employer contributions for employee and /or dependent coverage may affect quoted rates); - enrolled census; - employee location(s); - correct industry code (SIC); and - other pertinent underwriting factors. Jefferson Pilot Financial reserves the right to re -rate or refuse to issue coverage if there are changes in these factors. THIS IS NOT A CONTRACT: This illustration was prepared based on the information provided in the Request for Proposal. It is a description of dental coverage available from Jefferson Pilot Financial and not an offer to contract. More detailed information is available upon request concerning the terms, conditions and limitations contained in the master policy, if issued. If there are discrepancies between the information contained in this proposal and the master policy, the terms of the master policy will control. State - specific restrictions and requirements may not be addressed in this proposal. An Application for Group Insurance must be completed by the Employer and approved by Jefferson Pilot Financial before coverage can become effective. Whis proposal is subject to revision if not accepted on or before the Proposed Effective Date shown on the Benefits and Cost Summary page of this proposal. Jefferson Pilot Financial Insurance Company 25 11/02/01 SUNNYISLES 1703779 • EFFECTIVE DATE City of Sunny Isles Beach DENTAL INSURANCE PROPOSAL General Information The policy will become effective no earlier than the date the application is signed and the first month's premium, shown in the COST SUMMARY of this proposal, is received in Jefferson Pilot Financial's Omaha Office. ELIGIBLE EMPLOYEES All active, full -time permanent employees may be covered. "Active, full- time" means the employee works at least 30 hours per week. (Lower minimum hours may apply in certain states). Retired, temporary and seasonal employees are not eligible. For employees who enroll within 31 days of the date they become eligible, coverage usually becomes effective on the later of: - the first of the month following the date the employee completes the eligibility waiting period established by the employer; or - the first of the month following the date the employee enrolls and makes any required premium contribution. Employees who enroll more than 31 days after becoming eligible will be subject to the policy's late entrant 40 imitation. Newly hired employees will become eligible upon completion of the company's eligibility waiting period -- for example, 30 days of full -time employment. New employees can be covered by the dental plan on the first of the month following completion of that eligibility waiting period, provided they enroll and make any required premium contributions within 31 days of the date they become eligible. ELIGIBLE DEPENDENTS Dependents eligible for coverage include the employee's lawful spouse and unmarried children from birth through age 18 (through age 22, for full -time students). Higher age limits may apply in certain states. Stepchildren are eligible if they live in the employee's home and are chiefly dependent upon the employee for support. Foster children and dependent grandchildren may also be eligible under certain conditions. Dependents' coverage usually becomes effective on the same date as the employee's, if they are enrolled. Dependents acquired after the employee's coverage begins may be enrolled immediately, subject to payment of any increase in premium. Dependents enrolled more than 31 days after they are first eligible will be subject to the policy's late entrant limitation. • Jefferson Pilot Financial Insurance Company FL 26 11/02/01 SUNNYISLES 1703779 City of Sunny Isles Beach PARTICIPATION REQUIREMENTS 0 If the dental plan is provided on a noncontributory basis (the employer pays the entire premium), 100% of eligible persons must be enrolled in the plan. If the dental plan is contributory, no less than 75% of eligible employees and 60% of eligible dependent units must be enrolled. There are two exceptions to these requirements: - If an employee and /or dependent is covered by another group dental plan, that person(s) will not be counted as an eligible person, if a signed waiver card is submitted. However, if 30% or more of eligible employees do not enroll because of other coverage, Jefferson Pilot Financial reserves the right to reevaluate the plan and rates illustrated. - When a husband and wife are employed by the same company and have dependent children to enroll, then either the husband or the wife may be covered as a dependent of the other spouse. In any event, a minimum of 10 employees must be enrolled. A minimum of 8 family units must be covered in order to include - or continue - coverage for Orthodontics. PREFERRED PROVIDER OPTION* Jefferson Pilot Financial's dental Preferred Provider Option (PPO) allows each employee and each dependent to select the dentist of his or her choice -- each time he or she goes to the dentist. dn- Network benefits are payable when the patient receives treatment from a dentist who is participating in the dental network. With the PPO, employers and employees can save in several ways: - Negotiated discounts from participating dentists may allow Jefferson Pilot Financial to charge lower premium rates for a dental plan which includes a Preferred Provider option. - Those discounted fees can reduce the amount a participating dentist would charge the patient. - The PPO dental plan can include a higher level of reimbursement when patients visit a participating dentist. *inside Texas - Contracting Dentist Plan DIRECTORY OF PARTICIPATING DENTISTS Provider directories will be provided to eligible employees at the time of enrollment. Jefferson Pilot Financial also maintains a look -up function on its Website [www.jpfinancial.com] which allows plan participants to get current information about participating dentists, by specialty; or to verify if a specific dentist is participating in the PPO network. Copies of the directory can also be obtained by calling our Client Management Department. PRIOR CARRIER CREDIT PROVISION To prevent loss of coverage for plan participants because of a change in carriers, Jefferson Pilot Financial offers 'prior carrier credit' for employees and dependents who are covered on the policy effective date; but only if they were covered under the employer's prior group dental plan on the day before the policy effective date. Except in FL, ID and NJ, the employer's dental plan must have been in force with the current carrier for at least 12 months, to be eligible for the credit. r� U Jefferson Pilot Financial Insurance Company 27 11/2/01 SUNNYISLES 1703779 City of Sunny Isles Beach Covered persons can be given 'credit' toward: • _ covered charges applied to the prior plan's DEDUCTIBLE during the same calendar year. the BENEFIT WAITING PERIOD, if included in the policy, for each covered person's continuous months of coverage under the prior plan just before it terminated. (The 'credit' applies only if the prior plan included the Type(s) of coverage which are subject to the new policy's benefit waiting period.) The provision also extends coverage for replacement of natural teeth lost while covered under the prior plan. BENEFIT WAITING PERIOD The policy may include a benefit waiting period for employees and dependents. The benefit waiting period is a period of time a person must be covered by the plan before some of the more extensive dental procedures are covered. In takeover situations, credit toward benefit waiting periods may be given for the time employees and dependents were covered under the employer's previous plan. ALTERNATIVE BENEFITS The policy covers expenses incurred for necessary dental treatment. However, there may be two or more methods of treating a dental condition. In that case, the amount of covered expense will be limited to the charge for the least costly procedure which Jefferson Pilot Financial determines to be appropriate and adequate. This determination is based on current professional dental standards and the patient's total oral condition. PREDETERMINATION OF BENEFITS erhe policy includes a provision which allows the patient and the dentist to find out, before the work is done, how much of the dentist's charge will be covered by the plan. Jefferson Pilot Financial recommends that this predetermination be used whenever a dentist's charges for non - emergency treatment are expected to exceed $300. REQUIRED TMJ COVERAGE The proposed plan includes coverage for surgical and non - surgical treatment of disorders of the temporomandibular joint (TMJ), as required by state law. This treatment can include examinations, x -rays and surgery (including general anesthesia and postoperative care). If coverage for Type IV services is elected, TMJ benefits also would be payable for installation of braces or orthotic devices for eligible participants. LATE ENTRANT LIMITATION The policy may include a late entrant limitation of benefits. If included in the policy, the limitation says: When an employee or dependent: - is enrolled in the dental plan for more than 31 days after first becoming eligible; or - cancels then re- enrolls for coverage benefits are limited to Type I Services for the first 12 months of coverage. is Jefferson Pilot Financial Insurance Company FL 28 11/2/01 SUNNYISLES 1703779 City of Sunny Isles Beach COVERED DENTAL SERVICES OAfter any applicable deductible is satisfied, Jefferson Pilot Financial Insurance Company covers the following dental services, at the reimbursement rate quoted. Type III and Type IV procedures may be subject to a Benefit Waiting Period.* TYPE I - DIAGNOSTIC & PREVENTIVE SERVICES - ORAL EXAMINATIONS - up to two per calendar year - DENTAL X -RAYS, including: bitewing films - up to four films per calendar year one complete full mouth or panoramic series each five years PROPHYLAXIS (Routine Cleanings) - up to two per calendar year FLUORIDE TREATMENTS - for dependent children through age 15 one treatment per calendar year SPACE MAINTAINERS TYPE II - BASIC SERVICES - FILLINGS - STAINLESS STEEL CROWNS - for dependent children through age 15 - SEALANTS - first and second permanent molars for dependent children through age 15 one application per tooth in three years - ORAL SURGERY - includes extractions and many dental surgeries - PATHOLOGY - biopsy and examination of oral tissue - GENERAL ANESTHESIA and I.V. sedation - EMERGENCY TREATMENT and consultations ENDODONTICS (root canal therapy) PERIODONTAL CLEANINGS - following active periodontal therapy - PERIODONTAL SCALING AND ROOT PLANING - one treatment in 24 months PERIODONTAL SURGERY - including gingivectomy, osseous surgery, and soft tissue graft - REPAIR of DENTURES RECEMENTATION of CROWNS and BRIDGES TYPE III PROCEDURES - MAJOR SERVICES - CROWNS, BRIDGES, and ONLAYS - FULL and PARTIAL DENTURES - ALVEOLAR or GINGIVAL RECONSTRUCTION SURGERY - SURGICAL TREATMENT OF TEMPOROMANDIBULAR JOINT includes synovectomy, myotomy, joint reconstruction, arthrotomy, arthroplasty, arthroscopy and condylectomy TYPE IV PROCEDURES - ORTHODONTICS for dependent children - DIAGNOSTIC SERVICES - examinations, x -rays, and casts or study models - TREATMENT PLAN - including orthodontic extractions - ORTHODONTIC APPLIANCES - TREATMENT OF DISORDERS OF THE TEMPOROMANDIBULAR JOINT includes orthodontic appliances and occlusal orthotic devices *Where Benefit Waiting Periods are included, Prior Carrier Credit may apply. • Jefferson Pilot Financial Insurance Company 29 11/2/01 SUNNYISLES 1703779 City of Sunny Isles Beach DENTAL LIMITATIONS & EXCLUSIONS 40covered Expenses will not include and Dental Expense Benefits will not be payable for: any procedure begun: a) before the covered person was covered under the policy, subject to the Prior Carrier Credit provision, if included in the policy; or b) after termination of the covered person's coverage under the policy. 2. treatment or service which: a) is not recommended by a dentist or is not provided by or under the direct supervision of a dentist; b) is not a necessary dental procedure, required for the care and treatment of a dental condition, as determined by Jefferson Pilot Financial; c) is not specifically listed as covered by the policy; d) does not meet accepted standards of dental practice; or e) is provided by a physician or other health care provider, but is beyond the scope of his or her license. 3. charges which exceed covered expenses, as defined in the policy. Benefits will not be payable when: a) total benefit payments would exceed the annual maximum or lifetime orthodontic maximum benefits payable under the policy; or b) services exceed the frequency limitations contained in the policy. 4. procedures which are subject to a benefit waiting period or a late entrant limitation, until that benefit waiting period or late entrant limitation has been satisfied. •5. orthodontic (Type IV) procedures: a) which begin before the dependent child becomes covered under the policy for orthodontic services, subject to the Prior Carrier Credit provision, if included in the policy; b) received after the dependent child's coverage ends, due to attainment of the maximum age, or for any other reason; or c) received after coverage for Type IV services is terminated under the policy. 6. any treatment or services which: a) are for mainly cosmetic purposes (facings or veneers on crowns or pontics distal to the second bicuspid will be considered cosmetic); or b) are related to the repair or replacement of any prior cosmetic procedure. 7. services related to the repair or replacement of third molars (wisdom teeth) with prostheses. 8. bone grafts or any regenerative procedure in an extraction site. 9. orthognathic recording, orthognathic surgery, osteoplasty, osteotomy, LeFort procedure, stomatoplasty or magnetic resonance imaging (MRls). • FL Jefferson Pilot Financial Insurance Company 30 11/02/01 SUNNYISLES 1703779 City of Sunny Isles Beach DENTAL LIMITATIONS & EXCLUSIONS (Continued) 1010. initial placement of any prosthetic appliance or fixed bridge; unless such placement is needed to replace one or more functioning natural teeth extracted while the person is covered under the policy; subject to the Prior Carrier Credit provision, if included in the policy. Any such appliance or fixed bridge must include the replacement of the extracted tooth or teeth. 11. the retreatment or adjustment, recementation, reline, rebase, replacement or repair of restorations, crowns and prostheses, when made by the same dentist or dental office which provided the initial service, within 6 months of the completion of the service. 12. the replacement of: a) any full or partial denture, within five years; or b) fixed prosthetic (crown, inlay or onlay restoration, or fixed bridge) within eight years of the date of the last placement of these items. If a replacement is required because of an accidental dental injury sustained while the person is covered under the policy, it will be a covered expense. (Damage resulting from biting food or other objects is not considered to be an accidental injury.) 13. the insertion, maintenance or removal of implants, and any related expenses. 14. specialized procedures, including: a) precision or semi - precision attachments; b) precious metals for removable appliances; c) overlays and overdentures; or d) personalization or characterization. •15. duplicate prosthetics, or for initial placement or replacement of athletic mouth guards, bruxism appliances or any appliance to correct harmful habits; and for replacement of: a) space maintainers; or b) misplaced, lost or stolen dental appliances. 16. appliances, restorations or procedures, or their modifications, that: a) alter vertical dimension; b) restore or maintain occlusion or for occlusal adjustment or equilibration; or c) splint teeth or replace tooth structure lost as a result of erosion, abfraction, abrasion or attrition. 17. charges for services provided by: a) an ambulatory surgical facility; b) a hospital; c) any other facility; or d) an anesthesiologist. 18. analgesia, sedation, hypnosis or acupuncture, for anxiety or apprehension. 19. any medications administered outside the dentist's office or for prescription drugs. • Jefferson Pilot Financial Insurance Company FL 31 11/02/01 SUNNYISLES 1703779 •20 City of Sunny Isles Beach DENTAL LIMITATIONS & EXCLUSIONS (Continued) charges which do not directly provide treatment for a dental injury or condition, such as: a) the completion of claim forms; b) broken appointments; c) interest or collection charges; d) sales or other taxes or surcharges; e) education, training and supplies used for dietary or nutritional counseling, personal oral hygiene or dental plaque control; f) caries susceptibility tests, bacteriologic studies, histopathologic exams or pulp vitality testing; or g) duplication of x -rays or other dental records. 21. itemized or separated charges for dental services, supplies or materials when those services, supplies and materials may be combined into a single, more comprehensive procedure payable under the policy. This also includes itemized charges which are routinely included in the dentist's charge for the primary service, such as: a) sterilization or asepsis charges; b) a charge for local anesthesia; c) charges for pre- and post- operative care; or d) temporary dental services (for example, a temporary crown), which are considered to be part of the permanent service. If the temporary service is billed separately, benefits for the temporary service will be deducted from the amount payable for the permanent service. 22. duplication of services. 23. charges for which the covered person is not liable, or which would not have been made had no coverage • been in force. 24. a covered person, because of a dental injury or condition: a) for which he or she is paid for benefits under Workers' Compensation or any similar law; or b) sustained while performing military service. 25. services received for dental conditions caused directly or indirectly by: a) war or an act of war; b) intentionally self - inflicted injury; c) engaging in an illegal occupation; d) commission or attempt to commit a felony; or e) a covered person's active participation in a riot. 26. for treatment rendered by a Dentist or dental hygienist: a) who ordinarily resides in the covered person's household; or b) who is related to the covered employee or dependent by blood, marriage or legal adoption. "Related" persons include the employee's or dependent's spouse, siblings, parents, children and grandparents. 27. root planing; unless the presence of periodontal disease (bone and attachment loss of 4mm or more) is confirmed by x -rays and pocket depth charting of each tooth involved. • Jefferson Pilot Financial Insurance Company FL 32 11/02/01 • • ra JEFFERSON PILOT FINANCIAL Group Policyholder: Florida - Life Specimen Jefferson Pilot Financial Insurance Company 8801 Indian Hills Drive, Omaha NE 68114 -4066 (402) 361 -7300 A Stock Company In Consideration of the Group Policyholder's application for this Policy and payment of all premiums when due, Jefferson Pilot Financial Insurance Company agrees to make the payments provided in this Policy to the persons entitled to them. The first premium for this Policy is due on its effective date. Subsequent premiums are due on June 1, 2001, and on the same day of each month after that. Policy anniversaries will be each May 1st; unless shown otherwise on the Premium Rate Schedule inside. The provisions and conditions set forth on the following pages are a part of this Policy, as fully as if recited over the signatures below. Jefferson Pilot Financial Insurance Company has executed this Policy at its Home Office in Omaha, Nebraska. The issue date of this Policy is May 1, 2001. (�_ �s4 Chief Executive Officer GL1101 -TITLE PAGE V4&0_G_s Secretary GROUP INSURANCE POLICY No.XXXXXXXXXXXX PROVIDING LIFE INSURANCE ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE DEPENDENT LIFE INSURANCE 95 05/01/01 TABLE OF CONTENTS • Schedule of Insurance ................................................................................................. ............................... 3 Defmitions.................................................................................................................. ............................... 4 GeneralProvisions ...................................................................................................... ............................... 5 Eligibility and Effective Dates for Personal Insurance ............................................... ............................... 6 IndividualTerminations ............................................................................................. ............................... 7 Premiums and Premium Rates .................................................................................... ............................... 8 GracePeriod ............................................................................................................... ............................... 9 PolicyTermination ..................................................................................................... ............................... 9 Beneficiary................................................................................................................. ............................... 10 Facilityof Payment ..................................................................................................... ............................... 11 DeathBenefit .............................................................................................................. ............................... 11 SettlementOptions ..................................................................................................... ............................... 11 • Extension of Death Benefit ......................................................................................... ............................... 12 LivingBenefit ............................................................................................................. ............................... 13 ConversionPrivilege .................................................................................................. ............................... 15 Dependents Life Insurance ......................................................................................... ............................... 16 Claims Procedures for Life or Accidental Death and Dismemberment Benefits ....... ............................... 18 Accidental Death and Dismemberment Insurance ...................................................... ............................... 20 Prior Insurance Credit Provision ................................................................................ ............................... 21 GL1101 -1 2 05/01/01 SCHEDULE OF INSURANCE The amount of an Insured Person's insurance is determined from the following table. The initial amount of coverage is the amount which applies to an Insured Person's Class on the date his or her coverage takes effect. An Insured Person may Qecome eligible for increases in an amount of insurance in accord with the table. Any such increase will take effect on the atest of: (1) the first day of the Insurance Month which coincides with or follows the date on which the Insured Person becomes eligible for the increase; provided he or she is Actively at Work on that day; (2) the day the Insured Person resumes Active Work, if not Actively at Work on the day the increase would otherwise take effect; or (3) the day any required evidence of insurability is approved by the Company. Any decrease will take effect on the day of the change; whether or not the Insured Person is Actively at Work. The amount of an Insured Person's insurance shall be reduced by the amount of any Life insurance in effect as a result of exercising the rights under the Conversion Privilege Section of this Policy. CLASSIFICATION Class 1 All Full -Time Employees WAITING PERIOD: 30 days of continuous Active Work (For date insurance begins, refer to "Effective Date" section) • • GL1101 -2 3 05/01/01 SCHEDULE OF INSURANCE (CONTINUED) LIFE AND AD &D INSURANCE • Amount of Personal Life Insurance Class 1 $50,000 Personal Life and AD &D Insurance will be reduced as follows: - At age 65, benefits will reduce by 35% of the original amount; - At age 70, benefits will reduce an additional 25% of the original amount; - At age 75, benefits will reduce an additional 15% of the original amount. Benefits will terminate when the Insured Person retires. AD &D Insurance Principal Sum $50,000 If the Insured Person first enrolls for Personal Life and AD &D Insurance at age 65 or older, the above age reductions will apply to: - Any Guarantee Issue Amount available without evidence of insurability; and - The maximum amount of insurance for which he or she is eligible. r: • GL1101 -2 3 -2 05/01/01 SCHEDULE OF INSURANCE (CONTINUED) DEPENDENTSINSURANCE (For Class 1) �ependent Amount of Life Insurance Spouse $10,000 Dependent Child 250 (age 14 days to 6 months) Dependent Child 5,000 (age 6 months to 19 years, 23 years if a full -time student) Spouse Life Insurance will terminate when the Spouse attains age 70. Dependent's Life Insurance is subject to a maximum of 50% of the Insured Employee's Life Insurance Benefit. Insured Persons are not required to make contributions for Personal Life Insurance and AD &D Insurance. Insured Persons are required to make contributions for Dependent Life Insurance. Under the Policy Termination section on form GL1101 -7, the participation rate requirements in part (3) will not apply during policy years when the Employer's premium contributions are made through a Section 125 plan. • GL1101 -2 3 -3 05/01/01 DEFINITIONS ACTIVE WORK or ACTIVELY AT WORK means an employee's full -time performance of all customary duties of his or her Ocupation at: (1) the GROUP POLICYHOLDER'S place of business; or (2) any other business location where the employee is required to travel. Unless disabled on the prior workday or on the day of absence, an employee will be considered Actively at Work on the following days: (1) a Saturday, Sunday or holiday which is not a scheduled workday; (2) a paid vacation day, or other scheduled or unscheduled non - workday; or (3) an excused or emergency leave of absence (except a medical leave). COMPANY means Jefferson Pilot Financial Insurance Company, a Nebraska corporation, whose Home Office address is 8801 Indian Hills Drive, Omaha, Nebraska 68114 -4066. DAY OR DATE means at 12:01 A.M., Standard Time, at the GROUP POLICYHOLDER'S place of business; when used with regard to eligibility dates and effective dates. It means 12:00 midnight, Standard Time, at the same place; when used with regard to termination dates. FULL -TIME EMPLOYEE means an employee of the GROUP POLICYHOLDER: (1) whose employment with the GROUP POLICYHOLDER is the employee's principal occupation; (2) who is not a temporary or seasonal employee; and (3) who is regularly scheduled to work at such occupation at least 30 hours each week. GROUP POLICYHOLDER means the person, partnership, corporation, or trust as shown on the Title Page of this Policy. INSURANCE MONTH means that period of time: is (1) beginning at 12:01 A.M. Standard Time, at the GROUP POLICYHOLDER'S place of business on the first day of any calendar month; and (2) ending at 12:00 midnight on the last day of the same calendar month. INSURED PERSON means a PERSON for whom the coverages provided by this Policy are in effect PERSON means a FULL -TIME EMPLOYEE of the GROUP POLICYHOLDER: (1) who is a member of an employee class which is eligible for coverage under this Policy; and (2) who has completed an enrollment form. PERSONAL INSURANCE means the insurance provided by this Policy on Insured Persons. PHYSICIAN means a licensed practitioner of the healing arts other than the Insured Person or a relative of the Insured Person. POLICY means this Group Insurance Policy issued by the Company to the Group Policyholder. • GL1101 -3 91 (REV) 4 05/01/01 GENERAL PROVISIONS ENTIRE CONTRACT. The entire contract between the parties consists of: (1) this Policy and the Group Policyholder's application (a copy is attached); and (2) the Insured Persons' enrollment cards, if any. All statements made by the Group Policyholder and by Insured Persons are representations and not warranties. No statement made by an Insured Person will be used to contest the coverage provided by this Policy; unless: (1) it is contained in a written statement signed by that Insured Person; and (2) a copy of the statement is furnished to the Insured Person or Beneficiary. Only an Officer of the Company may change this Policy or extend the time for payment of any premium. No change will be valid unless made in writing and signed by an Officer of the Company. Any change so made will be binding on all persons referred to in this Policy. INCONTESTABILITY. Except for the non - payment of premiums, the Company may not contest the validity of this Policy as to any Insured Person after it has been in force for two years during his or her lifetime. This clause will not affect the Company's right to contest claims made for disability, accidental death, or accidental dismemberment benefits. NONPARTICIPATION. This Policy will not be entitled to share in the surplus earnings of the Company. BASIS OF RESERVE. The reserve for this Policy will not be less than the reserve computed using: (1) the 1970 Intercompany Group Life Disability Valuation Table; and (2) interest at not less than three percent per annum. INFORMATION TO BE FURNISHED. The Group Policyholder may be required to furnish any information needed to administer this Policy. Clerical error by the Group Policyholder will not: (1) affect the amount of insurance which would otherwise be in effect; or (2) continue insurance which otherwise would be terminated. Once an error is discovered, an equitable adjustment in premium will be made. If a premium adjustment involves the return of unearned premium, the amount of the return will be limited to the twelve month period which precedes the date the Company receives proof such an adjustment should be made. The Company may inspect any of the Group Policyholder's records which relate to this Policy. MISSTATEMENT OF AGE. If an Insured Person's age has been misstated, premiums will be subject to an equitable adjustment. If the amount of benefit depends upon age; then the benefit will be that which would have been payable, based upon the person's correct age. CERTIFICATES. The Group Policyholder will be furnished with individual Certificates for delivery to each Insured Person. These certificates summarize the benefits provided by this Policy. If there is a conflict between the Policy and the Certificate, the Policy will control. CONFORMITY WITH STATE STATUTES. If any provision of this Policy conflicts with any applicable law, the provision will be deemed to conform to the minimum requirements of the law. WORKER'S COMPENSATION. This Policy is not to be construed to provide benefits required by Worker's Compensation laws. • GL1101 -4 95 5 05/01/01 ELIGIBILITY AND EFFECTIVE DATES FOR PERSONAL INSURANCE ELIGIBILITY. A Person becomes eligible for the coverage provided by this Policy on the later of: (1) the Policy's date of issue; or (2) the date the Waiting Period is completed. WAITING PERIOD. (See Schedule of Insurance). EFFECTIVE DATE. Personal Insurance becomes effective on the latest of: (1) the first day of the Insurance Month coinciding with or next following the date the Person becomes eligible for the coverage; (2) the date the Person resumes Active Work, if not Actively at Work on the day he or she becomes eligible; (3) the date the Person makes written application for Personal Insurance; and signs: (a) a payroll deduction order, if Insured Persons pay any part of the Policy premium; or (b) an order to pay premiums from the Person's Section 125 Plan account, if Employer contributions are made through a Section 125 Plan; or (4) the date the Company approves the Person's coverage, if evidence of insurability is required. EVIDENCE OF INSURABILITY. Evidence of insurability satisfactory to the Company must be submitted when: (1) a Person makes written application for Personal Insurance more than 31 days after becoming eligible for the coverage; or (2) a Person makes written application for Personal Insurance after he or she has requested: (a) to cancel Personal Insurance; (b) to stop payroll deductions for the coverage; or (c) to stop premium payments from the Section 125 Plan account. EXCEPTION. If an Insured Person's coverage terminates due to an approved leave of absence or military leave, the �ompany will waive any Waiting Period or evidence of insurability requirement upon his or her return; provided: (1) the Person returns within six months after the leave begins; (2) the Person applies or is enrolled within 31 days after resuming Active Work; and (3) the reinstated amount of insurance does not exceed the amount which terminated. • GL 1101 -5 93 (FMLA) 6 05/01/01 INDIVIDUAL TERMINATIONS An Insured Person's coverage will terminate on the earliest of: is (1) the date this Policy terminates; (2) the last day of the Insurance Month in which the Insured Person requests termination; (3) the last day of the last Insurance Month for which premium payment is made on the Insured Person's behalf; (4) the date the Insured Person ceases to be in a class of employees which is eligible for coverage under this Policy; (5) with respect to any particular insurance benefit, the date the portion of the Policy providing that benefit terminates; (6) the date on which the Insured Person's employment with the Group Policyholder or Participating Employer terminates; or (7) the date the Insured Person enters the armed services of any state or country on active duty; except for duty of 30 days or less for training in the Reserves or National Guard. (If the Insured Person sends proof of military service, the Company will refund any unearned premium.) Ceasing Active Work results in termination of insurance; but coverage may be continued as follows: (1) If the Insured Person is disabled due to illness or injury, then coverage may be continued: (a) until the Person is no longer disabled; (b) provided premium payments are made on his or her behalf. (2) If the Insured Person ceases work due to a temporary lay off, an approved leave of absence, or a military leave; then coverage may be continued: (a) for three Insurance Months after the lay off or leave begins; (b) provided premium payments are made on his or her behalf. • • GL 1101 -5 93 (FMLA) 7 05/01/01 PREMIUMS AND PREMIUM RATES PAYMENT OF PREMIUMS. No coverage provided by this Policy will be in effect until the first premium for such coverage is paid. For coverage to remain in effect, each subsequent premium must be paid on or before its due date. The Group 0,olicyholder is responsible for paying all premiums as they become due. Premiums are payable on or before their due dates at the Company's Home Office. The premium must be paid in U.S. dollars. PREMIUM RATE CHANGE. The Company may change any premium rate on any of the following dates: (1) the date this Policy's terms are changed; (2) the date the Company's liability is changed due to a change in federal, state or local law; (3) the date the Group Policyholder (or any covered division, subsidiary or affiliated company) relocates, or is added to or removed from this Policy; (4) the date the number of Insured Persons changes by 25% or more from the enrollment on the date this Policy took effect, or the most recent Rate Guarantee Date expired, if later; or (5) on any premium due date on or after this Policy's first anniversary, or any later Rate Guarantee Date agreed upon by the Company. Unless the Company and the Group Policyholder agree otherwise, the Company will give at least 45 days' advance written notice of any increase in premium rates. PREMIUM AMOUNT. The amount of premium due on each due date will be the sum of the products obtained by multiplying each rate shown in the Premium Rate Schedule by the amount of insurance to which the rate applies. Premium adjustments will not be pro -rated daily. Instead, premium will be adjusted as follows. (1) When an Insured Person's insurance or increase takes effect, premium will be charged from the monthly due date coinciding with or next following that change. (2) When all or part of an Insured Person's insurance terminates, the applicable premium will cease on the monthly due date coinciding with or next following that termination. (3) When premiums are paid other than monthly, increases or decreases will result in adjustment from the premium due date coinciding with or next following that change. The above manner of charging premium is for accounting purposes only. It will not extend coverage beyond a date it Woeded uld have otherwise terminated. Each premium payment will include any adjustments in past premiums, which are due to changes that have not yet been taken into account. If a premium adjustment involves a return of unearned premium, the refund will be limited to the prior 12 -month period. PREMIUM RATE SCHEDULE Monthly Group Life Rate Monthly AD &D Rate Monthly Dependent Life Rate $.xx per $1,000 of insurance .xx per $1,000 of insurance x.xx per Family Unit The above rates are guaranteed until May 1, 2002, unless an exception listed in the Premium Rate Change section applies. After that, any premium rate change will be as shown in the renewal letter. The Company will send the Group Policyholder a renewal letter prior to each Policy Anniversary. • GL1101 -6 99 FL 8 05/01/01 GRACE PERIOD A grace period of 31 days from the due date will be allowed for the payment of each premium after the first. The Policy Will remain in effect during the grace period; unless the Group Policyholder gives the Company advance written notice of mination. The Group Policyholder will remain liable for payment of a pro rata premium for the time this Policy remained in force during the grace period. POLICY TERMINATION TERMINATION BY THE COMPANY. To terminate this Policy, the Company must give the Group Policyholder at least 45 days' advance written notice of its intent to do so. Until the premium rate has been in effect for at least 12 months, the Company can terminate coverage only if: (1) the total number of Insured Persons is less than ten; (2) all of the premium is paid by the Group Policyholder and less than 100% of those eligible for coverage are insured; (3) part of the premium is paid by Insured Persons and less than 75% of those eligible for coverage are insured; (4) the Group Policyholder, without good cause: (a) fails to promptly furnish any information the Company reasonably requires; or (b) fails to perform its duties pertaining to this Policy in good faith; (5) the Company's liability is changed as a result of any change in federal, state or local law which affects this Policy; (6) the Group Policyholder (or any covered division, subsidiary or affiliated company) relocates, dissolves or merges, or is added to or removed from this Policy; (7) any coverage for one, or more classes ceases to be provided under this Policy; or (8) the number of Insured Persons changes by 25% or more from the enrollment on the date this Policy took effect, or the most recent Rate Guarantee Date expired, if earlier. After the premium rate has been in effect for at least 12 months, the Company can terminate coverage on any premium �ue date, by giving 45 days' advance written notice. Such termination may be with respect to this Policy as a whole, to ny coverage(s) provided under it, or to any class of Insured Persons under it. TERMINATION BY GROUP POLICYHOLDER. The Group Policyholder may terminate this Policy at any time, by giving the Company advance written notice. Coverage will then terminate: (1) on the date the Company receives the notice; or (2) any later date the Group Policyholder and the Company have agreed upon. The Group Policyholder remains responsible for the payment of premiums to the date of termination. POLICY TERMINATION DUE TO NONPAYMENT OF PREMIUM. If any premium remains unpaid at the end of the Grace Period; then this Policy will terminate: (1) at midnight on the last day of the Grace Period, if the Company sends the Group Policyholder a written cancellation notice by the 45th day after the Grace Period expires; or (2) on the day the Company sends the Group Policyholder a written cancellation notice, if the notice is sent more than 45 days after the Grace Period expires. EFFECT ON INCURRED CLAIMS. Termination of this Policy will not affect benefits otherwise payable for a claim incurred while this Policy is in force. • GL1101 -7 99 FL No Bene. -ten lives 9 05/01/01 BENEFICIARY PAYMENTS TO BENEFICIARY. At an Insured Person's death, the amount of his or her Personal Life Insurance will be aid to the surviving Beneficiary. If the Insured Person has not named a Beneficiary, or if no named Beneficiary survives e Insured Person; then payment will be made to that Insured Person's: (1) surviving spouse; or, if none (2) surviving child or children in equal shares; or, if none (3) surviving parent or parents in equal shares; or, if none (4) surviving brothers and sisters in equal shares; or, if none (5) estate, or in accord with the Facility of Payment section of this Policy. The amount payable to anyone shown above will be reduced by any amount paid in accord with the Facility of Payment section. In determining who is to receive payment, the Company may rely upon an affidavit by a member of the class of relatives to receive payment. The Company will make payment based upon the affidavit it has; unless it receives notice of a valid claim by some other person, at its Home Office, before paying the proceeds. Such payment will release the Company from any further obligation for the Insured Person's life insurance benefit. If an Insured Person's named Beneficiary dies: (1) within 15 days of the Insured Person's death; and (2) before the Company receives satisfactory proof of the Insured Person's death; then payment will be made as if the Insured Person had survived that Beneficiary; unless other provisions have been made. NAMING THE BENEFICIARY. An Insured Person's Beneficiary will be as shown on his or her enrollment card, unless changed. This Policy may replace a group policy providing similar coverages. In that event, the Beneficiary which the Insured Person named under the prior policy will be the Beneficiary under this Policy, until changed. HANGING THE BENEFICIARY. Only the Insured Person, or his or her assignee, may change the Beneficiary. A new Beneficiary may be named by filing a written notice of the change with the Company at its Home Office. The change will be effective as of the date it was signed; subject to any action the Company takes before receiving notice of the change. When applying for a conversion policy under the Conversion Privilege Section, an Insured Person must name a Beneficiary. The Beneficiary named for the conversion policy may be someone other than the person named under this Policy. In that event, the application for the conversion policy will be treated as a written notice of change of Beneficiary. C] GL1101 -7.1A 96 Pref. Bene. 10 05/01/01 FACILITY OF PAYMENT Policy benefits may become payable to an Insured Person's estate, to a minor, or to a person who the Company does not consider Ornpetent to give a valid release. In that event, the Company has the option to pay one or more of the following: (1) a person who has assumed the care and support of the Insured Person or Beneficiary; (2) a person who has incurred expense as a result of the Insured Person's last illness or death; (3) the personal representative of the Insured Person's estate; or (4) any person related by blood or marriage to the Insured Person. No payment made under this section may exceed $2,000. Any payment made in good faith under this section will fully discharge the Company to the extent of the payment. Any remaining amount of benefit will be paid as shown in the Beneficiary section. DEATH BENEFIT AMOUNT PAYABLE ON DEATH. Upon receipt of satisfactory proof of an Insured Person's death, the Company will pay a death benefit equal to the amount of Personal Life Insurance in effect on the date of death. This amount is shown in the Schedule of Insurance. The benefit will be paid as shown in the Beneficiary, Facility of Payment, and Settlement Options sections. SETTLEMENT OPTIONS INSTALLMENTS. All or part of the death benefit may be received in installments, by making written election to the Company. ELECTION. While living, an Insured Person may direct the Company to pay the death benefit in installments. If no such direction is in effect at the time of the Insured Person's death, the Beneficiary may make such an election. CONDITIONS. Any election, whether by an Insured Person or a Beneficiary, must comply with the Company's practices at the time it is made. The amount applied under a settlement option must be at least $2,000. It must be sufficient to provide a payment of at least $20 per month. • • GL1101 -8 96 11 05/01/01 EXTENSION OF DEATH BENEFIT BENEFIT. Life insurance will be continued, without payment of premiums, for an Insured Person who: •(1) becomes Totally Disabled while insured under this policy and before reaching age 70; (2) remains Totally Disabled for at least 6 months in a row; and (3) submits satisfactory proof within the 7th through the 12th months of disability; or: (a) as soon as reasonably possible after that; but (b) not later than the 24th month of disability, unless he or she was legally incapacitated. PREMIUM PAYMENT. Premium payments must continue until: (1) the day the Insured Person is approved for this Extension of Death Benefit; or (2) the day this Policy terminates (whichever occurs first). Upon receipt of satisfactory proof, the Company will refund up to 12 months' premium paid for the Insured Person's life insurance, from the 1st day of Total Disability. DEFINITION. For this benefit, Total Disability or Totally Disabled means an Insured Person: (1) is unable, due to sickness or injury, to engage in any employment or occupation for which such Insured Person is or becomes qualified by reason of education, training, or experience; and (2) is not engaging in any gainful employment or occupation. AMOUNT CONTINUED. The life insurance continued by this section: (1) will be the amount of Personal Life Insurance and any Dependent Life Insurance in effect on the day the Insured Person's Total Disability begins; and (2) will be subject to the reductions and terminations in effect under this Policy on that day. If the Insured Person receives an Accelerated Death Benefit, the amount will be reduced in accord with that provision. Any Accidental Death and Dismemberment Benefit will not be continued. ADDITIONAL PROOF. At any time during this continuation, the Company may require the Insured Person: (1) to submit further proof of his or her continued Total Disability; and (2) to be examined by a Physician of the Company's choice, as often as reasonably necessary. After the first two years of Total Disability, the Company will not request proof or an exam more than once a year. Proof will be at Insured Person's expense; unless the Company requests an exam by a Physician of its choice. en an Insured Person dies after submitting proof, further proof must be submitted to the Company showing that he or she remained continuously and Totally Disabled until death. When an Insured Person dies within 12 months after Total Disability begins, but before submitting proof, then his or her death benefit will still be paid under the terms of this Policy. But the Company must first receive satisfactory proof of his or her continuous Total Disability, from the last day of Active Work until the date of death. TERMINATION. Any life insurance extended under this section will terminate automatically on: (1) the day the Insured Person ceases to be Totally Disabled; (2) the day the Insured Person fails to take a required medical examination; (3) the 60th day after the Company mails a request for additional proof, if it is not given; (4) the effective date of the Insured Person's individual conversion policy, with respect to any amount of life insurance converted in accord with the Conversion Privilege section; or (5) the day the Insured Person reaches age 70 (whichever occurs first). RIGHTS AFTER TERMINATION. If Total Disability ends, and the Insured Person does not return to a class eligible for Policy coverage; then he or she may exercise the Conversion Privilege. If Total Disability ends, and the Insured Person does return to an eligible class; then his or her Policy coverage will resume when premium payments are resumed, and any conversion policy is surrendered as provided below. CONVERSION POLICIES. If the Insured Person has exercised the Conversion Privilege, and the benefits payable under this Policy and the conversion policy combined would exceed: (1) the Insured Person's original amount of Policy coverage prior to the conversion; or (2) any greater amount for which he or she later becomes insured under this Policy; then benefits will be payable under the terms of this Policy. But the conversion policy must first be surrendered to the Company; and no claim may be made under the conversion policy, except for refund of premium less any dividends and policy loans. • GI-1 101-9 96 FL Stand. Ext. 12 05/01/01 LIVING BENEFIT BENEFIT. The Living Benefit is an advance payment of part of the Insured Person's Personal Life Insurance. It may be 10 aid to a Terminally III Insured Person, in a lump sum, once during his or her lifetime. To qualify, the Insured Person ust: (1) have satisfied the Active Work requirement under this Policy; (2) have been insured under this Policy for at least 12 months; (3) have qualified for the Extension of Death Benefit under this Policy; and (4) have at least $2,000 of Personal Life Insurance under this Policy on the day before the Living Benefit is paid. Receiving the Living Benefit will reduce the Remaining Life Insurance and the Death Benefit payable at the Insured Person's death, as shown on the next page. "Terminally III" means the Insured Person has a medical condition which is expected to result in death within 12 months, despite appropriate medical treatment. APPLYING FOR THE LIVING BENEFIT. To withdraw the Living Benefit, the Insured Person (or his or her legal representative) must send the Company: (1) written election of the Living Benefit, on forms supplied by the Company; and (2) satisfactory proof that the Insured Person is Terminally III, including a Physician's written statement. The Company reserves the right to decide whether such proof is satisfactory. The Company may have the Insured Person examined, at its own expense, by one or more Physicians of its choice. Before paying a Living Benefit, the Company must also receive the written consent of any irrevocable beneficiary, assignee or bankruptcy court with an interest in the benefit. (See Limitations 5, 6 and 7.) AMOUNT OF THE LIVING BENEFIT. The Insured Person may elect to withdraw a Living Benefit in any $1,000 increment; subject to: (1) a minimum of $1,000 or 10% of the Insured Person's amount of Personal Life Insurance (whichever is •greater); and (2) a maximum of $100,000 or 50% of the Insured Person's amount of Personal Life Insurance (whichever is less). To determine the Living Benefit, the Company will use the lesser of A or B below: A. the Insured Person's amount of Personal Life Insurance which is in force on the day before the Living Benefit is paid; or B. the Insured Person's amount of Personal Life Insurance which would be in force 12 months after that date; if the coverage is scheduled to reduce, due to age, within 12 months after the Living Benefit is paid. Before making payment to the Insured Person, the Company will reduce the Living Benefit by an early withdrawal fee. This early withdrawal fee will be 12 months' interest at the lesser of: (1) the annual interest rate the Company then charges on policy loans under its nonvariable individual life insurance policies; (2) the annual discount rate any applicable state law then permits for accelerated death benefits under life insurance contracts; or (3) the annual discount rate federal income tax regulations then permit for qualified accelerated death benefits under life insurance contracts. is GL 1101 -9.7 LB 13 05/01/01 EFFECT ON AMOUNT OF LIFE INSURANCE. "Remaining Life Insurance" means the amount of Personal Life Insurance which remains in force on the Insured Person's life after a Living Benefit is paid. The Remaining Life Insurance will equal: • (1) the Insured Person's amount of Personal Life Insurance which was used to determine the Living Benefit (A or B on the prior page); minus (2) any percentage by which the Insured Person's coverage is scheduled to reduce, due to age; if the reduction occurs more than 12 months after the Living Benefit is paid, and while he or she is still living; minus (3) the amount of the Living Benefit withdrawn (including the early withdrawal fee retained by the Company). CONDITIONS. If the Insured Person exercises the Conversion Privilege after a Living Benefit is paid, the amount of the conversion policy will not exceed the amount of his or her Remaining Life Insurance. If the Insured Person has Accidental Death and Dismemberment benefits under this Policy, the Principal Sum will not be affected by the payment of a Living Benefit. EFFECT ON DEATH BENEFIT. When the Insured Person dies after receiving a Living Benefit, the amount of Remaining Life Insurance in force on the date of death will be paid as a Death Benefit. Payment will be made in accord with the Beneficiary section of this Policy. If the Insured Person dies after applying for a Living Benefit, but before the Company has made payment; then the request will be void and no Living Benefit will be paid. The amount of Personal Life Insurance in force on the date of death will be paid in accord with the Beneficiary section of this Policy. EFFECT ON TAXES AND GOVERNMENT BENEFITS. Any Living Benefit amount withdrawn may be taxable income to the Insured Person. Receipt of the Living Benefit may also affect the Insured Person's eligibility for Medicaid, Supplemental Security Income and other government benefits. The Insured Person should consult his or her own tax and legal advisor before applying for a Living Benefit. The Company is not responsible for any tax owed or government benefit denied, as a result of the Living Benefit payment. LIMITATIONS. No Living Benefit will be paid: •(1) if this Policy does not include an Extension of Death Benefit provision; (2) if any required premium is due and unpaid; (3) on any Dependent Life Insurance under this Policy; (4) on any conversion policy purchased in accord with the Conversion Privilege; (5) without the written approval of the bankruptcy court, if the Insured Person has filed for bankruptcy; (6) without the written consent of the beneficiary, if the Insured Person has named an irrevocable beneficiary; (7) without the written consent of the assignee, if the Insured Person has assigned his or her rights under this Policy; (8) if any part of the Personal Life Insurance must be paid to the Insured Person's child, spouse or former spouse; pursuant to a legal separation agreement, divorce decree, child support order or other court order; (9) if the Insured Person is Terminally III due to a suicide attempt, while sane or insane; or due to an intentionally self- inflicted injury; (10) if a government agency requires the Insured Person to use the Living Benefit to apply for, receive or continue a government benefit or entitlement; or (11) if the Insured Person has previously received a Living Benefit under this Policy. • GL1101 -9.7 LB 14 05/01/01 CONVERSION PRIVILEGE - CONVERSION BENEFITS GENERAL BENEFIT. An individual life policy, known as a conversion policy, may be purchased from the Company *ithout evidence of insurability, if all or part of anyone's life insurance, provided by this Policy, terminates for any reason except: (1) termination or amendment of the Policy; or (2) the Insured Person's request for: (a) termination of insurance; or (b) cancellation of payroll deduction. To purchase a conversion policy, application and payment of the first premium must be made within 31 days after the life insurance is terminated. Any policy issued under the General Conversion Benefit will: (1) be for an amount not to exceed the amount of the life insurance which was terminated; (2) be on any form (except term) then issued by the Company at the age and amount for which application is made; (3) be issued at the Insured Person's age at nearest birthday; (4) be issued without disability or other supplemental benefits; and (5) require premiums based on the class of risk to which the person then belongs. CONVERSION BENEFIT - POLICY TERMINATION OR AMENDMENT. A conversion policy also may be purchased from the Company if: (1) all or a part of anyone's insurance terminates due to amendment or termination of this Policy; and (2) that person has been covered continuously under this Policy for at least five years. Any conversion policy issued due to Policy termination or amendment will be subject to the same conditions as a policy issued under the General Conversion Benefit except its amount may not exceed the lesser of: (1) $10,000; or (2) the Amount of Life Insurance which terminates less the amount of any group life insurance for which the Insured Person becomes eligible within 31 days after the termination. PROVISIONS APPLICABLE TO ALL CONVERSION POLICIES OFFECTIVE DATES. The coverage provided by a conversion policy issued under this Section will be effective on the later of: (1) its date of issue; or (2) 31 days