HomeMy WebLinkAboutStaff Report 13724
City of Palo Alto (ID # 13724)
City Council Staff Report
Meeting Date: 12/6/2021
City of Palo Alto Page 1
Title: Approval of contract with Life Insurance Company of North America
(CIGNA) for Underwriting of the City of Palo Alto’s Group Life, Accidental
Death and Dismemberment (AD&D), and Long Term Disability Insurance
(LTD) Plans for Up to Three Years for a total not to exceed $1,920,000.
From: City Manager
Lead Department: Human Resources
Recommended Motion
Staff recommends that Council approve and authorize the City Manager to execute the attached
contract with Life Insurance Company of North America (CIGNA) for an amount up to $1,920,000 for a
three-year term to provide group life, accidental death and dismemberment (AD&D) and long-term
disability (LTD) insurance benefits for eligible City of Palo Alto employees.
OBJECTIVE
The purpose of this staff report is to provide Council a review of the recent Request for Proposal (RFP)
results for Group Life Insurance, Long-term Disability (LTD) Insurance and Accidental Death and
Dismemberment (AD&D) insurance.
BACKGROUND
As part of the employee benefits package the City of Palo Alto contracts with a third-party vendor to
provide Basic Life Insurance, Long-Term Disability (LTD) and Accidental Death and Dismemberment
(AD&D) insurance. Existing agreements with City employee bargaining units provide for maintaining
these standard benefit policies. A summary of the plans is shown in Attachment A.
The work to be performed under this contract is for underwriting the City’s group Life Insurance, AD&D,
and LTD benefits. While the City pays for basic life insurance coverage for its employees, employees can
choose to purchase an additional supplemental life insurance plan. For LTD, employees contribute to
participate in the LTD plan. The prior Request for Proposal (RFP) for underwriting the Life, AD&D, and
LTD insurance policies was conducted in 2015. That process resulted in staff selecting CIGNA due to cost
savings.
SOLICITATION PROCESS
A request for proposals (RFP) was issued by the City’s benefit broker on behalf of the City. Seven
insurance companies were notified of the formal solicitation, which posted for 14 days and closed on
March 5, 2021. The RFP process was managed by the City’s benefit broker in partnership with Human
Resources and Procurement team. Staff reviewed and approved the solicitation documents and
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processes, prior to posting the solicitation, to ensure City procurement criteria were met. The
solicitation was also reviewed at key milestones during the process. As a result of the solicitation, six
proposals were received from The Hartford, Unum, Prudential, The Standard, Voya and CIGNA.
Human Resources staff reviewed the proposals with the assistance of the City’s benefit broker relative
to the following criteria: plan administration, cost, claims paying administration, knowledge of and
experience working with public agencies, customer service capabilities, statistical reports, ease of
implementation, ability to provide desired program design and competitive pricing.
CIGNA was chosen due to its ability to provide the City with a 14.5% cost reduction equivalent to a
savings of approximately $108,000 annually, continuation of benefits, track record of accuracy,
knowledge working with public sectors clients, administrative ease and continued satisfactory customer
service.
RESOURCE IMPACT
Funds for group life, AD&D, and LTD insurance are included in the FY 2022 Adopted Budget in the
General Benefits Fund operating budget. Funds for future years will be factored into the development of
the FY 2023 and FY 2024 operating budgets.
The rates for group life, AD&D, and LTD insurance policies are based on the number of City employees,
and on the current salary of employees. With a three-year rate guarantee, the annual rate would not
increase in years two (2) and three (3), however, the total annual premium for group life and AD&D will
vary based on changes to employee salaries. With employees contributing to participate in the
Supplement Life Insurance plan and LTD plan, approximately 50% of the cost of this contract amount will
come from payroll deductions.
