YOUR GROUP LIFE AND
ACCIDENTAL DEATH AND
DISMEMBERMENT BENEFITS
Kerr County
Effective January 1, 2005
HOW TO OBTAIN PLAN BENEFITS
To obtain benefits see the Payment of Claims provision.
Forward your completed claim form to:
Kerr County
Kerr County Courthouse
700 Main Street
Kerrville, TX 78028
CLAIM ASSISTANCE
If you need assistance with filing your claim or an explanation of how your claim was paid, contact the:
United of Omaha Life Insurance Company
Mutual of Omaha Plaza
Omaha, Nebraska 68175
Call Toll-Free: 1-800-775-8805
When contacting the Company please have your policy number available. Your policy number is
GLUG-487A.
BENEFITS SUMMARY
Kerr County
GLUG-487A
Effective: January 1, ?005
' This Benefits Summary provides a brief description of some of the features and benefits of Your group
Life Insurance Plan. This summary is not a contract. For a complete description of the benefits, covered
services and exclusions and limitations of the services, refer to the appropriate section of the Certificate.
Who is Covered :............................................................................................All eligible active employees
Minimum Work Hours Required :..............................................................................30 hours each week
Eligibility Waiting Period:
Present ................................................................................................For employees in an eligible class on
or before the Policy Effective Date:
30 days of continuous Active Work
Future ..................................................................................................For employees in an eligible class on
or after the Policy Effective Date:
30 days of continuous Active Work
Life Insurance Benefit for You :.....................................................................................................$20,000
Accidental Death & Dismemberment
Benefit for You :............................................................................An amount equal to the Amount of Life
Insurance in force on Your life
Reductions :..........................................
....................Benefits reduce at a specified age
Life Insurance
IMPORTANT NOTICE
To obtain information or to make a complaint you
may contact the Company that issued the
policy/certificate.
You may contact the Texas Department of
Insurance to obtain information on companies,
coverages, rights or complaints at:
1-800-252-3439
AVISO IMPORTANTE
Para obtener infonnacion o paza someter una queja
puede comunicarse con la compania que emitio la
poliza o el certificado.
Puede comunicarse con el Departamento de
Seguros de Texas paza obtener information acerca
de compaiiias, coberturas, derechos o quejas aL•
1-800-252-3439
You may write the Texas Department of Insurance: Puede escribir al Departamento de Seguros de
Texas:
P.O.Box 149104
Austin, TX 78714-9104
FAX # (512)475-1771
P.O.Box 149104
Austin, TX 78714-9104
FAX # (512)475-1771
PREMIUM OR CLAIM DISPUTES:
Should you have a dispute concerning your
premium or about a claim you should contact the
company first. If the dispute is not resolved, you
may contact the Texas Department of Insurance.
ATTACH THIS NOTICE TO YOUR
CERTIFICATE:
This notice is for information only and does not
become a part or condition of the attached
document.
7914GI-EZ 5-92
DISPUTAS SOBRE PRIMAS O RECLAMOS:
Si tiene una disputa concerniente a su prima o a un
reclamo, debe comunicarse con la compaiiia
primero. Si no se resuelve la disputa, puede
entonces comunicarse con el departamento (TDI).
ANEXE ESTE AVISO A SU CERTIFICADO:
Este aviso es solamente paza proposito de
information y no forma parte ni es condition del
documentos adjunto.
(*~~~
WORKERS' COMPENSATION NOTICE
THE INSURANCE POLICY UNDER WHICH THIS CERTIFICATE IS ISSUED IS NOT A
POLICY OF WORKERS' COMPENSATION INSURANCE. YOU SHOULD CONSULT YOUR
EMPLOYER TO DETERMINE WHETHER YOUR EMPLOYER IS A SUBSCRIBER TO THE
WORKERS' COMPENSATION SYSTEM.
Table of Contents
The key sections of your booklet
appear in the following order.
Page
CERTIFICATE OF INSURANCE ....................................................................................................1
DEFINITIONS .....................................................................................................................................2
EMPLOYEE ELIGIBILITY ..............................................................................................................3
RIDER FAMILY AND MEDICAL LEAVE .....................................................................................8
SCHEDULE ........................................................................................................................................10
LIFE INSURANCE BENEFITS
For You .........................................................................................................................................12
LIFE INSURANCE BENEFITS
For You LIVING BENEFITS OPTION ....................................................................................14
ACCH)ENTAL DEATH AND DISMEMBERMENT BENEFITS ...............................................16
GENERAL EXCLUSIONS AND LIMITATIONS ........................................................................19
PAYMENT OF CLAIMS ..................................................................................................................20
CLAIM REVIEW AND APPEAL PROCEDURES
(As Federally Mandated) .............................................................................................................22
STANDARD PROVISIONS .............................................................................................................25
CERTIFICATE OF INSURANCE
UNITED OF OMAHA
LIFE INSURANCE COMPANY
Home Office: Mutual of Omaha Plaza
Omaha, Nebraska 68175
United of Omaha Life Insurance Company certifies that Group Policy No(s). GLUG-487A (policy) has
been issued to Kerr County (Policyholder).
