HomeMy WebLinkAbout2000-02-14 City Council (7)TO:
City of Palo Alto
City Manager’s Report
HONORABLE CITY COUNCIL
FROM:CITY MANAGER DEPARTMENT: HUMAN RESOURCES
DATE:FEBRUARY 14, 2000 CMR: 137: t)~
SUBJECT:APPROVAL OF CONTRACT IN THE AMOUNT OF $750,000 WITH
STANDARD INSURANCE COMPANY FOR THE CITY OF PALO
ALTO’S GROUP LIFE,ACCIDENTAL DEATH AND
DISMEMBERMENT (AD&D), AND LONG TERM INSURANCE (LTD)
PLANS
RECOMMENDATION
Staff recommends that Council:
Approve and authorize the Mayor to execute .the attached contract with
Standard Insurance Company in the amount of $750,000 for one year to
provide group life, accidental death and dismemberment (AD&D) and long
term disability (LTD) insurance benefits.
Authorize the City Manager or designee to exercise the option, to renew the
contract for the second and third years, provided Standard Insurance Company
is responsive to the City’s needs, and the quality of its work is acceptable
during the term of the contract.
DISCUSSION
Project Description
The work to be performed under this contract is for underwriting the City’s group life,
AD&D and LTD benefits. Existing agreements with City employee bargaining units provide
for maintaining these benefits.
On March 1, 1990, the City entered into a contract with Group America to underwrite the
City’s group life, AD&D and LTD benefits. On January 1, 1993, Blue Cross of
Pennsylvania purchased Group America. Since that time, the entity has merged with three
other companies: Veritas, TransGeneral and now Highmark Insurance Company. On each
occasion there have been cutbacks in staff and costs, resulting in the deterioration of claims
and other administrative services. In July 1999, staff determined that Highmark Life
Insurance Company did not provide the level of quality demanded by the City.
CMR:137~0 Page 1 of 3
Selection Process
Staffsent a Request For Proposal (RFP) to 20 insurance companies on September 22, 1999.
The proposal response period was 30 days. Four companies submitted proposals: Minnesota
Mutual, UNUM, CIGNA and Standard Insurance. The current underwriter did not submit
a proposal.
The proposals ranged from $659,628 to $804,408. The high and low bids did not meet the
specifications and could not be considered. Those companies not responding indicated that
they either were not underwriting public agency business or they would not be competitive.
A selection advisory committee, consisting of representatives from employee bargaining
units and Human Resources staff, reviewed the proposals. CIGNA and Standard Insurance
were selected as finalists and invited to participate in oral interviews. The committee
carefully reviewed each finns qualifications relative to the following criteria:
Claims paying administration
Vocational rehabilitation capabilities
Knowledge of and experience in working with public agencies and the Public
Employees’ Retirement System
Customer service capabilities
Plan administration
Underwriting capabilities
Worker’s compensation interface
Statistical reports
Standard Insurance was selected because it demonstrated its ability to provide the highest
level of claims administration services required by the City at a very competitive cost.
RESOURCE IMPACT
The City of Palo Alto will save approximately $89,500 per year in premium payments.
There will be a decrease in the funds for the group life, AD&D and LTD insurance in the
1999-2000 Proposed Budget, and a decrease in funding in the General Benefits and Insurance
Internal Service Fund.
POLICY IMPLICATIONS
This request does not represent a change in existing policies.
ENVIRONMENTAL REVIEW
This is not a project under the California Environmental Quality Act
CMR:137:99 Page 2 of 3
ATTACHMENTS
Attachment A:Contract with Managed Health Network, Inc.
PREPARED BY: Leonard Manager of Employee Benefits
DEPARTMENT HEAD:
CITY MANAGER APPROVAL
of Human Resources
~ FLEI~NManager (
CMR: 137:99 Page 3 of 3
AGREEMENT
BY THIS AGREEMENT MADE AND ENTERED INTO ON THE DAY OF
BY AND BE’I3NEEN THE CITY OF PALO ALTO "CITY", AND RrP~,N]~’RO TNRURANCECOMPANY
NO,-
~
2000
/DATE TO BE ENTERED
~ I.BY CITY PURCHASING
,ajn Oregon corporation (Local)
(ADDRESS) 1100 .qW Rixth Avenue (cl7~3Portland; OR (ZIP) 97204 (PHONE~925) 947-
"CONTRACTOR"~ IN CONSIDERATION OF THEIR MUTUAL COVENANTS, THE PARTIES HERETO AGREE AS FOLLOWS:3 9 5 0
e CONTRACTOR SHALL PROV,DE OR FURNISH THE FOLLOWING SPECIFED 1) GOODS AND MATERIALS, 2) SERVICES OR 3) A COMBINATION
THEREOF AS SPECIFIED IN THE EXHIBITS NAMED BELOW AND ATTACHED HERETO AND INCORPORATED HEREIN BY THIS REFERENCE:
TITLE: (DESCRIPTION)
GROUP LIFE INSURANCE; ACCIDENTAL DEATH AND DISMEMBERMENT -INSURANCE;
GROUP LONG TERM DISABILITY INSURANCE
EXHIBITS THE FO~OW,NG ATTACHED EXH,S,TS HEREBYAREMADE RARTOF TH,S AGREEMENT:
***SEE ATTACHED LIST***
insuranceTERMTHE~I~I~II~ND/ORMATERIALSFURNISHEDUNDERTHISAGREEMENTSHALLCOMMENCE~ in accordance with
X~W~X~K~ Exhibits A & Bo One y~ar initial term and two-one year
renewal terms to be exercised at City’s option in accordance with RFP#119602°COMPENSATION FOR THE FU~ PERFORMANCE OF THIS AG~EMENT:
~ CI~SHA~PAYCONTRACTOR: in accordance with Exhibit C,
Insurance benefits in accordance With Exhibits A & B.
®
®
PAYMENT RECORD (DEPARTMENT USE REVERSE SIDE)
CITY ACCOUNT NUMBER:
KEY CODE OBJECT I PROJECT PHASE NO. DOLLAR AMOUNT
I
GENERAL TERMS AND CONDITIONS ARE INCLUDED ON BOTH SIDES OF THIS AGREEMENT.
THIS AGREEMENT SHALL BECOME EFFECTIVE UPON ITS APPROVAL AND EXECUTION BY CITY. IN WITNESS THEREOF, THE PARTIES HAVE EXECUTED THIS
AGREEMENT THE DAY, MONTH, AND YEAR FIRST WRrl-rEN ABOVE.HOLD HARMLESS. CONTRACTOR agrees to indemnify, defend and hold harmless CITY, its Council Members, officers, employe~s, and agents from any and all demands,
claims or liability of any nature, including wrongful death, caused by or arising out of CONTRACTOR’S, its officers’, directors’, employees’ or agents’ negligent acts, errors,
or omissions, or willful misconduct, or conduct for which the law imposes strict liability on CONTRACTOR in the performance of or failure to perform this agreement by
CONTRACTOR.
ENTIRE AGREEMENT. This agreement and the terms and conditions on the reverse hereof represent the entire agreement between the parties with respect to the purchaseand sale of the goods, equipment, materials or supplies or payment for services which may be the subject of this agreement. All prior agreements, representations,
statements, negotiations and undertakings whether oral or written are superseded hereby.
PROJECT MANAGER AND REPRESENTATIVE FOR C~TY
NAME Len Zucker
DEPT. Human Resources Chairman, .President and C~O
P.O.BOX 1O25O
PALOALTO, CA94303~, ,.,. ~,z / ~. ~ "
Telephone ( 6 ~ ~ ) ~ ? =.9_=2.2.3 5 By~~~~
INVOICING SENDALLINVOICESTOTHECI~’A~N:PROJECTMANAGER~itl~:~Vice President & Corporate
CITY OF PALO ALTO APPROVALS:(ROUTE FOR SIGNATURES ACCORDING TO NUMBERS IN APPROVAL3OXES BELOW) Secretar~
CI~ DEPARTMENT ~ FundsBudgetedHave Been INSURANCE REVIEW PURCHASING &CONTRACT_ ADMINISTRATION.
(1)(2)(3)
ATTACHMENT
Exhibits:
Group Life Insurance Policy (30 pages);
Group Long Term Disability Insurance Policy (24 pages)
Rate Schedules (i0 pages)
Non-Discrimination Certificate
Insurance Requirements (4 pages)
To the extent of any conflict with this Agreement and Exhibits 1
and 2, the exhibits will control.
EXHIBIT "A"
STANDARD INSURANCE COMPANY
A Stock Life Insurance Company
900 SW Fifth Avenue
Portland, Oregon 97204-1282
(503) 321.-7000
P~opk. Not ]ust Po~’d~.®
GROUP UFE INSURANCE POLICY
Policyowner:
Policy Number:
Effective Date:
City of Palo Alto
639022-A
January I, 2000
The consideration for this Group Policy is the application of the Policyowner and the payment by the
Policyowner of premiums as provided herein.
Subject to the Pollcyowner Provisions and the Incontestability Provisions, this Group Policy (a) is
issued for the Initial Rate Guarantee Period shown in the Coverage Features, and (b) may be renewed
for successige renewal periods by the payment of the premium set by us on each renewal date. The
length of each renewal period will be set by us, but will not be less than 12 months.
For purposes of effective dates and ending dates under this Group Policy, all days begin and end at
12:00 midnight Standard Time at the Policyowner’s address.
This policy includes an Accelerated Benefit. Death benefits will be reduced if an Accelerated
Benefit is paid. The receipt of this benefit may be taxable and may affect your eligibility for
Medicaid or other government benefits or entitlements. However, if you meet the definition of
"terminally ill individual" according to the Internal Revenue Code Section 101, your Accelerated
Benefit may be non-taxable. You should consult your personal tax and]or legal advisor before
you apply for an Accelerated Benefit.
All provisions on thi’s and the following pages are part of this Group Policy. ’Tou" and "your" mean the
Member. ’We", "us", and "our" mean Standard Insurance Company. Other defined terms appear with
their initial letters capitalized. Section headings, and references to them, appear in boldface type.
President
STANDARD INSURANCE COMPANY
By
Corporate Secretary
GP190-LIFE/S399
cALIFORNIA LIFE AND HEALTH INSURANCE GUARANTEE ASSOCIATION ACT
SUMMARY DOCUMENT AND DISCLAIMER
Residents of California who purch s life and health insurance and annuities should know that the
insurance companies licensed in th’is state to write these types of insurance are members of the
California Life and Health Insurance Guarantee Association ("CLHIGA").. The purpose of this
Association is to assure that policyholders will be protected, within limits, in the unlikely event that a
member insurer becomes flnanciall~ unable to meet its obligations. If this should happen, the
Guarantee Association will assess its other member insurance companies for the money to pay the
claims of the insured persons who live in this state and, in some cases, to keep coverage in force. The
valuable extra protection provided by these insurers through the Guarantee Association is not
unlimited, however, as noted below, and is not a substitute for consumers’ care in selecting insurers.
The California Life and Health Insurance Guarantee Association may not provide coverage for this
¯ policy. If coverage i’s provided, it may be subject to substantial limitations or exclusions, and
require continued residency in California. You should not rely on coverage by the Association in
selecting an insurance company or in selecting an insurance policy,
Coverage is NOT provided for your policy or any portion of it that is not guaranteed by the insurer
or for which you have assumed the risk, such as a variable contract sold by prospectus.
Insurance companies or their agents are required by law to give or send you this notice. However,
insurance companies and their agents are pro ,hiblted by law from using the ex/stence of the
guarantee association to induce ~you to purchase any kind of insurance policy.
Policyholders with additional questions should first contact their insurer or agent or may then contact:
TheCalifornia Life and Health Insurance Guarantee Association
PO Box 17319
Beverly Hills CA 90209-3319
OR
Consumer Services Division
California Department of Insurance
300 S Spring St, 14th F1
Los Angeles CA 90013
The state law that provides for this safety-net coverage is called the California Life and Health
Guarantee Association Act. Below is a brief summary of this law’s coverages, exclusions and limits.
This summary does not cover all provisions of the law; nor does it in any way change anyone’s rights
or obligations under the Act or the rights or obligations of the Association.
COVERAGE
Generally, individuals will be protected by the California Life and H~alth Insurance Guarantee
Association if they live in this state trod hold a life or health insurance contract, or an annuity, or if
they are insured under a group insurance contract, issued by a member insurer. The beneficiaries,
payees or assignees of insured persons are protected as well, even if they live in another state.
EXCLUSIONS FROM COVERAGE ~’-
However, persons holding Such policies are not protected by this Guarantffe Association if:
Their insurer was not authorized to do business in this state when it issued the policy or contract;
Their policy was issued by a health care service plan (HMO, Blue Cross, Blue Shield), a charitable
organ~lzation, a fraternal benefit society, a mandatory state pooling plan, a mutual assessment
company, an insurance exchange, or a grants and annuities society;
They are eligible for protection under the laws of another state. This may occur when the insolvent
insurer was incorporated in another state whose guaranty association protects insureds who live
outside that state.
The Guarantee Association also does not provide coverage for:
Unallocated annuity contracts; that is, contracts which are not issued to and owned by an
individual and which guarantee rights to group contract holders, not individuals;
Employer or association plans, to the extenf they are self-funded or uninsured;
Any policy or portion of a policy which is not guaranteed ’by the insurer or for which the individual
has assumed the risk, such as a variable contract sold by prospectus;
Any policy of reinsurance unless an assumption certificate was issued;
Interest rate yields that exceed an average rate;
Any portion of a contract that provides dividends or experience rating credits.
LIMITS ON AMOUNT OFCOVERAGE
The Act limits the Association to pay benefits as follows:
LIFE AND ANNUITY BENEFITS
80% of what the insurance company would owe under a policy or contract up to $I00,000 in cash
surrender values,
$100,000 in present value of annuities, or
$250,000 in life insurance death henefits.
A maximum of $250,000 for any one insured life no matter how many policies and contracts there
were with the same company, even ff the policies provided different types of coverages.
HEALTH BENEFITS
A maximum of $200,000 of the contractual obligations that the health insurance company would
owe were it not insolvent. The maximum may increase or decrease annually based upon changes
in the health care cost component of the consumer price index.
PREMIUM SURCHARGE
Member insurers are required to recoup assessments paid to the Association by way of a surcharge on
premiums charged for health insurance policies to which the Act applies.
CALIFORNIA NOTICE OF COMPLAINT PROCEDURE
Should any dispute arise about your premium or about a claim that you have filed, write to the
company that issued the group policy. If the problem is not resolved, you may also write to the
State-of Callfornia~ Department of Insurance, Consumer Services Division, 300 S. Spring Street,
14th FL, Los Angeles, CA 90013, or~ call toll-free 1-800-927-HELP (4357). This notice of
complaint procedure is for information only and does not become a part or condition of this
group policy/certificate.
Table of Contents
COVERAGE FEATURES .- ........................................................................................
GENERAL POLICY INFORMATION .....................................................................