Attachments:
• Attachment4.a: Attachment A - Plan Summary
• Attachment4.b: Attachment B_ Contract No. C22183900_Cigna
Proposal Description/Number RFP (via Broker) for provisions of LIFE, AD&D,
and LTD Services
Proposed Length of Project 3 years
Number of RFP Notifications 7 vendors
Total Days to Respond to RFP 14 days
Pre-Proposal Meeting None
Number of Proposals Received 6 proposals
Range of cost proposals submitted $543,537 - $708,392 annually
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Attachment A
Plan Description
Basic Term Life Insurance & Accidental Death and
Dismemberment (AD&D) insurance
Basic Term Life 1x Annual Compensation to a
maximum of $325,000. Basic AD&D Benefit 1x
Annual Compensation to a maximum of
$325,000.
Long-term Disability (LTD) Insurance Option 1 - Replaces 66.67% of the annual
earnings to a maximum of $4,000 per month
after 60 day waiting period.
Option 2 - Replaces 60% of the annual earnings
to a maximum of $1,800 per month after 60 day
waiting period.
Option 3 - Replaces 66.67% of the annual
earnings to a maximum of $10,000 per month
after 60 day waiting period.
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City of Palo Alto Professional Services Contract No. C22183900 Rev. Dec.15, 2020
CITY OF PALO ALTO CONTRACT NO. C22183900 AGREEMENT FOR PROFESSIONAL SERVICES BETWEEN THE CITY OF PALO ALTO AND LIFE INSURANCE COMPANY OF NORTH AMERICA, A WHOLLY OWNED SUBSIDIARY OF THE CIGNA CORPORATION This Agreement for Professional Services (this “Agreement”) is entered into as of the 6th day of December, 2021 (the “Effective Date”), by and between the CITY OF PALO ALTO, a California
chartered municipal corporation (“CITY”), and LIFE INSURANCE COMPANY OF NORTH AMERICA, A WHOLLY OWNED SUBSIDIARY OF THE CIGNA CORPORATION located at located at 1601 Chestnut Street, Philadelphia, PA 19192 (“CONSULTANT”). The following recitals are a substantive portion of this Agreement and are fully incorporated herein
by this reference: RECITALS A. CITY intends to provide for its employees Group Life, Accidental Death and Dismemberment (AD&D), and Long Term Disability Insurance (LTD) (the “Project”) and desires
to engage a consultant to underwrite these insurance benefits in connection with the Project (the “Services”, as detailed more fully in Exhibit A). B. CONSULTANT represents that it, its employees and subconsultants, if any, possess the necessary professional expertise, qualifications, and capability, and all required licenses and/or
certifications to provide the Services. C. CITY, in reliance on these representations, desires to engage CONSULTANT to provide the Services as more fully described in Exhibit A, entitled “SCOPE OF SERVICES”.
NOW, THEREFORE, in consideration of the recitals, covenants, terms, and conditions, in this Agreement, the parties agree as follows: SECTION 1. SCOPE OF SERVICES. CONSULTANT shall perform the Services described
in Exhibit A in accordance with the terms and conditions contained in this Agreement. The
performance of all Services shall be to the reasonable satisfaction of CITY. SECTION 2. TERM. The term of this Agreement shall be from the date of its full execution through December 31, 2024
unless terminated earlier pursuant to Section 19 (Termination) of this Agreement.
SECTION 3. SCHEDULE OF PERFORMANCE. Time is of the essence in the performance of Services under this Agreement. CONSULTANT shall complete the Services within the term of this Agreement and in accordance with the schedule set forth in Exhibit B, entitled “SCHEDULE
OF PERFORMANCE”. Any Services for which times for performance are not specified in this
Agreement shall be commenced and completed by CONSULTANT in a reasonably prompt and timely manner based upon the circumstances and direction communicated to the CONSULTANT. CITY’s agreement to extend the term or the schedule for performance shall not preclude recovery
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of damages for delay if the extension is required due to the fault of CONSULTANT. SECTION 4. NOT TO EXCEED COMPENSATION. The compensation to be paid to CONSULTANT for performance of the Services shall be based on the compensation structure detailed in Exhibit C, entitled “COMPENSATION,” including any reimbursable expenses
specified therein, and the maximum total compensation shall not exceed One Million Nine Hundred Twenty Thousand Dollars ($1,920,000.00). The hourly schedule of rates, if applicable, is set out in Exhibit C-1, entitled “SCHEDULE OF RATES.” Any work performed or expenses incurred for which payment would result in a total exceeding the maximum compensation set forth in this Section 4 shall be at no cost to the CITY.