You are insured as described in this Certificate, subject to the terms and conditions of the policy. Your
insurance begins on the date shown on your Certificate Validation Form.
CERTIFICATE VALIDATION FORM
NAME: JOHN DOE
GROUP POLICY NO: GLUG-487A
SOCIAL SECURITY NO: 000-00-0000
United of Omaha Life Insurance Company
Chairman an~ E%O V Corporate Secr
Attach this form to the Certificate of Insurance.
Form 70006V-U-EZ
No. 18 (")
Your insurance ends as set forth in the When Your Insurance Ends section of this Certificate.
If the provisions of this Certificate and those of the policy do not agree, the provisions of the policy will
apply.
I ~.*)
7000CI-U-EZ No.S
DEFINITIONS
When used in the policy or your certificate:
Our, We, i3s means the Company shown on your Certificate of Insurance.
You, Your, Insured Person means an employee or member who is insured under the policy.
Sickness means a disease, disorder or condition, which requires treatment by a physician.
Injury means an accidental bodily injury which requires treatment by a physician. It must result in loss
independently of sickness and other causes.
Physician means a licensed practitioner shown under Article 3.70-2 Subsection B of the Texas
Insurance Code who is operating within the scope of his or her license.
A physician does not include a person who lives with you or is part of your family (you; your spouse; or
a child, brother, sister or parent of you or your spouse).
Total Disability or Totally Disabled means that because of an injury or sickness you are completely
and continuously unable to perform any work or engage in any occupation.
Rider means a provision added to the policy or your certificate to expand or limit benefits or coverage.
TX No. 10 (***)
7001GD-EZ 93 2 Life or Life & AD&D
EMPLOYEE ELIGIBILITY
Life Insurance
Definitions
Terms defined in this provision may be used in, or apply to other provisions throughout this Policy,
Certificate and any Riders. Definitions of other terms may be found in other provisions. Any singular
- word shall include any plural of the same word.
Active Employment or Actively Employed means Actively Working on a regular and consistent basis
for the Policyholder 30 or more hours each week.
Actively Working or Active Work means performing the normal duties of a regular job for the
Policyholder at:
(a) the Policyholder's usual place of business;
(b) an alternative work site at the direction of the Policyholder; or
(c) a location to which one must travel to perform the job.
An Employee will be considered Actively Working on any day that is:
(a) a regular paid holiday or day of vacation;
(b) a regular or scheduled non-working day; or
(c) a day on which the Employee is on a qualified family or medical leave of absence as defined by
the Family and Medical Leave Act of 1993;
provided the Employee was Actively Working on the last preceding regular work day.
If an Employee's customary place of employment is at home, the Employee will be considered Actively
Working if not confined on that day as described in the Confinement Rule.
Confinement Rule
1. If an eligible Employee is confined due to an Injury or Sickness:
(a) in a hospital as an inpatient;
(b) in any institution or facility other than a hospital; or
(c) at home and under the supervision of a Physician;
insurance will begin on the first day of the Policy month which coincides with or follows the day the
Employee returns to Active Work.
2. If an eligible Employee is not:
(a) confined; and
3 2002 (*)
7017GP-EZ 7-86 WAIVER
(b) available for work because of an Injury or Sickness;
insurance will begin on the first day of the Policy month which coincides with or follows the day the
Employee returns to Active Work.
Employee means a person who receives compensation from the Policyholder for work performed for the
Policyholder.
The term Employee does not include any person performing services for the Policyholder:
(a) pursuant to an independent contractor relationship with the Policyholder;
(b) subject to the terms of a leasing agreement between the Policyholder and a leasing organization;
(c) who receives income which is reported by the Policyholder on IRS form 1099;
(d) on a seasonal basis; or
(e) on a temporary basis.
Eligible Employees
An Employee who has completed 30 days of continuous Active Employment on or before January 1,
2005 becomes eligible for insurance under this Policy on January 1, 2005.
An Employee who is not eligible for insurance under this Policy on January 1, 2005, or an Employee
who is hired after January 1, 2005, becomes eligible for insurance under this Policy on the day following
completion of 30 days of continuous Active Employment.
When Insurance Becins
An Employee will become insured on the first day of the Policy month which coincides with or follows
the day the Employee becomes eligible, provided the Employee is Actively Working on that day. If the
Employee is not Actively Working on that day, insurance will begin on the first day of the Policy month
which coincides with or follows the day the Employee returns to Active Work.
If an Employee was eligible for group life coverage under a plan maintained by the Policyholder
immediately prior to the effective date of this Policy but did not elect coverage under such plan, the
Employee may enroll for insurance under this Policy if the Employee is otherwise eligible and provides
Us with evidence of good health. If such evidence is acceptable to Us, We will determine the day
insurance begins.
When Your Classification or the Amount of Insurance Chances
Any change in Your classification, coverage or amount of Your insurance as shown in the Schedule will
take effect on the first day of the Policy month which coincides with or follows the day of the change,
provided You are Actively Working on that day. We will use the Policyholder's payroll records and
premiums We have received to determine the appropriate amount of insurance. If You are not Actively
Working on that day, the following conditions will apply:
(a) If the change involves an increase in the amount of insurance, the change will not take effect
until the first day of the Policy month which coincides with or follows the day You return to
Active Work.