after the date on which the person's life insurance terminated. DEATH DURING CONVERSION PERIOD. The Company will pay a death benefit under this Policy equal to the amount of the life insurance which could have been converted, if the person: (1) was entitled to purchase a conversion policy; and (2) dies within the 31 day conversion period. This death benefit will be paid even if no one applied for the conversion policy. If the first premium was paid for the conversion policy, the amount of the premium will be refunded and the conversion policy will be void. NOTICE OF CONVERSION PRIVILEGES - INSURED PERSONS. When an Insured Person's Personal Insurance terminates, written notice of the right to convert will be: (1) given personally to the Insured Person; (2) mailed by the Group Policyholder to the Insured Person at his last known address; or (3) mailed by the Company to the Insured Person at his last known address as furnished by the Group Policyholder. An additional period in which to convert will be granted if this written notice is not given to the Insured Person at least 15 days before the end of the 31 day conversion period. Any such extension of the conversion period will expire on the earliest of: (1) 15 days after the Insured Person is given the written notice; or (2) 60 days after the end of the 31 day conversion period even if the Insured Person is never given such notice. No death benefit will be payable under this Policy after the 31 day conversion period has expired even though the right to convert may be extended. • GL1101 -10 DER 15 05/01/01 DEPENDENTS LIFE INSURANCE BENEFIT. Upon receipt of satisfactory proof of a Dependent's death while insured under this Policy, the Company will pay the 4ount of the Dependents Life Insurance in effect on the date of such death. This amount is shown in the Schedule of Insurance. e death benefit will be paid: (1) to the Insured Person; or (2) if the Insured Person fails to survive the Dependent, to the Insured Person's Beneficiary or according to the Facility of Payment Section. DEPENDENT. A Dependent means a person who meets the definition of a dependent of the Insured Person under the provision of the U.S. Internal Revenue Code; and is an Insured Person's: (1) spouse who is not legally separated from the Insured Person; (2) unmarred child at least 14 days but less than 19 years of age; (3) unmarried child less than 23 years of age, if attending an accredited educational institution for the minimum credit hours required to maintain full -time student status there; or (4) unmarried child who is totally and permanently disabled and who became so disabled prior to reaching 19 years of age. A legally adopted child is considered the Insured Person's child from the date of placement in the Insured Person's home for an agency adoption; or from the date the adoption petition is filed, if later, for a private adoption. In addition to naturally born and legally adopted children, the word "child" includes an Insured Person's stepchild or foster child; provided the child resides in the Insured Person's household and is dependent on the Insured Person for principal support. The term Dependent does not include anyone serving in the armed forces of any state or country; except for duty of 30 days or less for training in the Reserves or National Guard. ELIGIBILITY. An Insured Person becomes eligible for Dependents Life Insurance on the latest of: (1) the date the Insured Person becomes eligible for Personal Insurance; (2) the effective date of this Section; or (3) the date the Insured Person first acquires a Dependent. OFFECTIVE DATES. An Insured Person's Dependents Life Insurance will become effective on the latest of the following dates: (1) the date the Insured Person becomes eligible for Dependents Life Insurance; (2) the date the Insured Person makes written application for Dependents Life Insurance and signs a payroll deduction order; and (3) the date the Company approves any required evidence of insurability on all the Insured Person's Dependents. If an Insured Person acquires a new Dependent while insured for Dependents Life Insurance, insurance for that Dependent will take effect on the date the Dependent is acquired. If a Dependent is confined in a hospital on the date his or her Dependents Life Insurance would otherwise take effect, then Dependents Life Insurance for that Dependent will not take effect until ten days after final discharge from the hospital. • GL1101 -11B 97 16 B - w/o Suicide Exclusion 05/01/01 P, ., EVIDENCE OF INSURABILITY. Each Insured Person's Dependent must submit evidence of insurability satisfactory to the Company if the Insured Person: • (1) makes application for Dependents Insurance more than 31 days after the date such Insured Person becomes eligible for Dependents Insurance; or (2) elects to be insured for Dependents Insurance after such Insured Person had requested: (a) termination of the Dependents Insurance; or (b) cancellation of the payroll deduction order; or (3) makes application for Dependents Insurance after it has automatically terminated, due to failure to pay premium by the end of the grace period. INDIVIDUAL TERMINATION OF DEPENDENT INSURANCE. An Insured Person's Dependents Insurance will cease for all of the Insured Person's Dependents on the earliest of: (1) the date the Insured Person's Personal Insurance terminates; (2) the date Dependent Insurance is discontinued under this Policy; (3) the date the Insured Person ceases to be in a class of employees eligible for Dependent Insurance; (4) the date the Insured Person requests that the Dependent Insurance be terminated; or (5) the last day of the premium paying period for which the Insured Person has made any required contribution toward the cost of the Dependent Insurance. Dependents Insurance on a particular Dependent will cease on the earliest of: (1) the date he or she ceases to be a Dependent as defined in this Policy; (2) the date he or she becomes covered under this Policy as an Insured Person; or (3) the date he or she enters the armed forces of any state or country; except for duty of 30 days or less in the Reserves or National Guard. (If the Insured Person sends proof of military service, the Company will refund any unearned premium.) MISSTATEMENT OF AGE. If the age of a Dependent has been misstated, premiums will be subject to an equitable adjustment. If the amount of benefit is dependent upon age, the benefit will be that which would have been payable based upon the Dependent's Wrrect age. ASSIGNMENT. Dependents Insurance may not be assigned. INCONTESTABILITY. Except for non - payment of premiums, the Company may not contest the validity of this Policy as to any Dependent, after it has been in force for two years during the lifetime of that Dependent. This clause will not affect the Company's right to contest claims made for accidental death, or dismemberment benefits. U GL1101 -12 97 17 05/01/01 , CLAIMS PROCEDURES FOR LIFE OR ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS 4OTE: If this Policy includes an Extension of Death Benefit or a Living Benefit (also called an Accelerated Death enefit), please refer to that section for special claim procedures. NOTICE OF CLAIM. Written notice of claim must be given within 20 days after the loss occurs. The notice must be sent to the Company's Home Office. It should include: (1) the Insured Person's name and address; and (2) the number of this Policy. If this is not possible, written notice must be given as soon as it is reasonably possible. CLAIM FORMS. When notice of claim is received, the Company will send claim forms for filing the required proof. If the Company does not send the forms within 15 days; then the Insured Person or Beneficiary may send the Company written proof of claim in a letter stating the nature, date and cause of the loss. PROOF OF CLAIM. The Company must be given written proof of claim within 90 days after the date of the loss. If it was not reasonably possible to give written proof in the time required, the claim will not be reduced or denied solely for this reason; provided the proof is filed as soon as reasonably possible. In any event, proof of claim must be given no later than one year from such time. These time limits will not apply while the Insured Person or Beneficiary lacks legal capacity, however. Proof of claim must be provided at the Insured Person's or Beneficiary's own expense. It must show the nature, date and cause of the loss. Documentation must include: (1) a certified copy of the death certificate, for proof of death; (2) a copy of any police report, for proof of accidental death or dismemberment; (3) a signed authorization for the Company to obtain more information; and (4) any other items the Company may reasonably require in support of the claim. EXAM OR AUTOPSY. At anytime while a claim is pending, the Company may: (1) have the Insured Person examined by a Physician of the Company's choice, as often as reasonably 0 required; and (2) deny or suspend benefits if the Insured Person fails to attend an exam, without good cause; or fails to cooperate with the examiner. In case of death, the Company may also have an autopsy done, where it is not forbidden by law. Any such exam or autopsy will be at the Company's expense. TIME OF PAYMENT OF CLAIMS. Death or dismemberment benefits payable under this Policy will be paid as soon as the Company receives acceptable proof of claim. In any event, the Company shall pay or deny any claim within 120 days after receiving it. If payment is not sent by the 120th day, any overdue payment of accidental death or dismemberment benefits will accrue simple interest at the rate of 10% per year. TO WHOM PAYABLE. Any benefits payable for the Insured Person's death will be paid in accord with the Beneficiary, Facility of Payment and Settlement Options sections of this Policy. If this Policy includes Dependent Life Insurance, any benefits payable for an insured Dependent's death will be paid to: (1) the Insured Person, if he or she survives that Dependent; or (2) the Insured Person's Beneficiary, or in accord with the Facility of Payment section; if the Insured Person does not survive that Dependent. If this Policy includes Accidental Death and Dismemberment Benefits; then any benefit, other than the Insured Person's death benefit, will be paid to the Insured Person. NOTICE OF CLAIM DECISION. Within a reasonable time after receiving proof of claim, the Company will send the Insured Person or Beneficiary a written notice of their claim decision. If the Company denies any part of the claim, the written notice will: (1) explain the reason for the denial under the terms of this Policy; and (2) inform the Insured Person or Beneficiary of the right to a review of the Company's decision. fithe Insured Person or Beneficiary does not receive a written decision within 90 days after the Company receives the laim; then there is a right to an immediate review, as if the claim was denied. GL1101 -13A FL L /ADD 18 05101101 CLAIMS PROCEDURES - CONTINUED REVIEW PROCEDURE. Within 60 days after receiving a denial notice, the Insured Person or Beneficiary may request a aim review by sending the Company a written request, along with any written comments or other items to support the claim. The Insured Person or Beneficiary may review certain non - privileged information relating to the request for review. The Company will review the claim and send the Insured Person or Beneficiary a written notice of their decision within 60 days after receiving the request for review; or within 120 days, if special circumstances require an extension. The notice will state the reasons for the Company's decision under the terms of this Policy. RIGHT OF RECOVERY. If benefits have been overpaid on any claim, full reimbursement to the Company is required within 60 days. If reimbursement is not made, the Company has the right to: (1) reduce future benefits until full reimbursement is made; and (2) recover such overpayments from the Insured Person or his or her Beneficiary or estate. Such reimbursement is required whether the overpayment is due to fraud, the Company's error in processing a claim, or any other reason. LEGAL ACTIONS. No legal action to recover any benefits may be brought until 60 days after the required written proof of claim has been given. No legal action may be brought after the expiration of the applicable statute of limitations, running from the time written proof of claim must be given. COMPANY'S DISCRETIONARY AUTHORITY. Except for those functions which this Policy specifically reserves to the Group Policyholder or Employer, the Company has the authority to manage this Policy, to administer claims, to interpret Policy provisions, and to resolve questions arising under this Policy. The Company's authority includes (but is not limited to) the right to: (1) establish and enforce procedures for administering this Policy and claims under it; (2) determine Employees' eligibility for insurance and entitlement to benefits; (3) determine what information the Company reasonably requires to make such decisions; and la(4) . resolve all matters when a claim review is requested. ny decision the Company makes, in the exercise of its authority, shall be conclusive and binding; subject to the Insured Person's or Beneficiary's right to request a state insurance department review or to bring legal action. • GL1101 -13A FL L /ADD 19 05101101 ]t 1 {a ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE BENEFIT. If an Insured Person sustains an accidental bodily injury, and the injury directly causes one of the following Osses within 90 days of the date of that injury; then the Company will pay the benefit listed: LOSS Loss of one hand by severance at or above the wrist Loss of one foot by severance at or above the ankle Irrecoverable loss of the sight in one eye Any combination of two or more of the losses listed above Loss of life BENEFIT One -half the Principal Sum One -half the Principal Sum One -half the Principal Sum Principal Sum Principal Sum The total benefit for all losses resulting from the same accident may not exceed the Principal Sum. The Principal Sum for the Insured Person's classification is shown in the Schedule of Insurance. TO WHOM PAYABLE. Benefits for loss of life will be paid in accord with the Beneficiary Section. All other benefits will be paid to the Insured Person. LIMITATIONS. Benefits are not payable for any loss to which a contributing cause is: •(1) intentional self- inflicted injury or self- destruction; (2) disease, bodily or mental infirmity, or medical or surgical treatment of these; (3) the Insured Person's participation in a riot; (4) duty as a member of any military, naval or air force; (5) war or any act of war, declared or undeclared; (6) the Insured Person's participation in the commission of a felony; (7) use of drugs; except when prescribed by a Physician; (8) voluntary inhalation of gas, including carbon monoxide; (9) travel or flight in any aircraft, including balloons and gliders; except as a fare regularly scheduled flight; or (10) the Insured Person's driving a vehicle while having an alcohol concentration of more per 100 milliliters of blood. • paying passenger on a 10 grams of alcohol or GL1101 -14 90 OCC. 20 05/01/01 AMENDMENT TO BE ATTACHED TO AND MADE PART OF GROUP POLICY NO.: 000011100388 �UEDSS TO: Florida - Life Specimen The Policy is amended by the addition of the following provisions. PRIOR INSURANCE CREDIT UPON TRANSFER OF LIFE INSURANCE CARRIERS This provision prevents loss of life insurance coverage for an Insured Person, which could otherwise occur solely because of a transfer of insurance carriers. This Policy will provide the following Prior Insurance Credit, when it replaces a prior plan. "Prior Plan" means a prior carrier's group life insurance policy, which this Policy replaced within 1 day of the prior plan's termination date. FAILURE TO SATISFY ACTIVE WORK RULE. Subject to payment of premiums, this Policy will provide life coverage for a Person who: (1) was insured under the prior plan on its termination date; (2) was otherwise eligible under this Policy; but was not Actively -At -Work due to Injury or Sickness on its Effective Date; (3) is not entitled to any extension of life insurance under the prior plan; and (4) is not Totally Disabled (as defined in the Extension of Death Benefit section of this Policy) on the date this Policy takes effect. AMOUNT OF LIFE INSURANCE. Until the Person satisfies this Policy's Active Work rule, the amount of his or her group life insurance under this Policy will not exceed the amount for which the Person was insured under the prior plan on its termination date. This Amendment takes effect on the effective date of coverage under this Policy. In all other respects, this Policy remains the same. • Jefferson Pilot Financial Insurance Company V4VL0_ G"'A Officer of the Company 0 GL 1101- AMEND. PC 1 Prior Ins. Cred. - Life 21 05/01/01 • JEFFERSON PILOT FINANCIAL In Consideration of the application for this Policy made by Jefferson Pilot Financial Insurance Company 8801 Indian Hills Drive, Omaha NE 68114 -4066 (402) 361 -7300 A Stock Company Florida - LTD Specimen (herein called the Policyholder) and the payment of all premiums when due, Jefferson Pilot Financial Insurance Company agrees to make the payments provided in this Policy to the person or persons entitled to them. Policy No. XXXXXXXXXXXX Policy Effective Date: January 1, 2001 Monthly Premium: .XX of Total Covered Payroll per Month The above rate is guaranteed until January 1, 2002, unless any of the Policy's terms are changed. Policy Anniversaries will be annually beginning on: January 1, 2002 The first premium is due on the Policy's Effective Date, and subsequent premiums are due on February 1, 2001, and on the same day of each month thereafter. The Policy is delivered in the state of Florida and subject to the laws of that jurisdiction. Jefferson Pilot Financial Insurance Company has executed this Policy at its Home Office in Omaha, • Nebraska this 18th day of May, 2001. Chief Executive Officer Secretary • GROUP LONG TERM DISABILITY INSURANCE POLICY GL3001 -LTD -1 Policy Face Page 01/01/01 s TABLE OF CONTENTS • Schedule of Benefits ................................................................................................... ............................... 3 Definitions.................................................................................................................. ............................... 4 GeneralProvisions ...................................................................................................... ............................... 9 ClaimsProcedures ...................................................................................................... ............................... 11 Eligibility.................................................................................................................... ............................... 13 EffectiveDates ........................................................................................................... ............................... 13 IndividualTermination .............................................................................................. ............................... 15 PolicyTermination ..................................................................................................... ............................... 16 ConversionPrivilege .................................................................................................. ............................... 17 Premiumsand Premium Rates .................................................................................... ............................... 18 Total Disability Monthly Benefit ................................................................................ ............................... 19 PartialDisability Monthly Benefit .............................................................................. ............................... 20 OtherIncome Benefits ................................................................................................ ............................... 22 • Recurrent Disability .................................................................................................... ............................... 23 Exclusions................................................................................................................... ............................... 24 Specified Injuries or Sicknesses Limitation ................................................................ ............................... 25 Voluntary Vocational Rehabilitation Benefit Provision ............................................. ............................... 26 ReasonableAccommodation Benefit ......................................................................... ............................... 27 Prior Insurance Credit Upon Transfer of Insurance Carriers ...................................... ............................... 28 FamilyIncome Benefit ............................................................................................... ............................... 29 C] GL3001 -LTD -2 2 01/01/01 Florida - Life Specimen 000011100264 SCHEDULE OF BENEFITS ELIGIBLE CLASS means: Class 1 All Full -Time Employees MINIMUM HOURS PER WEEK: 30 BENEFIT PERCENTAGE: 60% MAXIMUM MONTHLY BENEFIT: $5,000 MINIMUM MONTHLY BENEFIT: $50 Benefits for PRE - EXISTING CONDITIONS will be subject to the Pre - Existing Condition Exclusion on the Exclusion page. ELIMINATION PERIOD: 90 days of Disability due to the same or a related Sickness or Injury, which must be accumulated within a 180 day period. MAXIMUM BENEFIT PERIOD (For Sickness or Injury): The Insured Employee's Social Security Normal Retirement Age, or the Maximum Benefit Period shown below (whichever is later). Age at Disability Maximum Benefit Period Less than Age 60 To Age 65 60 60 months 61 48 months 62 42 months 63 36 months 64 65 • 30 months 24 months 66 21 months 67 18 months 68 15 months 69 and Over 12 months OWN OCCUPATION PERIOD means a period beginning at the end of the Elimination Period and ending 24 months later for Insured Employees. WAITING PERIOD: 30 days of continuous Active Work (For date insurance begins, refer to "Effective Dates" section) CONTRIBUTIONS: Insured employees are not required to contribute to the cost of the coverage. • GL3001- LTD -SB 3 01/01/01 DEFINITIONS As used throughout this Policy, the following terms shall have the meanings indicated below. Other parts of this Policy *contain definitions specific to those provisions. ACTIVE WORK or ACTIVELY -AT -WORK means an Employee's full -time performance of all main duties of such Employee's occupation at: 1. the Employer's usual place of business; or 2. any other business location to which the Employer requires the Employee to travel. Unless Disabled on the prior workday or on the day of absence, an Employee will be considered Actively at Work on the following days: 1. a Saturday, Sunday or holiday which is not a scheduled workday; 2. a paid vacation day or other scheduled or unscheduled non - workday; or 3. an excused or emergency leave of absence (except a medical leave) of 30 days or less. ANNUAL SALARY means the Insured Employee's Basic Monthly Earnings or Predisability Income multiplied by 12. BASIC MONTHLY EARNINGS or PREDISABILITY INCOME means the Insured Employee's average monthly base salary or hourly pay from the Employer before taxes on the determination date. The determination date is thelast day worked just prior to the date the Disability begins. It also includes: 1. commissions averaged over the 12 months just prior to the determination date or over the actual period of employment with the Employer just prior to that date, if shorter. It does not include bonuses, overtime pay, or any other extra compensation. It doesnot include income from a source other than the Employer. It will not exceed the amount shown in the Employer's financial records, the amount for which premium has been paid, or the maximum covered earnings permitted by this Policy; whichever is less. SOMPANY means Jefferson Pilot Financial Insurance Company, a Nebraska corporation, whose Home Office address is 8801 Indian Hills Drive, Omaha, Nebraska 68114. • GL3001 -LTD -3 98 4 01 /01 /01 DEFINITIONS (continued) •DAY or DATE means the period of time which begins at 12:01 a.m. and ends at 12:00 midnight, standard time, at the Policyholder's place of business. When used with regard to effective dates, it means 12:01 a.m. When used with regard to termination dates, it means 12:00 midnight. DISABLED or DISABILITY means Totally Disabled and /or Partially Disabled. DISABILITY BENEFIT when used with the term Retirement Plan, means a benefit which: 1. is payable under a Retirement Plan due to disability as defined in that plan; and 2. does not reduce the benefits which would have been paid as Retirement Benefits at the normal retirement age under the plan if the disability had not occurred. If the payment of the benefit does cause such a reduction, the benefit will be deemed a Retirement Benefit as defined in this Policy. ELIGIBILITY WAITING PERIOD means the period of time that: 1. begins with an Employee's most recent date of employment with the Employer; and 2. ends on the day prior to the day such Employee is eligible for coverage under this Policy. ELIMINATION PERIOD means the number of days of Disability during which no benefit is payable. The Elimination Period is shown in the Schedule of Benefits. It applies as follows. 1. The Elimination Period: (a) begins on the first day of Disability; and (b) is satisfied when the required number of days is accumulated within a period which does not exceed two times the Elimination Period. During a period of Disability, the Insured Employee may return to full -time work, at his or her own or any other occupation, for an accumulated number of days not to exceed the Elimination •Period. 