SECTION 5. INVOICES. In order to request payment, CONSULTANT shall submit monthly invoices to the CITY describing the Services performed and the applicable charges (including, if applicable, an identification of personnel who performed the Services, hours worked, hourly rates, and reimbursable expenses), based upon Exhibit C or, as applicable, CONSULTANT’s schedule
of rates set forth in Exhibit C-1. If applicable, the invoice shall also describe the percentage of completion of each task. The information in CONSULTANT’s invoices shall be subject to verification by CITY. CONSULTANT shall send all invoices to CITY’s Project Manager at the address specified in Section 13 (Project Management) below. CITY will generally process and pay invoices within thirty (30) days of receipt of an acceptable invoice.
SECTION 6. QUALIFICATIONS/STANDARD OF CARE. All Services shall be performed by CONSULTANT or under CONSULTANT’s supervision. CONSULTANT represents that it, its employees and subcontractors, if any, possess the professional and technical personnel necessary to perform the Services required by this Agreement and that the personnel have
sufficient skill and experience to perform the Services assigned to them. CONSULTANT represents that it, its employees and subcontractors, if any, have and shall maintain during the term of this Agreement all licenses, permits, qualifications, insurance and approvals of whatever nature that are legally required to perform the Services. All Services to be furnished by CONSULTANT
under this Agreement shall meet the professional standard and quality that prevail among
professionals in the same discipline and of similar knowledge and skill engaged in related work throughout California under the same or similar circumstances. SECTION 7. COMPLIANCE WITH LAWS. CONSULTANT shall keep itself informed of
and in compliance with all federal, state and local laws, ordinances, regulations, and orders that
may affect in any manner the Project or the performance of the Services or those engaged to perform Services under this Agreement, as amended from time to time. CONSULTANT shall procure all permits and licenses, pay all charges and fees, and give all notices required by law in the performance of the Services.
SECTION 8. ERRORS/OMISSIONS. CONSULTANT is solely responsible for costs, including, but not limited to, increases in the cost of Services, arising from or caused by CONSULTANT’s errors and omissions, including, but not limited to, the costs of corrections such errors and omissions, any change order markup costs, or costs arising from delay caused by the
errors and omissions or unreasonable delay in correcting the errors and omissions.
SECTION 9. COST ESTIMATES. If this Agreement pertains to the design of a public works project, CONSULTANT shall submit estimates of probable construction costs at each phase of
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design submittal. If the total estimated construction cost at any submittal exceeds the CITY’s
stated construction budget by ten percent (10%) or more, CONSULTANT shall make
recommendations to CITY for aligning the Project design with the budget, incorporate CITY
approved recommendations, and revise the design to meet the Project budget, at no additional cost
to CITY.
SECTION 10. INDEPENDENT CONTRACTOR. CONSULTANT acknowledges and agrees
that CONSULTANT and any agent or employee of CONSULTANT will act as and shall be
deemed at all times to be an independent contractor and shall be wholly responsible for the manner
in which CONSULTANT performs the Services requested by CITY under this Agreement.
CONSULTANT and any agent or employee of CONSULTANT will not have employee status
with CITY, nor be entitled to participate in any plans, arrangements, or distributions by CITY
pertaining to or in connection with any retirement, health or other benefits that CITY may offer its
employees. CONSULTANT will be responsible for all obligations and payments, whether
imposed by federal, state or local law, including, but not limited to, FICA, income tax
withholdings, workers’ compensation, unemployment compensation, insurance, and other similar
responsibilities related to CONSULTANT’s performance of the Services, or any agent or
employee of CONSULTANT providing same. Nothing in this Agreement shall be construed as
creating an employment or agency relationship between CITY and CONSULTANT or any agent
or employee of CONSULTANT. Any terms in this Agreement referring to direction from CITY
shall be construed as providing for direction as to policy and the result of CONSULTANT’s
provision of the Services only, and not as to the means by which such a result is obtained.