4
(b) If the change involves a decrease in the amount of insurance, the change will take effect on the
day of the change.
When Your Insurance Ends
Your insurance will end at midnight at the main office of the Policyholder on the earliest of:
(a) the day this Policy ends;
- (b) the day any premium contribution for Your insurance is due and unpaid;
(c) the day before You enter the Armed Forces on active duty (except for temporary active duty of
two weeks or less); or
(d) the last day of the Policy month in which You are no longer eligible. You will no longer be
eligible when the earliest of the following occurs:
(1) You are not in an eligible classification described in the Schedule;
(2) Your employment with the Policyholder ends;
(3) You are not Actively Employed; or
(4) You do not satisfy any other eligibility condition described in this Policy.
Continuation of Life Insurance and Accidental Death and Dismemberment Benefits
Upon uninterrupted payment of premium to Us, You may continue insurance in accordance with this
provision after insurance would otherwise end. You should contact the Policyholder to determine the
amount of contribution, if any, You are required to make in order to continue insurance.
Layoff or Leave of Absence
Your insurance will continue until the last day of the month in which You have been laid off or go on a
leave of absence approved by the Policyholder.
Disability Elimination Period
Your insurance will continue during the Disability Elimination Period as long as You remain Totally
Disabled. The Disability Elimination Period is the nine consecutive months of Total Disability
beginning on the date You first become Totally Disabled.
If Your employment or membership in a class ends, or if this Policy or a class terminates during Your
Disability Elimination Period, You may apply for an individual life insurance conversion policy
according to the terms of the Conversion Privilege provision in this Policy. If Your proof of Total
Disability is accepted by Us in accordance with the Continuation of Life Insurance Benefits Due to
Total Disability provision, You may surrender Your conversion policy and premiums paid for such
policy will be refunded.
If You die during the Disability Elimination Period, and We determine that You were Totally Disabled
on the day before the date of Your death, benefits under this Policy will be paid to Your beneficiary. If a
conversion policy has been issued to You, We will pay benefits under the Continuation of Life
Insurance Benefits Due to Total Disability provision:
(a) upon Our acceptance of Your proof of Total Disability in accordance with the Continuation of
Life Insurance Benefits Due to Total Disability provision; and
5
(b) upon Your death during the Disability Elimination Period,
only if the conversion policy is surrendered or terminated without claim. We will refund all paid
conversion policy premiums if Your conversion policy is surrendered or terminated for this reason.
After completing the Disability Elimination Period, You may continue Your insurance in accordance
with the Continuation of Life Insurance Benefits Due to Total Disability provision.
If You are eligible for continuation of Life Insurance Benefits during the Disability Elimination Period,
Accidental Death and Dismemberment Benefits will be continued under the same conditions as for Life
Insurance Benefits; however, Accidental Death and Dismemberment Benefits shall automatically
terminate on the earlier of:
(a) the completion of the Disability Elimination Period; or
(b) the date You are no longer Totally Disabled.
Continuation of Life Insurance Benefits Due to Total Disability
If You aze Totally Disabled, Your Life Insurance Benefits will not end in accordance with the When
Your Insurance Ends provision, but will be continued without payment of premium provided:
(a) the Total Disability began while You were insured under this Policy;
(b) the Total Disability began before You reached age 60;
(c) You have completed Your Disability Elimination Period; and
(d) Proof of the Total Disability is given to Us as described in the following pazagraphs.
You must notify Us in writing of Your Total Disability during the Disability Application Period. The
Disability Application Period is the nine consecutive months of Total Disability beginning on the date
You first become Totally Disabled. After receiving Your notification, We will send You an Initial Proof
of Total Disability form for You and Your Physician to complete. You must return this form to Us
within 90 days after receipt. Upon Our satisfactory acceptance of Your initial proof of Total Disability,
Your Life Insurance Benefits will continue without payment of premium for at least one year as long as
You continue to be Disabled.
After You have completed Your Disability Elimination Period, We will periodically send You a
Subsequent Proof of Disability form for You and Your Physician to complete. If Your Subsequent Proof
of Disability is not acceptable to Us, You will be notified in writing, otherwise Your Life Insurance
Benefits will be continued without payment of premium for at least one year, as long as You continue to
be Disabled.
In order to confirm that You are Totally Disabled, We have the right to have You examined by a
Physician of Our choice at Our expense. We may have You examined any time during the first two
years of disability and once a year thereafter.
Your continued Life Insurance Benefits is the amount of insurance in force on the day insurance would
have otherwise ended. However, continued Life Insurance Benefits provided under this Continuation of
Life Insurance Benefits Due to Total Disability provision shall be reduced or terminated in
accordance with the terms of the Schedule.
6
When Continuation of Life Insurance Ends
Total Disability
Your continued insurance will end at midnight at the main office of the Policyholder on the earliest of:
(a) the day You are no longer Totally Disabled;
(b) 90 days after an Initial or Subsequent Proof of Total Disability form is sent to You, but not
returned to Us;
(c) the day You fail to attend an examination or cooperate with an examiner in accordance with the
Continuation of Life Insurance Benefits Due to Total Disability provision; or
(d) the day You reach age 65.