2. Only days of Disability due to the same or a related Sickness or Injury will count towards the Elimination Period. Days on which the Insured Employee returns to full -time work will not count towards the Elimination Period. EMPLOYEE means a person: 1. whose employment with the Employer is: (a) on a regular full -time basis; (b) the person's principal occupation; and (c) for regular wage or salary; 2. who is regularly scheduled to work at such occupation at least the minimum number of hours shown in the Schedule of Benefits; and 3. who is a member of an Eligible Class which is eligible for coverage under this Policy; 4. who is not a temporary or seasonal employee; and 5. who is a citizen of the United States or legally works in the United States. EMPLOYER means the Policyholder and includes any division, subsidiary or affiliated company named in the Application. EVIDENCE OF INSURABILITY means a statement of proof of an Employee's medical history. The Company uses this to determine his or her acceptance for insurance, or for an increased amount of insurance. Such proof will be provided at the Employee's own expense. • GL3001- LTD -3A 98 Residual Partial 5 01/01/01 DEFINITIONS (continued) WAMILY OR MEDICAL LEAVE means a leave of absence which is approved in writing by the Employer; and which is subject to: 1. the federal Family and Medical Leave Act of 1993, and any amendments to it; or 2. any similar state law requiring the Employer to grant family or medical leaves. INSURED EMPLOYEE means an Employee for whom Policy coverage is in effect. INJURY means bodily injury which is caused by and results directly from an accident, independently of all other causes. For purposes of determining benefits under this Policy, a Disability will be considered due to an Injury only if: 1. the Disability begins within 90 days after the Injury; or 2. the Injury occurred while the Employee was insured under this Policy. The term "Injury" shall not include any: 1. condition to which a physical or mental sickness, the natural progression of a sickness, or the treatment of a sickness is a substantial contributing factor (based upon the preponderance of medical evidence); 2. condition caused solely by emotional stress or mental trauma; 3. repetitive trauma condition which results from repetitious, physically traumatic activities that occur over time; 4. pregnancy; except for complications which result from a covered Injury; 5. condition caused by infection; except pyogenic bacterial infection of a covered Injury; or 6. condition caused by medical or surgical treatment; except when the treatment is needed solely because of a covered Injury. is • GL3001 -LTD -4 98 6 01/01/01 DEFINITIONS (continued) WAIN DUTIES or MATERIAL AND SUBSTANTIAL DUTIES means those job duties which: 1. are normally required to perform the Insured Person's regular occupation; and 2. cannot reasonably be modified or omitted. It includes those main duties as performed in the national workforce; not as performed for a certain firm or at a certain work site. MEDICALLY APPROPRIATE TREATMENT means diagnostic services, consultation, care or services which are consistent with the symptoms or diagnosis causing the Insured Employee's Disability. Such treatment must be rendered: 1. by a Physician whose license and any specialty are consistent with the disabling condition; and 2. according to generally accepted, professionally recognized standards of medical practice. MONTHLY BENEFIT means the amount payable monthly by the Company to the Insured Employee who is Totally or Partially Disabled. OWN OCCUPATION PERIOD means a period as shown in the Schedule of Benefits. PARTIALLY DISABLED or PARTIAL DISABILITY shall be as defined in the Partial Disability Monthly Benefit sections. PARTIAL DISABILITY EMPLOYMENT means the Insured Employee is working at his or her own or any other occupation; but because of a Partial Disability: 1. the Insured Employee's hours or production is reduced; 2. one or more main duties of the job are reassigned; or 3. the Insured Employee is working in a lower -paid occupation. His or her current earnings must be at least 20% of Predisability Income, and may not exceed the percentage specified in the Partial Disability Benefit section. �HYSICIAN means: 1. a legally qualified medical doctor who is licensed to practice medicine, to prescribe and administer drugs, or to perform surgery; or 2. any other duly licensed medical practitioner who is deemed by state law to be the same as a legally qualified medical doctor. The medical doctor or other medical practitioner must be acting within the scope of his or her license; and must be qualified to provide medically appropriate treatment for the Insured Employee's disabling condition. Physician does not include the Insured Employee or a relative of the Insured Employee receiving treatment. (Relatives include the Insured Employee's spouse, siblings, parents, children and grandparents; and his or her spouse's relatives of like degree.) POLICY means this Group Long Term Disability Insurance Policy issued by the Company to the Policyholder. POLICYHOLDER means the person, individual, firm, trust or other organization as shown on the Face Page of this Policy. PREDISABILITY INCOME - See Basic Monthly Earnings. • GL3001 -LTD -5 98 7 01 /01 /01 DEFINITIONS (continued) WGULAR CARE OF A PHYSICIAN or REGULAR ATTENDANCE OF A PHYSICIAN means the Insured Employee: 1. personally visits a Physician, as often as medically required according to standard medical practice to effectively manage and treat his or her disabling condition; and 2. receives medically appropriate treatment, by a Physician whose license and any specialty are consistent with the disabling condition. REGULAR OCCUPATION or OWN OCCUPATION means the occupation, trade or profession: 1. in which the Insured Employee was employed with the Employer prior to Disability; and 2. which was his or her primary source of earned income prior to Disability. It includes any work in the same occupation for pay or profit; whether such work is with the Employer, with some other firm or on a self - employed basis. It includes the main duties of that occupation as performed in the national workforce; not as performed for a certain firm or at a certain work site. RETIREMENT BENEFIT when used with the term Retirement Plan, means a benefit which: 1. is payable under a Retirement Plan either in a lump sum or in the form of periodic payments; 2. does not represent contributions made by an Employee (payments which represent Employee contributions are deemed to be received over the Employee's expected remaining life regardless of when such payments are actually received); and 3. is payable upon: (a) early or normal retirement; or (b) disability, if the payment does reduce the benefit which would have been paid at the normal retirement age under the plan, if disability had not occurred. RETIREMENT PLAN means a defined benefit or defined contribution plan which provides Retirement Benefits to Employees and which is not funded wholly by Employee contributions. The term shall not include any 401(k), profit - sharing or thrift plan; informal salary continuance plan; individual retirement account (IRA); tax sheltered annuity (TSA); stock ownership plan; or a non - qualified it lan of deferred compensation. An Employer's Retirement Plan is deemed to include any Retirement Plan: 1. which is part of any federal, state, county, municipal or association retirement system; and 2. for which the Employee is eligible as a result of employment with the Employer. SICK LEAVE or ANY SALARY CONTINUANCE PLAN means a plan which: 1. is established and maintained by the Employer for the benefit of Insured Employees; and 2. continues payment of all or part of an Insured Employee's Predisability Income for a specified period after he or she becomes Disabled. It does not include compensation the Employer pays an Insured Employee for work actually performed during a Disability. SICKNESS means illness, pregnancy or disease. For a licensed health care practitioner, Sickness includes testing positive on an HIV (human immunodeficiency virus) test; but only when a state licensing board restricts the Insured Employee's ability to perform his or her profession, as a result of such test. In that case: 1. a Disability will be deemed to commence on the date of the state licensing board's action; and 2. the HIV positive status will be deemed Total Disability, if the state licensing board's action results in a loss of at least 80% of the Insured Employee's predisability income. TOTAL COVERED PAYROLL means the total amount of Basic Monthly Earnings for all Employees insured under this Policy. TOTAL DISABILITY or TOTALLY DISABLED shall be defined in the Total Disability Monthly Benefit section. U GL3001 -LTD -6 98 FL 8 01/01/01 GENERAL PROVISIONS ,JNTIRE CONTRACT. The entire contract between the parties shall consist of- 1 . this Policy and the Application (a copy of which is attached); 2. the Employer's Participation Agreement, if any; and 3. the Insured Employee's enrollment forms, if any. In the absence of fraud, all statements made by the Policyholder and by Insured Employees are representations and not warranties. No statement made by an Insured Employee will be used to contest the coverage provided by this Policy; unless a copy of the statement has been furnished to such Insured Employee. AUTHORITY TO MAKE OR AMEND CONTRACT. Only a Company Officer located in the Company's Home Office has the authority to: I . determine the insurability of a group or any individual within a group; 2. make a contract in the Company's name; 3. amend or waive any provision of this Policy; or 4. extend the time for payment of any premium. No change in this Policy will be valid; unless it is made in writing and signed by such a Company Officer. INCONTESTABILITY. Except for the non - payment of premiums or fraud, the Company may not contest the validity of this Policy as to any Insured Employee, after it has been in force for two years during his or her lifetime. RESCISSION. The Company has the right to rescind any insurance for which evidence of insurability was required, if: 1. an Insured Employee incurs a claim during the first two years of coverage; and 2. the Company discovers that the Insured Employee made a material misrepresentation on his or her enrollment form. A material misrepresentation is an incomplete or untrue statement that caused the Company to issue coverage which it would have disapproved, had it known the truth. To rescind means to cancel insurance back to its effective date. In that event, the Company will refund all premium paid for the rescinded insurance, less any benefits paid for the Insured Employee's Disability. The Company serves the right to recover any claims paid in excess of such premiums. NON - PARTICIPATION. This is a non - participating Policy. It will not share in the divisible surplus of the Company. INFORMATION TO BE FURNISHED. The Employer is required to furnish the Company any information needed to administer this Policy, including: 1. information about Employees who become eligible for insurance; whose amounts of coverage change; and whose eligibility or coverage ends; 2. occupational information and other facts that may be needed to manage a claim; and 3. any other information that the Company may reasonably require. The Company may inspect any of the Employer's records which relate to this Policy, at any reasonable time. Clerical error by the Employer: 1. will not affect insurance which otherwise would be in effect; and 2. will not continue insurance which otherwise would be terminated. Once an error is discovered, an equitable adjustment in premium will be made. If a premium adjustment involves the return of unearned premium, the amount of the return will be limited to the 12 -month period which precedes the date the Company receives proof that such an adjustment should be made. 0 GL3001 -LTD -7 98 9 01/01/01 GENERAL PROVISIONS (continued) OIISSTATEMENTS OF FACTS. If relevant facts about any person were misstated: 1. a fair adjustment of the premium will be made; and 2. the true facts will decide if and in what amount insurance is valid under this Policy. If an Insured Employee's age has been misstated; then any benefits shall be in the amount the paid premium would have purchased at the correct age. ACTS OF THE POLICYHOLDER. In administering this Policy, the Policyholder must: 1. treat Employees the same in like situations; and 2. allow the Company, without inquiry, to rely on its acts. POLICYHOLDER'S AGENCY. For all purposes of this Policy, the Policyholder acts on its own behalf or as Agent of the Employee. Under no circumstances will the Policyholder be deemed the Agent of the Company. COMPANY'S DISCRETIONARY AUTHORITY. Except for those functions which this Policy specifically reserves to the Policyholder or Employer, the Company has sole authority to manage this Policy, to administer claims, to interpret Policy provisions, and to resolve questions arising under this Policy. The Company's authority includes (but is not limited to) the right to: 1. establish and enforce procedures for administering this Policy and claims under it; 2. determine Employees' eligibility for insurance and entitlement to benefits; 3. determine what information the Company reasonably requires to make such decisions; and 4. resolve all matters when a claim review is requested. Any decision the Company makes in the exercise of its authority shall be conclusive and binding. CERTIFICATES. The Employer will be furnished with individual Certificates for delivery to each Insured Employee. These Certificates summarize the benefits provided by this Policy. If there is a conflict between this Policy and the Certificate, this Policy will control. WONFORMITY WITH STATE STATUTES. If, on its effective date, any provision of this Policy conflicts with any applicable law; then the provision will be deemed to conform to the minimum requirements of the law. CURRENCY. In administering this Policy, all Predisability Income will be expressed in U.S. dollars; and all premium and benefit amounts must be paid in U.S. dollars. WORKERS' COMPENSATION OR STATE DISABILITY INSURANCE. This Policy does not replace or provide benefits required by Workers' Compensation laws or any state disability insurance plan laws. ASSIGNMENT. The rights and benefits under this Policy may not be assigned. • GL3001 -LTD -7 98 10 01/01/01 CLAIMS PROCEDURES NOTICE OF CLAIM. Written notice of claim: • 1. may be given at any time during the Elimination Period; and 2. must be given by the 20th day after a covered period of Disability ends. The notice must be sent to the Company's Home Office. It should include: 1. the Insured Employee's name and address; and 2. the number of this Policy. If this is not possible, written notice must be given as soon as it is reasonably possible. CLAIM FORMS. When notice of claim is received, the Company will send claim forms to the Insured Employee. If the Company does not send the forms within 15 days; then the Insured Employee may send the Company written proof of Disability in a letter stating the date the Disability started, its cause and degree. The Company will periodically send the Insured Employee additional Claim Forms. PROOF OF CLAIM. The Company must be given written proof of claim within 90 days after the end of each period for which the Company is liable. If it was not reasonably possible to give written proof in the time required, the claim will not be reduced or denied solely for this reason; provided the proof is filed as soon as reasonably possible. In any event, proof of claim must be given no later than one year from such time. These time limits will not apply while an Insured Employee lacks legal capacity, however. Proof of claim must be provided at the Insured Employee's own expense. It must show the date the Disability started, its cause and degree. It must show any restrictions on performing the duties of the Insured Employee's regular occupation. Documentation must include: 1. completed statements by the Insured Employee, the Employer and the attending Physician; 2. a signed authorization for the Company to obtain more information; and 3. any other items the Company may reasonably require in support of the claim. Proof of continued Disability and regular attendance of a Physician must be given to the Company, within 60 days after the Company requests it; if it is not, benefits maybe denied or suspended. EXAM OR AUTOPSY. At anytime while a claim is pending, the Company may: 1. have the Insured Employee examined by a Physician, specialist or vocational rehabilitation expert of the Company's choice, as often as reasonably required; and • 2. deny or suspend benefits for an Insured Employee who fails to attend an exam, without good cause; or who fails to cooperate with the examiner. The Company may also have an autopsy done, where it is not forbidden by law. Any such exam or autopsy will be at the Company's expense. TIME OF PAYMENT OF CLAIMS. When the Company receives proof of claim, benefits payable under this Policy will be paid as follows. Any Long Term Disability benefits will be paid monthly, during any period for which the Company is liable. If benefits are due for less than a month, they will be paid on a prorata basis. The daily rate will equal 1/30 of the monthly benefit. Any balance which remains unpaid at the end of the period of liability will be paid immediately upon receipt of due written proof. TO WHOM PAYABLE. All benefits are payable to the Insured Employee; except after his or her death benefits will be payable as follows. Any Survivor Benefit will be payable in accord with that Policy provision. Any other benefits will be payable to the Insured Employee's estate. When a benefit becomes payable to the Insured Employee's estate, a minor or any other person who is not legally competent to give a valid receipt; then up to $3,000 may be paid to any relative of the Insured Employee that the Company finds entitled to payment. If payment is made in good faith to such a relative, the Company will not have to pay that benefit again. NOTICE OF CLAIM DECISION. Within a reasonable time after receiving proof of loss, the Company will send the Insured Employee a written notice of their claim decision. If the Company denies any part of the claim, the written notice will: 1. explain the reason for the denial under the terms of this Policy; and 2. inform the Insured Employee of the right to a review of the Company's decision. If the Insured Employee does not receive a written decision within 90 days after the Company receives his or her claim; then the Insured Employee has a right to an immediate review, as if the claim was denied. • GL3001 -LTD -8 98 FL 11 01/01/01 CLAIMS PROCEDURES (continued) &EVIEW PROCEDURE. Within 60 days after receiving a denial notice, the Insured Employee may request a claim review by sending the Company a written request, along with any written comments or other items to support the claim. The Insured Employee may review certain non - privileged information relating to the request for review. The Company will review the claim and send the Insured Employee a written notice of their decision within 60 days after receiving the request for review; or within 120 days, if special circumstances require an extension. The notice will state the reasons for the Company's decision under the terms of this Policy. RIGHT OF RECOVERY. If benefits have been overpaid on any claim, full reimbursement to the Company is required within 60 days. If reimbursement is not made, the Company has the right to: 1. reduce future benefits until full reimbursement is made; and 2. recover such overpayments from the Insured Employee or his or her estate. Such reimbursement is required whether the overpayment is due to fraud, the Company's error in processing a claim, the Insured Employee's receipt of Other Income Benefits, or any other reason. LEGAL ACTIONS. No legal action to recover any benefits may be brought until sixty days after the required written proof of claim has been given. No legal action may be brought after the expiration of the applicable statute of limitations, from the time written proof of claim must be given. • • GL3001 -LTD -8 98 FL 12 01 /01 /01 ELIGIBILITY ELIGIBLE CLASSES. The classes of Employees eligible for insurance are shown in the Schedule of Benefits. The loompany has the right to review and terminate any or all classes eligible under this Policy, if any class ceases to be overed by this Policy. ELIGIBILITY DATE. An Employee becomes eligible for coverage provided by this Policy on the later of: 1. the Policy's effective date; or 2. the date the Employee satisfies the Waiting Period. Prior service in an Eligible Class will apply toward the Waiting Period, when: 1. a former Employee is rehired within one year after his or her employment ends; or 2. an Employee returns from a Family or Medical Leave within the leave period required by federal or state law (whichever is greater). EFFECTIVE DATES EFFECTIVE DATE. Except as stated in the Delayed Effective Date provision, coverage for an Employee becomes effective at 12:01 a.m. on the latest of: 1. the first day of the Insurance Month coinciding with or next following the date the Employee becomes eligible for coverage; 2. the date the Employee makes written application for coverage; and signs: (a) a payroll deduction order, if the Employees pay any part of the Policy premiums; or (b) an order to pay premiums from the Employee's Flexible Benefits Plan account, if premiums are paid through such an account; or 3. the date the Company approves the Employee's evidence of insurability, if required. Evidence of insurability satisfactory to the Company must be submitted (at the Employee's expense) if: • 1. written application for coverage (or an increased amount of coverage) is made more than 31 days after the Employee becomes eligible for such coverage; 2. coverage is elected after the Employee has requested: (a) to terminate the insurance; (b) to stop payroll deductions for the insurance; or (c) to stop premium payments through a Flexible Benefits Plan account; 3. coverage is elected after the Employee has caused insurance to lapse by failing to pay the required premium when due; or 4. optional, supplemental, voluntary or Buy -Up Benefit coverage is elected in excess of any guaranteed issue amounts shown in the Schedule of Benefits. DELAYED EFFECTIVE DATE. An Employee's Effective Date of any initial, increased or additional coverage will be delayed; if such Employee is not Actively -at -Work on the date that coverage would otherwise be effective. Coverage will take effect on the Employee's second consecutive day of Active Work. r1 L_J GL3001 -LTD -9 94 13 01/01/01 EFFECTIVE DATE FOR CHANGE IN ELIGIBLE CLASS. An Insured Employee may become a member of a different Eligible Class. Except as stated in the Delayed Effective Date provision, coverage under the different Eligible Class will 46 e effective: 1. immediately, if the different Eligible Class involves any reduction in coverage; or 2. the first day of the month after the Insured Employee has been Actively -at -Work for at least 15 days, as a member of a different Eligible Class; if the different Eligible Class involves enhancement of any coverage. REINSTATEMENT AFTER FAMILY OR MEDICAL LEAVE. A new Waiting Period and evidence of insurability will be waived for an Employee, upon return from an approved Family or Medical Leave, provided: 1. the Employee returns within the leave period required by federal or state law (whichever is greater); 2. the Employee applies for insurance or is enrolled under this Policy within 31 days after resuming Active Work; and 3. the reinstated amount of insurance does not exceed the amount which terminated. If the above conditions are met, the months of leave will count towards any unm period; and a new Pre - Existing Condition Exclusion will not apply to the reinstated Existing Condition Exclusion will apply to any increased amount of insurance, however 40 • E t Pre - Existing Condition Exclusion amount of insurance. A new Pre- GL3001 -LTD -9 94 14 01/01/01 INDIVIDUAL TERMINATION TERMINATION OF COVERAGE. An Insured Employee's coverage will terminate at 12:00 midnight on the &INDIVIDUAL arliest of: 1. the date this Policy or the Employer's participation terminates; but without prejudice to any claim incurred prior to termination; 2. the date the Insured Employee's Class is no longer eligible for insurance; 3. the date such Insured Employee ceases to be a member of an Eligible Class; 4. the end of the period for which the last required premium has been paid; or 5. the date on which the Insured Employee's employment with the Employer terminates; unless coverage is continued as provided below. CONTINUATION. Ceasing Active Work is deemed termination of employment; but insurance may be continued as follows. Disability. If an Insured Employee is absent due to Total Disability, or is engaged in Partial Disability Employment; then Long Term Disability insurance may be continued during: (a) the Elimination Period; provided the Company receives the required premium from the Employer; and (b) the period for which Long Term Disability benefits are payable, without payment of premium. 2. Family or Medical Leave. If an Insured Employee goes on an approved Family or Medical Leave, and is not entitled to continue insurance due to Disability, as provided above; then Long Term Disability insurance may be continued, until the earliest of: (a) the end of the leave period approved by the Employer; (b) the end of the leave period required by federal or state law (whichever is greater); (c) the date the Insured Employee notifies the Employer that he or she will not return; or • (d) the date the Insured Employee begins employment with another employer; provided the Company receives the required premium from the Employer. 3. Lay -off or Other Leave. When an Insured Employee goes on a temporary lay -off, or an approved leave of absence which is not subject to the federal Family and Medical Leave Act (or any similar state law); then Long Term Disability insurance may be continued: (a) until the end of the calendar month following the month in which the lay -off or leave began; (b) provided the Company receives the required premium from the Employer. The Employer must not act so as to discriminate unfairly among Employees in similar situations. Insurance may not be continued when an Insured Employee ceases Active Work due to a labor dispute, strike, work slowdown or lockout. INDIVIDUAL TERMINATION DURING DISABILITY. Termination of an Insured Employee's coverage during a Disability will have no effect on benefits payable for that period of Disability. EXTENSION OF BENEFITS. In the event of Total Disability of an Insured Employee on the date of Policy termination, benefits will be continued for such disability until the earliest of: 1. the date the Insured Employee ceases to be Totally Disabled; 2. the date the Insured Employee fails to take a required medical exam; 3. the date the Insured Employee fails to submit any required proof to the Company; 4. the date the Insured Employee dies; or 5. the date the Maximum Benefit Period ends. GL3001- LTD -10 98 FL 15 01 /01 /01 POLICY TERMINATION POLICY TERMINATION BY THE COMPANY. Until the premium rate has been in effect for at least 12 months, or any later Rate Guarantee Date agreed upon by the Company; the Company may terminate this Policy on the due date of any premium if: 1. the number of Insured Employees totals less than 10; 2. part of the premium is paid by the Insured Employee and less than 75% of those eligible for coverage are insured; 3. all of the premium is paid by the Policyholder and less than 100% of those eligible for coverage are insured; 4. the Policyholder fails to promptly furnish any information which the Company may reasonably require; 5. the Policyholder, without good cause, fails to perform its duties pertaining to this Policy in good faith. 6. the Company's liability is changed as a result of any change in federal, state or local law which affects this Policy; 7. the Policyholder or any covered division, subsidiary or affiliated company relocates; 8. the Policyholder or any covered subsidiary or affiliated company dissolves or merges; 9. a division, subsidiary or affiliated company is added to or removed from this Policy; 10. any coverage for one or more classes of Insured Employees ceases to be provided under this Policy; 11. the number of Insured Employees changes by 25% or more from the number of Insured Employees on the date this Policy took effect, or the most recent Rate Guarantee Date expired, if later; or 12. the Employer ceases to be covered under the state Workers' Compensation program or any other program of like intent. After the premium rate has been in effect for at least 12 months, or any later Rate Guarantee Date agreed upon by the Company; the Company may terminate this Policy on the due date of any premium. Such termination may be with respect to the Policy as a whole, to any coverage(s) provided under it, or to any class of Insured Employees covered under it. The Company will give the Policyholder at least 45 days' advance written notice of its intent to terminate this Policy. �OLICY TERMINATION BY THE POLICYHOLDER. The Policyholder may terminate this Policy at any time by giving the ompany written notice. This Policy will then terminate on: 1. the date the Company receives the notice; or 2. some later date on which the Policyholder and the Company have agreed. However, termination will not become effective during any period for which premium has been paid to the Company. The Policyholder remains liable for the payment of premiums to the date of termination. AUTOMATIC POLICY TERMINATION. If any premium is not paid before the end of the Grace Period; then this Policy will terminate at the end of the Grace Period, without any action on the Company's part. The Policyholder remains liable for the payment of premiums to the date of termination. POLICY TERMINATION DURING DISABILITY. Termination of this Policy or an Employer's participation during a Disability shall have no effect on benefits payable to the Insured Employee for that period of Disability. F— -I LJ GL3001- LTD -10 98 FL 16 01 /01 /01 CONVERSION PRIVILEGE ELIGIBILITY. This Policy provides a conversion privilege, when an Insured Employee's insurance under this Policy ends ecause he or she: 1. resigns from employment with the Employer; 2. is terminated from employment with the Employer, with or without cause; 3. goes on a lay -off or leave of absence; or 4. remains on a lay -off or leave of absence beyond the continuation period provided in the Individual Termination section of this Policy. The Insured Employee may obtain converted long term disability insurance, without medical evidence of insurability. To be eligible for a converted policy, the Insured Employee must have been insured under the Employer's group plan for at least 12 months in a row, just before his or her insurance under this Policy terminated. The 12 months can be a combination of coverages under this Policy, and under any prior group long term disability plan which this Policy replaces. APPLICATION. Application to convert must be made within 31 days after insurance under this Policy terminates. The converted benefits and amount of insurance may differ from those under this Policy. CONDITIONS AND LIMITATIONS. This conversion privilege is not available to any Insured Employee whose insurance terminates because: 1. this Policy is terminated by the Employer or the Company; 2. this Policy is amended to exclude the class to which the Insured Employee belongs: 3. the Insured Employee no longer belongs to a class eligible for coverage under this Policy; 4. the Insured Employee retires or dies; 5. the Insured Employee fails to pay the required premium; or 6. the Insured Employee is Disabled under the terms of this Policy. Also, this conversion privilege is not available to an Insured Employee who becomes insured for long term disability �enefits under any other group plan; unless the other coverage takes effect more than 31 days after his or her insurance nder this Policy terminates. If an Insured Employee converts his or her Policy coverage, and later resumes active employment in an eligible class; then the Insured Employee's conversion coverage will terminate on the day before he or she is re- enrolled under this Policy. In no event will benefits be paid under both this Policy and the conversion coverage for the same period of Disability. • Conversion Privilege GL3001- LTD -10.1 17 01/01/01 PREMIUMS AND PREMIUM RATES PAYMENT OF PREMIUM. No coverage provided by this Policy will be in effect until the first premium for such coverage is paid. *or coverage to remain in effect, the Employer must pay each subsequent premium on or before its due date at the Company's Home ffice. The premium must be paid in U.S. dollars. PREMIUM RATES. The initial premium rates for this Policy are shown on the Face Page of this Policy. Premium rates are subject to change. PREMIUM RATE CHANGE. The Company may change any premium rate: 1. when this Policy's terms are changed: (a) as agreed upon by the Policyholder and the Company; or (b) as a result of a change in federal, state or local law which affects this Policy; 2. when the Company's liability is changed as a result of a change in federal, state, or local law; 3. when the Policyholder or any covered division, subsidiary or affiliated company relocates; 4. when a division, subsidiary, or affiliated company is added to or removed from this Policy; 5. when the number of Insured Employees changes by 25% or more from the number of Insured Employees on the date this Policy took effect or the most recent Rate Guarantee Date expired, if later; 6. when the Employer ceases to be covered by the state Workers' Compensation program or any other program of like intent; or 7. on any premium due date on or after: (a) this Policy's first anniversary; or (b) any later Rate Guarantee Date agreed upon by the Company. Unless the Company and the Group Policyholder agree otherwise, the Company will give at least 45 days' advance written notice of any increase in premium rates. MONTHLY PREMIUM AMOUNT. The amount of monthly premium due on each due date will be the Total Covered Payroll multiplied by the premium rate. Changes will not be pro -rated daily. Instead, premium will be adjusted as follows. 