BECOMING INSURED ..........~ ............................................................................1
PREMIUM CONTRIBUTIONS .............................................................’ ................2
SCHEDULE OF INSURANCE .............................................................................2 ’
REDUCTIONS IN INSURANCE ...........................................................................4
OTHER BENEFITS ............................................................................................4
OTHER PROVISIONS .........................................................................................4
PREMIUM RATES AND RENEWALS ...................................................’ ...............5
LIFE INSURANCE ...................................................................................................6
A.Insuring Clause ..........................................................................................6
B.Amount Of Life Insurance ...........................................................................6
C.Changes In Life Insurance ..........................................................................6
D.Repatriation Benefit ...................................................................................6
E.Suicide Exclusion: Life Insurance ...............................................................6
F.When Life Insurance Become Effective .........................................................6
G.When Life Insurance Ends ..........................................................................7
H.Reinstatement Of Life Insurance ......: ..........................................................7
ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE ...................................7
A.Insuring Clause ..............~ ...........................................................................7
B.Definition Of Loss For AD&D Insurance ......................................................8
C.Amount Payable .........................................................................................8
D.Changes In AD&D Insurance ......................................................................8
E.AD&D Insurance Exclusions .......................................................................8
F.Other AD&D Benefits ..................................................................................9
G.Becoming Insured For AD&D Insurance ......................................................10
H.When AD&D Insurance Ends ......................................................................11
ACTIVE WORK PROVISIONS .i ................................................................................11
CONTINUITY OF COVERAGE..~ ................................................................................11
STRIKE CONTINUATION ........! ................................................................................12
WAIVER OF PREMIUM I
ACCELERATED BENEFIT ]13
RIGHT TO CONVERT ..............................................................................................15
CLAIMS ....................., ............................................................................................16
ASSIGNMENT ........................................................................................................17
BENEFIT PAYMENT AND BENEFICIARY PROVISIONS .............................................17
ALLOCATION OF AUTHORITY .................................................................................19
TIME LIMITS ON LEGAL ACTIONS ..........................................................................20
INCONTESTABILITY PROVISIONS ...........................................................................20
DEFINITIONS ....................: ....................................................................................20
POLICYOWNER PROVISIONS .................................................................................22
]Index of Defined Terms
Accelerated Benefit, 13
Active Work, Actively At Work, 11
AD&D Insurance, 20
Annual Earnings, 20
Automobile, 9
Beneficiary,, 18
Child, 21
Class Definition, 1
Contributory, 21
Conversion Period, 15
Disabled, 21
Eligibility Waiting Period, 21
Employer(s), 1
Evidence Of Insurability, 21
Grace Period, 5
Group Policy, 22
Group Policy Effective Date, 1
Group Policy Number, 1
Initial Rate Guarantee Pe~od’, 5
Injury, 22
Insurance (for Accelerated Benefit), 15
Insurance (for Right to Convert), 15
Insurance (for Waiver Of Premium), 12
Leave Of Absence. Period, 4
Life Insurance, 22
Loss, 8
Maximum Conversion Amount, 4
Member, I
Minimum Participation, 5
Minimum Participation Number, 5
Minimum Participation Percentage, 5
Minimum Time Insured, 4
Noncontributory, 22
Notice of Rate Change, 5
Physician, 22
Policyowner, 1
Pregnancy, 22
Premium Due Dates, 5
Premium Rates, 5
Prior Plan, 22
Proof Of Loss, 16
Qualifying Event, 15
Qualifying Medical Condition, 14
Recipient, 18
Right To Convert, 15
Seat Belt System, 9
Sickness, 22
Spouse, 22
Totally Disabled, 12, 15
Waiting Period (for Waiver Of Premium),
12
Waiver Of Premium, 12
War, 8
You, Your(~rRightTo Convert),15
COV~H~GE FF_~TURES
This section contains many of the features of your group life insurance. Other provisions, including
exclusions and limitations, appear in other sections. Please’ refer to the text of each section for full
details. The Table of Contents and the Index of Defined Terms help locate sections and definitions.
Group Policy Number: ’
Type of Insurance Provided:
Life Insurance:
Accidental Death And Dismemberment
{AD&D) Insurance: [
Policyowner:’
Employer (s):
Group Policy Effective Date:
Policy Issued in:
GENERAL POLICY INFORMATION
639022-A
Yes
Yes
City of Palo Alto
City of Palo Alto
January i, 2000
California
BECOMING INSURED
To become insured for Life Insurance you must: (a) Be a Member; (b} Complete your Eligibility Waiting
ThePeriod; and (c) Meet the requirements in Life Insurance and Active Work Provisions.
requirements for becoming insured for coverages other than Life Insurance are set out in the text.
Definition of Member:
Class Definition:
Eligibility Waiting Period:
Evidence of Insurability:
Note: Evidence Of Insurability is not
January 1, 2000’.
You are a Member if you are:
1. An a~tive employee or council member of the
Employer; and
2. Regularly working at least 20 hours each week.
You are not a Member if you are:
1. A temporary or seasonal employee; or
2. A full time member of the armed forces of any country.
None
You are eligible on one of the following dates:
If you are a Member on the Group Policy Effective Date,-
you are eligible on that date.
If you become a Member after the Group Policy Effective
Date, you are eligible on the date you become a Member.
Required:
a. For late application for Plan 2 Life Insurance.
b. For reinstatements if r~l~ired.
required to become insured for Plan 2 Life Insurance on
Printed 12/6/99 1 639022-A
Life and AD&D Insurance:
Plan I:
Plan 2:
PREMIUM CONTRIBUTIONS
Noncontributory
Contributory
SCHEDULE OF INSURANCE
SCHEDULE OF LIFE INSURANCE
Life Insurance Benefit:
You will become insured under Plan 1 if you meet the requirements to become insured under the
Group Policy.
You may also become insured’ under Plan 2 if you meet the requirements to become insured for
Plan 2 Life Insurance under the Group Policy. Plan 2 is a Contributory plan requiring premium
contributions from Members.
Plan 1 (basic):1 times your Annual Earnings, rounded to the next higher
multiple of $1,000, if not already a multiple of 81,000.
The maximum amount is $325,000.
Plan 2 (additional):
The Repatriation Benefit:
1 times your Annual Earnings, rounded to the next higher
multiple of $1,000, if not already a multiple of 81,000.
The maximum amount is $325,000.
The expenses incurred to transport your body to a
mortuary near your primary place of residence, but not to
exceed $5,000 or 10% of the Life Insurance Benefit~
whichever is less.
SCHEDULE OF AD&D INSURANCE
AD&D Insurance Benefit:
Seat Belt Benefit:
The amount of your Plan 1 AD&D Insurance Benefit is
equal to the amount of your Plan 1 Life Insurance Benefit.
The amount payable for certain Losses is less than 100%
of the AD&D Insurance Benefit. See AD&D Table Of
Losses.
The amount of your Plan 2 AD&D Insurance Benefit is
equal to the amount of your Plan 2 Life Insurance Benefit.
The amount payable for certain Losses is less than 100%
of the AD&D Insurance Benefit. See AD&D Table Of
Losses.
The amount of the Seat Belt Benefit is the lesser of (1)
$10,000, or {2) the AD&D Insurance Benefit payable for
loss of life.
PHnted 12/6/99 -2-639022-A
Career Adjustment Benefit:
Child Care Benefit:
Higher Education Benefit:
Occupational Assault Benefit:
Public Transportation Benefit:
The tuition expenses for trainifig incurred by your Spouse
within 36 months after the date of your death, exclusive of
room and board, but not to exceed $5,000 per year, or the
cumulative total of $10,000 or 25% of the AD&D
Insurance Benefit, whichever is less.
The total child care expense incurred by your Spouse
within 36 months after the date of your death for all
Children under age 13, but not to exceed $5,000 per year,
or the cumulative total of 810,000 or 25% of the AD&D
Insurance Benefit, whichever is less.
The tuition expenses incurred per Child within 4 years
after the date of your death at an accredited institution of
higher education, exclusive of room and board, but not to
.exceed $5,000 per year, or the cumulative total of $20,000
or 25% of the AD&D Insurance Benefit, whichever is less.
The lesser of (i) $25,000, or (2) 50% of the AD&D
Insurance Benefit otherwise payable for the Loss.
The lesser of (I) $200,000, or (2) 100% of the AD&D
Insurance Benefit otherwise payable for the Loss of your
life.
AD&D TABLE OF LOSSES
The amount payable is a percentage of the AD&D Insurance Benefit in effect on the date of the
accident and is determined by the Loss suffered as shown in the following table:,
Loss:Percentage Payable:
a.Life 100%
. b.One hand or one foot ’50%
c.Sight in one eye, speech, or
hearing in both ears
50%
d.Two or more of the Losses listed
.in b. and c. above
100%
e.Thumb and index finger of the 25% *
same hand
f.Quadriplegia 100%
g.Hemiplegia 50%
h.Paraplegia 50%
No more than 100% of your AD&D Insurance will be paid for all Losses resulting from one
accident.
* No AD&D Insurance Benefit ~’vill be paid for Loss. of thumb and index finger- of, the. same.~ .-. : ,
hand if an AD&D Insurance Ben~fit :i~ pa~bl~ fo~ the I)o~s of that entire hand. " ’ " "
P~nted 12/6/99 -3-639022-A
REDUCTIONS IN INSURANCE
If you reach an age shown below; the amount 6f insurance will be the amount determined from the
Schedule of Insurance, multiplied by the appropriate percentage below:
Plan 1 Life and AD&D Insurance:
Age
70 through 74
75 or over
Plan 2 Life and AD&D Insurance:
Age
70 or over
Percentage
65%
50%
Percentage
0%
Waiver Of Premium:
Accelerated Benefit:
OTHER BENEFITS
Yes
Yes
Limits on Right To Convert if
Group Policy terminates
or is amended:
Minimum Time Insured:
Maximum Conversion Amount:
Suicide Exclusion:
Leave Of Absence Period:
Continuity of Coverage;
Strike Continuation:
Annual Earnings based on:
OTHER PROVISIONS
5 years
$2,000
Applies to:
a. Plan 2 Life Insurance
b. AD&D Insurance
60 days
Yes
Yes. The Strike Continuation premium percentage is 120%
of the Premium Rate.
Earnings in effect on your last full day of Active Work.
Printed 12/6/99 4 639022-A
Premium R~tes:
Plan l~Life Insm:ance:
Plan 2 Life Insurance:
Plan 1 AD&D Insurance."
Plan 2 AD&D Insurance:
Premium Due Dates:
Grace Period:
Initial Rate Guarantee Period:
Notice of Rate Change:
Minimum Participation:
Life Insurance:
Number:
Percentage:
PREMIUM RATES AND RENEWALS
$0.22 monthly per $I,000 of Plan 1 Life Insurance
$0.30 monthly per $I,000 of Plan 2 Life Insurance
$0.03 monthly per $1,000 of Plan 1 AD&D Insurance
$0.03 monthly per $.1,000 of Plan 2 AD&D Insurance
January 1, 2000 and the first day of each calendar month
thereafter.
31 days .
January 1, 2000 to January 1, 2003
60 days
10 insured Members
Plan 1: 100% of eligible Members
Plan 2: 25% of eligible Members
Printed 12/6/99 -5-639022-A
LIFE INSURANCE
A.Insuring Clause
If you-die while insured for Life Insurance, we will pay benefits according to the terms of the Group
Policy after we receive satisfactory Proof Of Loss.
B. Amount Of Life Insurance
See the Coverage Features for the Life Insurance schedule. ¯
C,Changes In Life Insurance
A change in your Life Insurance because of a change in your classification, age or Annual Earnings
becomes effective on the first day of the calendar month coinc~iding with or next following the date
of the change.
D.Repatriation Benefit
The amount of the Repatriation B~neflt is shown in the Coverage Features.
We will pay a Repatriation Benefit! if all of the following requirements are met.
1. A Life Insurance Benefit is p able because of your death.
2. You die more than 200 miles from your primary place of residence.
3.Expenses are incurred to transport your body to a mortuary near your primary place of
residence.
E. Suicide Exclusion: Life Insurance
The Coverage features states which Life Insurance plan is subject to this suicide exclusion.
If your death results from suicide or other i.ntentionally self-inflicted Injury, while sane or insane, 1
and 2 below apply.
The amount payable will exclude the amount of your Life Insurance which is subject to this ’
suicide exclusion and which has not been continuously in effect for at least 2 years on the date
of your death. In computing the 2-year period, we will include time you were insured under the
Prior Plan.
2.We will refund all premiums paid for that portion of your Life Insurance which is excluded from
payment under this suicide exclusion.
F.When Life Insurance Become Effective
Subject to the Active Work Provisions, your Life Insurance becomes effective as follows:
1. Plan 1 Life Insurance
Plan 1 Life Insurance becomes effective on the date you become eligible.
2. Plan 2 Life Insurance
You must apply in writing for Plan 2 Life Insurance and agree fo pay premiums. Plan 2 Life
Insurance becomes effective on:(i) ._The date you become el.ig.ib!e", i..f.you apply on o~ before th..at. date.
(ii) The date you apply, if you apply within 31 days after you become eligible.
Printed 12/6/99 -6-639022-A
(iii}The date we approve your Evidence Of Insurability, if you apply more than 31
you become eligible. ,~
When Life Insurance Ends
days after’
Life
I.
o
Insurance ends automatically on the earliest of:
The date the last period ends ~for which you made a premium contribfition, if your insurance isContributory; ~n~
The date the Group Policy te inates;
The date your employment terminates; and
The date you cease to be a Member. However, if you cease to be a Member because you are
working less than the required minimum number of hours, your Life Insurance will be
continued with premium payment during the followingperiods, unless it ends under 1 through
3 above.
a.While your Employer is paying you at least the same Annual Earnings paid to you
immediately before you ceased to be a Member.
b.While your ability to work is limited because of Sickness, Injury, or Pregnancy.
c.During the first 60 days of a temporary layoff.
d.During a leave of absence if continuation of your insurance under the Group Policy is
required by a state-mandated family or medical leave act or law.
e.During any other scheduled leave of absence approved by your Employer in advance and in
writing and lasting not more than the period shown in the Coverage Features.
Reinstatement Of Life Insurance
if your Life Insurance ends, you may become insured again as a new Member. However, I through
4 below will apply.
1.If your Life Insurance ends because you cease to be a Member, and if you becomea Member
again within 90 days, the Eligibility Waiting Period will be waived.
2. If your Life Insurance ends because you fail to make a required premium contribution, you
must provide Evidence Of Insurability to become insured again.
3. If you exercised your Right To Convert, you must provide Evidence Of Insurability to become
insured again.
o If your Life Insurance ends because you are on a federal or state-mandated family or medical
leave of absence, and you become a Member again immediately following the period allowed,
your insurance will be reinstated pursuant to the federal or state-mandated family or medical
leave act or law.
(REPAT_SUIC)LI.LF.~.J~ IX
ACCIDENTAL DEA.TH AND DISMEMBERMENT INSURANCE
A.Insuring Clause
If you have an accident, including accidental exposure to adverse conditions, while insured for. .AD&D .Insur .ance_, .and .t~e. accident r.esul.ts" .i.n a L0. ss, .we ..will.pay benefit.s., according to theterms of
the Group Policy after we receive satisfactory Proof Of Loss, ~ " . , ....
Printed 12/6/99 - 7 -639022-A
Definition Of Loss For AD&IJ Insurance
Loss means Io~s of life, hand, foot, sight, speech, hearing in both ears, thumb and index finger of
the same hand and Quadriplegia, Hemiplegia or Paraplegia which meets all of the follswing
requirements:
I.Is caused solely and directly by an accident.
2.Occurs independently of all other causes.
3.Occurs within 365 days of the accident.
4.With respect to Loss of life, is evidenced by a certified copy of the death certificate.’
5.With respect to all other Losses, is certified by a Physician in the appropriate specialty as
determined by us.
With respect to Loss of life, death will be presumed if you disappear and the disappearance:
1.Is caused solely and directly by an accident that reasonably could have caused Loss Of life;
2.Occurs independently of all other causes; and
3.Continued for a period of 365 days after the date of the accident, despite reasonable search
efforts.
With respect to a hand or foot, Loss means actual and permanent severance from the body at or
above the wrist or ankle joint, whether or not surgically reattached.
With respect to sight, Loss means entire, uncorrectabie, and irrecoverable loss of sight.
With respect to speech, Loss means entire, uncorrectable, and irrecoverable loss of audible speech.
With respect to hearing, Loss means entire, uncorrectable~ and irrecoverable loss of hearing in both
ears.
With respect to thumb and index finger of the same hand, Loss means actual and ~permanent
severance from the body at or above the metacarpophalangeal joints.
With respect to Quadriplegia, Herniplegia, and Paraplegia, Loss must be permanent, complete, and
irreversible.
Quadriplegia means total paralysis of both upper and lower limbs. Hemiplegia means total
paralysis of the upper and lower limbs on the same side of the body. Paraplegia means total
paralysis of both lower limbs.
C.Amount Payable
See Coverage Features for the AD&D Insurance schedule. The amount payable is a percentage of
the AD&D Insurance Benefit in effect on the date of the accident and is determined by the Loss
suffered. See AD&D Table Of Losses in the Co, verage Features.
D. Changes In AD&D Insurance
Changes in your AD&D Insurance will become effective on the date your Life Insurance changes.
E. AD&D Insurance Exclusions
No AD&D Insurance benefit is payable if the accident or Loss is caused or contributed to by any of
the following:
I. War or act ~f War.. War means declared ok undeclared was, whefller° civil’ or international, and
any substantial armed conflict between o.rganized forces of a military nature.
2. Suicide or other intentionally self-inflicted Injury, while sane or insane.
Printed 12/6/99 8 639022-A
Committing or attempting to commit an assault or felony, or actively participating in a violent
disorder or riot. " Actively participating does not include being at the scene of a violent disorder
or riot while performing your official duties,
4. The voluntary use or consumption of any poison, chemical compound or drug, unless used or
consumed according to the directions of a physician.