When Your Total Disability ends, You have 31 days to convert Your insurance to an individual life
insurance conversion policy; but Your conversion insurance will end if You again become insured under
this Policy. A conversion policy may only be obtained in accordance with the Conversion Privilege
provision in this Policy.
Layoff or Leave of Absence
Your continued insurance will end at midnight at the main office of the Policyholder on the earliest of:
(a) the day this Policy ends;
(b) the day any premium contribution for Your insurance is due and unpaid;
(c) the day before You enter the Armed Forces on active duty (except for temporary active duty of
two weeks or less);
(d) the day You return to Active Employment or begin employment with an employer other than the
Policyholder; or
(e) on the last day of the month in which You have been laid off or go on a leave of absence
approved by the Policyholder.
7
RIDER
FAMILY AND MEDICAL LEAVE
as Federally Mandated
This rider is made a part of Group Policy GLUG-487A.
This rider is effective on the later o£
(a) the effective date of the policy; or
(b) the date required by Federal law.
If the provisions of this rider and those of the policy or Your certificate do not agree, the provisions of
this rider will apply.
Family and Medical_Leave
If You become eligible for a family or medical leave of absence in accordance with the Family and
Medical Leave Act of 1993 (FMLA) (including any amendments to such Act) Your insurance coverage
may be continued on the same basis as if You were an Actively at Work employee for up to 12 weeks
during the 12 month period, as defined by Your employer, for any of the following reasons:
(a) to care for Your child after the birth or placement of a child with You for adoption or foster care;
so long as such leave is completed within 12 months after the birth or placement of the child;
(b) to care for Your spouse, child, foster child, adopted child, stepchild, or parent who has a serious
health condition; or
(c) for Your own serious health condition.
In the event You or Your spouse are both insured as employees of the Policyholder, the continued
coverage under (a) may not exceed a combined total of 12 weeks. In addition, if the leave is taken to
care for a parent with a serious health condition, the continued coverage may not exceed a combined
total of 12 weeks.
Conditions
If, on the day Your insurance is to begin, You aze already on an FMLA leave of absence You will be
considered Actively at Work. Insurance for You and any eligible dependents (if applicable) will
begin in accordance with the terms of the policy. However, if Your leave of absence is due to a
serious health condition, benefits for that condition will not be payable to the extent benefits are
payable under any prior group plan.
2. You are eligible to continue coverage under FMLA i£
(a) You have worked for Your employer for at least one year;
(b) You have worked at least 1,250 hours over the previous 12 months;
(c) Your employer employs at least 50 employees within 75 miles from Your worksite; and
TX (*)
11969GR-EZ 8 94 FMLA-B
(d) You continue to pay any required premium for yourself and any eligible dependents (if
applicable) in a manner determined by Your employer.
3. In the event You choose not to pay any required premium during Your leave, Your insurance
coverage will not be continued during the leave. You will be able to reinstate Your coverage on the
day You return to work, subject to any changes that may have occurred in the policy during the time
You were not insured. You and any insured dependents (if applicable) will not be subject to any
evidence of good health requirement provided under the policy. Any partially-satisfied waiting
periods, including any limitations for a preexisting condition, which are interrupted during the period
of time premium was not paid will continue to be applied once coverage is reinstated.
4. You and Your dependents (if applicable) are subject to all conditions and limitations of the policy
during Your leave, except that anything in conflict with the provisions of the FMLA will be
construed in accordance with the FMLA.
5. If requested by Us, You or Your employer must submit proof acceptable to Us that Your leave is in
accordance with FMLA.
6. FMLA continuation ends on the earliest of:
(a) the day You return to work;
(b) the day You notify Your employer that You are not returning to work;
(c) the day Your coverage would otherwise end under the policy; or
(d) the day coverage has been continued for 12 weeks.
Definitions
Prior Group Plan means the group plan providing similar benefits (whether insured or self-insured
plans provided by the Policyholder) in effect immediately prior to the effective date of this policy.
Serious Health Condition is defined as stated in the FMLA.
Important Notice
Contact Your employer for additional information regarding FMLA.
9
THE DEFINITIONS, GENERAL EXCLUSIONS AND LIMITATIONS AND RIDERS ARE
VERY IMPORTANT PARTS OF YOUR POLICY. PLEASE READ THOSE PAGES
CAREFULLY.
SCHEDULE
The amount of insurance for You will be in accord with Your classification in this Schedule.
Classification(s)
All eligible active employees
For You
LIFE INSURANCE
Any group life insurance benefits combined will not exceed the greater o£
(a) $250,000; or
(b) Five times Your annual salary.
Life Insurance Benefits
Amount of Life Insurance ..............................
Facility of Payment Amount ..........................
......................................................................$20,000
......................................................................... * $250
*This amount, if paid, will be deducted from the Amount of Life Insurance shown above.
Life Insurance Benefits will be reduced as follows:
If you are age:
65 ............................................................
70 .....................
75 .....................