1. When an Insured Employee's insurance (or increased amount of insurance) takes effect, premium will be charged •from the monthly due date coinciding with or next following that change. 2. When all or part of an Insured Employee's insurance terminates, the applicable premium will cease on the monthly due date coinciding with or next following that termination. 3. When premiums are paid other than monthly, increases or decreases will result in an adjustment from the premium due date coinciding with or next following that change. The above manner of charging premium is for accounting purposes only. It will not extend insurance coverage beyond a date it would have otherwise terminated. Each premium payment will include any adjustments in past premiums, which are needed due to changes that have not yet been taken into account. If a premium adjustment involves a return of unearned premium, the amount of the return will be limited to the prior 12 -month period. GRACE PERIOD. A Grace Period of 31 days from the due date will be allowed for the payment of each premium after the first. This Policy will remain in effect during the Grace Period. The Policyholder will be liable to the Company for the payment of all premiums due for the period this Policy remains in effect, however. WAIVER OF PREMIUM. Premium will be administered as follows during any period for which benefits are payable. 1. Long Term Disability premium payments are waived for an Insured Employee who is Disabled, during any period for which benefits are payable. 2. If coverage is to be continued following a period during which premiums were waived; then premium payments must be resumed, as they become due. • GL3001- LTD -11 98 FL 18 01 /01 /01 TOTAL DISABILITY MONTHLY BENEFIT �ENEFIT. The Company will pay a Total Disability Monthly Benefit to an Insured Employee, after the completion of the limination Period; if he or she: 1. is Totally Disabled; 2. is under the regular care of a Physician; and 3. at his or her own expense, submits proof of continued Total Disability and Physician's care to the Company upon request. The Total Disability Monthly Benefit will cease on the earliest of: 1. the date the Insured Employee ceases to be Totally Disabled or dies; 2. the date the Maximum Benefit Period ends; 3. the date the Insured Employee is able, but chooses not to engage in Partial Disability Employment: (a) in his or her regular occupation, during the Own Occupation Period; or (b) in any gainful occupation, after the Own Occupation Period; 4. the date the Insured Employee fails to take a required medical exam, without good cause; or 5. the 60th day after the Company mails a request for additional proof, if not given. AMOUNT. The amount of the Total Disability Monthly Benefit equals: 1. the Insured Employee's Basic Monthly Earnings multiplied by the Benefit Percentage (limited to the Maximum Monthly Benefit); minus 2. Other Income Benefits. The amount of the Total Disability Monthly Benefit will not be less than the Minimum Monthly Benefit. The Benefit Percentage, Maximum Monthly Benefit, Minimum Monthly Benefit and Maximum Benefit Period are shown in the Schedule of Benefits. DEFINITION Total Disability" or "Totally Disabled" will be defined as follows. 1. During the Elimination Period and Own Occupation Period, it means that due to an Injury or Sickness the Insured Employee is unable to perform each of the substantial and material duties of his or her own occupation. 2. After the Own Occupation Period, it means that due to an Injury or Sickness the Insured Employee is unable to perform each of the main duties of any gainful occupation which his or her training, education or experience will reasonably allow. The loss of a professional license, an occupational license or certification, or a driver's license for any reason does not, by itself, constitute Total Disability. BENEFIT PERIOD EXTENSION. The Maximum Benefit Period is shown in the Schedule of Benefits. However, benefits will be extended beyond the end of the Maximum Benefit Period if a Totally Disabled Employee attains the age specified in the benefit duration and has not received twelve Monthly Benefit payments. In this event, the benefit period will be extended during the continuance of Total Disability until twelve monthly payments have been paid. • G L3001 -LTD-1 2A 98 FL Standard Integration, Any Occ. Disability Definition 19 01/01/01 PARTIAL DISABILITY MONTHLY BENEFIT BENEFIT. The Company will pay a Partial Disability Monthly Benefit to an Insured Employee, after completion of the Elimination �eriod; if he or she: 1. is Disabled; 2. is engaged in Partial Disability Employment; 3. is earning at least 20% of Predisability Income when Partial Disability Employment begins; 4. is under the regular care of a Physician; and 5. at his or her own expense, submits proof of continued Partial Disability, Physician's care and reduced earnings to the Company upon request. The Insured Employee does not have to be Totally Disabled prior to receiving Partial Disability Monthly Benefits. The Elimination Period may be satisfied by days of Total Disability, Partial Disability or any combination thereof. The Partial Disability Monthly Benefit will cease on the earliest of: 1. the date the Insured Employee ceases to be Partially Disabled or dies; 2. the date the Maximum Benefit Period ends; 3. the date the Insured Employee earns more than: (a) 99% of Predisability Income, until Partial Disability Monthly Benefits have been paid for 24 months for the same period of Disability; or (b) 85% of Predisability Income, after Partial Disability Monthly Benefits have been paid for 24 months for the same period of Disability;* 4. the date the Insured Employee is able, but chooses not to work full -time: (a) in his or her regular occupation, during the Own Occupation Period; or (b) in any gainful occupation, after the Own Occupation Period; 5. the date the Insured Employee fails to take a required medical exam, without good cause; or 6. the 60th day after the Company mails a request for additional proof, if not given. *If the Insured Employee's earnings from Partial Disability Employment fluctuate, the Company has the option to average the most lecent three months' earnings and continue the claim; provided that average does not exceed the percentage of Predisability Income illowed above. A Monthly Benefit will not be payable for any month during which earnings exceeded that percentage, however. DEFINITIONS "Full- Time" means the average number of hours the Insured Employee was regularly scheduled to work, at his or her regular occupation, during the month just prior to: 1. the date the Elimination Period begins; or 2. the date an approved leave of absence begins, if the Elimination Period begins while the Insured Employee is continuing coverage during a leave of absence. "Partially Disabled" or "Partial Disability" will be defined as follows. 1. During the Elimination Period and Own Occupation Period, it means that due to an Injury or Sickness the Insured Employee: (a) is unable to perform one or more of the main duties of his or her regular occupation, or is unable to perform such duties full -time; and (b) is engaged in Partial Disability Employment. 2. After the Own Occupation Period, it means that due to an Injury or Sickness the Insured Employee: (a) is unable to perform one or more of the main duties of any gainful occupation which his or her training, education or experience will reasonably allow; or is unable to perform such duties full - time; and (b) is engaged in Partial Disability Employment. • GL3001- LTD -13A 98 Residual Disability, Any Occ. Disability Defmition 20 01/01/01 PARTIAL DISABILITY MONTHLY BENEFIT (Continued) 0 ENEFIT AMOUNT. The Partial Disability Monthly Benefit will replace the Insured Employee's Lost Income; provided it does not exceed the Total Disability Monthly Benefit, which would otherwise be payable during Total Disability without the Partial Disability Employment. Thus, the amount of the Partial Disability Monthly Benefit will equal the lesser of A or B below. A. LOST INCOME: The Insured Employee's Predisability Income, minus all Other Income Benefits (including earnings from Partial Disability Employment). B. TOTAL DISABILITY MONTHLY BENEFIT otherwise payable: 1. The Insured Employee's Predisability Income multiplied by the Benefit Percentage (limited to the Maximum Monthly Benefit); minus 2. Other Income Benefits, except for earnings from Partial Disability Employment. The Partial Disability Monthly Benefit will never be less than the Minimum Monthly Benefit. The Benefit Percentage, Maximum Monthly Benefit, Minimum Monthly Benefit, and Maximum Benefit Period are shown in the Schedule of Benefits. r1 ICJ r � U Progressive Calculation GL3001- LTD -13.4 21 01 /01 /01 OTHER INCOME BENEFITS �THER INCOME BENEFITS means those benefits shown below: 1. Any temporary or permanent benefits or awards for which the Insured Employee is paid under: (a) Worker's or Workmen's Compensation Law; (b) occupational disease law; or (c) any other act or law of like intent. 2. Any disability income benefits which the Insured Employee receives under any compulsory benefit act or law. 3. Any disability income benefits which the Insured Employee receives under: (a) any other group plan, sick leave or salary continuance plan of the Employer; or (b) any governmental retirement system as a result of the Insured Employee's job with the Employer. 4. Any Disability Benefits or Retirement Benefits the Insured Employee receives under a Retirement Plan. 5. Benefits under the United States Social Security Act, the Canada Pension Plan, the Quebec Pension Plan or any similar plan or act as follows: (a) disability or unreduced retirement benefits which the Insured Employee and any spouse or child receives, because of the Insured Employee's Disability; or (b) reduced retirement benefits received by the Insured Employee and any spouse or child because of the Insured Employee's receipt of reduced retirement benefits. 6. Earnings the Insured Employee earns or receives from any form of employment. These Other Income Benefits, except Retirement Benefits, are benefits resulting from the same Disability for which a Monthly Benefit is payable under this Policy. An Insured Employee who may be entitled to some Other Income Benefit is required to actively pursue it; if he or she does not, Policy benefits may be denied or suspended. COST -OF -LIVING FREEZE. After the first deduction for each of the Other Income Benefits, the Monthly Benefit will not be further reduced due to any cost -of- living increases payable under these Other Income Benefits. No reduction in benefits shall be put into effect because of an increase in Social Security disability benefits during a benefit period. DUMP SUM PAYMENTS. Other Income Benefits which are paid in a lump sum will be prorated on a monthly basis over the time period for which the sum is given. If no time period is stated, the sum will be prorated on a monthly basis over the time the Company expects the Insured Employee to live. ESTIMATED PAYMENTS. When the Insured Employee may qualify for certain Other Income Benefits, the Company may estimate the amount of such benefits. The Company may reduce the Insured Employee's Monthly Benefits by such estimated amounts, which: 1. have not yet been awarded or denied; or 2. have been denied, if the denial is being appealed. If an Insured Employee's Monthly Benefits have been reduced by an estimated amount; then such payments will be adjusted when the Company receives proof. 1. of the amount actually awarded; or 2. that benefits have been denied, and that any appeal the Company deems necessary has been completed. (In that event, a lump sum will be refunded to the Insured Employee.) • GL3001- LTD -14 98 FL Full SS Integ. 22 01 /01 /01 RECURRENT DISABILITY "Recurrent Disability" means a Disability due to an Injury or Sickness which is the same as, or related to, the cause of a prior *isability for which Monthly Benefits were payable. A Recurrent Disability will be treated as follows. A Recurrent Disability will be treated as a new period of Disability, and a new Elimination Period must be completed before further Monthly Benefits are payable; if the Insured Employee returns to his or her regular occupation on a full -time basis for six months or more. 2. A Recurrent Disability will be treated as part of the prior Disability, if an Insured Employee returns to his or her regular occupation on a full -time basis for less than six months. To qualify for a Monthly Benefit, the Insured Employee must earn less than the percentage of Predisability Income specified in the Partial Disability Monthly Benefit section. Monthly Benefit payments will be subject to all other terms of this Policy for the prior Disability. If an Insured Employee becomes eligible for coverage under any other group Long Term Disability policy, this Recurrent Disability provision will cease to apply to that Insured Employee. r � L_J • GL3001- LTD -15 98 23 01 /01 /01 GENERAL EXCLUSIONS. EXCLUSIONS 1 • due to war This Policy will not cover an • , declared or undeclared, or an Y period of Total or Partial Disability: 2. due to intentionally self-inflicted injuries; act of war; 3. due to active participation in a riot; 4. due to the Insured Employee's battery; committing of or the attempting to commit a felon 5• during which the Insured Employee is incarcerated for Y or an 6. during which the Insured Employee is not under the regular Ye of assault or the commission of a felon PRE- EXISTING CONDITION EXCLUSIO g care of a Physician. y' or 1 w N. which This his Pol' caused or contributed to b icy will not cover an 2• which be Y, or results from a Pre - Existing Total ti Partial Disability: gins in the first 12 months after the Insured Employee's Effective Date. "Pre-Existing ,, g Condition; and Insured Employee's iEffective Date. Sickness or Injury for which the Insured Employee received treatment within 3 months prior to the "Treatment" means consultation, care or services Provided b of prescription, or taking of any prescribed p Y a Physician. It includes diagnostic measure drugs or medicines. s and the prescription, refill is 13001- LTD -16.0 98 24 3/12 Pre -Ex LIMITATION• SPECIFIED INJURIES OR SICKNESSES then Partial or Employee is Disabled LIMITATION 1 Total Disability prim Y du • 2 ill be payable subject t ty Monthly Benefits: e to one or more of the S Will be limited to 24 the terms of this Policy; Specified Injuries or Sicknesses defined Hospital. months for an Y; but _ Y one period of Disability; unless the Insured Employee "Specified Injuries or Sicknesses" 6 p oyee is confined to a include any Mental CONDITIONS use Sickness, or Substance Abuse, , as defined below. If the Insured Employee is confined for the Specified In' in a Hospital at 2' In no event will the Injury or Sickness; then benefits will beend of the 24th Monthly Benefit be month for which Polic Insurance, however. Payable until he or she is discharged from enefi facility. paid paid beyond the Maximum Benefit period shown in the he Schedule of "Hospital," as used in this hospital provision 1 a general ' means: Which: (a) is licensed, approved or certified b (b) is recognized by the Joint Commission the state where it is located- is is operated to mmission on treat resident in the Accreditation of facility and place where patients; has a registered nurse a waspitals, or 2. a skilled nursing ajor surgery skilled g care facility or unit ge is performed; and Ys on duty; and has The to nursing care facili 'which provides convalescent or a lab x-ray term Hospital also includes: ty under Medicare. l • a Mental nursing care; and which is recognized as a a Treatment Center when trey Mental Sic treatment is for Substance mess. and tental Hospital" means a health care f Abuse. l is licensed, certified or a facility ty m its psychiatric unit) which.- is equipped to treat resident approved as a mental hospital b 3• has a resident patients' Y the state where it is located; Psychiatrist on du mental diseases or disorders duty or on call at all t' , and "Mental Sickness" tines. disorder, disturbance deans any emotional, or 'behavioral, psychological, Personality 1 schizo syndrome; regardless of its cause. 1 2. p schizophrenia or schizoaffective disorder; �' adjustment bi bipolar affective disorder, It includes ,mood or stress- related abnorrnality, 3. obsessive -coin but is not limited to: manic depression, or other psychosis These conditions are pulsive, depressive Treatment usually sually treated b 'panic or anxiety disorders. and Y involves psychothera Y a psychiatrist, a clinical PY, psychotropic dings ors' psychologist or other Mental Sickness does not ' similar methods t treatment. mental l include ' tment. health care provider. stroke, trauma irreversible dementia resulting from; 2 ,viral infection, Alzhe- other conditions which are not usualllMer s disease; or drugs, or similar methods of trey Y treated by a mental health care 'Substance „ treatment. provider using Abuse means alcoholism, drug g psychotherapy, psychotropic Treatment Center g abuse, or chemical dependent I " means a health care facility of any type is licensed, certified or a ty for its medical or 2• has a program for in approved b psychiatric unit 3 Y the state where it is located; ) Which: provides such treatmentlbas based treatment of substance upon a written abuse; and • plan approved and supervised by a physician. 1001- LTD -17 98 FL 25 VOLUNTARY VOCATIONAL REHABILITATION BENEFIT PROVISION •BENEFIT. If an Insured Employee is Disabled and is receiving Policy benefits; then he or she may be eligible Rehabilitation Benefit. This Benefit consists of services which may include: 1 • vocational evaluation, counseling training or job placement; y for a Vocational 2. job modification or special equipment; and 3. other services which the Company deems reasonably necessary to help the Insured Employee return to wo rk. The Company will determine the Insured Employee's eligibility and the amount of any Benefit payable. ELIGIBILITY. An Insured Employee may be eligible for this Benefit, if the Company finds that he or she: 1 • has a Disability that prevents the performance of his or her regular occupation; and, after the Own Occupation Period, also lacks the skills, training or experience needed to perform any other gainful occupation; 2. has the physical and mental abilities needed to complete a Program; and 3. is reasonably expected to return to work after completing the Program; in view of his or her - degree of mot and the labor force demand for workers in the proposed occupation. The Company must also find that the cost of the proposed services is less than its expected claim liability. motivation AMOUNT. The amount of any Vocational Rehabilitation Benefit will not exceed the Company's expected claims benefit will not be payable for services covered under the Insured Employee's health care plan or any other vocational rehabilitation Program. Payment may be made to the provider of the services, at the Company's option liability. This CONDITIONS. Either the Company, the Insured Employee, or his or her Physician may first propose vocational When a Program is approved by the Company, this Policy's definition of "Disability" will be waived during he re but it will be reapplied after the Program ends. The Company will determine the amount and duration of an rehabilitation. benefits payable after the Program ends, g habilitation period; y Long Term Disability LIMITATION. This Policy will not cover any period of Disability for an Insured Employee who has receiv ed a Vocational Rehabilitation Benefit and has failed to complete the Program, without Good Cause. W-FINITIONS "Good Cause ", as used in this provision, means the Insured Employee's: 1 • documented physical or mental impairments, which render the Insured Employee unable to take p art in or complete a Program; with the Insured Employee's taking 2, involvement in a medical program, which prevents or interferes win completing a Program; or g p art in or 3. participating in good faith in some other vocational rehabilitation program, which: (a) conflicts with taking part in or completing a Program developed by the Company; and (b) is reasonably expected to return the Insured Employee to work. "Program" means a written vocational rehabilitation program: 1 • which the Company develops with input from the Insured Employee; his or her Physician; and an current prospective employer, when appropriate; and 2• which describes the Program's y t or g goals; each party's responsibilities; and the times, dates and costs of the rehabilitation services. GL3001- LTD -17.3 98 26 Voluntary Rehab. 01/01/01 If an Insured Ern REASONABLE ACCOMMODATION Employee of the Employer BENEFIT • a Reasonable Accommodation P yer is Disabled reasonable acco Benefit. Disabled, is receiving Policy benefits; then the This Benefit reimburses the 1 • a maximum benefit of Employer Employer ma 2 $5,000 for Employee; but will not exceed: for 50 °�° of the Y be eligible for the Compan ,s any one Insured expense incurred for less). Y expected liability for the Insured Employee; or Employees Long Term Disability Such services y claim (whichever is may include: 1 • Providing the Insured Employee a more accessible 2' removing barriers or hazards to the Insure 3 special seating, Parking space or entrance; 4. 9, furniture ore equipment d Employee from the providing special training pment for the Insured Employee's 5• other services the Corp g materials or translation services dlurin e's Y work station; With the Employer. pant deems reasonably g the Insured P yer, y necessary to help Employee's training; and R BENEFIT. Employee return to work the Benefit, the Em to The Company will determine the Employer must have an Insured Employers eligibility to receive the Be �a) whose Disability prevents the Employee: ib) who has the p Yee Benefit. To Physical and Performance of his or her re qualify for Employer's mental abilities needed to regular occupation A yer's worksite; but only pation at the ic) who is reasonably y with the help of the perform his or her own Employer's worksite; The Company must also find that they to return to proposed accommodation; °r another occupation at the the Insured work with the mmodation; and Employees Lon quested Reasonable help of the proposed accommodation. Long Term Disability Accommodation Benefit is less than the expected developed accommodation liability for ped with input from: mmodation services 1 • the E must be 03. 2 mployer; provided in accord the Insured Em to with a written ro his or her Physician, P Yee' and P posal, The proposal must state the when appropriate. Purpose of the proposed CONDITIONS. accommodation; and the times, accommodation. Either the Company, the Employer, dates and moONS.. costs of the services. P Yer, the Insured Employee, or his or her Physician rp The proposal must be approved b may first propose an by the Company in writing. The Company will then reimburse the 1 has provided the b Employer, upon receipt of proof that the Em 2 has services for the Insured to Yer: paid the provider for the services. Employee; and P • 3001 -LTD -17.3 27 PRIOR INSURANCE CREDIT UPON TRANSFER OF INSURANCE CARRIERS To prevent loss of coverage for an Employee because of a transfer of insurance carriers, this Policy will provide Prior •Insurance Credit for employees insured under the prior carrier's policy on its termination date as follows. FAILURE TO BE ACTIVELY -AT -WORK DUE TO INJURY OR SICKNESS. Subject to premium payments, this Policy will provide coverage to an Employee: 1. who was insured by the prior carrier's policy at the time of transfer; and 2. who was not Actively -At -Work due to Injury or Sickness on this Policy's Effective Date. The coverage will be that provided by the prior carrier's policy, had it remained in force. The Company will pay: 1. the benefit that the prior carrier would have paid; minus 2. any amount for which the prior carrier is liable. DISABILITY DUE TO A PRE - EXISTING CONDITION. Benefits may be payable for a Total Disability due to a Pre - Existing Condition for an Employee who: 1. was insured by the prior carrier's policy at the time of transfer; and 2. was Actively -At -Work and insured under this Policy on this Policy's Effective Date. The benefits will be determined as follows: 1. The Company will apply this Policy's Pre - Existing Condition Exclusion. If the Insured Employee qualifies for benefits, such Insured Employee will be paid according to this Policy's benefit schedule. 2. If the Insured Employee cannot satisfy this Policy's Pre - Existing Condition Exclusion, but can satisfy the prior carrier's pre- existing condition exclusion giving consideration towards continuous time insured under both policies; then he or she will be paid in accord with the benefit schedule and all other terms, conditions and limitations of: (a) this Policy without applying the Pre - Existing Condition Exclusion; or (b) the prior carrier's policy; iswhichever is less. 3. If the Insured Employee cannot satisfy the Pre - Existing Condition Exclusion of this Policy or that of the prior carrier, no benefit will be paid. C GL3001- LTD -18 99 Prior Insurance Credit 28 01/01/01 FAMILY INCOME BENEFIT The Company will pay a lump sum benefit to the Eligible Survivor, w 1 - after Disability had continued for 180 or more consecutive days; when proof is received that an Insured Employee died: 2. while receiving a Monthly Benefit; and 3. as a result of the Disability for which the Monthly Benefit was s ' ee mplo The benefit will be equal to three times the Insured Employee's paid, or as a result of an accident. installments. Y Last Monthly Benefit. It "Last Monthly Benefit" means the gross Monthly Benefit ll be paid in three monthly fit payable to the Insured Employee immediately rEmployment, t reductions for Other Income Benefits, or for earnings the Insured Em I not apply. p ogee received for Partial Disab lity eath, qny "Eligible Survivor" means the Insured Employee's: will 1. surviving spouse; or, if none 2. surviving children who are under age 25 on the Insured Em to If payment becomes due to the Insured Employee's children; then a p Yee's date of death. 