SECTION 11. ASSIGNMENT. The parties agree that the expertise and experience of
CONSULTANT are material considerations for this Agreement. CONSULTANT shall not assign
or transfer any interest in this Agreement nor the performance of any of CONSULTANT’s
obligations hereunder without the prior written approval of the City Manager. Any purported
assignment made without the prior written approval of the City Manager will be void and without
effect. Subject to the foregoing, the covenants, terms, conditions and provisions of this Agreement
will apply to, and will bind, the heirs, successors, executors, administrators and assignees of the
parties.
SECTION 12. SUBCONTRACTING. CONSULTANT shall not subcontract any portion of the
Services to be performed under this Agreement without the prior written authorization of the City
Manager or designee. In the event CONSULTANT does subcontract any portion of the work to
be performed under this Agreement, CONSULTANT shall be fully responsible for all acts and
omissions of subcontractors.
SECTION 13. PROJECT MANAGEMENT. CONSULTANT will assign Terri Prince as the
CONSULTANT’s Project Manager to have supervisory responsibility for the performance,
progress, and execution of the Services and represent CONSULTANT during the day-to-day
performance of the Services. If circumstances cause the substitution of the CONSULTANT’s
Project Manager or any other of CONSULTANT’s key personnel for any reason, the appointment
of a substitute Project Manager and the assignment of any key new or replacement personnel will
be subject to the prior written approval of the CITY’s Project Manager. CONSULTANT, at
CITY’s request, shall promptly remove CONSULTANT personnel who CITY finds do not
perform the Services in an acceptable manner, are uncooperative, or present a threat to the adequate
or timely completion of the Services or a threat to the safety of persons or property.
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CITY’s Project Manager is Angelica Jimenez, Human Resources Department, 250 Hamilton Avenue, Palo Alto, CA, 94301, Telephone: (650) 329-2454. CITY’s Project Manager will be CONSULTANT’s point of contact with respect to performance, progress and execution of the Services. CITY may designate an alternate Project Manager from time to time. SECTION 14. OWNERSHIP OF MATERIALS. All work product, including without limitation, all writings, drawings, studies, sketches, photographs, plans, reports, specifications, computations, models, recordings, data, documents, and other materials and copyright interests developed under this Agreement, in any form or media, shall be and remain the exclusive property
of CITY without restriction or limitation upon their use. CONSULTANT agrees that all copyrights which arise from creation of the work product pursuant to this Agreement are vested in CITY, and CONSULTANT hereby waives and relinquishes all claims to copyright or other intellectual property rights in favor of CITY. Neither CONSULTANT nor its subcontractors, if any, shall make any of such work product available to any individual or organization without the prior written
approval of the City Manager or designee. CONSULTANT makes no representation of the suitability of the work product for use in or application to circumstances not contemplated by the Scope of Services. SECTION 15. AUDITS. CONSULTANT agrees to permit CITY and its authorized
representatives to audit, at any reasonable time during the term of this Agreement and for four (4) years from the date of final payment, CONSULTANT’s records pertaining to matters covered by this Agreement, including without limitation records demonstrating compliance with the requirements of Section 10 (Independent Contractor). CONSULTANT further agrees to maintain and retain accurate books and records in accordance with generally accepted accounting principles
for at least four (4) years after the expiration or earlier termination of this Agreement or the completion of any audit hereunder, whichever is later. SECTION 16. INDEMNITY.
16.1. To the fullest extent permitted by law, CONSULTANT shall indemnify, defend and hold harmless CITY, its Council members, officers, employees and agents (each an “Indemnified Party”) from and against any and all demands, claims, or liability of any nature, including death or injury to any person, property damage or any other loss, including all costs and
expenses of whatever nature including attorney’s fees, experts fees, court costs and disbursements
(“Claims”) resulting from, arising out of or in any manner related to performance or nonperformance by CONSULTANT, its officers, employees, agents or contractors under this Agreement, regardless of whether or not it is caused in part by an Indemnified Party.