80 .....................
85 .....................
90 ......................
The Amount of Life Insurance
shown above will reduce to:
......................................................................................65
......................................................................................45%
......................................................................................30%
......................................................................................20%
............................................................................................................................15
............................................................................................................................10%
The reduction will be made on the first day of the Policy month which coincides with or follows the day
You attain the specified age.
If You are age 65 or older on the day You become insured under the Policy, the reduction will be made
in accord with Your attained age.
Life Insurance Benefits end on the date of Your retirement.
NOTE: The Amount of Life Insurance outlined above will be reduced by the Amount of Living
Benefits paid under the Living Benefits Option. In the event of Your death, the life insurance
benefit will equal the original Amount of Life Insurance multiplied by the life reduction
percentage, reduced by any Living Benefits paid under this Policy.
7000GS-U-EZ 10
Life Insurance Benefts
Living Benefits Option
Amount of Living Benefits ...................................................................50% of the amount of life insurance
in force on Your life, but not to exceed $100,000.
HEALTH INSURANCE
(For You)
Accidental Death and Dismemberment Benefits
Principal Sum ..............................An amount equal to the Amount of Life Insurance in force on Your life;
however, if Your Life Insurance Benefit has been reduced by the
Living Benefits Option, such reduction will not apply to this
Accidental Death and Dismemberment Principal Sum.
11
LIFE INSURANCE BENEFITS
For You
Benefits
If you die while insured under this provision, we will pay the Amount of Life Insurance shown in the
Schedule. Benefits will be paid to the beneficiary you name. If you do not name a beneficiary or if no
beneficiary survives you, benefits will be paid:
(a) to your surviving spouse; if none, then
(b) to your surviving natural and/or adopted children; if none, then
(c) to your surviving parent(s); if cone, then
(d) to your estate.
Benefits will be paid equally among surviving children or surviving parents.
Mode of Pa ment
We will pay benefits:
(a) in a lump sum; or
(b) in other than a lump sum if:
(1) another mode of payment is requested as described below; and
(2) we agree to it in writing.
Beneficiary or Mode of Pavment Chance
The beneficiary and mode of payment may be changed unless this right has been given up. To make a
change, written request should be sent to the office where the beneficiary records are kept. If you do not
know where the records are kept, send the request to us. When recorded and acknowledged, the change
will take effect as of the date the request is signed. However, the change will not apply to any payments
or other action taken by us before the request was acknowledged.
Facility of Pavment
We may pay up to the Facility of Payment Amount to any person who has incurred expenses for your
fatal illness or burial. The Facility of Payment Amount is shown in the Schedule.
We may also make monthly payments of not more than $50.00 to someone other than a beneficiary if:
(a) the beneficiary is a minor or, in our opinion, does not have the legal capacity to sign a receipt for
payment; and
(b) there is no court-appointed guardian or conservator.
We will make these payments to the person or institution who cares for or supports the beneficiary until
claim is made for the remainder of the proceeds by acourt-appointed guardian or conservator.
1008GI-C-EZ
No. 2 (**)
12
Conversion Privileee
If any of your life insurance ends because your employment or membership in a class ends, you may
apply for an individual policy of life insurance (called a conversion policy) without giving information
about your health. Issuance of a conversion policy is subject to the following conditions:
(a) You may apply for any of our individual life insurance policies except term insurance. You may
not apply for any supplemental coverage.
(b) You may apply for an amount which is not more than the amount of your terminated group life
insurance.
(c) The premium for your conversion policy will be at our standard rate for that type of policy
according to:
(1) your class of risk; and
(2) your age on the date the policy takes effect.
(d) You must submit your written application and your first conversion premium to us within 31
days after your group life insurance ends or reduces.
If your group life insurance ends because of termination of the policy or termination of a class, and you
have been insured under the policy at least five years, you may apply within 31 days for a conversion
policy. Issuance of the conversion policy is subject to conditions (a), (c) and (d) above. Your converted
life insurance may not exceed the lesser of:
(a) $2,000; or
(b) the amount of your terminated group life insurance less the amount of any other group life
insurance for which you become eligible within 31 days.
If you die within the 31-day period after insurance ends, we will pay the amount of group life insurance
you were entitled to convert.
If we issue a conversion policy and you again become eligible for group life insurance under the policy,
coverage will become effective only if:
(a) you terminate the conversion policy; or
(b) you submit, at your own expense, evidence of good health acceptable to us.
13
LIFE INSURANCE BENEFITS
For You LIVING BENEFITS OPTION
(ACCELERATED BENEFITS)
DISCLOSURE: The acceleration of life insurance benefits offered under this rider may or may not
qualify for favorable tax treatment under the Internal Revenue Code of 1986. Whether such benefits
qualify depends on factors such as Your life expectancy at the time benefits are accelerated or whether
You use the benefits to pay for necessary long-term care expenses, such as nursing home care. If the
accelerated life insurance benefits qualify for favorable tax treatment, the benefits will be excludable
from Your income and not subject to federal taxation. Tax laws relating to accelerated life insurance
benefits aze complex. You are advised to consult with a qualified tax advisor about circumstances under
which You could receive accelerated life insurance benefits excludable from income under federal law.