1 the surviving children, in equal shares; or payment will be made to: 2• a person named by the Company to receive payments on the children's behalf. s This payment will be valid and effective against all claim If there are no Eligible Survivors, by others representing, or claiming to represent, the children. payment will be made to the Insured Employee's estate. • • Three Month Survivor Benefit 3L3001- LTD -19 94 FL 29 0 L • © JEFFERSON PILOT Jefferson Pilot Financial Insurance Company r FINANCIAL 8801 Indian Hills Drive, Omaha NE 68114 -4066 (402) 361 -7300 A Stock Company • Group Policyholder Florida - Dental PPO Specimen In consideration of the Group Policyholder's application for this Policy and payment of all premiums when due, Jefferson Pilot Financial Insurance Company agrees to make the payments provided in this Policy to the persons entitled to them. The fast premium for this Policy is due on its effective date. Subsequent premiums are due on October 1, 2001, and on the same day of each month after that. Policy anniversaries will be each September lst; unless shown otherwise on the Premium Rate Schedule inside. The provisions and conditions set forth on the following pages are a part of this Policy, as fully as if recited over the signatures below. Jefferson Pilot Financial Insurance Company has executed this Policy at its Home Office in Omaha, Nebraska. • Chief Executive Officer Secretary THIS POLICY CONTAINS A DEDUCTIBLE. is GROUP DENTAL INSURANCE POLICY No.XXXXXXXXXXXXX GL11 -1 -FP FL 97 09/01/01 TABLE OF CONTENTS • Schedule of Benefits ................................................................................................... ............................... 3 Definitions.................................................................................................................. ............................... 4 GeneralProvisions ...................................................................................................... ............................... 8 Eligibility and Effective Dates for Employee Dental Coverage ................................. ............................... 10 Termination of Employee Dental Coverage ............................................................... ............................... 11 Eligibility for Dependent Dental Coverage ................................................................ ............................... 13 Termination of Dependent Dental Coverage .............................................................. ............................... 15 Premiums and Premium Rates .................................................................................... ............................... 16 PolicyTermination ..................................................................................................... ............................... 17 DentalExpense Benefits ............................................................................................. ............................... 18 AlternativeProcedures ............................................................................................... ............................... 19 Limitations and Exclusions ........................................................................................ ............................... 20 Coordination of Dental Expense Benefits .................................................................. ............................... 23 • Claims Procedures for Dental Coverage ..................................................................... ............................... 25 Predeterminationof Benefits ...................................................................................... ............................... 27 DentalCoverage Continuation ................................................................................... ............................... 28 TypeI Procedures ....................................................................................................... ............................... 31 TypeII Procedures ..................................................................................................... ............................... 32 TypeIII Procedures .................................................................................................... ............................... 35 PriorCarrier Credit Provision ..................................................................................... ............................... 37 • G L 11 -2 -TC 2 09/01/01 SCHEDULE OF BENEFITS 4 e amount of a Covered Employee's coverage is determined from the following table. The initial amount of coverage is the amount ich applies to a Covered Employee's Classification on the date his or her coverage takes effect. If a Covered Employee becomes eligible for an increase, it will take effect on the later of: (1) the first day of the Coverage Month which coincides with or follows the date on which the Covered Employee becomes eligible for the increase, provided he or she is Actively at Work on that day; or (2) the day the Covered Employee resumes Active Work, if not Actively at Work on the day the increase would otherwise take effect. Any decrease will take effect on the day of the change, whether or not the Covered Employee is Actively at Work. DENTAL PREFERRED PROVIDER ORGANIZATION (PPO). This plan is designed to provide high quality dental care while controlling the cost of such care. To do this, the Policy encourages a Covered Person to seek dental care from Dentists who have signed a contract with the dental network being offered by the Policy. These Dentists are called Participating Dentists. Use of a Participating Dentist is voluntary. The Covered Person may receive treatment from any Dentist he or she chooses. And he or she is free to change Dentists at any time. But, the Covered Employee's out -of- pocket expenses are usually lower when a Participating Dentist is used. Conversely, out -of- pocket expenses are usually higher when treatment is provided by a Non - Participating Dentist, even if the treatment was recommended or ordered by a Participating Dentist. A listing of Participating Dentists is available from the Employer. Information about Participating Dentists may also be obtained by: (1) accessing the Company's web site at www.jpflnancial.com; or (2) calling the Company's Client Services Department (800) 842 - 3729. This information is included on the ID card provided to each Covered Employee. When the Covered Employee enrolls Eligible Dependents, two ID cards will be provided. hen using a Participating Dentist, the Covered Person must present the ID Card. Most Participating Dentists prepare the necessary claim forms, and submit them to the Company for the Covered Person. Benefits are based on the terms of the Policy. CLASSIFICATION Plan 1 - All Active Full -time Employees located in a PPO service area Class 1 All Full -Time Employees located in a PPO service area Plan 2 - All Active Full -time Employees located outside a PPO service area Class 2 All Full -Time Employees located outside a PPO service area ELIGIBILITY WAITING PERIOD (For date coverage begins, refer to "Effective Date" section) (a) None for employees who were hired on or before the Policy issue date. (b) 90 days of continuous Active Work for employees who were hired after the Policy issue date. is GL11 -3 -SB 09/01/01 SCHEDULE OF BENEFITS (CONTINUED) • Plan 1 - All Active Full -time Employees located in a PPO service area BENEFITS FOR CLASS 1 Eligible Class: All Full -Time Employees located in a PPO service area Contributions: Covered Employees are not required to contribute to the cost for Employee Dental Coverage. Covered Employees are required to contribute to the cost for Dependent Dental Coverage. Benefit Waiting Period: Type II Procedures: None Type III Procedures: 6 Months The Benefit Waiting Period(s) shown above for Type III Procedures will not apply to Covered Persons who become covered on the Policy Effective Date; but only if they were covered under the Group Policyholder's prior group dental plan on the day before the Policy Effective Date. Terms of the Prior Carrier Credit Provision apply for persons enrolled on the issue date of the Policy: Yes Late Entrant Limitation (when applicable): Type II Procedures: 12 Months Type III Procedures: 12 Months DENTAL BENEFITS PPO PLAN PPO PLAN In- Network Out -of- Network Services Services OALENDAR YEAR DEDUCTIBLE for these Procedure Types (combined) Types II & III Types II & III INDIVIDUAL $50 $50 FAMILY $150 $150 PERCENT PAYABLE Type I - Diagnostic & Preventive Services 100% 100% Type II - Basic Services 85% 75% Type III - Major Services 55% 45% CALENDAR YEAR MAXIMUM $2,000 $2,000 for these Procedure Types (combined) Types I, II & III Types I, II & III Under the CLAIMS PROCEDURES provision, the paragraph captioned "TO WHOM PAYABLE" is amended to read as follows. TO WHOM PAYABLE. Dental Expense Benefits generally will be paid to the Covered Employee; unless the Covered Employee has assigned such benefits to the Dentist, or an overpayment has been made. However, if services are provided by a Participating Dentist, benefits are automatically assigned to that Dentist, unless the bill has been paid. • GL11 -3 -SB 3 -2 09/01/01 SCHEDULE OF BENEFITS (CONTINUED) • Plan 2 - All Active Full -time Employees located outside a PPO service area BENEFITS FOR CLASS 2 Eligible Class: All Full -Time Employees located outside a PPO service area Contributions: Covered Employees are not required to contribute to the cost for Employee Dental Coverage. Covered Employees are required to contribute to the cost for Dependent Dental Coverage. Benefit Waiting Period: Type II Procedures: None Type III Procedures: 6 Months The Benefit Waiting Period(s) shown above for Type III Procedures will not apply to Covered Persons who become covered on the Policy Effective Date; but only if they were covered under the Group Policyholder's prior group dental plan on the day before the Policy Effective Date. Terms of the Prior Carrier Credit Provision apply for persons enrolled on the issue date of the Policy: Yes Late Entrant Limitation (when applicable): Type II Procedures: 12 Months Type III Procedures: 12 Months DENTAL BENEFITS CALENDAR YEAR DEDUCTIBLE Type II and III Procedures (combined) INDIVIDUAL $50 FAMILY $150 PERCENT PAYABLE Type I - Diagnostic & Preventive Services 100% Type II - Basic Services 80% Type III - Major Services 50% CALENDAR YEAR MAXIMUM for Type I, II and III Procedures (combined) $2,000 is GL11 -3 -SB 3 -3 09/01/01 DEFINITIONS SCTIVF, WORK or ACTIVELY AT WORK means an employee's full -time performance of all customary duties of his or her cupation at: (1) the Group Policyholder's place of business; or (2) any other business location where the employee is required to travel. Unless disabled on the prior workday or on the day of absence, an employee will be considered Actively at Work on the following days: (1) a Saturday, Sunday or holiday which is not a scheduled workday; (2) a paid vacation day, or other scheduled or unscheduled non - workday; or (3) an excused or emergency leave of absence (except a medical leave) of three days or less; or a leave of absence which qualifies under the Family and Medical Leave Act (FMLA) of 1993. APPROPRIATE TREATMENT (includes APPROPRIATE) means the range of services and supplies by which a dental condition may be treated, which falls within the accepted standards of dentistry. Appropriate Treatment may vary in techniques, materials utilized and technical complexity, as well as cost. BENEFIT WAITING PERIOD means the period of time a Covered Person must be covered for Dental Expense Benefits -- or for a specific Type of Dental Expense Benefits -- under this Policy before that Type of Service becomes eligible for coverage. COMPANY means Jefferson Pilot Financial Insurance Company, a Nebraska corporation, whose Home Office address is 8801 Indian Hills Drive, Omaha, Nebraska 68114 -4066. COVERAGE MONTH means that period of time: (1) beginning at 12:01 A.M. on the same day of each month as this Policy's anniversary; and (2) ending at 12:00 midnight on the day prior to the same day of the following month; at the Group Policyholder's primary place of business. 90VERED EMPLOYEE means an eligible Employee for whom the coverage provided by this Policy is in effect. COVERED EXPENSES, for Employees located in a PPO service area, means expenses incurred for Necessary Dental Procedures shown on the List of Covered Dental Procedures contained in this Policy. Covered Expenses will not exceed: (1) for a Participating Dentist, the Dentist's: (a) fee, as allowed by the Dentist's contract with the dental network; or (b) usual charge for a service; whichever is less. (2) for a Non - Participating Dentist, this Policy's Usual, Customary and Reasonable allowances. These expenses must be Incurred for procedures performed by a Dentist or by a dental hygienist, under the direction of a Dentist. The expenses must be Incurred while covered by this Policy for those procedures for which a claim is being submitted. Covered Expenses are subject to the terms and limitations of this Policy. COVERED EXPENSES, for Employees located outside a PPO service area, means expenses which: (1) are incurred for Necessary Dental Procedures shown on the List of Dental Procedures; and (2) do not exceed the Company's Usual, Customary and Reasonable allowances. These expenses must be Incurred for procedures performed by a Dentist or by a dental hygienist, under the direction of a Dentist. The expenses must be Incurred while covered by this Policy for those procedures for which a claim is being submitted. Covered Expenses are subject to the terms and limitations of this Policy. COVERED PERSON means an eligible Employee or an eligible Dependent for whom the coverage provided by this Policy is in effect. • GL11 -4 -DF 4 09/01/01 DEFINITIONS (continued) *AY OR DATE means at 12:01 A.M., at the Group Policyholder's primary place of business; when used with regard to eligibility dates and effective dates. It means 12:00 midnight, at the same place, when used with regard to termination dates. DENTIST means a licensed doctor of dentistry, operating within the scope of his or her license, in the state in which he or she is licensed. A Dentist does not include a Covered Person or a relative of the Covered Person. Relatives include spouses, siblings, parents, children and grandparents. DEPENDENT: See the Eligibility for Dependent Dental Coverage section of this Policy. DEPENDENT DENTAL COVERAGE means the coverage provided by this Policy for eligible Dependents. ELIGIBILITY WAITING PERIOD means the continuous period of time that an Employee must be employed in an eligible class with the Group Policyholder, before he or she becomes eligible to enroll for coverage under this Policy. This Eligibility Waiting Period may be waived for an Employee who qualifies for reinstatement of his or her coverage, as provided in this Policy. EMPLOYEE means a full -time employee of the Group Policyholder: (1) whose employment with the Group Policyholder is the employee's principal occupation; (2) who is not a temporary or seasonal employee; (3) who is regularly scheduled to work at such occupation at least 30 hours each week; (4) who is a member of an employee class which is eligible for coverage under this Policy; and (5) who is a citizen of the United States or who legally works in the United States. EMPLOYEE DENTAL COVERAGE means the coverage provided by this Policy for eligible Employees. OUENSES INCURRED (includes INCURRED). An expense is Incurred at the time a service is rendered or a supply is furnished, except that an expense is considered Incurred: (1) for an appliance (or change to an appliance), at the time the impression is made; (2) for a crown or bridge, at the time the tooth or teeth are prepared; and (3) for root canal therapy, at the time the pulp chamber is opened; provided the service is completed within 31 days from the date it is begun. • GL11- 4.1 -DF FL 5 09/01/01 DEFINITIONS (continued) GROUP POLICYHOLDER means the person, partnership, corporation, or trust as shown on the Title Page of this Policy. LATE ENTRANT means an eligible Employee who makes written application: (1) more than 31 days after the Employee first becomes eligible for Employee Dental Coverage; (2) after Employee Dental Coverage has been cancelled; or (3) after Employee Dental Coverage has been terminated due to failure to pay premiums when due. LATE ENTRANT also means an eligible Dependent for whom written application is made: (1) more than 31 days after he or she first qualifies for Dependent Dental Coverage; (2) after the Covered Employee has requested to terminate Dependent Dental Coverage; or (3) after Dependent Dental Coverage has been terminated due to failure to pay premiums when due. A person will not be considered to be a Late Entrant if the Employee's spouse was covered under an employer's group dental plan; and the spouse's dental coverage was terminated due to: (1) termination of the dental plan by the spouse's employer; or (2) loss of the spouse's eligibility due to termination of employment or change in the spouse's employment classification. In order to qualify for waiving the Late Entrant Limitation, each person applying for coverage under the Group Policyholder's dental plan must: (1) provide proof of coverage under the spouse's prior dental plan; and (2) enroll for coverage and pay premiums for the Group Policyholder's plan within 31 days following the loss of coverage under the spouse's plan. NECESSARY DENTAL PROCEDURE (includes NECESSARY and DENTAL NECESSITY) means a procedure, service or *ply which the Company, or a qualified party selected by the Company, determines is: (I) required by, and Adequate and Appropriate for the diagnosis or treatment of a dental disease, condition or injury; (2) Appropriate and consistent with the symptoms and findings, or with the diagnosis and treatment of the Covered Person's dental disease, condition or injury; (3) provided in accord with the generally accepted professional standards for dental practice; (4) on the List of Dental Procedures contained in this Policy; and (5) the most Appropriate and Professionally Adequate level of service or supply which can be provided on a cost effective basis without adversely affecting the Covered Person's dental condition. Necessary Dental Procedures include the Diagnostic and Preventive Services contained in the List of Dental Procedures contained in this Policy. The fact that a person's Dentist prescribes a service or supply does not automatically mean that such services or supplies are considered as Necessary Dental Procedures and are covered by this Policy. • GL11- 4.2 -DF 09/01/01 DEFINITIONS (continued) SN- PARTICIPATING DENTIST means a Dentist who is not participating in the dental network being made available through this Policy. PARTICIPATING DENTIST means a Dentist who: (1) has signed a contract with the dental network being made available through this Policy; and (2) has agreed to abide by the rules of that network. The Company will periodically provide the Group Policyholder with a listing of Participating Dentists for distribution to Covered Employees. It is the Covered Employee's responsibility to verify whether the Dentist is a Participating Dentist at the time of service. Participating Dentists are independent contractors; they are not employees or agents of the network or the Company. The Company does not supervise, control or guarantee the services of the Participating Dentist or any other Dentist. POLICY means this group dental policy issued by the Company to the Group Policyholder. PROFESSIONALLY ADEQUATE (includes ADEQUATE) means the least expensive form of treatment, within the range of Appropriate Treatments, for a given dental condition, that conforms to the accepted standards of dentistry. TYPE (includes TYPE OF SERVICE) means a level of dental services, contained in the List of Dental Procedures and covered by this Policy: (1) TYPE I procedures are categorized as Diagnostic & Preventive Services, such as routine oral exams, dental x- rays and cleanings; (2) TYPE II procedures are categorized as Basic Services, such as fillings, extractions and many oral surgeries; (3) TYPE III procedures are categorized as Major Services. Major services are generally considered the most complex and expensive dental care, including crowns and dentures; and (4) TYPE IV procedures provide Orthodontic Care. QSUAL, CUSTOMARY AND REASONABLE (UCR) means the allowable charge for a procedure which is the lesser o£ (1) the amount usually charged by that Dentist for the same or similar procedure(s); or (2) the amount charged by most other Dentists, with similar training and experience within the same geographic area, for a comparable service. The Company will determine the size of the area needed to obtain an accurate cross - section of dental charges data. "Area" means a city, a county, a metropolitan area or a greater area, if needed to find a cross section of Dentist performing the same or similar procedure. If Covered Expenses are Incurred outside of the United States, the UCR allowance will be the amount that would be allowed for that procedure if it had been performed at the Company's Home Office in Omaha, Nebraska. • GL11- 4.3 -DF 09/01/01 GENERAL PROVISIONS TIRE CONTRACT. The entire contract between the parties consists of: (1) this Policy and the Group Policyholder's application (a copy of which is included with this Policy); (2) the Participating Employer's Participation Agreement, if any; and (3) the Covered Employees' enrollment forms, if any. All statements made by the Group Policyholder, Participating Employers, if any, and Covered Employees are representations and not warranties. No statement made by a Covered Employee will be used to contest the coverage provided by this Policy; unless: (1) it is contained in a written statement signed by the Covered Employee; and (2) a copy of the statement is furnished to the Covered Employee. AUTHORITY TO AMEND CONTRACT. Only an Officer of the Company located in the Company's Home Office, may change this Policy or extend the time for payment of any premium. No change will be valid unless it is made in writing and signed by the Company Officer. No person other than a Company Officer, or a Home Office employee designated by the Officer, has the authority, expressed or implied, to: (1) determine the insurability of a group or any individual within the group; (2) make a contract in the name of the Company; or (3) amend or waive any provision of this Policy. INCONTESTABILITY. Except for the non - payment of premiums, the Company may not contest the validity of this Policy as to any Covered Person after his or her coverage has been in force for two years during his or her lifetime. NONPARTICIPATION. This Policy will not be entitled to share in the surplus earnings of the Company. INFORMATION TO BE FURNISHED. The Group Policyholder may be required to furnish any information needed to administer this Policy. Clerical error by the Group Policyholder will not: (1) affect the amount of coverage which would otherwise be in effect; or (2) continue coverage which otherwise would be terminated. Once an error is discovered, an equitable adjustment in premium will be made. If a premium adjustment involves the return of unearned premium, the amount of the return will be limited to the three month period which precedes the date the Company receives proof such an adjustment should be made. The Company may inspect any of the Group Policyholder's records which relate to this Policy. MISSTATEMENT OF AGE. If a Covered Person's age has been misstated, premiums will be subject to an equitable adjustment. If the amount of benefit depends upon age; then the benefit will be that which would have been payable, based upon the person's correct age. CERTIFICATES. The Group Policyholder will be furnished with individual certificates of coverage for delivery to each Covered Employee. These certificates summarize the benefits provided by this Policy. If there is a conflict between this Policy and the certificate, this Policy will control. 0 GL11 -5 -GP 09/01/01 CONFORMITY WITH STATE STATUTES. If any provision of this Policy conflicts with any applicable state law, the provision will be deemed to conform to the minimum requirements of the law. OORKERS' COMPENSATION. This Policy is not to be construed to provide benefits required by Workers' Compensation laws. COMPANY'S DISCRETIONARY AUTHORITY. By purchasing this Policy, the Group Policyholder grants the Company the discretion and final authority to resolve all questions arising from the administration, interpretation and application of this Policy. This authority includes the right to determine: (1) eligibility for coverage; (2) entitlement to benefits; (3) the amount of benefits payable; and (4) the amount and sufficiency of information reasonably required to make such decisions. In making any decision, the Company may rely on the accuracy and completeness of any information furnished by the Group Policyholder or any Covered Person. Decisions made by the Company in the exercise of its discretionary authority shall be conclusive and binding. Failure by the Company to enforce any provision of this Policy does not render that provision unenforceable. The Group Policyholder, as plan sponsor, agrees that the Group Policyholder retains full responsibility for the legal and tax status of its benefits program; and releases the Company from all responsibility for the reporting and the design of the program; and from all other responsibilities not accepted in writing by a designated Officer in the Company's Home Office. CURRENCY. All premiums and all claims will be payable in United States dollars. • • GL 11 -5 -GP 09/01/01 ELIGIBILITY AND EFFECTIVE DATES FOR EMPLOYEE DENTAL COVERAGE WIGIBILITY. An Employee becomes eligible for the coverage provided by this Policy on the later of: (1) the Policy's date of issue; or (2) the completion of the Eligibility Waiting Period as a full -time Employee. The Eligibility Waiting Period is shown in the Schedule of Benefits. EFFECTIVE DATE. Employee Dental Coverage becomes effective on the latest of: (1) the first day of the Coverage Month coinciding with or next following the date the Employee becomes eligible for the coverage; (2) the date the Employee resumes Active Work, if not Actively at Work on the day he or she becomes eligible. The Employee will be deemed Actively at Work on any regular non - working day, if he or she: (a) is not totally disabled or hospital confined on that day; and (b) was Actively at Work on the regular working day before that day; (3) if the Employee contributes to the cost of the Employee Dental Coverage, the first day of the Coverage Month coinciding with or next following the date the Employee makes written application for coverage; and signs: (a) a payroll deduction order, if Covered Employees pay any part of the Policy premium for Employee Dental Coverage; or (b) an order to pay premiums from the Employee's Section 125 Plan account, if any contributions are paid through a Section 125 Plan; or (4) the first day of the Coverage Month coinciding with or next following the date the Company approves a Late Entrant's application. • GL 11 -6 -ELE 10 09/01/01 TERMINATION OF EMPLOYEE DENTAL COVERAGE &RMINATION. An Employee's coverage will terminate on the earliest of: (1) the date this Policy is terminated (see the Policy Termination section); (2) the last day of the Coverage Month in which the Covered Employee requests termination; (3) the last day of the last Coverage Month for which premium payment is made on the Covered Employee's behalf; (4) the last day of the Coverage Month in which the Covered Employee ceases to be in a class of Employees which is eligible for coverage under this Policy; (5) with respect to a benefit for a specific Type of dental care, the date the portion of this Policy providing benefits for that Type of care terminates; or (6) the last day of the Coverage Month in which the Covered Employee's employment with the Group Policyholder terminates. CONTINUATION OF COVERAGE. Ceasing Active Work results in termination of coverage; but Employee and Dependent Dental Coverage may be continued as follows. DISABILITY. If the Covered Employee is disabled due to illness or injury; then coverage may be continued until the earliest of: (1) the date coverage has been continued for three Coverage Months after the disability begins: (2) the date the Covered Employee is no longer disabled; or (3) the date coverage would otherwise terminate, if the Covered Employee had remained an Active Employee; provided premium payments are made on the Covered Employee's behalf. LAY -OFF OR LEAVE OF ABSENCE. If the Covered Employee ceases work due to a temporary layoff or an approved leave of absence; then coverage may be continued: (1) for three Coverage Months after the layoff or leave of absence