16.2. Notwithstanding the above, nothing in this Section 16 shall be construed to
require CONSULTANT to indemnify an Indemnified Party from a Claim arising from the active negligence or willful misconduct of an Indemnified Party that is not contributed to by any act of, or by any omission to perform a duty imposed by law or agreement by, CONSULTANT, its officers, employees, agents or contractors under this Agreement.
16.3. The acceptance of CONSULTANT’s Services and duties by CITY shall not operate as a waiver of the right of indemnification. The provisions of this Section 16 shall survive the expiration or early termination of this Agreement.
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SECTION 17. WAIVERS. No waiver of a condition or nonperformance of an obligation under this Agreement is effective unless it is in writing in accordance with Section 29.4 of this Agreement. No delay or failure to require performance of any provision of this Agreement shall constitute a waiver of that provision as to that or any other instance. Any waiver granted shall
apply solely to the specific instance expressly stated. No single or partial exercise of any right or remedy will preclude any other or further exercise of any right or remedy. SECTION 18. INSURANCE.
18.1. CONSULTANT, at its sole cost and expense, shall obtain and maintain, in full force and effect during the term of this Agreement, the insurance coverage described in Exhibit D, entitled “INSURANCE REQUIREMENTS”. CONSULTANT and its contractors, if any, shall obtain a policy endorsement naming CITY as an additional insured under any general liability or automobile policy or policies.
18.2. All insurance coverage required hereunder shall be provided through carriers with AM Best’s Key Rating Guide ratings of A-:VII or higher which are licensed or authorized to transact insurance business in the State of California. Any and all contractors of CONSULTANT retained to perform Services under this Agreement will obtain and maintain, in
full force and effect during the term of this Agreement, identical insurance coverage, naming CITY as an additional insured under such policies as required above. 18.3. Certificates evidencing such insurance shall be filed with CITY concurrently with the execution of this Agreement. The certificates will be subject to the approval
of CITY’s Risk Manager and will contain an endorsement stating that the insurance is primary coverage and will not be canceled, or materially reduced in coverage or limits, by the insurer except after filing with the Purchasing Manager thirty (30) days’ prior written notice of the cancellation or modification. If the insurer cancels or modifies the insurance and provides less than thirty (30)
days’ notice to CONSULTANT, CONSULTANT shall provide the Purchasing Manager written
notice of the cancellation or modification within two (2) business days of the CONSULTANT’s receipt of such notice. CONSULTANT shall be responsible for ensuring that current certificates evidencing the insurance are provided to CITY’s Chief Procurement Officer during the entire term of this Agreement.
18.4. The procuring of such required policy or policies of insurance will not be construed to limit CONSULTANT’s liability hereunder nor to fulfill the indemnification provisions of this Agreement. Notwithstanding the policy or policies of insurance, CONSULTANT will be obligated for the full and total amount of any damage, injury, or loss
caused by or directly arising as a result of the Services performed under this Agreement, including
such damage, injury, or loss arising after the Agreement is terminated or the term has expired. SECTION 19. TERMINATION OR SUSPENSION OF AGREEMENT OR SERVICES.
19.1. The City Manager may suspend the performance of the Services, in whole
or in part, or terminate this Agreement, with or without cause, by giving ten (10) days prior written notice thereof to CONSULTANT. If CONSULTANT fails to perform any of its material obligations under this Agreement, in addition to all other remedies provided under this Agreement
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or at law, the City Manager may terminate this Agreement sooner upon written notice of termination. Upon receipt of any notice of suspension or termination, CONSULTANT will discontinue its performance of the Services on the effective date in the notice of suspension or termination.
19.2. In event of suspension or termination, CONSULTANT will deliver to the City Manager on or before the effective date in the notice of suspension or termination, any and all work product, as detailed in Section 14 (Ownership of Materials), whether or not completed, prepared by CONSULTANT or its contractors, if any, in the performance of this Agreement. Such work product is the property of CITY, as detailed in Section 14 (Ownership of Materials).