Receipt of Living Benefits may affect eligibility for public assistance programs, such as Medicaid, Aid
to Families with Dependent Children, Supplemental Social Security Income and drug assistance
programs for You or Your family. You should consult with Your personal tax advisor and social service
agencies as to how this benefit will affect You, Your spouse and your family's eligibility for public
assistance.
Benefits
If We receive a satisfactory medical opinion; based on standard and accepted medical practices as
determined by Our Physicians, that You have incurred a Terminal Illness, You or Your legal
representative, while You are living, may request Living Benefits.
The Amount of Living Benefits is shown in the Schedule, and will be payable provided You are living at
the time payment is made. Benefits will be paid in one lump sum.
Conditions
(a) DEATH BENEFITS WILL BE REDUCED IF AN ACCELERATED LIFE INSURANCE
BENEFIT I5 PAID.
A statement will be sent to You specifying the effect of the benefit payment on the death benefit
and future premiums.
(b) To be insured for Living Benefits, You must be insured for Life Insurance Benefits.
(c) We may require Your beneficiary's, and in community property states, Your spouse's written
consent before Living Benefits are paid.
(d) The accelerated benefit and the balance of the death benefit will constitute the full settlement on
maturity of the face amount of the benefit.
(e) An Insured Person may receive Living Benefits only once.
Definition
Terminal Illness means an illness or physical condition, including a physical injury that can reasonably
be expected to result in death in 24 months or less.
(***)
9536GI-EZ TX 00 14 W/O Supp
Exceptions
This Living Benefits provision will not apply:
(a) when You have irrevocably assigned Your Life Insurance Benefits;
(b) when all or a portion of Your Life Insurance Benefits are to be paid to Your former spouse as
part of a divorce agreement;
(c) to any intentionally self-inflicted injury or suicide attempt;
(d) if Your Life Insurance ends;
(e) if the required premium is due and unpaid;
(f) to any supplemental life insurance benefits to which you may be entitled; or
(g) if the Master Policy ends.
15
ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS
For You
Benefits
If, while insured under this provision, You are injured as a result of an Accident, and that Injury is
independent of Sickness and all other causes, We will pay the Benefit shown in the Table below for any
of the following losses:
TABLE
Loss
Loss of Life .....................................................................
Loss of Both Hands .........................................................
Loss of Both Feet ............................................................
Loss of Entire Sight of Both Eyes ...................................
Loss of Entire Sight of One Eye .....................................
Loss of One Hand and One Foot .....................................
Loss of One Hand and Entire Sight of One Eye .............
Loss of One Foot and Entire Sight of One Eye ...............
Loss of Thumb and Index Finger of same Hand .............
Loss of Speech and Hearing (both ears) .........................
Loss of Speech or Hearing (both eazs) ............................
Loss of One Hand or One Foot .......................................
Benefit
........................................................Principal Sum
........................................................Principal Sum
........................................................Principal Sum
........................................................Principal Sum
.........................................One-half Principal Sum
........................................................Principal Sum
........................................................Principal Sum
........................................................Principal Sum
.....................................One-fourth Principal Sum
........................................................Principal Sum
.........................................One-half Principal Sum
.........................................One-half Principal Sum
The Principal Sum is shown in the Schedule.
If the Injury causes more than one loss, We will pay only the largest Benefit.
Definitions
Accident means a sudden, unexpected and unintended event, independent of sickness and all other
causes. Accident does not include sickness, disease, bodily or mental infirmity or medical or surgical
treatment thereof, bacterial or viral infection, regardless of how contracted. Accident does include
bacterial infection that is the natural and foreseeable result of an accidental external bodily injury or
accidental food poisoning.
Loss of a Hand or Foot means complete Severance of at least four whole fingers from one hand or
Severance above the ankle joint.
Loss of Sight means the total, permanent Loss of Sight of the eye. The Loss of Sight must be
irrecoverable by natural, surgical or artificial means.
Loss of Speech means total, permanent and irrecoverable loss of audible communication.
Loss of Hearing means total and permanent Loss of Hearing in both ears which cannot be corrected by
any means.
~*)
306GI-EZ 97 16
Loss of a Thumb and Index Finger means complete Severance through or above the
metacarpophalangeal joints (the joints between the fingers and the hand).
Severance means the complete separation and dismemberment of the part from the body.
Traveling on Business of the Policyholder means any trip made by You on assignment by or with
authorization of the Policyholder for the purpose of furthering the business of the Policyholder.
Pavment For Loss of Life
Beneficiary
Benefits payable under this provision because of Your death, will be paid to the beneficiary You name.
If You do not name a beneficiary or if no beneficiary survives You, benefits will be paid:
(a) to Your surviving spouse; if none, then
(b) to Your surviving natural and/or adopted children; if none, then
(c) to Your surviving parent(s); if none, then
(d) to Your estate.
Benefits will be paid equally among surviving children or surviving parents.
Mode of Payment
We will pay death benefits:
(a) in a lump sum; or
(b) in other than a lump sum if:
(1) another mode ofpayment is requested as described below; and
(2) We agree to it in writing.