begins; (2) provided premium payments are made on the Covered Employee's behalf. Dan Employee's coverage is continued as provided above, but Dependent Dental Coverage is terminated; then any Dependents who are re- enrolled at a later date will be treated as Late Entrants. MILITARY LEAVE OF ABSENCE /TERMINATION OF EMPLOYMENT DUE TO MILITARY SERVICE. If a Covered Employee goes on leave for military service of more than 30 days, Dental Coverage may be continued for up to 18 Coverage Months, subject to payment of premiums. REINSTATEMENT OF COVERAGE. The Company will reinstate Dental Coverage and waive any Eligibility Waiting Period, new Late Entrant Limitation, or new Benefit Waiting Period if- (1) a Covered Employee's coverage ends due to termination of employment, reduction of hours, or going on an approved leave of absence; and he or she returns to qualifying full -time employment within six months of that event; or (2) a Covered Employee's coverage ends due to military service of more than 30 days; and he or she applies for or returns to qualifying full -time employment: (a) by the 14th day after completing military service of 31 to 180 days; (b) by the 90th day after completing military service of 181 days or longer; or (c) within 2 years if disabled upon completing such military service. The Employee's accumulated leave for military service may not exceed 5 years; except as provided by federal law. To reinstate coverage, the Employee must enroll within 31 days after resuming Active Work; and must sign a payroll deduction order or Section 125 Plan election, if required. An Employee who resumes Active Work or enrolls later will be treated as a new Employee. C7 GL 11 -7 -TE 98 FL 11 09/01/01 EXTENDED DENTAL BENEFITS. Extended Dental Benefits will be paid if, on the date this Policy terminates, the Covered Employee requires dental services due to an injury which occurred or a sickness which was diagnosed before his or her coverage �nded. In that event, benefits will be continued as if his or her coverage remained in force; provided: (1) the attending Dentist or Physician must recommend the course of treatment or dental procedures to the Covered Employee in writing, and start treatment while Policy coverage is in effect; (2) the services must be other than routine exams, prophylaxis, x -rays, sealants or orthodontic services; (3) the Covered Expenses are incurred within 90 days after Policy termination; and (4) policy termination must not occur due to the Covered Employee's failure to pay premiums or request to cancel coverage. • C7 GL11 -7 -TE 98 FL 12 09/01 /01 ELIGIBILITY FOR DEPENDENT DENTAL COVERAGE &PENDENT means a person who is a Covered Employee's: (1) legal spouse, who is not legally separated from the Covered Employee; (2) unmarried natural and adopted child until the end of the calendar year in which the child reaches 25 years of age, if the child: (a) is dependent on the Covered Employee for support; (b) is living in the Covered Employee's household; or (c) is a full -time or part-time student. This includes: (a) a child placed with Covered Employee for adoption; or (b) a child named in a court order for which the Covered Employee is required by law to provide dental benefits; (3) unmarried child age 25 years or older, who is incapable of self - sustaining employment by reason of mental retardation or physical handicap; and who is chiefly dependent upon the Covered Employee for support and maintenance. The child must be covered by the dental plan on the day before coverage would otherwise end due to his or her age. Proof of the continuing handicap must be sent to the Company when a claim is denied due to the fact the child has attained a limiting age; (4) stepchild or foster child, who resides in the Covered Employee's household; and who is chiefly dependent upon the Covered Employee for support; or (5) grandchild, who is newly born to the Covered Employee's covered dependent. ELIGIBILITY. A Covered Employee becomes eligible for Dependent Dental Coverage on the latest of: (1) the date the Covered Employee becomes eligible for Employee Dental Coverage; (2) the effective date of this dental plan; or (3) the date the Covered Employee first acquires a Dependent. aEmployee must be covered for Employee Dental Coverage to cover his or her dependents. When a child's parents are both Covered Employees under this Policy, the child can be covered as a Dependent of only one parent. A spouse or child who is eligible as an Employee and a Dependent can be covered under this Policy for either Employee Dental Coverage or Dependent Dental Coverage; but not both at the same time. is GL11 -8 -ELD FL 13 09/01/01 ELIGIBILITY FOR DEPENDENT DENTAL COVERAGE OFFECTIVE DATES. Except as provided in the NEW DEPENDENTS section, Dependent Dental Coverage will become effective on the latest of: (1) the first day of the Coverage Month coinciding with or next following the date the Covered Employee becomes eligible for Dependent Dental Coverage; (2) the first day of the Coverage Month coinciding with or next following the date the Covered Employee makes written application for Dependent Dental Coverage; and, if additional premium is required, the Employee signs: (a) a payroll deduction order, if the Covered Employee pays any part of the premium for Dependent Dental Coverage; or (b) an order to pay premiums from the Employee's Section 125 Plan account, if any contributions for Dependent Dental Coverage are paid through a Section 125 Plan account; or (3) the first day of the Coverage Month coinciding with or next following the date the Company approves a Late Entrant application for each Dependent applying for Dependent Dental Coverage. COURT ORDERED COVERAGE. If coverage is provided to a child based on a court order which requires the Covered Employee to provide dental benefits for the child, the coverage will become effective on the date stated in the court order; subject to payment of any additional premium. NEW DEPENDENTS. If a Covered Employee acquires a new Dependent while covered under this Policy, coverage will become effective for the Covered Employee's Spouse or stepchild on the date the Covered Employee is married or takes custody of the child. If additional premium is required, a written application, and a payroll deduction order or Section 125 Plan election, must be made within 31 days of the date the Dependent is acquired. Coverage for a Covered Employee's newborn child will be effective from the moment of birth. 9overage for a newborn child born to any family member while this Policy is in force will be effective from the moment of birth and 11 terminate 18 months after the birth of the child. Coverage for a Covered Employee's adopted child, foster child or other child in court- ordered custody, placed in compliance with Chapter 63, will be effective from the moment of placement in the Covered Employee's home. In the case of a newborn child, coverage will be effective from the moment of birth if the Covered Employee has entered into such a written agreement to adopt prior to the birth, whether or not such agreement is enforceable. However, coverage for such child shall not be required in the event that the child is not ultimately placed in the Covered Employee's home. Written notice of a newly acquired Dependent may be given to the Company within 31 days of the birth or placement of a child. If timely notice is given, additional premium will not be charged for the notice period. If timely notice is not given, any applicable additional premium will be charged from the date of birth for newborns or the date of placement in the home for an adopted child. Coverage will not be denied for a child due to the Covered Employee failing to notify the Company, within the 31 -day notice period, of the birth of the child. r1 U GL11 -8 -ELD FL 14 09/01/01 TERMINATION OF DEPENDENT DENTAL COVERAGE ORMINATION. Dental coverage on a Dependent will cease on the date he or she ceases to be an eligible Dependent, as defined in this Policy. Dependent Dental Coverage will cease for all of the Covered Employee's Dependents: (1) when the Covered Employee's Dental Coverage terminates; (2) when Dependent Dental Coverage is discontinued under this Policy; (3) when the Covered Employee ceases to be in a class of employees eligible for Dependent Dental Coverage; (4) when the Covered Employee requests that the Dependent Dental Coverage be terminated; or (5) on the last day of the premium paying period for which the Covered Employee has made any required contribution toward the cost of the Dependent Dental Coverage. SURVIVING DEPENDENTS. If Employee Dental Coverage terminates due to the Covered Employee's death, Dependent Dental Coverage may be continued: (1) for three Coverage Months; or any longer period, if required by state or federal law; (2) provided the Group Policyholder submits the premium on behalf of the surviving Dependents; and this Policy remains in force. REINSTATEMENT OF DEPENDENT COVERAGE. If a Dependent's Dental Coverage ends due to the Employee's termination of full -time employment, approved leave of absence, or military leave; then the Company will reinstate Dependent coverage and waive any Eligibility Waiting Period, new Benefit Waiting Period, or new Late Entrant Limitation; provided the Employee: (1) returns from termination of employment or an approved leave of absence to qualifying full -time employment within six months; or (2) returns to qualifying full -time employment following a military leave of up to five years, as provided under the Reinstatement of Employee Coverage section. The Covered Employee must enroll eligible Dependents within 31 days after resuming Active Work; and sign a payroll deduction Wer or Section 125 Plan election, if required. EXTENDED DENTAL BENEFITS. Extended Dental Benefits will be paid if, on the date this Policy terminates, the Covered Employee's Dependent requires dental services due to an injury which occurred or a sickness which was diagnosed before his or her coverage ended. In that event, benefits will be continued as if his or her coverage remained in force; provided: (1) the attending Dentist or Physician must recommend the course of treatment or dental procedures to the Covered Employee's Dependent in writing, and start treatment while Policy coverage is in effect; (2) the services must be other than routine exams, prophylaxis, x -rays, sealants or orthodontic services; (3) the Covered Expenses are incurred within 90 days after Policy termination; and (4) policy termination must not occur due to the Covered Employee's failure to pay premiums or request to cancel coverage. C GL -9 -TD 98 FL 15 09/01/01 PREMIUMS AND PREMIUM RATES AYMENT OF PREMIUMS. No coverage provided by this Policy will be in effect until the first premium for such coverage is id. For coverage to remain in effect, each subsequent premium must be paid on or before its due date. The Group Policyholder is responsible for paying all premiums as they become due. Premiums are payable on or before their due dates at the Company's Home Office. GRACE PERIOD. A grace period of 31 days from the due date will be allowed for the payment of each premium after the first. During the grace period, the Policy will remain in effect. However, the Group Policyholder will remain liable for payment of a pro rata premium for the time this Policy remained in force during the grace period. PREMIUM RATE CHANGE. The Company may change any premium rate: (1) when this Policy's terms are changed: (a) as agreed upon by the Group Policyholder and the Company; or (b) as a result of a change in federal, state or local law which affects this Policy; (2) when a division, subsidiary or affiliated company is added or removed from this Policy; (3) when the Group Policyholder or division, subsidiary or affiliates company relocates; (4) when the number of Covered Employees changes by 15% or more from the number covered on this Policy's effective date or the most recent anniversary; or (5) on any premium due date after this Policy's first anniversary, or later Rate Guarantee Date agreed upon by the Company. Unless the Company and the Group Policyholder agree otherwise, the Company will give at least 45 days advance written notice of any increase in premium rates. PREMIUM AMOUNT. The amount of premium due on each due date will be the total of the premium amounts obtained by multiplying: •(1) each rate shown in the Premium Rate Schedule; by (2) the number of employee and family units covered; and then adding the monthly billing fee, if any. For premium purposes, the effective date of any change in coverage is the first day of the Coverage Month which coincides with or follows the change. Changes will not be pro -rated daily. PREMIUM RATE SCHEDULE Monthly Dental Rates Employee Only Coverage Employee and one Dependent Employee and two or more Dependents $20.93 per employee $41.29 per family unit $60.34 per family unit The above rates are guaranteed until September 1, 2003, unless any of the Policy's terms or the Company's liability are changed, as described in parts 1 through 4 of the PREMIUM RATE CHANGE section, above. After that, any premium rate change will be as shown in the renewal letter. The Company will send the Group Policyholder a renewal letter prior to each Policy anniversary. n LJ GL11 -10 -PR FL 16 09/01/01 POLICY TERMINATION TERMINATION BY THE COMPANY. When terminating this Policy for a reason other than nonpayment of premium, the ompany must give the Group Policyholder at least 45 days' advance written notice of cancellation, nonrenewal or expiration of this Policy. The Group Policyholder shall forward, as soon as practical, the notice of cancellation, nonrenewal or expiration to each Covered Person. Until the premium rate has been in effect for at least twelve months, the Company can terminate coverage only if: (1) the number of Covered Employees is less than ten; (2) part of the premium is paid by Covered Employees or through a Section 125 plan; and (a) for Employee Dental Coverage, less than 75% of the eligible Employees are covered; and/or (b) for Dependent coverage, less than 60% of eligible Employees with dependents, are covered for Dependent Dental Coverage; (3) all of the premium is paid from the Group Policyholder's general funds: (a) for Employee coverage; and less than 100% of eligible Employees are covered by the Policy; or (b) for Employee and Dependent Coverage; and less than 100% of eligible Employees and Dependents are covered by this Policy; (4) the Group Policyholder fails to promptly famish any information which the Company may reasonably require; (5) the Group Policyholder, without good cause, fails to perform its duties pertaining to this Policy in good faith; (6) this Policy's terms are changed as a result of a change in federal, state or local law which affects this Policy; (7) a division, subsidiary or affiliated company is added or removed from this Policy; (8) the Group Policyholder or a division, subsidiary or affiliates company relocates; or (9) when the number of Covered Employees changes by 15% or more from the number covered on this Policy's effective date or the most recent anniversary. In determining the above participation rates, "eligible employees" will not include any employee who declines to enroll, because it would result in duplicate coverage: (1) under this Policy as an Employee and a Dependent at the same time; or (2) under this Policy and another group dental plan with his or her spouse's employer. �fter the premium rate has been in effect for at least 12 months, the Company can terminate coverage on any premium due date, by giving the Group Policyholder at least 45 days advance written notice. TERMINATION BY GROUP POLICYHOLDER. The Group Policyholder may terminate this Policy at any time by giving the Company advance written notice. Coverage will then terminate: (1) on the date the Company receives the notice; or (2) any later date the Group Policyholder and the Company have agreed upon. The Group Policyholder remains responsible for the payment of premiums to the date of termination. AUTOMATIC TERMINATION. This Policy will terminate without any action on the part of the Company on the day before the due date of any premium which remains unpaid at the end of the grace period. is GL 11 -11 -PT FL (10 lives) 17 09/01/01 DENTAL EXPENSE BENEFITS lNEFIT. The Company will pay Dental Expense Benefits if a Covered Person incurs Covered Expenses in excess of the ductible during a Calendar Year. The Company will pay the Percentage Payable shown in the Schedule of Benefits for that Type of service; provided any Benefit Waiting Period is satisfied. Benefits will be paid up to the Maximum shown in the Schedule of Benefits for each Covered Person. BENEFIT DETERMINATION. The amount of benefits payable for Type I, II and III Procedures will be determined as follows: (1) Dates of service are reviewed and categorized by: (a) services prior to effective date; (b) services after termination date; and (c) covered services by benefit period or calendar year. (2) Each procedure, service or supply is evaluated to ensure that it qualifies as a Necessary Dental Procedure which is determined to be Professionally Adequate under the terms of the Policy. (3) Covered Expenses are determined, then grouped by Type of dental service. The Covered Expenses for each Type are added. (4) The total for each Type of dental service is reduced by any unmet Deductible amount. The total is reduced: (a) for Type I Procedures first, if the Deductible applies to Diagnostic and Preventive Procedures; (b) for Type II Procedures next; and for Type III, last. (5) Then, each remaining amount is multiplied by the Percent Payable for that Type of Service, to determine the Dental Expense Benefits payable, subject to Policy provisions, maximums, limitations and exclusions. Benefits for Covered Expenses are based on Dental Necessity. Services which are determined to be not Necessary are not covered by this Policy, even if they are recommended or provided by a Dentist. DEDUCTIBLE. The Deductible shown in the Schedule of Benefits is the amount of Covered Expenses which must be incurred before benefits are payable. The Deductible applies separately to the Covered Expenses incurred by each Covered Person. Benefits 11 be based on those Covered Expenses which are in excess of the Deductible. 0'fter Covered Expenses Incurred b all covered family members combined exceed the Family Deductible shown in the Schedule of P Y Y Y Benefits, no additional Covered Expenses will be applied toward the Deductible in that Calendar Year. BENEFIT WAITING PERIOD. The Benefit Waiting Period is shown on the Schedule of Benefits page of this Policy. LATE ENTRANT LIMITATION. For a Late Entrant, Dental Expense Benefits will be limited to Type I benefits only; until the Late Entrant has completed the Late Entrant Limitation, for each Type of service shown on the Schedule of Benefits page. • GL 11 -12 -DB 18 09/01/01 ALTERNATIVE PROCEDURES W eere may be two or more methods of treating a dental condition. The amount of Covered Expense will be limited to the charge for least costly procedure or treatment which: (1) the dental profession recognizes to be Professionally Adequate, in accord with widely accepted standards of dental practice; and (2) the Company determines to be both Adequate and Appropriate, in view of the Covered Person's total current oral condition. To determine its liability for a dental procedure submitted for consideration, the Company may request the pre- operative dental x -rays and any other pertinent information. Based on its review of this information, the Company will decide which procedure would provide Professionally Adequate restoration, replacement or treatment. The Covered Person may receive the more expensive procedure or treatment. However, the Company's liability for Covered Expense will be limited to the least expensive procedure which it determines to be Professionally Adequate care. To find out in advance what charges or alternative procedures will be considered Covered Expenses, a Covered Employee may use the Dental Claim Procedure for Predetermination of Benefits, described in this Policy. • • GL11 -13 -AP 19 09/01/01 LIMITATIONS AND EXCLUSIONS �overed Expenses will not include, and Dental Expense Benefits will not be payable, for: (1) any procedure begun: (a) before the Covered Person was covered under this Policy, subject to the Prior Carrier Credit Provision, if included in this Policy; or (b) after termination of the Covered Person's coverage under this Policy. (2) treatment or service which: (a) is not recommended by a Dentist or is not provided by or under the direct supervision of a Dentist; (b) is not a Necessary Dental Procedure, required for the care and treatment of a dental condition, as determined by the Company; (c) is not specifically listed as covered by this Policy; (d) does not meet accepted standards of dental practice; (e) is considered experimental or unproven in nature; or (f) is provided by a physician or other health care provider, but is beyond the scope of his or her license. (3) charges which exceed Covered Expenses, as defined in this Policy. Benefits will not be payable when: (a) total benefit payments would exceed the annual maximum benefits payable under this Policy; or (b) services exceed the frequency limitations contained in this Policy. (4) procedures which are subject to a Benefit Waiting Period or a Late Entrant Limitation, until that Benefit Waiting Period or Late Entrant Limitation has been satisfied. (5) Orthodontic Procedures. • (6) any treatment or services which: (a) are for mainly cosmetic purposes (facings or veneers on crowns or pontics distal to the second bicuspid will be considered cosmetic); or (b) are related to the repair or replacement of any prior cosmetic procedure. (7) services related to the repair or replacement of third molars (wisdom teeth) with prostheses. (8) bone grafts or any regenerative procedure in an extraction site. (9) any procedure related to a dental disease or injury to natural teeth or bones of the jaw, which is considered a covered service under any group medical plan. (10) orthognathic recording, orthognathic surgery, osteoplasty, osteotomy, LeFort procedure, stomatoplasty or magnetic resonance imaging (MRIs). (11) initial placement of any prosthetic appliance or fixed bridge; unless such placement is needed to replace one or more functioning natural teeth extracted while the Covered Person is covered under this Policy, subject to the Prior Carrier Credit Provision, if included in this Policy. Any such appliance or fixed bridge must include the replacement of the extracted tooth or teeth. • GL 1- 16B -EX FL Has TMJ, (I -III) 20 09/01 /01 (12) the retreatment or adjustment, recementation, reline, rebase, replacement or repair of cast restorations, crowns and • prostheses, when made by the same Dentist or dental office which provided the initial service, within 6 months of the completion of the service. (13) the replacement of: (a) any full or partial denture, within five years; or (b) fixed prosthetic (crown, inlay or onlay restoration, or fixed bridge) within eight years; of the date of the last placement of these items. If a replacement is required because of an accidental dental injury sustained while the Covered Person is covered under this Policy, it will be a Covered Expense. (Damage resulting from biting food or other objects is not considered to be an accidental injury.) (14) the insertion, maintenance or removal of implants, and any related expenses. (15) specialized procedures, including: (a) precision or semi- precision attachments; (b) precious metals for removable appliances; (c) overlays and overdentures; or (d) personalization or characterization. (16) duplicate prosthetics, or for initial placement or replacement of athletic mouth guards, bruxism appliances or any appliance to correct harmful habits; and for replacement of: (a) space maintainers; or (b) misplaced, lost or stolen dental appliances. (17) appliances, restorations or procedures, or their modifications, that: (a) alter vertical dimension; (b) restore or maintain occlusion or for occlusal adjustment or equilibration; or • (c) splint teeth or replace tooth structure lost as a result of erosion, abfraction, abrasion or attrition. (18) charges for services provided by: (a) an ambulatory surgical facility; (b) a hospital; (c) any other facility; or (d) an anesthesiologist. (19) analgesia, sedation, hypnosis or acupuncture, for anxiety or apprehension. (20) any medications administered outside the dentist's office or for prescription drugs. (21) charges which do not directly provide treatment for a dental injury or condition, such as: (a) the completion of claim forms; (b) broken appointments; (c) interest or collection charges; (d) sales or other taxes or surcharges; (e) education, training and supplies used for dietary or nutritional counseling, personal oral hygiene or dental plaque control; (f) caries susceptibility tests, bacteriologic studies, histopathologic exams or pulp vitality testing; or (g) duplication of x -rays or other dental records. Ll GL 11- 16B -EX FL Has TMJ, (I -III) 21 09/01/01 (22) itemized or separated charges for dental services, supplies or materials when those services, supplies and materials may be combined into a single, more comprehensive procedure payable under this Policy. This also • includes itemized charges which are routinely included in the Dentist's charge for the primary service, such as: (a) sterilization or asepsis charges; (b) a charge for local anesthesia; (c) charges for pre- and post- operative care; (d) temporary dental services (for example, a temporary crown), which are considered to be part of the permanent service. If the temporary service is billed separately, benefits for the temporary service will be deducted from the amount payable for the permanent service. (23) duplication of services. (24) charges for which the Covered Person is not liable, or which would not have been made had no coverage been in force. (25) a Covered Person's dental injury or condition: (a) for which he or she is paid under Workers' Compensation or any similar law; or (b) sustained while performing military service. (26) services received for dental conditions caused directly or indirectly by: (a) war or an act of war; (b) intentionally self - inflicted injury; (c) engaging in an illegal occupation; (d) commission or attempt to commit a felony; or (e) a Covered Person's active participation in a riot. (27) treatment rendered by a Dentist or dental hygienist: • (a) who ordinarily resides in the Covered Person's household; or (b) who is related to the Covered Employee or Dependent by blood, marriage or legal adoption. "Related" persons include the Employee's or Dependent's spouse, siblings, parents, children and grandparents. (28) root planing; unless the presence of periodontal disease (bone and attachment loss of 4mm or more) is confirmed by x -rays and pocket depth charting of each tooth involved. LJ GL 11- 1613-EX FL Has TMJ, (I -III) 22 09/01/01 COORDINATION OF DENTAL EXPENSE BENEFITS 4FECT ON BENEFITS. If a Covered Person is covered by another Plan, the Dental Expense Benefits under this Policy and nefits under the other Plan(s) will be coordinated for the Claim Period. The Order of Benefit Determination Rules on the next page decide which Plan pays first. (1) Primary Benefits. When this Plan must pay its full benefits first, the Dental Expense Benefits under this Policy will be paid as if the other coverage did not exist. (2) Secondary Benefits. When another Plan must pay its full benefits first, the Dental Expense Benefits under this Policy: (a) will be calculated as if the other coverage did not exist; and then (b) will be reduced so that total benefits, from all Plans combined, will not exceed 100% of the Allowable Expenses incurred by the Claimant during that Claim Period. Benefits will be coordinated with any benefit amounts that would be payable for the Allowable Expenses under the other Plan(s), whether or not claim is actually made. When this Plan's benefits are reduced, each benefit is reduced in proportion. Then, the reduced benefit payments are applied towards the Maximums of this Plan. BENEFIT SAVINGS. The amount by which this Plan's benefits have been reduced due to such coordination will accrue during the Claim Period. This amount will be used to pay any Allowable Expenses which: (1) are incurred by that Claimant during the same Claim Period; and (2) are not otherwise paid by any Plan. DEFINITIONS. The following definitions apply only to this coordination provision. "Plan" means any group hospital, surgical, medical or dental expense policy, group health care services plan, or group type self - 46 . surance plan that provides protection or insurance against hospital, surgical, medical or dental expenses or services, including: (1) Blue Cross and Blue Shield