5.Sickness or Pregnancy existing at the time of the accident.
6.Heart attack or stroke.
7.Medical or surgical treatment for any of the above.
F.Other AD&D Benefits
Seat Belt Benefit
The
We
1.
amount of the Seat Belt Benefit is shown in the Coverage Features. ’
will pay a Seat Belt Benefit if all of the following requirements are met:
You die as a result of an Automobile accident for which an AD&D Insurance Benefit is
payable for Loss of your Life; and
2. You are wearing and properly utilizing a Seat Belt System at the time of the accident, as
evidenced by a police accklent report.
Seat Belt System means a properly installed combination lap and shoulder restraint system
that meets the Federal Vehicle Safety Standards of the National Highway Traffic Safety
Administration. Seat Belt System will include a lap belt alone, but only if the Automobile did
not have a combination lap and shoulder restraint system when manufactured. Seat Belt
System does not include a shoulder restraint alone.
Automobile means a motor vehicle licensed for use on public highways.
Career Adjustment Benefit
The amount of the Career Adjustment Benefit is shown in the Coverage Features.
We will pay a Career Adjustment Benefit to your Spouse if all of the following req{tirements are
met:
I. You are insured under the Group Policy.
2. You die as a result of an accident for which an AD&D Insurance Benefit is payable for Loss
of your llfe.
3, Your Spouse is, within 36 months after the date of your death, registered and in attendance
at a professional or trades training program for the purpose of obtaining employment or
increasing earnings.
No Career Adjustment Benefit will be paid if you have no surviving Spouse. ’
Child Care Benefit
The amount of the Child Care Benefit is shown in the Coverage Features.
We will pay a Child Care Bene~fit to your Spouse if all of the following requirements are met:
1. You are insured under theI Group Policy.
’ 2.~ Yoti die as a result, of at{ a~"identfor which a~. AD&D’!nsurarice. Benefit’ i~ ’payable for LO~,
of your life.
3. Your Spouse pays a licensed child care provider who is not a member o~ your family for
Printed 12/6/99 - 9 -639022-A
child care provided to your Child(ren} under age 13 within 36 months of your death.
4. The child care is necessary in order for your Spouse to work, or to obtain training for work
or to increase earnings.
No Child Care Benefit will be paid if you have no surviving spouse.
Highe~Education Benefit
The amount of the Higher Education Benefit is shown in the Coverage Features.
We will pay-a Higher Education Benefit to your Child if all of the following requirements are
met:
1. You are insured under the Group Policy.
2. You die as a result of an accident, for which an AD&D Insurance Benefit ispayable for Loss
of your life.
3. Your Child is, within 12 months after the date of your death, registered and in full-time
attendance at an accredited institution of higher education beyond high school.
The Higher Education ’Benefit will be paid annually to each Child who meets the requirements
of item 3 above, for a maximum of 4 consecutive years beginning on the date of your death, No
Higher Education Benefit will be paid if there is no Child eligible to receive it.
Occupational Assault Benefit
The amount of the Occupational Assault Benefit is shown in the Coverage Features.
We will pay an Occupational Assault Benefit if all of the following requirements are met:
I. While Actively At Work you suffer a Loss for which an AD&D Insurance Benefit is payable.
2.The Loss is the result of an act of physical violence against you that is punishable by law
and is evidenced by a police report.
Public Transportation Benefit
The amount of the Public Transportation Benefit is shown in the Coverage Features.
We will pay a Public Transportation Benefit if all of the following requirements are met:
1.You die as a result of an a~ccident for which an AD&D Insurance Benefit is payable for Loss
of your life. l
2. The accident occurs wl~ile you are riding as a fare-paying passenger on Public
Transportation.
Public Transportation means a public passenger conveyance operated by a licensed common
carrier for the transportation of the general public for a fare and operating on regular
passenger routes with a definite schedule of departures and arrivals.
Becoming Insured For AD&D Insurance
1. Eligibility
You become eligible for AD&D Insurance on the date your Life Insurance is effective,
Effective Date
Subje. ct.to the, Active Work Provis.10ns, AD&D insurafic~, be~c0mes effective:as..follows.: .::~ ~ ~. ~..,:..~ ~. =.~ "
a. Plan 1 AD&D Insurance
Plan 1 AD&D Insurance becomes effective on the date you become eligible.
Printed 12/6/99 - 10-639022-A
Ho
Plan 2 AD&D Insurance
You must apply in writing for Plan 2 AD&D Insurance and agree to pay premiums. Plan 2
AD&D Insurance becomes effective on the later of:
(i) The date you become eligible, if you apply on oi- before that date.
- (ii) The date you apply, if you apply after you become eligible.
When AD&D Insurance Ends .
AD&D Insurance ends automatic,ally on the earliest of:
The date your Life Insurance ends.
The date your Waiver Of Premium begins.
The date AD&D Insurance terminates under the Group Policy.
(FB_NO DEP REQD_FULL XP PKG)LI.AD,OT.RX
ACTIVE WORK PROVISIONS
If you are incapable of Active Work because of Sickness, Injury or Pregn~incy on the day before the
scheduled effective date of your insurance or an increase in your insurance, your insurance or
increase will not become effective until the day after you complete one full day of Active Work as an
eligible Memberl
Active Work and Actively At Work mean performing the material duties of your own occupation at your
Employer’s usual place of business.
You will also meet the Active Work re,quirement if:
1. You were absent from Active Work because of a regularly scheduled day off, holiday, or vacation
day;
You were Actively At Work on your last scheduled work day before the date of your absence; and
You were capable of Active Work on the day before the scheduled effective date of your insurance or
increase in your insurance.
LI.AW.OT.I
CONTINUITY OF COVERAGE
Waiver Of Active Work Requirement
If you were insured under the Prior Plan on the day before the effective date of your Employer’s
coverage under the Group Policy, you can become insured on the effective date of your Employer’s
coverage without meeting the Active Work requirement. See Active Work Provisions.
B. Payment Of Benefit
The benefits payable before you meet the Active Work requirement will be:
1.The benefits which would have been payable under the terms of the Prior Plan if it had remained
in force; reduced by
2. Any benefits payable under the Prior Plan.
U.CC.01
PHnted !2/6/99 -il-639022-A
STRIKE CONTINUATION
Insurance may be continued for up to 6 months while you are absent from Active Work because of a
strike, lockout or other general work stoppage caused by a labor dispute, Rules 1 through 4 below will
apply.
1. When your compensation is suspended or terminated because of a work stoppage, your Employer
will immediately notify you in writing of your rights under this provision. Your Employer will marl
the notice to you at your last address on record with the Employer,
2. Yod must pay the entire premium for your insurance, including the Employer’s share, if any, to
your Employer on or before each Premium Due Date. .~
3. The premiums for your insurance during the work stoppage will equal a percentage of the premium
rate in effect on the date the work stoppage began (see Coverage Features). We may change
premium rates during the work sfoppage according to the.terms of the Group PolicY.
4. Insurance continued under this p~rovision will end on the earliest of,;
Any Premium Due Date if you fail to make the required premium contribution to your Employer
on or before that date.
The date you have been absent from Active Work for 6 months.
On the date you begin full-time employment with another employer.
d.At our option, on any .Premium Due Date if less than 75% of the Members eligible to continue
insurance under this provision make the required premium payment to the Employer.
LI.SK,OT. I
WAIVER OF PREMIUM
A.Waiver Of Premium Benefit
Insurance will be continued without payment of premiums while you are Totally Disabled if:
1. You become Totally Disabled while insured under the Group Policy and under age 60;
2. You complete your Waiting Period; and
3. You give us satisfactory Proof Of Loss.
Insurance will be continued for 12 months without payment of premiums while you are Totally
Disabled if:
1.You become Totally Disabled while insured under the Group Policy, and while age 60 or older
but under age 65;
2, You complete your Waiting Period; and
3. You give us satisfactory Proof Of Loss.
B. Definitions For Waiver Of Premium
I. Insurance means your Plan 1 and Plan 2 Life Insurance under the Group Policy.
2.Totally Disabled means that, as a result of Sickness,, accidental Injury, or Pregnancy, you are
unable to perform with reasonable continuity the material duties of any gainful occupation for
....... whi~h,ybu are reasonably fitted by.educatiisn, training and experienc.e. "
3.Waiting Period means the 180 consecutive day period beginning on the date you become Totally
Disabled. Waiver Of Premium begins when you complete the Waiting Period.
Printed 12/6/99 -12-639022-A
Do
Fo
Go
Premium Payment
Premium payment must contlnuei until the later of:
1, The date you complete your Waiting Period; and
2. The date we approve your clai for Waiver Of Premium.
Refund Of Premiums
We will refund up to 12 months of the premiums that were paid for Insurance after the date you
become Totally Disabled.
Amount Of Insurance
The amount of Insurance continued without payment of premium is the amount in effect on the
day before you become Totally Disabled, subject to the following re~ements: .....
1. Plan 2 Life Insurance will terminate at age 70.
2. If you receive an Accelerated Benefit, Insurance will be reduced according to the Accelerated
Benefit provision.
Effect Of Death During The Waiting Period
If you die during the Waiting Period and are otherwise eligible for Waiver Of Premium,-the Waiting
Period will be waived.
Termination Or Amendment Of The Group Policy
Insurance will not be affected by termination or amendment of the Group Policy after you become
Totally Disabled.
ik’hen Waiver Of Premium Ends
Waiver Of Premium ends on the earliest of:
1.The date you cease to be Totally Disabled;
2.90 days after the date we mail you a request for additional Proof Of Loss, if it is not given;
3.The date you fail to attend an examination or cooperate with the examiner;
4.With respect to the amount of Insurance which an insured has converted, the effective date of
the individual life insurance policy issued to the insured;
5. If you became Totally Disabled on or after age 60, 12 months following the date you became
Totally Disabled; and
6. With respect to Plan 2 Life Insurance, the date you reach age 70.
~AG~ TE~M) ~X.WP.OT.XX
ACCELERATED BENEFIT
A. Accelerated Benefit
If you qualify for Waiver Of Premium and give us satisfactory proof of having a Qualifying Medical
Condition while you are insured under the Group Policy, you may have the right to receive during
your lifetime a portion of your Insurance as an Accelerated Benefit. You must have at least $10,000
f i,ligibl ¯ "., ,. = o nsuranoe An effect to be e
If your Insurance is scheduled to end within 24 months following the date you apply for the
Accelerated Benefit, you will not be eligible for the Accelerated Benefit.
Printed 12/6/99 ’ ~- 13- ’639022-A
Qualifying Medical Condition means you are terminally ill as a result of an illness or .physical
condition which is reasonably expected to result in death within 12 months.
We may have you examined at our expense in connection with your claim for an Accelerated
Benefit. Any such examination will be conducted by one or more Physicians of our choice.
B. Application For Accelerated Benefit
You must apply for an Accelerated Benefit. To apply you must give us satisfactory Proof Of Loss on
our forms. Proof Of Loss must include a statement from a Physician that you have a Qualifying
Medical Condition.
C. Amount Of Accelerated Benefit
You may receive an Accelerated Benefit of up to 75%0 of your Insurance. The maximum Accelerated
Benefit is $500,000.The minimum Accelerated Benefit is $5,000 or 10% of your Insurance,
whichever is greater.
If the amount of your Insurance is scheduled to reduce within 24 months following the date you
apply for the Accelerated Benefit, your Accelerated Benefit will be based on the reduced amount.
The Accelerated Benefit will be paid to you once in your lifetime in a lump sum. If you recover from
your Qualifying Medical Condition after receiving an Accelerated Benefit, we will not ask you for a
refund.
D. Effect On Insurance And Other Benefits
For any purpose other than premium payment, the amount of your Insurance after payment of the
Accelerated Benefit will be the greater of the amounts in (1) and (2) below; however, if you assign
’your rights under the Group Policy, the amount of your Insurance will be the amount in (2) below.
(1) 10% of the amount of your Insurance as if no Accelerated Benefit had been paid; or
(2) The amount of your Insurance as if no Accelerated Benefit had been paid; minus
The amount of the Accelerated Benefit; minus
An interest charge calculated as follows:
A times B times C divided by 365 = interest charge.
A = The amount of the Accelerated Benefit.
B = The monthly average of our variable policy loan interestrate.
C = The number of days from payment of the Accelerated Benefit to the earlier of (I) the date
you die, and (2). the date you have a Right To Convert.
Your AD&D Insurance, if any, is not affected by payment of the Accelerated Benefit.
E. Exclusions
No Accelerated Benefit will be paid if:
All or part of your Insurance must be paid to your Child(ren), or your Spouse or former Spouse
as part of a court approved divorce decree, separate maintenance agreement, or property
settlement agreement.
2.You are married and live in a community property state unless you give us a signed written
consent ..frog your S.pouse.
.
’3. You have made an assignment ~’f all or part of your Insurance unless you giveus a sigr~ed
written, consent from the assignee.
I
Printed 12/6/99 - 14-639022-A
You have filed for bankruptcy, unless you giv8 us written approval from the Bankruptcy Court
for payment of the Accelerated Benefit.
You are required by a government agency to use the Accelerated Benefit to apply for, receive, or
continue a government benefit or entitlement.
You have previ0u~ly received ah Accelerated Benefit under the Group Policy.
Definitions For Accelerated Benefit
Insurance means your Plan 1 and Plan 2 Life Insurance under the Group Policy.
LLAB.OT.1X
RIGHT TO CONVERT
A. Right To Convert
You may buy an individual policy of life insurance without Evidence Of Insurability if:
1. Your Insurance ends or is reduced due to a Qualifying Event; and
2. You apply in writing and pay us the first premium during the Conversion Period.
Except as limited under C. Limits On Right To Convert, the maximum amount you have a Right To
Convert is the amount of your Insurance which ended.
Definitions For Right To Convert
1.Conversion Period means the 31-day period after the date of any QualiS!ing Event.
2.Insurance means all your insurance under the Group Policy, including insurance continued
under Waiver Of Premium, but excluding AD&D Insurance.
3. Qualifying Event means termination or reduction of your Insurance for any reason except:
a. The Member’s failure to make a required premium contribution.
b. Payment of an Accelerated Benefit.
4.You and your mean any person insured under the Group Policy.
5.Totally Disabled means that, as a result of Sickness, accidental Injury, or Pregnancy, you are
unable to perform with reasonable continuity the material duties of any gainful occupation for
which you are reasonably fitted by education, training and experience.
C. Limits On Right To Convert
If your Insurance ends or is reduhed because of termination or amendment of the Group Policy, 1
and 2 below will apply. ~
1. You may not convert Insurahce which has been in effect for less than the Minimum Time
Features.Insured, See Coverage ~
2. The maximum amount you have a Right To Convert is the lesser of:
a.The amount of your Insurance which ended, minus any other group life insurance for
which you become eligible during the Conversibn Period; and
The Maximum Conversion Amount. See Coverage Features.
Printed 12/6/99 - 15-639022-A
D. Investigation Of Claim
We may have you examined-at our expense at reasonable intervals. Any such examination will be
conducted by specialists of our choice.
We may have anautopsy performed at our expense, except where prohibit.ed by law.
E. Time Of Payment
We will pay benefits within 60 days after Proof Of Loss is satisfied.
F. Notice Of Decision On Claim
The claimant will receive a written decision on a claim within a reasonable time after we receive the
claim.
If the claimant does not receive our decision within 90 days after we receive the claim, the claimant
will have an immediate right to request a review as if the claim had been denied.
If we deny may part of the ~laim, the claimant will receive a written notice of denial containing:
I. The reasons for our decision; ’ .
2. Reference to the parts of the Group Policy on which our decision is based;
3~ A description of any additional information needed to Support the Claim; and.
4. Information concerning the cllaimant’s right to a review .of our decision.
G. Review Procedure
If all or part of a claim is denied, the claimant must request a review in writing within 60 days after
receiving notice of the denial.
The claimant may send us written comments or other items to support the claim, and may review
any nonprivileged information that relates to the request for review
We will review the claim promptly after we receive the request. We will send notice of our decision
within 60 days after we. receive the request, or within 120 days if special circumstances require an
extension. We will state the reasons for our decision and refer to the relevant parts of the Group
Policy.