19.3. In event of suspension or termination, CONSULTANT will be paid for the Services rendered and work products delivered to CITY in accordance with the Scope of Services up to the effective date in the notice of suspension or termination; provided, however, if this Agreement is suspended or terminated on account of a default by CONSULTANT, CITY will be
obligated to compensate CONSULTANT only for that portion of CONSULTANT’s Services provided in material conformity with this Agreement as such determination is made by the City Manager acting in the reasonable exercise of his/her discretion. The following Sections will survive any expiration or termination of this Agreement: 14, 15, 16, 17, 19.2, 19.3, 19.4, 20, 25, 27, 28, 29 and 30.
19.4. No payment, partial payment, acceptance, or partial acceptance by CITY will operate as a waiver on the part of CITY of any of its rights under this Agreement, unless made in accordance with Section 17 (Waivers). SECTION 20. NOTICES. All notices hereunder will be given in writing and mailed, postage prepaid, by certified mail, addressed as follows:
To CITY: Office of the City Clerk City of Palo Alto Post Office Box 10250 Palo Alto, CA 94303
With a copy to the Purchasing Manager To CONSULTANT: Attention of the Project Manager at the address of CONSULTANT recited on the first page of this Agreement.
CONSULTANT shall provide written notice to CITY of any change of address. SECTION 21. CONFLICT OF INTEREST.
21.1. In executing this Agreement, CONSULTANT covenants that it presently
has no interest, and will not acquire any interest, direct or indirect, financial or otherwise, which would conflict in any manner or degree with the performance of the Services.
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21.2. CONSULTANT further covenants that, in the performance of this Agreement, it will not employ subcontractors or other persons or parties having such an interest. CONSULTANT certifies that no person who has or will have any financial interest under this Agreement is an officer or employee of CITY; this provision will be interpreted in accordance with the applicable provisions of the Palo Alto Municipal Code and the Government Code of the
State of California, as amended from time to time. CONSULTANT agrees to notify CITY if any conflict arises. 21.3. If the CONSULTANT meets the definition of a “Consultant” as defined by the Regulations of the Fair Political Practices Commission, CONSULTANT will file the
appropriate financial disclosure documents required by the Palo Alto Municipal Code and the Political Reform Act of 1974, as amended from time to time. SECTION 22. NONDISCRIMINATION; COMPLIANCE WITH ADA.
22.1. As set forth in Palo Alto Municipal Code Section 2.30.510, as amended from time to time, CONSULTANT certifies that in the performance of this Agreement, it shall not discriminate in the employment of any person due to that person’s race, skin color, gender, gender identity, age, religion, disability, national origin, ancestry, sexual orientation, pregnancy, genetic information or condition, housing status, marital status, familial status, weight or height of such
person. CONSULTANT acknowledges that it has read and understands the provisions of Section 2.30.510 of the Palo Alto Municipal Code relating to Nondiscrimination Requirements and the penalties for violation thereof, and agrees to meet all requirements of Section 2.30.510 pertaining to nondiscrimination in employment.
22.2. CONSULTANT understands and agrees that pursuant to the Americans Disabilities Act (“ADA”), programs, services and other activities provided by a public entity to the public, whether directly or through a contractor or subcontractor, are required to be accessible to the disabled public. CONSULTANT will provide the Services specified in this Agreement in a
manner that complies with the ADA and any other applicable federal, state and local disability
rights laws and regulations, as amended from time to time. CONSULTANT will not discriminate against persons with disabilities in the provision of services, benefits or activities provided under this Agreement.
SECTION 23. ENVIRONMENTALLY PREFERRED PURCHASING AND ZERO WASTE REQUIREMENTS. CONSULTANT shall comply with the CITY’s Environmentally Preferred Purchasing policies which are available at CITY’s Purchasing Department, hereby incorporated by reference and as amended from time to time. CONSULTANT shall comply with waste reduction, reuse, recycling and disposal requirements of CITY’s Zero Waste Program. Zero
Waste best practices include, first, minimizing and reducing waste; second, reusing waste; and,
third, recycling or composting waste. In particular, CONSULTANT shall comply with the following Zero Waste requirements: (a) All printed materials provided by CONSULTANT to CITY generated from a personal computer and printer including but not limited to, proposals, quotes, invoices, reports,
and public education materials, shall be double-sided and printed on a minimum of 30% or greater
post-consumer content paper, unless otherwise approved by CITY’s Project Manager. Any submitted materials printed by a professional printing company shall be a minimum of 30% or greater post-consumer material and printed with vegetable-based inks.