Beneficiary or Mode of Payment Change
The beneficiary and mode of payment may be changed unless this right has been given up. To make a
change, written request should be sent to the office where the beneficiary records aze kept. If You do not
know where the records aze kept, send the request to Us. When recorded and acknowledged, the change
will take effect as of the date the request is signed. However, the change will not apply to any payments
or other action taken by Us before the request was acknowledged.
Pavment For Other Than Loss Of Life
Benefits payable under this provision for any loss other than life will be paid to You in a lump sum.
Exposure and Disappearance
You will be presumed to have died, for the purposes of this coverage, if after the forced landing,
stranding, sinking or wrecking of a vehicle:
(a) You disappear;
(b) Your body is not found; and
17
(c) a valid death certificate is issued by a court of appropriate jurisdiction.
Exceutions
We will not pay for any loss which:
(a) is not permanent;
(b) occurs more than 365 days after the Injury;
Note: This 365 day limit will not apply if You are in a coma or being kept alive by an artificial
support system at the end of the 365 days.
(c) does not result from an Accident;
(d) is caused by intentional, self-infliction of carbon monoxide poisoning emanating from a motor
vehicle;
(e) results from injuries You receive in any aircraft other than while riding as a passenger in a
commercial aircrafr on a regularly scheduled flight; or while:
(1) operating;
(2) riding as a passenger in; or
(3) boarding or leaving;
any aircraft while You are Traveling on Business of the Policyholder, provided the aircraft:
(1) has a current and valid FAA (Federal Aviation Administration of the United States) standard
air worthiness certificate; and
(2) is operated by a person holding a current and valid FAA pilot's certificate of rating
authorizing him or her to operate the aircraft;
(f) results in injuries You receive while riding in any aircraft engaged in:
(l) racing;
(2) endurance tests; or
(3) acrobatic or stunt flying;
(g) is caused by You, and is a result of injuries You receive, while under the influence of any
Controlled Drug, unless administered on the advice of a Physician;
Note: Controlled Drug means any drug having the capacity to affect behavior and regulated by
law with regard to possession and use.
(h) is caused by You, and is a result of injuries You receive, while Intoxicated;
Note: Intoxicated means Your blood alcohol level at death or dismemberment equals or exceeds
the legal limit for operating a motor vehicle in the jurisdiction in which the loss occurs; or
(i) is excluded under the General Exclusions and Limitations.
18
GENERAL EXCLUSIONS AND LIMITATIONS
These General Exclusions and Limitations do not apply
to any Life Insurance Benefits provisions.
We do not pay under the Accidental Death and Dismemberment Benefits provisions for:
(a) any loss which results, whether the insured person is sane or insane, from:
(1) an intentionally self-inflicted injury or sickness; or
(2) suicide or attempted suicide;
(b) any loss resulting from the insured person's participation in a riot or in the commission of a
felony;
(c) any loss which results from an act of declared or undeclazed war or armed aggression; or
(d) any loss:
(1) which is incurred while the insured person is on active duty or training in the Armed Forces,
National Guazd or Reserves of any state or country; and
(2) for which any governmental body or its agencies are liable.
19 No. 8 LIFE & AD&D ONLY (**)
7002GE-EZ 93 AD&D:OCC
PAYMENT OF CLAIMS
How to File Claims
Before benefits are paid, we must be given a written proof of loss, as described below. In the event of
your death or incapacity, your beneficiary or someone else may give us the proof.
Proof of Loss Requirements
1. First, request a claim form from the Plan Administrator or from us.
This request should be made:
(a) within 20 days after a loss occurs; or
(b) as soon as reasonably possible.
When we receive the request, we will send a claim form for filing proof of loss. If we do not send it
within 15 days, you can meet the proof of loss requirement by giving us a written statement of what
happened. We must receive a written statement within the time shown in 3 below.
2. Next, complete and sign the claim form. If a physician must complete part of the claim form, have
the physician complete and sign that part.
3. Finally, return the claim form to the Plan Administrator or to us. The claim form is due:
(a) within 90 days after the loss occurs; or
(b) as soon as reasonably possible, but not later than one yeaz after (a) above, unless the claimant is
not legally capable.
When Claims are Paid
Policy benefits will be paid as soon as we receive acceptable proof of loss, but in no event more than 60
days.
Direct Payments
Any loss of life benefit will be paid in accord with the Life Insurance Benefits and/or Accidental Death
and Dismemberment Benefits provision(s).
Any other benefits will be paid to you except that benefits unpaid at your death may be paid, at our
option to:
(a) your beneficiazy; or
(b) your estate.
If your beneficiary is unable to give a valid release or if benefits unpaid at your death are not more than
$1,000, we may pay up to $1,000 to any relative of yours who we find is entitled to the benefit.
Any payment made in good faith will fully discharge us to the extent of the payment.
(*)
7023PC-U-EZ 20 No. 7 TX
Examination and Autonsy
We sometimes require that a claimant be examined by a physician of our choice. We will pay for these
examinations. We will not require more than a reasonable number of examinations. Where not
prohibited by law, we may also require an autopsy. We will pay for this autopsy.