LI.(~L,OT. I
ASSIGNMENT
The rights and benefits under the Group Policy cannot,be assigned.~
BENEFIT PAYMENT AND BENEFICIARY PROVISIONS
¯ A. Payment Of Benefits
I.Except as provided in item 4 below, benefits payable because of your death will be paid to the
Beneficiary you name. See B through E of this section.
2. AD&D Insurance benefits payable for Losses other than Loss of Life will be paid to you. Any
..such benefits rem~ning unpaid at yoUr.death v~.ll be paid according...t0?:the,.provis!ons ’for
payment of adeath benefit. )
Printed 12/6/99 -17-639022-A
3. Accelerated Benefits will be paid to you if you are living.
4. Other Benefits will be paid as follows:
The Child Care Benefit will be paid to your surviving Spouse. No Child Care Benefit will be paid
if you have no Spouse.
The CareerAdjustment Benefit will be paid to your Spouse. No Career Adjustment Benefit will
be paid if you have no Spouse!
The Higher Education Benefit will be paid annually to each eligible Child. No Higher Education
Benefit will be paid if there is no Child eligible to receive it.
The Repatriation Benefit will l~e paid to the person who incurs the transportation expenses.
B. Naming A Beneficiary
Beneficiary means a person you name to receive death benefits.
You may name one or more Beneficiaries. Two or more surviving Beneficiaries will share equally,
unless you specify otherwise. You may name or change Beneficiaries at any time without the
con.sent of a Beneficiary.
Your Beneficiary designation must be the same for Life Insurance and AD&D Insurance death
benefits.
You must name or change Beneficiaries in .writing. Your designation:
1.Must be dated and signed by you;
2.Must be delivered to the Polihyowner or Employer during your lifetime;
3.Must relate to the insurance provided under the Group Policy; and
4.Will take effect on the date it is delivered to the Policyowner or Employer.
If we approve it, a written designation signed and dated by you under the Prior Plan will be
accepted as your Beneficiary designation under the Group Policy.
C. Simultaneous Death Provision
If a Beneficiary dies on the same day you die, or within 15 days thereafter, benefits will be paid as
if that Beneficiary had died before you, unless Proof Of Loss with respect to your death is delivered
to us before the date of the Beneficiary’s death.
D. No Surviving Beneficiary
..If you do not name a Beneficiary, or if you are not survived by one, benefits will be paid in equal
shares to the first surviving class of the classes below.
1.Your spouse.
2.Your children.
3.Your parents.
4.Your brothers and sisters.
5.Your estate.
E. Methods Of Payment
¯ " Recipient means’a person who is entitled to benefits under this B~n~flt Paymenf a~d Ben~fl~larF
Provisions section.
Printed 12/6/99 - 18-639022-A
Lump Sum
If the amount payable to a Recipient is less than $10~000, We will pay it in a lump sum.
Standard Secure Access Checking Account
If the amount payable to a Recipient is $10,000 or more, we will deposit it into a Standard
Secure Access checking account which:
a.
b.
Co
Bears interest;
Is owned by the Recipient;
Is subject to the terms and conditions of a confirmation certificate which will be given to the
Recipient; and
d. Is fully guaranteed by us.
3. Installments
Payment to a Recipient may be made in installments if:
a. The amount payable is $10,000 or more;
b. The Recipient chooses; and
c. We agree.
To the extent permitted by law, the amount payable to the "Recipient will not be subject to any legal
process or to the claims of any creditor or creditor’s representative.
~FB_R~P~T) LI.BB.OT. iX
ALLOCATION OF AUTHORITY ¯
Except for those functions which the Group Policy specifically reserves to the Policyowner, we have full
and exclusive authority to control and manage the Group Policy, to administer claims, and to interpret
the Group Policy and resolve all questions arising in the administration, interpretation, and
application of the Group Policy.
Our authority includes,¯ but is not limited to:
I.
2.
The right to resolve all matters when a review has been requested;
The right to establish and enforce rules and procedures for the administration of the Group
Policy and any claim under it;
3. The right to determine:
a.Eligibility for insurance;
b.Entitlement to benefits;
c.Amount of benefits payable;
d.Sufficiency and the amount of information we may reasonably require to determine a., b.,
or c., above.
Subject to the review procedures of the Group Policy, any decision we make in the exercise of our
authority is conclusive and binding. ..
:’~:’" ~" ’ :"’"’" " "-" ...."’" ’ ’" ""-’ ’;’:: "~ "" ...." "~’~’ ’ ’:" ’~’~" "’" ""- : ’"’~ " ": .....LI.AL.OT.I"
Printed 12/6/99 - 19-639022-A
r TIME’LIMITS ON LEGAL ACTIONS
No action at law or in equity may be brought until 60 days after we have beengiven Proof Of Loss. ’ No
such action may be brought more than three years after the earlier of:
1. The date we receive Proof Of Loss; and
2. The time within which Proof Of Loss is required to be given.
LI.TL.OT. 1
INCONTESTABILITY PROVISIONS
.A.Incontestability Of Insurance
Any statement made to obtain insurance is a representation and not a warranty.
No misrepresentation will be Used to reduce or deny a claim unless:
1. The insurance would not have been approved if we had known the truth; and
2.We have given you or any other person claiming benefits a copy of the signed written
instrument which contains the misrepresentation.
We will not use a misrepresentation to reduce or deny a claim afte~ the insured’s insurance has
been in effect for two years.
Incontestability Of Group Policy
Any statement made by the Policyowner or Employer to obtain the Group Policy is a representation
and not a warranty.
No misrepresentation by the Policyowner or. Employer will be used to deny a claim or to deny the
validity of the Group Policy unless:
I. The Group Policy would not have been issued if we had known the truth; and
2.We have given the Policyowner or Employer a copy of a written instrument signed by the
P~licyowner or Employer which contains the misrepresentation.
The validity of the Group Policy will not be contested after it has been in force for two years, except
for nonpayment of premiums.
LI.IN.OT. I
DEFINITIONS
AD&D Insurance means accidental death and dismemberment insurance, if any, under the Group
Policy.
Annual Earnings means your annual rate of earnings from your Employer. Your Annual Earnings will
be based on you.r earnings in effect on your last full day of Active Work unless a different date applies
(see the Coverage Features). Annual Earnings includes:
1. Contributions you make thro~igh a salary reduction agreement with your Employer to:
a. An Internal Revenue C~ode (IRC) Section 401(k), 403(b), 408(k), or 4.57 deferred
compensation arrangemenlt; or
: b.-’An e~cuti~e~r~i~qijaiified ~deferred c~mpen~tion aiTange~nent: ’ ~ ":’ ~’" ’~ .....:.-:~ " ’ "
2. Shift differential pay.
Printed 12/6/99 - 20 -639022-A
3.Amounts contributed to your fringe benefits according to a salary reduction agreement under
an IRC Section 125 plan.
Annual Earnings does not include:
1.Bonuses.
2.Commissions.
3.Overtime pay.
4.Your Employer’s contributions~ on your behalf to any deferred compensation arrangement or
pension plan.
5. Any other extra compensation.
Child means:
1. Your unmaITied child fromlive birth through age 20 (through age 24 if a registered student in
full time attendance at an accredited educational institution); or
2. Your unmarried child who meets either of the following requirements:
a.The child is insured under the Group Policy and, on and after the date on which insurance
would otherwise end because of the Child’s age, is continuously Disabled.
b. The child was insured under the Prior Plan on the day before the effective date of your
Employer’s coverage under the Group Policy and was Disabled on that day, and is
continuously Disabled thereafter.
Child includes any of the following, if they otherwise meet the definition of Child:
i. Your adopted child; or
ii. Your stepchild, if living in your home.
Your child is Disabled if your child is:
1.Continuously incapable of self-sustaining employment because of mental retardation or
physical handicap; and
2.Chiefly dependent upon you for’ support and maintenance, or institutionalized because of
mental retardation or physical handicap,
You must give us proof your Child is Disabled on our forms within 31 days after a) the date on
which insurance would otherwis~ end because qf the Child’s age or b) the effective date of your
Employdr’s coverage under the G~roup Policy if your child is Disabled on that date. At reasonabl.e
intervals there.after, we may requilre further proof, and have your Child examined at our expense.
Contributory means you pay all or part of the premium for insurance.
Eligibility Waiting Period means the period you must be a Member before you become eligible for
insurance, See Coverage Features.
Evidence Of Insurability means an applicant must:
2.
3.
4.
Complete and sign our medical history statement;
Sign our form authorizing us to obtain information about the applicant’s health;
Undergo a physical examination, if re.qu,.ired by us, which may include blood testing; and
Provide any additional information about the applicant’s insurability’ that we may reasonably
require.
Printed 12/6/99 - 21 -639022-A
Group Po.licy means the group life insurance policy issued by us to the Po~cyowner and identified by
the Group Policy Number.
Injury means an injury to your body.
Life Insurance means life insurance under the Group Policy.
Noncontribut6ry means the Policyowner or Employer pays the entire premium for insurance.
Physician means a licensed M.D. or D.O., acting within the scope of the license. Physician does not
include you or your spouse, or the brother, sister, parent or Child of either you or your spouse.
Pregnancy means your pregnancy, Childbirth, or related.medical conditions, including complications of
pregnancy.
Prior Plan means your Employer’s group life insurance plan in effect on the day before the effective
date of your Employer°s coverage under the Group Policy and which is replaced by the Group Policy.
Sickness means your sickness, illness, or disease.
Spouse means a person to whom you are legally married.
~ ~o COM~ U.D~.O~.~X
POLICYOWNER PROVISIONS
A. Premiums
The premium due on each Premium Due Date is the sum of the premiums for all persons then
insured. Premium Rates are shoran in the Coverage Features.
Contributions From Members
The Policyowner determines the amount, if any, of each Member’s contribution toward the cost of
insur’ance under the Group Policy.
Changes In Premium Rates
We may change Premium Rates when:
1.A change or clarification in law or governmental regulation affects the amount payable under
the Group Policy. Any such change in Premium Rates will reflect only the change in our
obligations; or
2. The number of insured Members changes by 25% or more; or
3. We and the Policyowner mutually agree to change Premium Rates.
Except as provided above, Premium Rates will not be changed during the Initial Rate Guarantee
Period shown, in the Coverage Features. Thereafter, except as provided above, we may "change
Premium Rates upon advance written notice to the Policyowner. The minimum advance notice is
shown in the Coverage Features as Notice of Rate Change. Any such change in Premium Rates
may be made effective on any Premium Due Date, but no such change will be made more than
once in any contract year. Contract years are successive 12 month periods computed from the end
of the Initial Rate Guarantee Period.
D. Payment Of Premiums
All premiums are due on the Premium Due Dates shown in the Coverage Features.
Eachp~emt~m is payable on 0r before its Premium DUe Date d{z’~ctly to us at our home office. The
payment of each premium as it becomes due will maintain the Group Policy in force until the next
Premium Due Date.
Printed 12/6/99 - 22 -639022-A
E. Grace Period And Termination For Nonpayment
If a premium is not paid on or before its Premium Due Date, it may be paid during the following
Grace Period. The length of the Grace Period is shown in the Coverage Features. The Group
Policy will remain in force during the Grace Period.
If the-premium is not paid during the Grace Period, the Group Policy will terminate automatically
at the end of the Grace Period.
The Policyowner is liable for premium for insurance under the Group Policy during the Grace
Period. We may charge interest at the legal rate for any premium which is not paid during the
Grace Period, beginning with the first day after the Grace Period.
F. Termination For Other Reasons
The Policyowner may terminate the Group Policy by giving us written notice.
termination will be the later of:
1. The date stated in the notice; and
2. The date we receive the notice!
We may terminate the Group Policy as follows:
The effective date of
1. On any Premium Due Date if the number of persons insured is less than the Minimum
Participation Number or less than the Minimum Participation Percentage shown in the
Coverage Features.
2.On any Premium Due Date if we determine that the Policyowner has failed to promptly furnish
any necessary information requested by us, or has failed to perform any other obligations
relating to the Group Policy.
The minimum advance notice of such termination by us is the same as the Notice of Rate Change
stated in the Coverage Features.
G. Premium Adjustments
Premium adjustments involving a return of unearned premiums to the Policyowne.r will be limited
to the 12 months just before the date we receive a request for premium adjustmen~t.
H. Certificates
We will issue certificates to the Policyowner showing the coverage under the Group Policy. The
Policyowner will distribute a certificate to each insured Member.
I.Records And Reports
The Policyowner or Employer will furnish on our forms all information reasonably necessary to
administer the Group Policy. We have the right at all reasonable times to inspect the payroll and
other records of the Policyowner or Employer which relate to insurance under the Group Policy.
Clerical error by the Policyowner will not:
1.Cause a person to become insured;
2.Invalidate insurance otherwise validly in force; or
3.Continue insurance otherwise validly terminated.
J. Miss .tatement. Of .Ag.e.
if a~ person’s age has been misstated, we will make an equitable adjustment of’ premiums, benefits,
or both. The adjustment will be based on:
1. The amount of insurance based on the correct age; and
Printed 12/6/99 - 23-639022-A
2.The difference between the premiums paid and the premiums which would have been paid if
the age had been correctly stated. . .
Entire Contract, Changes.
The Group Policy and .the application of the Policyowner constitute the entire contract between the
parties. A copy of the Policyownet’s application is attached to the Group Policy when issued.
The Group Policy may be changed in whole or in part. No change in the Group Policy will be valid
unless it is approved in writing by one of our executive officers and given to the Policyowner for
attachment to the Group Policy. No agent has authority to change the Group Policy or to waive
any of its provisions.
L. Effect on.Workers’ Compensation, State Disability Insurance
The coverage provided under the Group Policy is not a substitute for coverage under a workers’
compensation or state disability income benefit law and does not relieve the Employer of any
obligation to provide such coverage.
[No D~’) LLPO.,O’r.’~X
ALl99
Printed 12/6/99 -24-639022-A
EXHIBIT "B"
STANDARD INSURANCE COMPANY
A Stock Life Insurance Company
, 900 SW Fifth Avenue
Portland, Oregon 97204-1282
I (503) 321-7000
CERTIFICATE
GROUP LONG TERM DISABIUTY INSURANCE
Policyowner:Fleet National Bank, Trustee of
The Standard Insurance
Company Group
Policy Number: 638213-T
Policy Effective Date: August 1, 1909
Employer:
Group Number:
Employer Effective Date:
City of Palo Alto
639022-B
January 1,2000
The Group Policy has been issued to the Policyowner. The Employer has joined the Standard
Insurance Company Group Insurance Trust and been approved for group long term disability
insurance coverage under the Group Policy. The Group Policy contains numerous optional and
variable provisions. The Employer selects ’the options and variables it requests be approved for its
employees. The options and variables we have approved for the Employer’s coverage under the Group
Policy are contained in the Statement Of Coverage we provided to the Employer. Only those provisions
of the Group Policy which appear in the Statement Of Coverage will apply to the Employer’s coverage
under the Group Policy.
We certify that you will be insured according to the terms of your Employer’s coverage under the
Group Policy. If the terms of this Certificate differ from the terms of your Employer’s coverage under.
the Group Policy, the latter will govern. If your insurance is changed by an amendment to your
Employer’s coverage under the Group Policy, we will provide the Employer with a revised Certificate or
other notice to be given to you.
Possession of this Certificate does not necessarily mean you are insured. You are insured only if you
meet the requirements set out in this Certificate.
The terms "you" and "your" mean the Member: "We", "us", and "our" mean Standard Insurance
Company. Other defined terms appear with their initial letters capitalized. Section headings, and
references to them, appear in boldface type.
GC 190-LTD/TRUST
President
~@Printed on reegcled paper.