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(b)Goods purchased by CONSULTANT on behalf of CITY shall be purchased inaccordance with CITY’s Environmental Purchasing Policy including but not limited to Extended Producer Responsibility requirements for products and packaging. A copy of this policy is on file at the Purchasing Department’s office. (c)Reusable/returnable pallets shall be taken back by CONSULTANT, at no
additional cost to CITY, for reuse or recycling. CONSULTANT shall provide documentation from the facility accepting the pallets to verify that pallets are not being disposed.
SECTION 24. COMPLIANCE WITH PALO ALTO MINIMUM WAGE ORDINANCE. CONSULTANT shall comply with all requirements of the Palo Alto Municipal Code Chapter 4.62
(Citywide Minimum Wage), as amended from time to time. In particular, for any employee otherwise entitled to the State minimum wage, who performs at least two (2) hours of work in a calendar week within the geographic boundaries of the City, CONSULTANT shall pay such employees no less than the minimum wage set forth in Palo Alto Municipal Code Section 4.62.030 for each hour worked within the geographic boundaries of the City of Palo Alto. In addition,
CONSULTANT shall post notices regarding the Palo Alto Minimum Wage Ordinance in accordance with Palo Alto Municipal Code Section 4.62.060.
SECTION 25. NON-APPROPRIATION. This Agreement is subject to the fiscal provisions of the Charter of the City of Palo Alto and the Palo Alto Municipal Code, as amended from time to
time. This Agreement will terminate without any penalty (a) at the end of any fiscal year in the event that funds are not appropriated for the following fiscal year, or (b) at any time within a fiscal year in the event that funds are only appropriated for a portion of the fiscal year and funds for this Agreement are no longer available. This Section shall take precedence in the event of a conflict with any other covenant, term, condition, or provision of this Agreement.
SECTION 26. PREVAILING WAGES AND DIR REGISTRATION FOR PUBLIC WORKS CONTRACTS. This Project is not subject to prevailing wages and related requirements. CONSULTANT is not required to pay prevailing wages and meet related
requirements under the California Labor Code and California Code of Regulations in the
performance and implementation of the Project if the contract: (1) is not a public works contract;(2)is for a public works construction project of $25,000 or less, per CaliforniaLabor Code Sections 1782(d)(1), 1725.5(f) and 1773.3(j); or
(3)is for a public works alteration, demolition, repair, or maintenance project of
$15,000 or less, per California Labor Code Sections 1782(d)(1), 1725.5(f) and1773.3(j).
SECTION 27. CLAIMS PROCEDURE FOR “9204 PUBLIC WORKS PROJECTS”. For
purposes of this Section 27, a “9204 Public Works Project” means the erection, construction,
alteration, repair, or improvement of any public structure, building, road, or other public improvement of any kind. (Cal. Pub. Cont. Code § 9204.) Per California Public Contract Code Section 9204, for Public Works Projects, certain claims procedures shall apply, as set forth in Exhibit F, entitled “Claims for Public Contract Code Section 9204 Public Works Projects”.
This Project is not a 9204 Public Works Project.