21
CLAIM REVIEW
AND APPEAL PROCEDURES
(As Federally Mandated)
For Group Policy GLUG-487A, this provision is effective the later of:
(a) the effective date of the Policy; or
(b) the date required by Federal law.
Claim Review Procedures
Once We receive information necessary to evaluate the claim, We will make a decision within the time
periods set forth below. Please refer to the Payment of Claims provision of the Policy.
In the event an extension is necessary due to matters beyond Our control, We will notify the person
submitting the claim of the extension and the circumstances requiring the extension. Extensions are
limited as set forth below.
If an extension is necessary due to failure to submit complete information, We will notify the person
submitting the claim of the additional information required. Such notice of incomplete information will
be sent within the time periods set forth below.
In order for Us to continue processing the claim, the missing information must be provided to Us within
the time periods set forth below.
We may contact the person submitting the claim at any time for additional details about the processing
of the claim.
Claim Review Decisions
(a) Initial review: We will notify the person submitting the claim of Our claim decision within 45
days after Our receipt of the claim, unless additional information is requested as set forth below;
(b) Extension period: 30 days; and
(c) Maximum number of extensions: two.
If additional information is needed, We will notify the person submitting the claim within 30 days of
Our receipt of the claim. Once Our request for additional information is received, the person submitting
the claim will have 45 days to submit the additional information to Us. We will have a total of 105 days
(which includes an additional 30-day extension, if necessary, due to circumstances beyond Our control)
to process the claim. If We do not receive the additional information within the specified time period,
We will make Our determination based on the available information.
Claim Denials
If a claim is denied or partially denied, the person submitting the claim will receive a written or
electronic notice of the denial that will include:
(a) the specific reason(s) for the denial;
~***~
SPD Claims 22 Life
(b) reference to the specific Policy provisions on which the denial is based;
(c) if applicable, a description of any additional material or information necessary to complete the
claim and the reason We need the material or information;
(d) a description of the appeal procedures; including the right to request an appeal within 180 days
and the right to bring a civil action following the appeal process; and
(e) any other information which may be required under state or federal laws and regulations.
Opportunity To Request An Aoueal
The person submitting the claim may appeal Our claim review decision in accordance with this Claim
Review and Appeal Procedures provision. As part of the appeal, We will perform a full and fair review
of the decision.
The request for an appeal can be submitted to Us in writing, electronically, or orally and should include
any additional information that the person submitting the claim believes should have been considered by
Us.
The request for an appeal should include:
(a) the name of the person for whom the claim has been submitted;
(b) the name of the person filing the appeal;
(c) the policy number; and
(d) the nature of the appeal.
We will establish and maintain procedures for hearing, researching, recording and resolving any appeal.
The notification of Our claim review decision will include instructions on how and where to submit an
appeal.
The person submitting the claim will:
(a) have 180 days from receipt of notification to submit a request for an appeal;
(b) be provided the opportunity to submit written comments, documents, records and other
information relating to the claim; and
(c) be provided, upon request and free of chazge, reasonable access to and copies of documents,
records and other information relevant to the claim.
In reviewing the appeal, We will consider all comments, documents, records and other information
submitted without regard to whether such information was submitted or considered in the claim
decision.
A request for an appeal authorizes Us, or anyone designated by Us, to review records relevant to the
claim.
23
Our Response To An Appeal
Once We receive a request for an appeal, We will respond within 45 days, unless additional information
is requested. If additional information is requested, the following extensions apply:
(a) extension period: 45 days; and
(b) maximum number of extensions: one.
We will have a total of 90 days to process the appeal.
When We make Our decision, the person submitting the claim will be provided with:
(a) information regarding Our decision; and
(b) information regarding other internal or external appeal or dispute resolution alternatives, if
available, including any required state mandated appeal rights.
24
STANDARD PROVISIONS
Insurance Contract
The insurance contract consists of:
(a) the policy;
(b) the Policyholder's application attached to the policy; and
(c) your application, if required.
Chances in the Insurance Contract
The insurance contract may be changed (including reducing or terminating benefits or increasing
premium costs) any time we and the Policyholder both agree to a change. No one else has the authority
to change the insurance contract. A change in the insurance contract:
(a) does not require your or your beneficiary's consent; and
(b) must be:
(1) in writing;
(2) made a part of the policy; and
(3) signed by one of our officers.
A change may affect any class of insured persons, including retirees if retired coverage is included in the
policy.
Applications
We may use misstatements or omissions material to the risk in your application to contest the validity of
insurance, reduce coverage or deny a claim; but we must first famish you or your beneficiary with a
copy of that application. We will not use your application to contest or reduce insurance which has been
in force for two years or more during your lifetime. However, if you are not eligible for insurance, there
is no time limit on our right to contest insurance or deny a claim.
Statements in an application are treated as representations, not as warranties.
Leval Actions
No legal action can be brought until at least 60 days after we have been given written proof of loss. No
legal action can be brought more than three years after the date written proof of loss is required.
25 (*)
7024SP-EZ 12/84 TX EO/LTD
Group Policy Number GLUG-487A
Mmva~~Omaea