Table of Contents
COVERAGE FEATURES .........................................................................................1
-GENERAL POLICY INFORMATION ...............~ .....................................................1
SCHEDULE OF INSURANCE ...: .......................................................................’.. 1
PREMIUM CONTRIBUTIONS .............................................................................4
INSURING CLAUSE .....................................................................¯ ...........................5
BECOMING INSURED ............................................................................................5
WHEN YOUR INSURANCE BECOMES EFFECTIVE ..................................................5
ACTIVE WORK PROVISIONS ..................................................................................6
CONTINUITY OF COVERAGE ..................................................................................7
WHEN YOUR INSURANCE ENDS ......: .....................................................................7
WAIVER OF PREMIUM ...........................................................................................8
REINSTATEMENT OF INSURANCE .............................’ ............................................8 "
DEFINITION OF DISABILITY ...................................................................................8
RETURN TO WORK PROVISIONS ............................................................................9
REASONABLE ACCOMMODATION EXPENSE BENEFIT ...........................................11
REHABILITATION PLAN PROVISION .......................................................................11
TEMPORARY RECOVERY ............................................................................~ ..........11
WHEN LTD BENEFITS END ..................................................................................... 12
PREDISABILITY EARNINGS ....................................................................................12
DEDUCTIBLE INCOME ..........................................................................................13
EXCEPTIONS TO DEDUCTIBLE INCOME ................................................................14
RULES FOR DEDUCTIBLE INCOME .......................................................................14
SUBROGATION ......................................................................................................15
SURVIVORS BENEFIT ............................................................................................15
CONVERSION OF INSURANCE .....................’. .........................................................16
BENEFITS AFTER INSURANCE ENDS OR IS CHANGED ..........................................16
EFFECT OF NEW DISABILITY .................................................................................17
DISABILITIES EXCLUDED FROM COVERAGE ........................................................17
DISABILITIES SUBJECT TO LIMITED PAY PERIODS ...............................................1S
LIMITATIONS .........................................................................................................19
CLAIMS .................................................................................................................19
ALLOCATION OF AUTHORITY ...........................; ......................................; ..............21
TIME LIMITS ON LEGAL ACTIONS ..........................................................................21
INCONTESTABILITY PROVISIONS ...........................................................................21
CLERICAL ERROR, AGENCY, AND MISSTATEMENT ...............................................22
TERMINATION OR AMENDMENT OF GROUP POLICY OR EMPLOYER COVERAGE ..22
DEFINITIONS .......................................................................................... ’ ............... 23
Index of Defined Terms
Active Work, Actively At Work, 6
Allowable Periods, 11
Any Occupation, 9
Any Occupation Period, 2 .
Benefit Waiting Period, 2, 3, 4, 23
Class Definition, 1
Contributory, 23
CPI-W, 23
Deductible Income, 13
Disabled, 8
Eligibility Waiting Period, 2
Employer, 23
Employer Effective Date, 1
Employer(s), 1
Evidence Of Insurability, 6
Group Number, 1
Group Policy, 23
Group Policy Effective Date, 1
Group Policy Number, 1
Hosp!tal, 18
Indexed Predisability Earning.,~, 23
Injury, 23
LTD Benefit, 23
Material Duties, 9
Maximum Benefit Period, 2, 3~ 4, 23
Maximum LTD Benefit, 2, 3, 4
Member, 1, 5
Mental Disorder: 18
Minimum LTD Benefit, 2, 3, 4
Noncontributory, 24
Other Limited Conditions, 18
Own Occupation, 9
Own Occupation Period, 2
Physical Disease, 24
Physician, 24
Policyowner, 1
Predisability Earnings, 12
Preexisting Condition, 17
Pregnancy, 24
Prior Plan, 24
Proof Of Loss, 20
Reasonable Accommodation Expense
Benefit, 11
Rehabilitation Plan, 11
Social Security Normal Retirement Age
{SSNRA), 2, 4
Substance Abuse, 18
Survivors Benefit, 15
Temporary Recovery, 11
War, 17
Work Earnings, I0
COVERAGE FEATUHES
This section contains many. of the features of your long term disability (LTD) insurance. Other
provisions, including exclusions, limitations, and Deductible Income, appear in other sections. Please
refer to the text of each section for full details~ The Table of Contents and the Index of Defined Terms
help locate sections and deihaitions.
Group Policy Number:
Policyowner:
Employer{s}:
Group Number:
Group Poli,cy Effective Date:
Employer Effective Date:
Policy Issued in:
GENERAL POLICY INFORMATION
638213-T
Fleet National Bank, Trustee of the Standard Insurance
Insurance Company Group Insurance Trust
One Constitution Plaza, 14th Floor "
Hartford, CT 06115
City ofPaloAlto
639022-B
August I, 1999
January1,2000
RhodeIsland
Member means:
A regular employee of the Employer (excluding a bargaining sworn police or fn-e department
employee); i
2. Actively At Work at least 20 h6urs each week (for purposes of the M~mber definition, Actively At
Work will Include regularly scl’aeduled days off, holidays, or vacation days, so long as the person
is capable of Active Work on those days); and
3. A citizen or resident of the United States or Canada.
Member does not include a temporary or seasonal employee, a full-time member of the armed
forces of any country, a leased employee, or an independent contractor.
Class Definition:
Class I:
Class 2:
Class 3:
All Members (other than Management and Confidential
Members)
Management andConfidential Members wl{ose
Predisability Earnings are $6,000 or less
Management and Confidential Members whose
Predisability Earnings exceed $6,000
Eligibility Waiting Period:
SCHEDULE OF INSURANCE
Yol.~ are eligible on one of the following dates: ’ ’
If you are a Member on the Employer Effective Date, you
are eligible on that date.
Printed 12/6/99 - 1 -639022-B
If you become a Member after the Employer Effective Date,
you are eligible on the date you become a Member.
Eligibility a/Caiting Period means the period you must be a Member before you become eligible for
insurance.
Own Occupation Period:
Any Occupation Period:
The first 24 months for which LTD. Benefits are payable.
From the end of the Own Occupation Period to the end of
the Maximum Benefit Period.
Class 1: If you are a Class 1 Member and you meet the requirements to become insured under the
Group Policy, you may elect insurance under either Plan A or Plan B.
Class 2: If you are a Class 2 Member and you meet the requirements to become insured under the
Group Policy, you automatically will be insured under Plan C.
Class 3: If you are a Class 3 Memb’er and you meet the requirements to become insure.d under the
G~-oup Policy, you may elect insurance under either Plan C or Plan D. If you do not elect to become
insured under Plan D, you automatically will be insured under Plan C.
Classes 1 and 3: If you apply for coverage more than 31 days after becoming eligible, or if you wish to
increase your insurance by changing from one plan to another, you will be required to submit
satisfactory Evidence Of Insurability. ]
Plan A
LTD Benefit:.
(available to Class 1 Members only)
Maximum LTD Benefit:
Minimum LTD Benefit:
Benefit Waiting Period:
Maximum Benefit Period:
Age
61 or younger ..................................
66 2/3% of the first 86,000 of your Predisability Earnings,
reduced by Deductible Income.
$4,000 before reduction by Deductible Income,
8100
60 days
Determined by your age when Disability begins, as follows:
Maximum Benefit Period
To age 65, or to SSNRA, or 3 years 6 months, whichever is
longest.
62 ...................................................To SSNRA, or 3 years 6 months, whichever is longer.
63 ...................................................To SSNRA, or 3 years, whichever is longer.
64 ...................................................To SSNRA, or 2 years 6 months, whichever is longer.,
65 ...................................................2 years
66 ...................................................I year 9 months
67 .................~ ...............................:. 1 year 6 months
68 ...................................................I year 3 months
69 or older ......................................1 year
Social Security Normal Retirement Age (SSNRA) means your normal retirement age under the Federal
Social Security Act, as amended.
Plan B (available to Class 1 Members ordy)
LTD Benefit:60% of the first 83,000 of your Predisability Earnings,
reduced by Deductible Income.
Printed 12/6/99 - 2~-639022-B
Maximum LTD Benefit:
Minimum LTD Benefit:
Benefit Waiting Period: :
Maximum Benefit Period:
81,800 before reduction by Deductible Income.
Sloo
60 days
Determined by your age when Disability begins and
nature o.f your Disability, as shown below.
t.he
If you are Disabled as a result of a Physical Disease, Pregnancy or Mental Disorder, your Maximum
Benefit Period is determined as follows:
Maximum Benefit Period
61 or younger ..................................To age’ 65 or for 5 years, whichever is shorter.
62 ...................................................3 years 6 months
63 ....................................................3 years
64 ...................................................2 years 6 months
65 ...................................................2 years
66 ...................................................1 year 9 months
67 ...................................................1 year 6 months
68 ...................................................1 year 3 months
69 or older ..............................................1 year
If you are Disabled as a result of an Injury, your Maximum Benefit Period is determined as follows:
Age Maximum Benefit Period
61 or younger ..................................To age 65 or 3 years 6 months, whichever is longer.
62 ...................................................3 years 6 months
65 ...................................................2
66 ...................................................1
67 ...................................................1
68 ...................................................1
69 or older ..............................................1
years
years 6 months
years
year 9 months
year 6 months
year 3 months
year
Plan C
LTD Benefit:
Maximum LTD Benefit:
Minimum LTD Benefit:
Benefit Waiting Period:
(available to Class 2 and Class 3 Members only)
66 2/3% of the first $6,000 of your Predisability Earnings,
reduced by Deductible Income.
$4,000 before reduction by Deductible Income.
$100
60 days
Printed 12/6/99 -3-639022-B
Maximum Benefit Period:.Determined by your age when Disability begins, as follows:
Age Maximum Benefit Period
61 or younger ..................................To age 65, or to SSNRA, or 3 years 6 months, whichever is
longest.
62 ...................................................To SSNRA, or 3 years 6 months, whichever is longer.
63 ...................................................To SSNRA, or 3 years, whichever is longer.
64 ...................................................To SSNRA, ’or 2 years 6 months, whichever is longer;
65 ...................................................2 years
66 ...................................................~1 year 9 months
67 ...................................................I year 6 months ’ ~
68 ...................................................1 year 3 months
69 or older .........: ............................1 year
Social Security Normal Retirement Age {SSNRA) means your normal retirement age under the Federal
Social Security Act,-as amended.
Plan D
LTD Benefit:
(available to Class 3 Members only] ..
Maximum LTD Benefit:
Minimum LTD Benefit:
Benefit Waiting Period:
Maximum Benefit Period:
Age
61 or younger ..................................
66 ~2/3% of the first $15,000 of your Predisability
Earnings, reduced by Deductible Income.
$10,000 before reduction by Deductible Income.
$1oo
60 days
Determined by your age when Disability begins, as follows:
Maximum Benefit Period
To age 65, or to SSNRA, or 3 years 6 months, whichever is
longest.
62 .............~ .....................................To SSNRA, ot 3 years 6 months, which.ever is longer.
63 ......~ ............................................To SSNRA, or 3 years, whichever is longer.
64 ...................................................To SSNRA, or 2 years 6 months, whichever is longer.
65 ..................................................; 2 years
66 ...................................................1 year 9 months
67 ...................................................1 year 6 months
68 ...................................................1 year 3 months
69 or older .................~ ....................1 year
Social Security Normal Retirement Age (SSNRA) means your normal retirement age under the Federal
Social Security Act, as amended.
PREMIUM CONTRIBUTIONS
For Plans A, B and D, insurance is:Contributory
For Plan C, insurance is:Noncontributory
Printed 12/6/99 4 639022-B
INSURING CLAUSE
If you become Disabled while insured under the Group Policy, we will pay LTD Benefits according to
the terms of your Employer’s coverage under the Group Policy after we receive Proof Of Loss
satisfactory to us. "
LT.IC.OT.2
BECOMING INSURED
To become insured you must be a Member, complete your Eligibility Waiting Period, and meet the
requirements in Active Work Provisions and When You~ Insurance Becomes Effective.
Youare a Member if you are:
1. A regular employee of the Employer (excluding a bargaining sworn police or fire department
employee);
2. Actively At Work at least 20 hours each week (for purposes of the Member definition, Actively At
Work will include regularly scheduled days off, holidays, or vacatibn days, ’so long as you are
capable of Active Work on those days); and
3. A citizen or resident of the United States or Canada.
You are not a Member if you are a temporary or seasonal employee, a full-time member of the
armed forces of any country, a leased employee, or an independent contractor.
Eligibility Waiting Period means the: period you must be a Member before you become eligible for
insurance. Your Eligibility Waiting Period is shown in the Cove.rage Features..
WHEN YOUR INSURANCE BECOMES EFFECTIVE
When Insurance Becomes Effective
Subject to the Active Work Provl.siona, your insurance becomes effective as follows:’
1.Insurance Subject To Evidence Of Insurability
Insurance subject to Evidence Of Insurability becomes effective on the date we approve your
Evidence Of Insurability.
Insurance Not Subject To Evidence of Insurability
The Coverage Features states whether insurance is Contributory or Noncontributory.
a. Noncontributory Insurance
Noncontributory insurance not subject to Evidence Of Insurability becomes effective on the
date you become eligible.
b. Contributory Insurance
You must apply in writing for Contributory. insurance and agree to pay premiums.
Contributory insurance not subject to Evidence Of Insurability becomes effective on:
i.The date you become e~ligible if you apply on or before that date; or
iL The date you apply if y[ou apply within 3 idays after you become eligible. ¯
Late application: Evidence Of Insurability is required if you apply more than 31 days after
you become eligible.
Printed 12/6/99 ,-5-639022-B
lo
Elective increase: Evidence Of insurability is requtred to increase the amount of your LTD
Benefit by changing the Plan you have selected.
Takeover Provisions
1. If you were insured under the Prior Plan on the day before the effective date of your Emplo3~er’s
coverage under the Group Policy, your Eligibility Waiting Period is waived on the effective date
of your Employer’s coverage under the Group Policy.
2. You must submit satisfactory Evidence Of Insurability to become insured if you were eligible for
insurance under the Prior Plan for more than 31 days but were not insured.
3. You must submit satisfactory Evidence Of insurability to become insured under a Plan which
provides an LTD Benefit which exceeds the amount of the benefit for which you were insured
on December 31, 1999 under the Prior Plan.
Evidence Of Insurability Requirement
Evidence Of Insurability satisfactory to us is required:
a.For late application for. Contributory insurance,
b.For an increase in your LTD Benefit due to a change in the Plan selected..
c.For an LTD Benefit which exceeds the amount of your benefit under the Prior Plan.
d.For Members eligible but not insured under the Prior Plan.
e.For reinstatements if required.
Providing Evidence Of Insurability means you must:
1.Complete and sign our medical history statement;
2.Sign our form authorizing us to obtain lnfo .rmation about your health;
3.Undergo a phy’sical examination, if required by us, which may include blood testing; and
4.Provide any additional information about your insurability that we may reasonably require.
WAR EOI~ LT.EF.OT.1X
ACTIV~ WORK PROVISIONS
Active Work Requirement
You must be capable of’ Active iWork on the day before the scheduled effective date of your
insurance or your insurance will ,not become effective as scheduled. If you are incapable of Active
Woflt because of Physical Disease, Injury, Pregnancy or Mental Disorder on the day before the
scheduled effective date of your insurance, your insurance will not become effective until the day
after you complete one full day of Active Work as an eligible Member.
Active Work and Actively At Work mean performing with reasonable continuity the Material Duties
of your Own Occupation at your Employer’s usual place of business.
Changes In Insurance
This Active Work r~qulrement also applies to any increase in your insurance.
LT.AW.OT.1
Printed 12/6/99 - 6 -639022-B
CONTINUITY OF COVERAGE
If your Disability is subject to the Preexisting Condition Exclusion, LTD Benefits will be payable if:
I. You were insured under the Prior Plan on the day before the effective date of your Employer.’s
coverage under the Group Policy;
You became insured under the Group Policy when your insurance under the Prior Plan ceased;
You were continuously insured under the Group Policy from the effective date of your insurance
under the Group Policy through the date you became Disabled from the Preexisting Condition; and
Benefits would have been payable under the terms of the ’Prior Plan if it had remained in force,
taking into account the preexisting condition exclusion, if any, of the Prior Plan.
For such a Disability, the amount of your LTD Benefit will be the lesser of:
a. The monthly benefit that would have been payable under the terms of the Prior Plan if it had
remained in force; or
b.The LTD Benefit payable under the terms of your Employer’s coverage under the Group Policy,
but without application of the Preexisting Condition Exclusion.
Your LTD Benefits for such a Disability will end on the earlier of the following dates:
a. The date benefits would have ended under the terms of the Prior Plan if it had remained in
force; or
b. Under the terms of your Employer’scoverage under the GroupThe date LTD Benefits end
Policy.
WHEN YOUR INSURANCE ENDS
(Px3
Your insurance ends automatically on the earliest of:
I. The date the last period ends for which a premium contribution was made for your insurance.
2. The date the Group Policy terminates.
3. The date your Employer’s coverage under the Group Policy terminates.
The date your employment terminates.
The date you cease to be a Member. However, your insurance will be continued during the
following periods when you are absent from Active Work, unless it ends under any of the above.
a. During the first 90 days of a temporary or indefinite administrative or involuntary l~ave of
absence or sick leave, provided your Employer is paying you at least the same Predisability
Earnings paid to you immediately before you ceased to be a Member. A period when you are
absent from Active Work as part of a severance or other employment termination agreement is
not a leave of absence, even if you are receiving the same Predisability Earnings.
b. During a leave of absence if continuation of your insurance under ~he Group Policy is required
by a state-mandated family or medical leave act or law.