group plans; (2) Health Maintenance Organization (HMO) and Dental Maintenance Organization (DMO) plans; and (3) other prepayment, group practice and individual practice plans. It also includes any coverage under a government medical or dental plan required or provided by law; except Medicaid. This Plan must pay its benefits before Medicaid pays. Coordination with Medicare will be in accord with federal law. Each of the above coverages is a separate Plan. If an arrangement has two or more parts, and its coordination provision applies only to some benefits or services; then each part is a separate plan. "Allowable Expense" means any necessary, reasonable and customary expense for dental care, which is at least partly covered under at least one of the Plans covering the Claimant. When a Plan provides benefits in the form of services rather than cash payments, the reasonable cash value of each service rendered during the Claim Period will be considered Allowable Expense. "Claimant" means the Covered Person for whom claim is made. "Claim Period" means a calendar year (or part of a calendar year) during which the Claimant has been covered under this Policy. • GL I -17 -COB FL Savings 23 09/01/01 ORDER OF BENEFIT DETERMINATION RULES. To decide which Plan pays first, the Company will use the first of the following rules which applies. • (1) Noncoordinated /Coordinated Plan. A Plan without a coordination provision will pay its benefits before a Plan which includes a coordination provision. (2) Nondependent/Dependent. A Plan covering the Claimant as an employee, member or subscriber will pay its benefits before a Plan covering the Claimant as a dependent. (3) Child of Parents Not Separated or Divorced. If the Claimant is a dependent child whose parents are not separated or divorced, the Plan of the parent whose birthday falls earlier in the calendar year will pay first. However: (a) if both parents have the same birthday, the Plan which has covered the parent longer will pay first; and (b) if the Plan coordinates benefits based upon the sex of the parents, the male parent's plan will pay first. (4) Child of Separated or Divorced Parents. If the Claimant is a dependent child whose parents are separated or divorced, then: (a) the Plan of the parent who is required by court decree to pay the child's dental expenses will pay first; (b) provided the Plan receives notice of the court decree before paying or providing benefits. If there is no notice of a court decree requiring payment of such expense, then: (a) the custodial parent's Plan pays first; (b) the Plan of the custodial parent's spouse pays next (if the custodial parent is remarried); and (c) the noncustodial parent's Plan pays last. • When a noncustodial parent is responsible for the Claimant's dental expenses, benefits may be paid directly to the provider, if the custodial parent requests this. (5) Active/Inactive Employee. A Plan covering the Claimant as a laid off or retired employee (or a dependent of such an employee) will pay after a Plan covering the Claimant on some other basis; provided the other Plan: (a) includes this coordination rule for laid off or retired employees; or (b) is issued in a state which requires this rule by law. A Plan covering the Claimant pursuant to federal COBRA Continuation law will pay after a Plan covering the Claimant as an employee (or a dependent of an employee). (6) Length of Coverage. If none of the above rules apply, then the Plan which has covered the Claimant longer will pay first. RIGHT TO EXCHANGE DATA. To determine the benefits payable under this section, the Company has the right to exchange information with any insurance company, organization or person. Such data may be exchanged without the consent of (or any notice to) the Covered Person. A Covered Person who claims benefits under this Policy must provide the Company with the data required to apply this Section. PAYMENT AND OVERPAYMENT. Other Plans may make payments which this Plan should have made in accord with this Section. In that event, the Company has the right to reimburse any amount it deems necessary to satisfy the intent of this Section. If the Company pays such benefits to an organization in good faith, it will not be liable to the extent of the payment. The Company also has the right to recover any overpayment it makes because of coverage under another Plan. The Company may recover the amounts needed to satisfy the intent of this Section from any insurance company, organization or person to or for whom Policy benefits were paid. • G1,11 -17.1 COB Savings 24 09/01/01 CLAIMS PROCEDURES FOR DENTAL COVERAGE OOTICE OF CLAIM. Written notice of a claim for Dental Expense Benefits must be given within 20 days after the claim occurs. The notice must be sent to the Company's Home Office and should include: (1) the Group Policyholder's (or Participating Employer's) name and Policy number; (2) the Covered Employee's name, address and certificate number, if available; and (3) the name and relationship of the claimant. If it is not reasonably possible to send notice in the time required, the claim will not be reduced or denied solely for this reason; provided notice is sent as soon as reasonably possible. CLAIM FORMS. When notice of claim is received, the Company will send forms for filing the required proof to the Covered Employee. If the Covered Employee does not receive these forms within 15 days, the proof of claim requirement may be met by giving the Company a written statement of the nature and extent of the claim within the time limit stated in the Proof of Claim provision. PROOF OF CLAIM. The Company must be given written proof of claim within 90 days after the date of services. If it is not reasonably possible to give written proof in the time required, the claim will not be reduced or denied solely for this reason; provided proof is filed as soon as reasonably possible. In any event, proof of the claim must be given no later than one year from such time, unless the claimant was legally incapacitated. Proof of claim may include: (1) a description of the services provided and the Dentist's charges for those services; (2) study models, treatment records or charting; and (3) copies of x -rays or other diagnostic materials. W cePEAL PROCEDURE. The Covered Employee may request a claim review or appeal a claim decision within 60 days after iving the written notice; by sending the Company a written request, along with any written comments or other items to support the appeal. The Company will make its decision within 60 days of its receipt of the appeal; or within 120 days, if an unusual circumstance requires an extension of time to investigate and consider the appeal. TIME OF PAYMENT. The Company will pay any Dental Expense Benefits within 45 days after receipt of acceptable Proof of Loss. If benefits have not been assigned, the Company has the option either to pay the Covered Employee or the provider of services, unless prior to payment the Covered Employee requests otherwise in writing. The Covered Employee or any assignee will be notified in writing within 45 days after receipt of a claim if the claim or any part of it is contested or denied. The notice will identify the contested portion of the claim and the reasons for the contest or denial. The Company will pay or deny any claim within 120 days of its receipt and pay or deny any contested claim within 60 days after receipt of any additional information requested from the Covered Employee or his assignees. Upon written notice, the Company will investigate a Covered Employee's claim of improper billing by a provider of services. If the Company determines the billing was improper, the Company will notify the provider, make an appropriate reduction in the amount of the payment to the provider and pay the Covered Employee the lesser of 20% of the reduction or $500. • GL 1 -18 -CP FL 25 09/01/01 TO WHOM PAYABLE. Dental Expense Benefits will be paid to the Covered Employee; unless such benefits have been assigned or an overpayment has been made. QHIRD PARTY RESPONSIBILITY. If a Covered Person is injured through the act or omission of a third party, and benefits are paid by this Policy due to that injury; then the Company is entitled to a refund of such benefits paid, to the extent any recovery is made by the Covered Person. Upon request, the Covered Person must complete and sign any recovery forms requested by the Company The Company may file a lien for this refund of benefits. LEGAL ACTIONS. No legal action to recover any benefits may be brought until 60 days after the required written Proof of Claim has been submitted. No legal action may be brought after the expiration of the applicable statute of limitations from the time written Proof of Claim is required to be given. PHYSICAL EXAMINATIONS. While a dental claim is pending, the Company may (at its expense): (1) examine any pre- operative dental x -rays and any other pertinent information; and (2) have the Covered Employee or covered Dependent examined, as often as is reasonably necessary. CJ • GL11 -18 -CP FL 26 09/01 /01 DENTAL CLAIM PROCEDURE for • PREDETERMINATION OF BENEFITS If a Covered Person is advised to have non - emergency dental treatment which will cost $300 or more, he or she should find out in advance what charges may be considered Covered Expenses under this Policy. To use this procedure: (1) the Covered Employee should request a claim form and take it to the Dentist; (2) the Dentist will list the proposed procedures and fees on the claim form and return it to the Company; and (3) the Company will verify current eligibility and determine what benefits would be payable for the procedures listed. • �J GL 11- 19B -PD 27 09/01/01 DENTAL COVERAGE CONTINUATION e following provisions comply with the federal Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) as amended. ese provisions apply when Dental Coverage is provided by a private Employer with 20 or more employees (as defined by COBRA). Any further changes made to the COBRA continuation requirements will automatically apply to these continuation provisions. RIGHT TO CONTINUE. Insurance may be continued in accord with the following provisions when: (1) a Covered Person becomes ineligible for Policy coverage due to a Qualifying Event shown below; and (2) this Policy remains in force. "Qualifying Event" means one of the following events, if it would otherwise result in a Qualified COBRA Beneficiary's loss of Policy coverage: (1) the Covered Employee's termination of employment or hours reduction; (2) the Covered Employee's death, divorce or legal separation; (3) the Covered Employee's becoming entitled to Medicare benefits; or (4) a child's ceasing to be an eligible Covered Dependent, under the terms of this Policy. "Qualified Beneficiary" means the Covered Employee and any Covered Dependent who is entitled to continue insurance under this Policy, from the date of the Covered Employee's first Qualifying Event. It also includes the Covered Employee's natural child, legally adopted child or child placed for the purpose of adoption; when the new child: (1) is acquired during the Covered Employee's 18- or 29 -month continuation period; and (2) is enrolled for insurance in accord with the terms of this Policy. But it does not include the Covered Employee's new spouse, stepchild or foster child acquired during that continuation period; whether or not the new Dependent is enrolled for Policy coverage. CONTINUATION PERIODS. The maximum period of continued coverage for each Qualifying Event shall be as follows. - ermination of Employment. When eligibility ends due to the Covered Employee's termination of employment; then coverage for he Covered Employee and any Covered Dependents may be continued for up to 18 months, from the date employment ended. Termination of employment includes a reduction in hours or retirement. Exceptions: (1) Misconduct. If the Covered Employee's termination of employment is for gross misconduct, coverage may not be continued for the Covered Employee or any Covered Dependents. (2) Disability. "Disability" or "Disabled" as used in this section, shall be as defined by Title II or XVI of the Social Security Act and determined by the Social Security Administration. If the Covered Employee: (a) becomes disabled by the 60th day after his or her employment ends; and (b) is covered for Social Security Disability Income benefits; then coverage for the Covered Employee and any Covered Dependents may be continued for up to 29 months, from the date the Covered Employee's employment ended. If the Covered Employee's Dependent: (a) becomes disabled by the 60th day after the Covered Employee's employment ends; and (b) is covered for Social Security Disability Income benefits; then coverage for that Covered Dependent may be continued for up to 29 months, from the date the Covered Employee's employment ended. • GL 11 -20 -COBRA 28 09/01/01 The Covered Employee must send the Company a copy of the Social Security Administration's notice of disability status: • (a) within 60 days after they find that the Covered Person is disabled, and before the 18 -month continuation period expires; and again (b) within 30 days after they find that he or she is no longer disabled. (3) Subsequent Qualifying Event. If the Covered Employee's Dependent: (a) is a Qualified Beneficiary; and (b) has a subsequent Qualifying Event during the 18- or 29 -month continuation period; then coverage for that Covered Dependent may be continued for up to 36 months, from the date the Covered Employee's employment ended. Loss of Dependent Eligibility. If a Covered Dependent's eligibility ends, due to a Qualifying Event other than the Covered Employee's termination of employment; then that Dependent's coverage may be continued for up to 36 months, from the date of the event. Such events may include: (1) the Covered Employee's death, divorce, legal separation, or Medicare entitlement; and (2) a child's reaching the age limit, getting married or ceasing to be a full -time student. One or more subsequent Qualifying Events may occur during the Covered Dependent's 36 -month period of continued coverage; but coverage may not be continued beyond 36 months, from the date of the first event. Medicare Entitlement. If the Covered Employee's eligibility under this Policy ends when he or she becomes entitled to Medicare benefits; then coverage may not be continued for the Covered Employee. But coverage may be continued for any Covered Dependents for up to 36 months, from the Covered Employee's Medicare entitlement date. If the Covered Employee's eligibility under this Policy continues beyond Medicare entitlement, but later ends upon termination of employment or retirement; then any Covered Dependents may continue coverage for up to: (1) 36 months from the Covered Employee's Medicare entitlement date; or • (2) 18 months from the date the Covered Employee's employment ended (whichever is later). NOTICE REQUIREMENTS. The Group Policyholder is required by law to notify the Company within 30 days after the following Qualifying Events: (1) the Covered Employee's termination of employment, hours reduction or retirement; and (2) the Covered Employee's death or becoming entitled to Medicare benefits. The Covered Employee: (1) must notify the Group Policyholder within 60 days of a divorce; a legal separation; or a child's ceasing to be an eligible Dependent, as defined by this Policy; and (2) must notify the Company within 60 days of the Social Security Administration's finding that a Covered Person was disabled within 60 days after the Covered Employee's termination of employment. ELECTION. To continue Dental Insurance, the Covered Person must notify the Group Policyholder of such election within 60 days from the latest of: (1) the date of the Qualifying Event; (2) the date coverage would otherwise end due to the Qualifying Event; or (3) the date the Group Policyholder sends notice of the right to continue. Payment for the cost of the insurance for the period prior to the election must be made to the Group Policyholder, within 45 days after the date of such election. Subsequent payments are to be made to the Group Policyholder, in the manner described by the Group Policyholder. The Group Policyholder will remit all payments to the Company. • GL11 -20 -COBRA 29 09/01 /01 TERMINATION. Continued coverage will end at the earliest of the following dates: (1) the end of the maximum period of continued coverage shown above; •(2) the date this Policy or the Employer's participation under this Policy terminates; (3) the last day of the period of coverage for which premium has been paid, if any premium is not paid when due; (4) the date on which the Covered Person: (a) again becomes covered under this Policy; (b) becomes eligible for benefits under Medicare; or (c) becomes covered under any other group dental plan, as an employee or otherwise. OTHER CONTINUATION PROVISIONS. If any other continuation privilege is available to the Covered Person under this Policy, it will apply as follows. (1) FMLA. If a Covered Employee continues coverage during leave subject to the Family and Medical Leave Act (FMLA); then COBRA continuation may be elected from the day after the FMLA continuation period ends. (2) Other. If a Covered Person continues coverage under any other continuation privilege under this Policy; then that continuation period will run concurrently with any COBRA continuation period provided above. Another continuation privilege may provide a shorter continuation period, for which the Employer pays all or part of the premium. In that event, the Covered Person's share of the premium may increase for the rest of the COBRA continuation period provided above. • • GL11 -20 -COBRA 30 09/01/01 LIST OF DENTAL PROCEDURES TYPE I PROCEDURES �J DIAGNOSTIC & PREVENTIVE SERVICES DIAGNOSTIC SERVICES ORAL EXAMINATIONS - up to two per calendar year DENTAL X -RAYS - x -rays taken for orthodontia or for the diagnosis and treatment of craniomandibular or temporomandibular (TMJ) joint disorders are not covered under this provision of this Policy Bitewing films - up to four per calendar year, including any bitewings taken as part of a full mouth or panoramic series Panoramic x -rays, including bitewings; or Full mouth x -rays, with periapical x -rays and bitewings - one complete full mouth or panoramic series in any five consecutive years Other dental x -rays, needed to diagnose a specific dental condition - maximum of 6 per calendar year PREVENTIVE CARE PROPHYLAXIS (Routine Cleanings) - up to two per calendar year - includes scaling, removal of stain and polishing of teeth FLUORIDE TREATMENTS - one treatment per calendar year • - for Dependent children through age 15 SPACE MAINTAINERS (Passive Appliance) - for Dependent children through age 15 - for the purpose of maintaining spaces created by the premature loss of primary teeth - includes all adjustments within six months after installation - does not include repairs and replacement costs • GL11 -DP.1 31 09/01/01 TYPE II PROCEDURES • BASIC SERVICES SEALANTS: - for Dependent children through age 15 - for the occlusal surface of unrestored and non - decayed first and second permanent molars only - one treatment per tooth in any 36 consecutive months BASIC RESTORATIONS Fillings: amalgam, silicate or composite - benefits for composite fillings of posterior teeth will be limited to the amount payable for an equivalent amalgam filling - multiple restorations on the same tooth will be treated as one restoration with multiple surfaces; and multiple restorations on one surface or adjacent surfaces will be treated as one restoration Prefabricated stainless steel or resin crowns - for covered Dependent children through age 15 - one per tooth, in any 5 consecutive years ORALSURGERY - oral surgery includes local anesthesia and routine post operative visits Simple extraction Surgical removal of erupted tooth Removal of impacted tooth (soft tissue, partially or completely bony) Surgical exposure of impacted or unerupted tooth, to aid eruption - extractions of asymptomatic teeth, except third molars (wisdom teeth), are not covered • - where related to orthodontic treatment, extractions and surgical exposure of teeth are not covered under this provision Removal of exposed roots Surgical removal of residual tooth roots Excision of lesions, malignant or benign tumors Radical resection of bone for tumor with bone graft Incision and removal of foreign body from soft tissue Removal of foreign body from bone Maxillary sinusotomy for removal of tooth fragment or foreign body Suture of soft tissue wound - excludes closure of surgical incisions Incision and drainage of abscess, intraoral or extraoral Frenulectomy Sialolithotomy and Sialodochoplasty Dilation of salivary duct Sequestrectomy for osteomyelitis or bone abscess Closure of fistula, salivary or oroantral Reimplantation of tooth or tooth bud r1 �J GL 11 -DP.2 32 09/01 /01 TYPE II PROCEDURES (continued) OATHOLOGY Biopsy and examination of oral tissue ADMINISTRATION OF ANESTHESIA General anesthesia or I.V. sedation - administered in the Dentist's office by the Dentist or other person licensed to administer anesthesia - payable in connection with a Necessary complex oral surgery procedure - payable when underlying medical condition, age or health factors render anesthesia medically necessary not covered when benefits for the accompanying surgical procedure are not payable not covered when administered due to patient anxiety anesthesia for orthodontic procedures (or for procedures to treat craniomandibular or temporomandibular joint disorders where required by state law) is not covered under this provision of this Policy EMERGENCY TREATMENT Emergency examination and palliative treatment Palliative treatment is limited to: - opening and drainage of a tooth when no endodontics is to follow - smoothing down a chipped tooth - dry socket treatment - pericoronitis treatment - treatment for apthous ulcers Benefits for emergency treatment are payable only if services are rendered in order to relieve dental pain or • dental injury CONSULTATIONS Diagnostic services - provided by a Dentist other than the Dentist providing any treatment - payable if no other services are rendered ENDODONTICS (treatment of diseases of root canal, periapical tissue and pulp chamber) Pulpotomy - primary teeth only Root canal therapy - permanent teeth only - includes necessary x -rays and cultures Apexification Apicoectomy Root amputation Hemisection OTHER BASIC SERVICES Injection of antibiotics - by the Dentist, in the Dentist's office • GL 11 -DP.2 33 09/01/01 TYPE II PROCEDURES (continued) IRERIODONTICS (treatment of disease of the soft tissue or bone surrounding the tooth) - periodontal therapy is not covered unless bone and attachment loss is 4 mm or greater, by quadrant; and confirmed by x -rays and pocket depth charting for each tooth - surgical treatment includes post operative visits - benefits for multiple periodontal surgeries within the same quadrant on the same day will be paid based on the most comprehensive procedure provided that day Gingivectomy or gingivoplasty, by tooth or quadrant Osseous or mucogingival surgery - one per quadrant in each 36 consecutive months Soft tissue graft Bone replacement graft Subepithial connective tissue graft Guided tissue regeneration, per tooth Crown lengthening, per tooth Scaling and root planing, per quadrant, for pathological alveolar bone loss - one treatment per quadrant in each 24 consecutive months Periodontal maintenance cleanings - following active periodontal therapy - four per calendar year; but no more than two in any calendar year if benefits are paid for two routine cleanings in that same calendar year Chemotherapeutics, for areas of refractory disease localized delivery of chemotherapeutic agent by means of a controlled release vehicle - following active periodontal therapy which has failed to resolve the condition - does not include irrigation OEPAIR of PROSTHETICS - no benefits are payable within six months of installation if the repair is provided by the same Dentist who installed the prosthetic Repair of dentures - Repair of complete denture includes repair of broken base and replacement of missing or broken teeth - Repair of partial dentures includes repair of acrylic saddles on base, cast framework, repair or replacement of broken clasp, and replacement of missing or broken teeth Repair or recementation of inlays, crowns and bridges • GL 11 -DP.2 34 09/01/01 • TYPE III PROCEDURES MAJOR SERVICES MAJOR RESTORATIONS Inlays and onlays Crowns and posts - not covered for claimants prior to age 16 Crown build -up, in conjunction with a crown Cast post and core, in conjunction with a crown Cast post, as part of a crown - Inlays, onlays and crowns are covered only when needed due to substantial loss of tooth structure caused by decay or accidental injury to teeth, which cannot be repaired by fillings - replacement of inlays, onlays and crowns is limited to one time in any eight years ORAL SURGERY - ALVEOLAR OR GINGIVAL RECONSTRUCTION Alveolectomy (with or without extractions) Vestibuloplasty Removal of exostosis of the maxilla or mandible - includes removal of tori Excision of hyperplastic tissue PROSTHODONTICS - Fixed or Removable Services to replace teeth extracted or accidentally lost while covered under this Policy - precision attachments, overdentures, specialized techniques and characterizations are not covered Bridge abutments and pontics - replacement is limited to one time in any eight consecutive years • Dentures - includes adjustments, within six months of placement - replacement is limited to once in any five consecutive years, per denture - fees for partial dentures include all conventional clasps, rests and teeth Complete denture - upper or lower Partial denture - upper or lower - acrylic base or predominantly base cast with acrylic saddles Removable unilateral partial denture - one piece, predominantly base casting, clasp attachments (including pontics) Adjustments to dentures, more than six months after installation Special tissue conditioning - one per arch per calendar year Reline of complete or partial denture - once in any 36 consecutive months, per denture Rebase of complete or partial denture - once in any five consecutive years, per denture Addition of teeth or clasp(s) to existing partial denture to replace natural teeth extracted or accidentally lost while covered under this Policy C: GL 11 -DP.3 35 09/01/01 TYPE III PROCEDURES (continued) OURGICAL TREATMENT OF TEMPOROMANDIBULAR JOINT - includes anesthesia and postoperative care - reduction of dislocation, open or closed - manipulation under general anesthesia - condylectomy - excision or repair of disc - synovectomy - myotomy - joint reconstruction - arthrotomy - arthroplasty - arthrocentesis - arthroscopy • • GL 11 -DP.3 36 09/01/01 AMENDMENT TO BE ATTACHED TO AND MADE PART OF GROUP POLICY NO.: XXXXXXXXXXX 0SSUED TO: Florida - Dental Specimen PRIOR CARRIER CREDIT PROVISION. This provision applies when: (1) the Schedule of Benefits shows that the Prior Carrier Credit Provision applies; and (2) the Covered Person: (a) is covered under the Group Policyholder's prior group dental plan on the day before Dental Expense Benefits under this Policy take effect; and (b) immediately becomes covered under this dental plan on the day the Group Policyholder's Dental Expense Benefits under this Policy take effect. If this provision applies, then the Covered Person's Dental Expense Benefits will be payable as follows. (1) Any amounts used to satisfy the Covered Person's Deductible under the prior plan will be credited towards the satisfaction of his or her Deductible under this Policy; provided: (a) the expenses would be Covered Expenses under this Policy; (b) the expenses are incurred during the same Calendar Year in which Dental Expense Benefits under this Policy take effect; and (c) the Covered Person sends the Company a claim worksheet explaining the benefits paid by the prior plan. (2) The Covered Person's continuous months of coverage under the prior plan just before it terminated will count towards this Policy's Benefit Waiting Period for Type II Procedures (Basic Care) or Type III Services (Major Care), if any. (3) Expense that the Covered Person incurs for initial placement of a prosthetic appliance or fixed bridge will be covered; provided: (a) the placement is needed to replace one or more natural teeth extracted while insured for Dental Expense Benefits under this Policy or under the prior plan; (b) the replacement would have been covered under the prior plan; and • (c) the extracted teeth are not third molars (wisdom teeth). This amendment takes effect on the day the Group Policyholder's Dental Expense Benefits under this Policy take effect. In all other respects, this Policy remains the same. Error! Not a valid filename. • GL 11- R -PIC.2 Jefferson Pilot Financial Insurance Company 37 09/01/01