During any other temporary leave of absence approved by your Employer in advance and in
writing and scheduled to !ast 30. days or less. A period of Disability i.s not a leave of absence., ¯
LT.EN,OT,2
Printed 12/6/99 -’ 7 -639022-B
WAIVER OF PREMIUM
Wewill waive payment of premium for your insurance while LTD Benefits are payable.
LT.WP.~T. I
REINSTATEMENT OF INSURANCE
If your insurance ends, you may become insured again as a new Member. However, the following will
apply:
1.If you cease to be a Member because of a covered Disability, your insurance will end; however, if
you become a Member again immediately after LTD Benefits end, the Eligibility Waiting Period will
be waived and, with respect to the condition(s) for which LTD Benefits were payable, the
Preexisting Condition Exclusion will be applied as if your insurance had remained in effect during
that period of Disability. i
~o be a Member for any reason other than a covered2.If your insurance ends because lyou cease
Disability, and if you become a Member again within 90 days,, the Eligibility Waiting Period will be
waived. ~
If your insurance ends because you fail to make a required premium contribution, you must
provide Evidence Of Insurability to become insured again.
If your insurance ends becauseyou are on a federal or state-mandated family Or medical leave of
absence, and you become a Member again immediately following the period allowed, your
insurance will be reinstated pursuant to-the federal or state-mandated family or medical leave act
or law.
o The Preexisting Conditions Exclusion will be applied as if insurance had remained in effect in the
following instances:
a. If you become insured again within 90 days.
b. If required by federal or state-mandated family or medical leave act or law and you become
insured again immediately following the period allowed under the family or medical leave act or
law.
6. In no event will insurance be retroactive.
LT.RE.OT.I
DEFINITION OF DISABILITY
You are Disabled if you meet the following definitions during the periods they apply:
A. Own Occupation Definition Of Disability.
B.’ Any Occupation Definition Of Disability.
A. Own Occupation Definition Of Disability
During the Benefit Waiting Period and the Own Occupation Period you are required to be Disabled
only from your Own Occupation.
You are Disabled from your Own Occupation if, as a result of Physical Disease, Injury, Pregnancy
or Mental Disorder:
’i~You are ’unable to~ perform with reasonable contir~uity the Material Duties of your Own
Occupation; and ’
Printed 12/6/99 -8-639022-B
2.You suffer a loss of at least 20% in your Indexed Predisability Earnings when working in your
Own Occupation.
Note: You are not Disabled mgrely because your right to perform your Own Occupation is
restricted, including a restrictio!!or loss of license, . . . ,
During the Own Occupation Pe od you may work in another occupation While you meet the Own
Occupation Definition Of Disability. However, you will no longer be Disabled when your Work
Eamings from another occupation meet or exceed 80% of your Indexed Predisability Earnings.
Your Work Earnings may be Deductible Income. See Return To Work Provisions and Deductible
Income.
Own Occupation means any employment, business, trade, profession, calling or vocation that
involves Material Duties of the same general character as the occupation you are regularly
performing for your Employer when Disability begins. In determining your Own. Occupation, we
are not limited to looking at the way you perform your job for your Employer, but we may also look
at the way the occupation is generally performed in the national economy. If your Own Occupation
involves the rendering of professional services and you are required to have a professional or
occupational license in order to work, your Own Occupation is as broad as the scope of your
license.
Material Duties means the essential tasks, functions and ’operations, and the skillsl abilities,
knowledge, training and experience, generally required by employers from those engaged in a
particular occupation that cannot be reasonably modified or omitted. In no event will we consider
working an average of more than 40 hours per week to be a Material Duty.
B. Any Occupation Definition Of Disability
During the Any Occupation Period you are required to be Disabled from all occupations.
You are Disabled from all occupations if, as a result of Physical Disease, Injury, Pregnancy or
Mental Disorder, you are unable to perform with reasonable continuity the Material Duties of Any
Occupation.
Any Occupation means any occupation or employment which you are able to perform, whether due
to education, training, or experience, which is available at one or more locations in the national
economy and in which you can be expected to earn at least 60% of your Indexed Predisability
Earnings within twelve months following your return to work, regardless of whether you are
working in that or any other occupation.
Material Duties means the essential tasks, functions and operations, and the skills, abilities,
knowledge, training and experience, generally required by employers from those engaged in a
particular occupation that cannot be reasonably modified or omitted. In no event will we consider
working an average of more than 40 hours per week to be a Material Duty.
Your Own Occupation Period and Any Occupation Period are shown in ~he Coverage Features.
(OWN_ANY_WITH 40) LT.DD.OT. I
RETURN TO WORK PROVISIONS
A. Return To Work Responsibility
During the Own Occupation Period no LTD Benefits will be payable for any period when you are
able to work in your Own Occupation and able to earn at least 20% of your Indexed Predisability
Earnings, but you elect not to work.
During theAny Occupation Period no LTD Benefits will be payable for any period when you are
able to work in Any Occupation and able to earn at least 20% of your Indexed Predisability
Earnings, but you elect not to work.
Printed 12/6/99 - 9 -639022-B
B. Return To Work Incentive
You may serve your Benefit Waiting Period while working if you meet the Own Occupation
Definition Of Disability.
You are eligtble for the Return To Work Incentive on the first day you work after the Benefit Waitifig
Period- If LTD Benefits are payable on that date. The Return To Work Incentive changes 12 months
after that date, as follows:
1.During the first 12 months, your Work Earnings will be Deductible Income as determined tn a.,
b. and c:
a.Determine the amount of your LTD Benefit as if there were no Deductible Income, and add
your Work Earnings to that amount.
b. Determine 100% of your Indexed Predisability Earnings.
c. If a. is greater than b., the difference will be Deductible Income.
2. After those first 12 months, 50% of your Work Earnings will be Deductible Income.
Work Earnings Definition
Work Earnings means your gross monthly earnings from work you perform while Disabled, plus
the earnings you could receive if you worked as much as you are able to, conside.ring your
Disability, in work that is reasonably available:
a. In your Own Occupation during the Own Occupation Period; and
b. In Any Occupation during the Any Occupation Period.
Work Earnings includes earnings from your Employer, any other employer, or self-employment,
and any sick pay, vacation pay, annual or personal leave pay or other salary continuation earned
or accruedwhile working.
Earnings from work you perform will be included in Work Earnings when you have the right to
receive them. If you are paid in a lump sum or on a basis other than monthly, we will prorate your
Work Earnings over the period of time to which they apply. If no period of time is stated, we will
use a reasonable one.
In determining your Work Eamlngs we:
1. Will use the financial accounting method you use for income tax purposes, if you use that
method on a consistent basis.
2. Will not be limited to the taxable income you report to the Internal Revenue Service.
3.May ignore expenses under section 179 of the IRC as a deduction.from your gross earnings.
4.May ignore depreciation as a deduction from your gross earnings.
5.May adjust the financial information you give us in order to clearly reflect your Work Earnings.
If we determine that your earnings vary substantially from month to month, we may determine
your Work Earnings by averaging your earnings over the most recent three-month period. During
the Own Occupation Period you will no longer be Disabled when your average World Earn!ngs over
the-last three months exceed 80% of your Indexed Predlsabillty Earnings. During the Any
Occupation Period you will no longer be Disabled when your average Work Earnings over the last
three months exceed 60% of your Indexed Predisabihty Earnings. . .
’
Printed 12/6/99 -10-639022-B
REASONABLE ACCOMMODATION EXPENSE BENEFIT
If you return to work in any occupation for any employer, not including self-employment, as a result of
a reasonable accommodation made by such employer, we will pay that employer a Reasonable
Accommodation Expense Benefit of up to $25,000, but not to exceed the expenses incurred.
The Reasonable Accommodation Expense Benefit is payable only.if the reasonable accommodation is
approved by us in writing prior to its implementation.
REHABILITATION PLAN PROVISION
~While you are Disabled you m,ay qualify to participate in a Rehabilitation Plan. Rehabilitation Plan
means a written plan, program or course of vocational training or education that is intended to
prepare you to return to work.
To participate in a Rehabilitation Plan you must apply on our forms or in a letter to us. The terms,
conditions and objectives of the plan must be accepted by.you and approved by us in advance. We
have the sole discretion to approve your Rehabilitation Plan.
An approved Rehabilitation Plan may include our payment of some or all of the expenses you incur in
connection with the plan, including:
a. Training and education expenses.
b.Family care expenses.~.
c.Job-related expenses.
d.Job search expenses.
LT.RH.OT.1
TEMPORARY RECOVERY
You may temporarily recover from your Disability and then become Disabled again from the same
cause or causes without having to serve a new Benefit Waiting Period. Temporary Recovery means you
cease to be Disabled for no longer than the applicable Allowable Period. See Definition Of Disability.
A. Allowable Periods
I. During the Benefit Waiting Period: a total of 30 days of recovery.
2. During the Maximum Benefit Period: 180 days for each period of recovery.
B. Effect Of Temporary Recovery
If your Temporary Recovery does not exceed the Allowable Periods, the following will apply.
1. The Predisability Earnings use~d to determine your LTD Benefit will not change.
2. ,The period of Temporary Reclovery will not count toward your Benefit Waiting Period, your
"Maximum Benefit Period or yo~ur Own Occupation Period.
3. No LTD Benefits will be payable for the period of Temporary Recovery.
4,No LTD Benefits will be payable after benefits become payable to you i~nder any other disability
,.insurance plan under which you become insured during your period o.f T9mpor.ary, Recovery., ¯ ,’ "
5.Except as stated above, the provisions of the Group Policy will be applied as if there had been
no interruption of your Disability.
Printed 12/6/99 -II -639022-B
WHEN LTD BENEFITS END
Your LTD Benefits end automatically on the earliest of:
2.
3.
4.
So
LT.TR.OT.I
The d~ite you are no longer Disabled.
The date your Maximum Benefit Period ends.
-The date you die.
The date benefits become payable under any other LTD plan under which you become insured
through employment during a period of Temporary Recovery.
The date you fat to provide proof of continued Disability and entitlement to LTD Benefits.
LT.BE.OT.1
an IRC Section 125 plan.
Predisability Earnings does not include:
PR.EDISABILITY EARNINGS
Your Predisability Earnings will be based on your earnings in effect on y.our last full day of Active
Work. Any subsequent change in your earnings after that last ftfll dayof Active Work will not affect
your Predisability Earnings.
Predisability Earnings means your monthly rate of earnings from your Employer, including:
1. Contributions you make through a salary reduction agreement with your Employer to:
a. An Internal Revenue Code (IRC) Section 401(k), 403(b), 408(k), 408(p), or 457 deferred
compensation arrangement; or
b. An executive nonqualified deferred compensation arrangement.
Shift differential pay.
Amounts contributed to your ,~ringe benefits according to a salary reduction agreement under
I. Bonuses.
2. Commissions.
3.. Overtime pay.
4.Your Employer’s contributions on your behalf to any deferred compensation arrangement or
pension plan.
5. Any other extra compensation.
If you are paid on an annual contract basis, your monthly rate of earnings is one-twelfth (1/12th) of
your annual contract salary.
If you are paid hourly, your monthly rate of earnings is based on your hourly pay rate multiplied by
the number of hours you are regularly scheduled to work per month, but not more than 173 hours. If
you do not have regular Work hours, your monthly rate of earnings is based on the average number of
hours you worked per month during the preceding 12 calendar months (or during your period of
era. ploymentit"less~.than 12months), butnot’mor~tlian I7~hours.. -."-~.~.-~.~:~.:~"..’,., :~. :.~:-.:.’..:~. ::. .... ~ := .,~-~ :~
(REG NO COM)LI.PD.OT.2
Printed 12/6/99 - 12-639022-B
DEDUCTIBLE INCOME
Subject to Exceptions TO Deductible Income, Deductible Income means: ,
I. Sick pay, annual or personal leave pay, severance pay, or other salary continuation, Includi.ng
donated amounts, (but not vacation pay) payable to you by your Employer,
2. Your Work Earnings, as described in the Retur~ To Work Provisions.
3. Any amount you receive or are eligible to receive because of your disability, including amounts for
partial or total disability, whether permanent, temporary, or vocational, under any of the following:
a. A workers’ compensation law;
b.The Jones Act;
o
c.Maritime Doctrine of Maintenance, Wages, .or Cure;
d.Longshoremen’s and Harbor Worker’s Act; or.
e.Any similar act or law.
Any amount you, your spouse, or your child under age 18 receive or are eligible to receive because
of your disability or retirement under:
a.The Federal Social Security Act;
b.The Canada Pension Plan;
c.The Quebec Pension Plan;
d.The Railroad Retirement Act; or
e.Any similar plan or act.~
Full offset: Both the primary benefit (the benefit awarded to you) and dependents benefit are
Deductible Income.
Benefits your spouse or a child receives or are eligible to receive because of your disability are
Deductible Income regardless of marital status, custody, or place of residence. The term "child"
has the meaning given in the applicabl~e plan or act.
Any amount you receive or are eligible to ’receive because of your disability under any state
disability income benefit law or similar law.
Any amount you receive or are eligible to receive because of your disability under another group
insurance coverage.
Any disability or retirement benefits you receive or are eligible to receive under your Employer’s
retirement plan, including a public employee retirement system, a state teacher retirement system,
and a plan arranged and maintained by a union or employee association for the benefit of its
members.
If any of these plans has two or more payment options, the option which comes closest to providing
you a monthly income for life with no survivors benefit will be Deductible Income, even if you
choose a different option.
8,Any earnings or compensation included in Predisability Earnings which you receive or are eligible
to receive while LTD Benefits are payable.
.......L ....~.: 9.,,:~kny amount y~u r~eive or~e ~iigibl~ ~0 ~:e~i~re ~=der: an~ Ui~:e’mpl-6~Tie~t"c-ompens~tion. law or
similar act or law.
’P~nted 12/6/99 -13-639022-B
I0.Any amount you receive or are eligible t~ receive from or on behalf of a third party because of your
disability, whether by judgement, settlement or other method. If you notify us before filing suit or
setting your claim against such third party, the. amount used as Deductible Income will be
reduced bY a pro rata share of your costs of recovery, including reasonable attorney fees.
11.Any amount you receive by compromise, settlement, or other method as a .result of a claim for any
of the above, whether disputed or undisputed.
(NO OTHR OFFST..PUB:WITH 3RD) LT.DI.OT.1
EXCEPTIONS TO DEDUCTIBLE INCOME
Deductible Income does not include:
1.Any cost of living increase in any Deductible Income other than Work Earnings, if the increase
becomes effective while you are Disabled and while you are eligible for the Deductible Income.
2.Reimbursement for hospital, medical, or surgical expense.
3.Reasonable attorneys fees incurred in connectiox~ with a claim for Deductible Income.
4.Benefits from any individual disability insurance policy.
5.Early retirement benefits under the Federal Social Security Act which are not actually received.
6.Group credit or mortgage disability insurance benefits.
7.Accelerated death benefits paid under a life insurance policy.
8.Benefits from the following:
a. Profit sharing plan.
b. Thrift or savings plan.
c.Deferred compensation plan.
d.Plan under IRC Section 40 l(k), 408(k), 408(p), or 457.
e.Individual Retirement Account (IRA).
f.Tax Sheltered Annuity (TSA.) under IRC Section 403(b).
g.Stock ownership plan.
h.Keogh (HR-10) plan.
(PUB_NO OTHR OFFST)LT.ED.OT.1
RULES FOR DEDUCTIBLE INCOME
A. Monthly Equivalents
Each month we will determine your LTD Benefit using the Deductible Income for the same monthly
period, even.if you actually receive the Deductible Income in another month.
If you are paid Deductible Income in a lump sum or by a method other than monthly, we will
dete .rmine your LTD Benefit using a prorated amount. We will use the period of time to which the
Deductible Income applies. If no period of time is stated, we will use a reasonable one.
You must pursue Deductible Income for which you may be eligible. We may ask for written
documentation of your pursuit of Deductible Income. You must provide it within 60 days after we
Printed 12/6/99 -14-639022-B’
Do
mail you our request. Otherwise, x’ve may reduce your LTD Benefits by the amount we estimate you
would be eligible to receive upon p~roper pursuit of the Deductible Income. "
Pending Deductible Income
We will not deduct pending Deductible Income until it becomes payable. You must notify us of the
amount of the Deductible Income when it is approved.You must repay us for the resulting
overpayment of your claim.
Overpayment Of Claim
We will notify you of the amount of any overpayment of your claim under any group disability
insurance policy issued by us. You must immediately repay us. You will not receive any LTD
Benefits until we have been repaid in full. In the meantime, any LTD Benefits paid, including the
Minimum LTD Benefit, will beapplied’to reduce the amount of the overpayment. We may charge
you interest at the legal rate for any overpayment which is not repaid within 30 days after we ~irst
mail you notice of the amount of the overpayment.
LT.RU.OT. 1
SUBROGATION
If LTD Benefits are paid or payable to you under the Group Policy as the result of any act or omission
of a third party, we will be subrogated to all rights of recovery you may l~ave in respect to such act or
omission. You must execute and deliver to us such instruments and papers as may be required to do
whatever else is needed to secure such rights. You must avoid doing anything that would prejudice
our rights of subrogation.
If you notify us before filing suit or settling your claim against such third party, the amount to which
we are subrogated will be reduced by a pro rata share of your costs of recovery, including reasonable
attomey fees. If suit or action is filed, we may record a notice of payments of LTD Benefits, and such
notice shall constitute a lien on any judgement recovered.
If you or your legal representative fail to bring suit or action promptly against such third party, we may
institute such suit or action in our name or in your name. We are entitled to retain from any
judgement recovered the amount of LTD Benefits paid or to be paid to you or on your behalf, together
with our costs of recovery, including attorney fees. The remainder of such recovery, if any, shall be
paid to you or as the court may direct.
LT.~O.OT.1
SURVIVORS BENEFIT
If you die while LTD Benefits are payable, and on the date you die you have been continuously
Disabled for at least 180 days, we will pay a Survivors Benefit accgrding to I through 4 below.
I. The Survivors Benefit is a lump sum equal to 3 times your LTD Benefit without reduction by
Deductible Income.
2. The Survivors Benefit will first be applied to reduce any overpayment of your claim.
3. The Survivors Benefit will be paid at our option to any one or more of the following:
a. Your. surviving spouse;
b. Your surviving unmarried children, including adopted children, under age 25;
d. Any person providing the care and support of any person listed in a., b., or c. above.
PHnted 12/6/99 -15-639022-B
4. No Survivors Benefit will be paid if you are not survived by any person listed ina., b., or c. above.
LT, SB.OT.1
CONVERSION OF INSURANCE
Conversion Of Insuran.ce Benefit,
When your insurance ends, you may buy LTD conversion insurance if you meet 1 through 5 below.
1. Your insurance ends for a reason other than:
a. Termination or amendment Of the Group Policy;
b. Your failure to make a required premium contribution; or
c. Your retirement. .~
2.You were continuously insured under your Employer’s long term disability insurance plan for at
least one year as of the date your insurance ended.
3. You are not Disabled on the date your insurance ends.
4. You are a citizen or resident of the United States or Canada.
5.You must apply in writing and pay the first premium to us within 31 days after your insurance
ends.
Your LTD conversion insurance becomes effective on the day after your insurance ends.
The maximum LTD conversion insurance benefit you may select is the smallest of:
1.$4,000 {however, if you provide satisfactory Evidence Of Insurability, this upper limit is $8,000);
2.60% of your insured Predisability Earnings on the date your insurance ended; and
3.The LTD Benefit payable if you had become Disabled on the day before your insurance ended and
you had no Deductible Income.
The maximum LTD conversion insurance benefit is reduced by deductible income. The certificate we
will issue to you when your LTD conversion insurance becomes effective will contain other provisions
which will also differ from the Group Policy.
LT.CV,OT.I
BENEFITS AFTER INSURANCE ENDS OR IS CHANGED
During each period of continuous Di.sability, we will pay LTD Benefits according to the terms of your
Employer’s coverage under the Group Policy in effect on the date you become Disabled, Your right to
receive LTD Benefits will not be affected by:
1.Any amendment to the Group Policy or your Employer’s coverage under the Group Policy that is
effective after you become Disabled.
Termination of the
become Disabled.
Group Policy or your Employer’s coverage under the Group Policy after you
LT.KOT.2
Printed 12/6/99 - 16-639022-B
EFFECT OF NEW DISABILITY ’:
If a period of Disability is extended by a new cause while LTD Benefits axe payable, LTD Benefits will
continue whil.e you remain Disabled. However, I and 2 apply.
1. LTD Benefits will not continue beyond the end of the original Maximum Benefit Period.
2.The Disabilities Excluded From Coverage, Disabilities Subject To Limited Pay Periods, and
Limitations sections will apply to the new cause of Disability.
LT.ND,OT.I
A. War
Bo
DISABILITIES EXCLUDED FROM COVERAGE
You are not covered fo~ a Disability caused or contributed to by War or any act of War. War means
declared or undeclared war, whether civil or international, and any substantial armed conflict
between organized forces of a.military nature.
Intentionally Self-Inflicted Injury
You are not covered for a Disability caused or ’contributed to by an intentionally self-inflicted
Injury, while sane or insane.
Preexisting Condition
1. Definition
Preexisting Condition means a mental or physical condition, whether or not diagnosed or
misdiagnosed:
a. For which you have done or for which a reasonably prudent person would have done any of
the following:
i. Consulted a physician or other licensed medical professional;
ii, Received medical treatment, services or advice;
iii. Undergone diagnostic procedures, including self-administered procedures;
iv. TalCen prescribed drugs or medications;
b.Which, as a result of any medical examination, including routine examination, was
discovered or suspected;
at any time during the 90-day period just before your insurance becomes effective.
Exclusion
You are not covered for a Disability caused or contributed to by a Preexisting Condition or
medical or surgical treatment of a Preexisting Condition unless, on the date you become
Disabled, you:
a.Have been Continuously insured under the Group Policy for 12 months; and
b.Have been Actively At Work for at least one full day after the end of that 12 months.
D. Loss Of License Or Certification
Y0u~ are not covered fo~a~Disability caused or contributed to by-the, loss of..your .p~ofessional.
license, occupational license or certification.
Printed 12/6/99 - 17-639022-B
E. Violent Or Criminal Conduct
You are not covered for a Disability caused or contributed to by your committing or attempting to
commit an assault or felony, or actively participating in a violent disorder or riot. Actively
participating does not include being at the scene of a violent disorder or riot while performing yo.ur
official duties.
DISABILITIES SUBJECT TO LIMITED PAY PERIODS
A. Mental Disorders, Substance Abuse and Other Limited Conditions
Payment of LTD Benefits is limited to 24 months during your er~tire lifetime for a Disability caused "
or contributed to by any one or more of the following, or medical or surgical treatment of one. or
more of the following:
1.Mental Disorders;
2.Substance Abuse; or
3.Other Limited Conditions.-
However, if you are confined in a Hospital solely because of a Mental Disorder at the end of the 24
months, this limitation will not apply while you are continuously confined.
Mental Disorder means any mental, emotional, behavioral, psychological, personality, cognitive,
mood or stress-related abnormality, disorder, disturbance, dysfunction or syndrome, regardless of
cause (including any biological oi- biochemical disorder or imbalance of the brain) or the presence
of physical symptoms. Mental I~isorder includes, but is not limited to, bipolar affective disorder,
organic brain syndrome, schizop!~renia, psychotic illness, manic depressive illness, depression and
depressive disorders, anxiety and~ anxiety disorders.
Substance Abuse means use of cohol, alcoholism, use of any drug, including hallucinogens, or
drug addiction.
Other Limited Conditions means chronic fatigue conditions (such as .chronic fa~’igue syndrome,
chronic fatigue immunodeficiency syndrome, post viral syndrome, limbic encephalopathy, Epstein-
Barr virus infection, herpesvirus type 6 infection, or myalgic encephalomyelitis), any allergy or
sensitivity to chemicals or the environment (such as environmental allergies, sick building
syndrome, multiple chemical.sensitivity syndrome or chronic toxic encephalopathy), chronic pain
conditions (such as fibromyalgia, reflex sympathetic dystrophy or myofascial pain), carpal tunnel
or repetitive motion syndrome, temporomandibular joint disorder, or craniomandibular joint
disorder.
However, Other Limited Conditions does not include neoplastic diseases, neurologic diseases,
endocrine diseases, hematologic diseases, asthma, allergy-induced reactive lung disease, tumors,
malignancies, or vascular malformations, demyelinating diseases, or lupus.
Hospital means a legally operated .hospital providing full-time medical care and treatment under
the direction of a full-time staff of licensed physicians. Rest homes, nursing homes, convalescent
homes, homes for the aged, and facilities primarily affording custodial, educational, or
rehabilitative care are not Hospitals.
Printed 12/6799 -18-639022-B
Rules For Disabilities Subject, To Limited Pay Periods -
i, If you are Disabled as a result of a Mental Disorder or any Physical Disease or Injury for which
payment of LTD Benefits is subject to a limited pay period, and at the same time are Disabled
as a result of a Physical Disease, Injury, or Pregnancy that is not subject to such limitation,
LTD Benefits will be payable first for conditions that are subject to the limitation.
2.No LTD Benefits will be payable after the end of the limited pay period, .unless on that date you
continue to be Disabled as a result of a Physical Disease, Injury, or Pregnancy for which
payment of LTD Benefits is not. limited.
LT.LP. OT. 1
LIMITATIONS
A. Care Of A Physlclan
Bo
You must be under the ongoing tare of a Physician in the appropriate specialty as determined by
us during the Benefit Waiting Period. No LTD Benefits will be paid for any period of Disability
when you are not under the ongoing care of a Physician in the appropriate specialty as determined
by us.IReturn To Work Responsibility
During the Own Occupation Period no LTD Benefits will be paid for any period of Disability when
you are able to work in your Own Occupation and able to earn at least 20% of your Indexed
Predisability Earnings, but you elect not to work.
During the Any Occupation Period, no LTD Benefits will be paid for any I~eriod of Disability when
you are able to work in Any Occupation and able to earn at least 20% of your Inde~xed Predisability
Earnings, but elect not to work.
C. Rehabilitation Program
No LTD Benefits will be paid for any period of Disability when you are not parti~ipatlng in good
faith in a plan, program or course of medical treatment or vocational training or education
approved by us unless your Disability prevents you .from participating.
D. Foreign Residency
Eo
Payment of LTD Benefits is limited to 12 months for each period of continuous Disabilitywhile you
reside outside of the United States or Canada.
Imprisonment
No LTD Benefits will be paid for any period of Disability when you are confined for any reason in a
penal or correctional institution.
LT.LM.OT. 1
CLAIMS
Filing A Claim
Claims should be filed on our forms. If we do not provide our forms within 15 days after they are
requested, you may submit your claim in a letter to us.The letter should include the date
disability began, and the cause and nature of the disability.
.... fOl~LOSS ’ ..-. ,
B. Time Limits On Filing Proo " : : -: .....
You must give us Proof Of Loss within 90 days after the end of the Benefit Waiting Period. If you
cannot do so, you must give it to us as soon as reasonably possible, but not later than one year
Printed 12/6/99 -19-639022-B
after that 90-day period. If Proof Of Loss is filed outside these time limits, your claim will be
denied. These limits will not apply while you lack legal capacity.
Proof Of Loss
Proof i)f Loss means writfen prOof that you are Dlsabled and entitled to LTD Benefits. Proof ~)f
Loss must be provided at your expense.
For claims of Disability due to ~onditions other than Mental Disorders, we may require proof of
physical impairment that results from anatomical or physiological abnormalities which are
demonstrable by medically acceptable clinical and laboratory diagnostic techniques.
D, Documentation
Completed Claims statements, a signed authorization for us to obtain information, and any other
items we may reasonably require in support of a claim must be submitted at your expense. If the
required documentation is not provided within 60 days after we mail our request, your claim may
be denied.
Eo Investigation Of Claim
We may investigate your claim at any time.
At our expense, we may have you examined at reasonable inte~-vals by ~peciallsts of our choice. We
may deny or suspend LTD Benefits if you fail to attend an examination or cooperate with the
examiner.
F. Time Of Payment
We will pay LTD Benefits within 60 days after you satisfy Proof Of Loss.
LTD Benefits will be paid to you at the end of each month you qualify for them. LTD Benefits
remaining unpaid at your death will be paid to the person(s) receiving the Survivors Benefit. ,If no
Survivors Benefit is paid, the unpaid LTD Benefits will be paid to your estate.
G. Notice Of Decision On Claim .
You will receive a written decision on your claim within a reasonable time after we receive your
claim.
If you do not receive our decision within 90 days after we receive your claim, you will have an
immediate right to request a review as if your claim had been denied.
If we deny any part of your claim, you will receive a written notice of denial containing:
1. The reasons for our decision;
Ho
2. Reference tothe parts of the Group Policy on which our decision is based;
3. A description of any additional information needed to support your claim; and
4. Information concerning your right to a review of our decision.
Review ProcedUre
If all or part of your claim is denied, you may request a review. You must request a review in
writing within 60 days after receiving notice of the denial.
You may send us written comments or other items to support your klaim, and may review any
.non-privileged information that relates to yo.ur request for review.
We will review your claim pr~n~ly"aft~ ~e receive your request. :’~’e will send you a notice of our
decision within 60 days after we receive your request, or within 120 days if special circumstances
Printed 12/6/99 -20-639022-B
require an extension.
of the Group Policy.
We will state the reasons for our decision and refer you to the relevant parts
Assignment
The rights and benefits under the Group Policy are not assignable.
ALLOCATION OF AUTHORITY
Except for those functions which the Group Policy specifically reserves to the Policyowner or Employer,
we have full and exclusive authority to control and manage the Group Policy, to administer claims, and
to interpret the Group Policy and resolve all questions arising in the administration, interpretation,
and application of the Group Policy.
Our autho.rity includes, but is not limited to:
1. The right to resolve all matters when a review has been requested;
2. The right to establish and enforce rules and procedures for the administration of the Group
. Policy and any claim under it;
3. The right to determine:
a.Eligibility for insurance;
b.Enti’flement to benefits;’
c.The amount of benefits payable; and
d.The sufficiency and the amount of information we may reasonably require to determine a.,
b., or c., above.
Subject to the review procedures of t~e Group Policy, any decision we make in the exercise of our
authority is conclusive and binding.
LT.AL.OT.I
TIME LIMITS ON LEGAL ACTIONS
No action at law or in equity may be brought until 60 days after you have giver~ us Proof Of Loss.
such action may be brought more than three years after the earlier of:
1. The date we receive Proof Of Loss; and
2. The time within which Proof Of Loss is required to be given.
LT.TL.OT, I
INCONTESTABILITY PROVISIONS
A. Incontestability Of Insurance
.Any statement made to obtain insurance or to increase insurance is a representation and not a
warranty.
No mi.srepresenfation will be used to reduce or deny a claim or contest the validity of insurance
unless; . .. ,. ......
1. The insurance ~ould not have been approved if we had known the truth; and
Printed 12/6/99 - 21 -639022-B
City of Palo Alto
EXHIBIT "C"
Basic Life and AD&D Plan
An active full-tlme or part-time employee or Council Member of the Employer regularly scheduled to
work 20 hours perweek
Benefit Formula
Rounding
Maximum Benefit
Age Based Benefit
Reduction
Guarantee Issue
Employer Contribution
Minimum Participation
1 X Annual Earnings
Up to next 81,000
8300,000
To 65% at age 70,
To 50% at age 75
Full Benefit
100%
100%
Rate: Per MonthlyMembersVolumeX$1,000 --Premium
All Eligible Life 997 858,468,000 0.22 $12,863
AD&D 997 $58,468,000 0.03 $1,754
Total 814,617
60 day Notice of Rate Change.
Three-year rate guarantee.
Includes Accelerated Benefit.
Waiver of Premium included. No termination at any age. Scheduled reductions do not apply.
Continuity of Coverage is provided.
Repatriation benefit included up to 85,000 or 10% of the Life benefit.
Expanded AD&D benefit included.
Page 2 The Standard Insurance Company 10051 -WD
Rate and Plan Feature Pages
CJty of Palo Alto
o Repatriation up to 5,000 or 10% of the Life benefit.
Page 3 The Standard Insurance Company
Rate and Plan Feature Pages
I0051-WD
City of Palo Alto
Additional Life Plan
An active full-time or part-tlme employee or Council Member of the Employer regularly scheduled to
work 20 hours per week
Benefit Formula 1 X Annual Eamings
Rounding Up to next $1,000
Maximum Benefit $300,000
Age Based Benefit Terminates at Age ,70Reduction
Guarantee Issue Full Benefit
Employer Contribution 0%
Minimum Participation 25%
Enrolled
Rate: Per.MonthlyMembersVolumeX$1.000 =Premium
Life 427 $24,855,000 0.30 $ 7,457
AD&D 427 $24,855,000 0.03 746
Total $ 8,203
Three year rate guarantee.
60 day Notice of Rate Change.
Waiver of Premium included. No termination at any age. Scheduled reductions do not apply.
Expanded AD&D included.
Evidence required for enrolling more than 31 days after eligibility.
A one-time open enrollment will be allowed on the effective date ofchange of carriers.
Page 4 The Standard Insurance Company 10051 -WD
Rate and Plan Feature Pages
City of Palo Alto
Rates assume 42% enrollment.
Assumes census includes participants only.
Page 5 The Standard Insurance Company
Rate and Plan Feature Pages
10051-WD
City of Palo Alto
LTD Plan A
An active full-time or part-time employee of the Employer other than a sworn member of the police or
fire department covered under a Collective Bargaining Agreement working 20 hours per week. (Excludes
Management and Confidential employees.)
LTD Monthly Benefit 66 2/3%
Insured Predisabflity Earnings $6,000
Maximum Monthly Benefit $4,000
Minimum Monthly Benefit $100
Benefit Waiting Period 60 Days
Maximum Benefit Period To age 65
Own Occupation Period 24 Months
Guarantee Issue (benefit)Full Benefit
Employer Contribution 50%
Minimum Participation 75%
Rate: Percent of MonthlyMembers Volume X =Earnings_Premium
446 $1,764,317 1.35 $23,818
Three-year rate guarantee.
60 day Notice of Rate Change.
The Standard pays employer’s portion of a claimant’s FICA and Medicare and prepares W-2’s.
Reasonable Accommodation Expense Benefit up to $25,000.
Partial disability always covered
Consolidated management of LTD and Life Waiver of Premium claims
Plan includes Lump Sum, Non-lntegrated Survivors Benefit
Page 6 The Standard Insurance Company 10051 -WD
Rate and Plan Feature Pages
City of Palo Alto
24 month combined limitation for mental disorders, drug, alcohol, and subjective conditions.
Includes Rehabilitation Plan provisions.
Evidence required for enrolling more than 31 days after eligibility.
Full Social Security offset.
Social Security Normal Retirement Age Maximum Benefit Period.
Includes conversion.
3/12 Preexisting Condition Exclusion.
Assumes census includes participants.
Rates assume 100% enrollment.
Assumes group participates in Public Employee Retirement System.
Employer must participate in a Workers’ Compensation Plan.
Evidence required for enrolling more than 31 days after eligibility.
Page 7 The Standard Insurance Company
Rate and Plan Feature Pages
10051-WD
City of Palo Alto
LTD Plan B
An active full-time or part-time employee of the Employer other than a sworn member of the police or
fire department covered under a Collective Bargaining Agreement working 20 hours per week. (Excludes
Management and Confidential employees.)
Class 2
LTD Monthly Benefit 60%
Insured Predisabflity Earnings $3,000
Maximum Monthly Benefit $1,800
Minimum Monthly Benefit $ i00
Benefit Waiting Period 60 Days
5 Year Sickness
Maximum Benefit Period To Age 65
Accident
Own Occupation Period 24 Months
Guarantee Issue (benefit)Full Benefit
Employer Contribution 50%
Minimum Participation 75%
Members
109
Volume
8323,917
X Rate: Percent of
Earning~
0.68
Monthly
Premium
$2,203
Three-year rate guarantee
60 day notice of rate change
Page 8 The Standard Insurance Company
Rate and Plan Feature Pages
10051 -WD
City of Palo Alto
The standard pays employer’s portion of a claimant’s FICA and Medicare and prepares W-2°s.
Reasonable Accommodation Expense Benefit up to $25,000.
Partial disability always covered
Consolidated management of LTD and Life waiver of Premium claims
Plan includes Lump Sum, Non-Integrated Survivors Benefit
24 month combined limitation for mental disorders, drug, alcohol, and subjective conditions.
Includes Rehabilitation Plan provisions.
Evidence required for enrolling more than 31 days after eligibility.
Full Social Security offset.
Includes conversion.
3/12 Preexisting Condition Exclusion.
Assumes census includes participants and non-p.articipants.
Rates assume 100% enrollment.
Assumes group participates in Public Employee Retirement System.
Employer must participate in a Workers’ Compensation Plan.
Page 9 The Standard Insurance Company
Rate and Plan Feature Pages
10051-WD
City of Palo Alto
LTD Plan C
An active full-time or part-time employee of the Employer other than a swom member of the police or
fire department covered under a Collective Bargaining Agreement working 20 hours per week
Class 1 Management or Confidential Employees with predisabflity earnings of less than $6,000 or not
enrolled in Contributory Plan
Class 2 Management or Confidential Employees enrolled in LTD plan with $6,000 or more of
predisability earnings
LTD Monthly Benefit
Insured Predisability Earnings
Maximum Monthly Benefit
Minimum Monthly Benefit
Benefit Waiting Period
Maximum Benefit Period
Own Occupation Period
Guarantee Issue (benefit)
Employer Contribution
Minimum Participation
Class 1
66 2/3%
S6,OOO
84,000
Szoo
60 Days
To age 65
24 Months
Full Benefit
100%
100%
Class 2
66 2/3%
89,00
86,000
$1oo
60 Days
To age 65
24 Months
Full Benefit
6O%
75%
$I 0,000 Benefit may be offered for the same rate as shown below. (66 2/3%-of $i 5,GO0}
Rate: Percent of MonthlyMembers. Volume X =Earnings Premium
223 $1,473,709 0.79 $I 1,642
Three-year rate guarantee.
60 day Notice of Rate Change
Page lO The Standard Insurance Company
Rate and Plan Feature Pages
10051 -WD
City of Palo Alto
.The Standard pays employer’s portion of a claimant’s FICA and Medicare and prepares W-2’s.
¯Reasonable Accommodation Expense Benefit up to $25,000.
.Partial disability always covered
,Consolidated management of LTD and Life waiver of Premium claims
o Plan includes Lump Sum, Non-Integrated Survivors Benefit
¯Includes Rehabilitation Plan provisions.
¯For class 2 Evidence required for enrolling more than 31 days after eligibility.
¯For class 2 evidence required for members eligible but not enrolled.
¯24 month combined limitation for mental disorders, drug, alcohol, and subjective conditions.
¯Includes Rehabilitation Plan provisions.
¯Full Social Security offset.
~Social Security Normal Retirement Age Maximum Benefit Period.
¯Includes conversion.
.3/12 Preexisting Condition Exclusion.
¯Assumes group participates in Public Employee Retirement System.
¯Employer must participate in a Workers’ Compensation Plan.
Page 11 The Standard Insurance Company 10051 -WD
Rate and Plan Feature Pages
EXHIBIT "D"
PART err FORM 410
PROJECT TITLE: Long Term Disability Administration
Certification of Nondiscrimination: As suppliers of goods or services to the City of Palo Alto, the finn
and individuals listed below certify that they do not discriminate in employment with regards to age, race,
color, religion, sex, national origin, ancesu-y, disabilky, or sexual preference; that they are in compliance
with all Federal, State and local directives and executive orders regarding nondiscrimination in employment.
Firm: The Standard DATE: October 21, 1999
Signature % ~~.
R_FP NO. 119602 PART [[I Page 9 of 11
PART ]II EXHIBIT ~’ "E"¯ ..FORM 650
Insurance Requirements for Contractor/Consultant
CONTRACTOR:Standard Insurance Company
Leon~dZuc~rPROI~CT MANAGER:
CONTRACT NAME:Lo.ng Term Disability Administration
GENERAL TERMS AND INSTRUCTIONS
THIS INSTRUCTION $HE~’T SHOULD BE GIVEN TO YOUR INSURANCE AGENT/BROKER.,
THE CONSULTANT,’CONTRACrOR RETAI~I-~,’AT THEIR SOLE E(PENSF- SHALL OBTAIN AND MAINTAIN INSURANCE FOR THE TERM OF THE
CONTRACT. CONTRACTORS WILL BE R~QUIR~D TO PROVmE A cmrn~cAr£ mnD~NCING T~E INSUR~NCa AND NAMmG THE CITY AS AN
ADDITIONAL ]INSURED. ALL INSURANCE covr~AG~. R~QUIR~D SHALL B~- PROVIDED THROUGH CARRIERS WITH A BEST RATING OF A:X OR
HIGHER THAT ARE ADMIITED TO DO BUSINESS ~N THE STATE OF CALIFORNIA. ~ C~RTIHCAT£ OF INSURANCE MUST BE COMPLEI~D AND
EXECUTED BY AN AU’I~IORIZED REPK~TrA~£ OP TH~ COMPANY PROVIDING INSURANCE. FILED wrfH THE CITY, AND APPROVED BY THE
CITY BHFORB CONTRACT WILL BE CON$1D~RBD COMPLETE AS RSSPSL-fS INSURANCF_
REZIIRN THE COMP~ CERTIFICATE TO THE CITY OF PALO ALTO, PURCHASING &
CONTRACT ADMINISTRATION, 250 HAMILTON AVENUE, PALO ALTO 94301.
TIlE INSURANCE REQIBRE/vfENTS CHECKED BELOW ARE REQIBRED.
TYPe: O~ COV]~RAG~,R~.. t~[R~,~MhW~" .....,LOH(] ~=O~M (Minimum L]m~s)
WorkerCs Compe.~afion
Automobile Liability
Compr~hensiv~ General Liabilit~
INCLUDING:
¯NON-OWNED
Professional Li~bKity:
]I~CLUD]I%TG:
¯ ERRORS AND OMISSIONS
¯ MALPRACTICE (IfAlrpltc~ble)
DAMAGE COMBEIED
THE CITY OF PALO ALTO IS TO BE NAM[ED AS AN ADDITIONAL INSURED
$1,000,o00
$1,000,000
RFP NO. 119602 PART lII Page 12 of 11
PART Ill FORM 650
Bo
C.
D.
E.
The City of Palo Alto, its officers, agents and employees are named as additional insured, but only as to work performed under contract. Said coverage
as to the City of Palo Alto, etc., shall be primary coverage, wkhout ol~et against City’s existing insurance and any other insurance carried by the CitT
being excess insurance only.
Where the work involves excavating, collapse coverage is provided in the amounts above.
_The policy includes a "Severability of Interest" provision.
Deductibles over .$5,000 must be indicated and are subj~ to approval.
If such policies ar~ canceled or changed during the period of coverage as sta~] herein, in such a manner as to affect the Certificate, thirty (30) days wrk~n
notice will be mailed to the City of Palo Alto, Contract Administration, P.O. Box 102.50, 94303
The liability insurance policy includes a conwacmal liability endorseraem provMing insurmce coverage for Conwactor’s agreement to indemnify ~he City.
The coverage afforded under the policies is subject to all terms of the policies desi~ated herein and meets all of the provisions called
for herein.
DATE:CONTRACT. ADMINISTRATOR:Baldernar J. Troche, Contract Manager (650) 329-2162
The Standard is self insured for professional, errors and omissions liability.
We have directors and officers insurance of $15 million and product liability
insurance of $21 million.
Plaase see attached policy
RFPNO. 119602 PARTK[ Page 13 ofll
Portland. OR 97201
Daniel j. Sloan
INSURED
StanCorp Financial G~oup, Inc.
P.O. Box 711
Portland, Oregon 97207-1093
(503) 248-1207
CERTIFICATE NUMBER
0016001-00198
THIS C~H/iPiCATE IS ISSUED AS A MATrER OF INFORMATION ONLY AND CONFERS
NO RIGHTS UPON THE CERTIFICATE HOLDER OTHER THAN THOSE PROVIDED IN
THE POUCY. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE
COVERAGE AFFORDED BY THE POUCIES DESCRIBED HEREIN.
COMPANIES AFFORDING COVERAGE
COMPANY
A AMERICAN MOTORISTS INS CO
COMPANY
B
COMPANY
c
COMPANY
D
THIS IS TO CERTIFY THAT POLICIES OF INSURANCE DESCRIBED HEREIN HAVE BEEN ISSUED TO THE INSURED NAMED HEREIN FOR THE POLICY PERIOD INDICATED.
NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THE CERTIFICATE MAY
OFBE ISSUED SUCH POLICIES. OR MAY PERTAIN, LIMITS SHOWN THE INSURANCE MAY HAVE AFFORDED BEEN REDUCED BY THE BY PAID POLICIES CLAIMS. DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, CONDITIONS AND EXCLUSIONS
COLTR
A
TYPE OF INSURANCE
GENERAL UABIUTY~COMMERCIAL GENERAL LIABILITY
OWNER’S & CONTRACTOR’S PROT
AUTOMOBILE UABIUTY
ANY AUTO
! ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON-OWNED AUTOS
GARAGE UABIUTY
ANY AUTO
EXCESS UABIUTY
~UMBREL~ FORM
OTHER THAN UMBRELLA FORM
WORKER’S COMPENSATION AND
EMPLOYERS’ UABIMTY
THE PROPRIETOR/F’--’--] INCLPARTNERS/EXECUTIVEOFFICERS ARE:I ! EXCLOTHER
POUCY NUMBER
3AB 03955305
F3H 011 917 02
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / SPECIAL ITEMSFor Informational Use only.
POUCY EFFEC3’IVE
DATE (MM/DDiYY)
6/30/99
6/30/99
POUCY EXPIRATION
DATE IMM/DD/Yy)
7/01/00
7/01/00
UMITS
GENERAL AGGREGATE
PRODUCTS - COMP/OP AGG
PERSONAL & ADV INJURY
EACH OCCURRENCE
FIRE DAMAGE {Any one fire)
MED EXP (Any one person)
COMBINED SINGLE UMIT
BODILY INJURY(Per person~
BODILY INJURY(Per accidentl
PROPERTY DAMAGE
AUTO ONLY - EA ACCIDENT
OTHER THAN AUTO ONLY:
EACH ACCIDENT
AGGREGATE
EACH OCCURRENCE
AGGREGATE
TORY UMITSI EL EACH ACCIDENT
"EL DISEASE. POUCY LIMIT
EL DISEASE - EA EMPLOYEE
=3,000,000
=I. 000,000
~I. 000.000
~I. 000.000
*500,000
’1 O, 000
i, 000,000 ~
:
(* 10 DAYS FOR NON-PAYMENT)
SHOULD ANY OF THE POLICIES DESCRIBED HEREIN BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE INSURER AFFORDING COVERAGE WILL ENDEAVOR
TO MAIL 30___~~ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED
HEREIN, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR
LIABtLI’P( OF ANY KIND UPON THE INSURER AFFORDING COVERAGE, ITS AGENTS
OR REPRESENTATIVES.’"’..
Marsh USA Inc."
BY:
STATE OF CALI~OI~NIA
DEPARTMENT OF INSURANCE
S~N F~LNCESCO
Cerd icate Authority
Tx-~s Is ro C~tT"~, That, pursuant to the Insurance Code of the State o[ Cali[ornia,
STANDARD INSURANCE COMPAN~
of POR~ID, OREGON , organized under the
laws of OREGON , subject to its Articles of Incorporation or
other fundamental organizational documents, is hereby authorized to transact within this State, sub~ect
to all provisions of Ibis Certificate, the followi,g classes o[ insurance:
LIFE AND DISABILITf
as such classes are now or may herea[ter be defined in the Inmrance Laws of the State of California.
THxs C~caa-~ is expressly conditioned, up~ the holder hereof n~u and hereafter b~ing in full
comfliance with all, and not in violati~ of any, of the applicable laws and law[ul requirements made
under aulh~ity of the laws of ~he S~a~e of California ~ lo~g as such laws or req~drements are in effect
and applicable, and ~ such laws and requirements now are, or may h~eafger be changed or amended.
I~ WIx~Ess W~o~, effective as o[ the ...... ~.~ ...... day
of ..............~_~. ........................, I95~. , I have bereut~to
set my band and caused my o~cld seal to be a~xed this
day AUG 2 7 1956of .............................................................Iy .........
I nsurance Coat,missioner
Dr~.~y