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SECTION 28. CONFIDENTIAL INFORMATION. 28.1. In the performance of this Agreement, CONSULTANT may have access to CITY’s Confidential Information (defined below). CONSULTANT will hold Confidential Information in strict confidence, not disclose it to any third party, and will use it only for the
performance of its obligations to CITY under this Agreement and for no other purpose. CONSULTANT will maintain reasonable and appropriate administrative, technical and physical safeguards to ensure the security, confidentiality and integrity of the Confidential Information. Notwithstanding the foregoing, CONSULTANT may disclose Confidential Information to its employees, agents and subcontractors, if any, to the extent they have a need to know in order to
perform CONSULTANT’s obligations to CITY under this Agreement and for no other purpose, provided that the CONSULTANT informs them of, and requires them to follow, the confidentiality and security obligations of this Agreement. 28.2. “Confidential Information” means all data, information (including without
limitation “Personal Information” about a California resident as defined in Civil Code Section 1798 et seq., as amended from time to time) and materials, in any form or media, tangible or intangible, provided or otherwise made available to CONSULTANT by CITY, directly or indirectly, pursuant to this Agreement. Confidential Information excludes information that CONSULTANT can show by appropriate documentation: (i) was publicly known at the time it
was provided or has subsequently become publicly known other than by a breach of this Agreement; (ii) was rightfully in CONSULTANT’s possession free of any obligation of confidence prior to receipt of Confidential Information; (iii) is rightfully obtained by CONSULTANT from a third party without breach of any confidentiality obligation; (iv) is independently developed by employees of CONSULTANT without any use of or access to the
Confidential Information; or (v) CONSULTANT has written consent to disclose signed by an authorized representative of CITY. 28.3. Notwithstanding the foregoing, CONSULTANT may disclose Confidential
Information to the extent required by order of a court of competent jurisdiction or governmental
body, provided that CONSULTANT will notify CITY in writing of such order immediately upon receipt and prior to any such disclosure (unless CONSULTANT is prohibited by law from doing so), to give CITY an opportunity to oppose or otherwise respond to such order.
28.4. CONSULTANT will notify City promptly upon learning of any breach in
the security of its systems or unauthorized disclosure of, or access to, Confidential Information in its possession or control, and if such Confidential Information consists of Personal Information, CONSULTANT will provide information to CITY sufficient to meet the notice requirements of Civil Code Section 1798 et seq., as applicable, as amended from time to time.
28.5. Prior to or upon termination or expiration of this Agreement, CONSULTANT will honor any request from the CITY to return or securely destroy all copies of Confidential Information. All Confidential Information is and will remain the property of the CITY and nothing contained in this Agreement grants or confers any rights to such Confidential
Information on CONSULTANT.
28.6. If selected in Section 30 (Exhibits), this Agreement is also subject to the terms and conditions of the Information Privacy Policy and Cybersecurity Terms and Conditions.
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City of Palo Alto Professional Services Contract No. C22183900 Rev. Dec.15, 2020
SECTION 29. MISCELLANEOUS PROVISIONS. 29.1. This Agreement will be governed by California law, without regard to its conflict of law provisions.
29.2. In the event that an action is brought, the parties agree that trial of such action will be vested exclusively in the state courts of California in the County of Santa Clara, State of California.
29.3. The prevailing party in any action brought to enforce the provisions of this Agreement may recover its reasonable costs and attorneys’ fees expended in connection with that action. The prevailing party shall be entitled to recover an amount equal to the fair market value of legal services provided by attorneys employed by it as well as any attorneys’ fees paid to third parties.
29.4. This Agreement, including all exhibits, constitutes the entire and integrated agreement between the parties with respect to the subject matter of this Agreement, and supersedes all prior agreements, negotiations, representations, statements and undertakings, either oral or written. This Agreement may be amended only by a written instrument, which is signed by the
authorized representatives of the parties and approved as required under Palo Alto Municipal Code, as amended from time to time. 29.5. If a court of competent jurisdiction finds or rules that any provision of this Agreement is void or unenforceable, the unaffected provisions of this Agreement will remain in
full force and effect. 29.6. In the event of a conflict between the terms of this Agreement and the exhibits hereto (per Section 30) or CONSULTANT’s proposal (if any), the Agreement shall
control. In the event of a conflict between the exhibits hereto and CONSULTANT’s proposal (if
any), the exhibits shall control. 29.7. The provisions of all checked boxes in this Agreement shall apply to this Agreement; the provisions of any unchecked boxes shall not apply to this Agreement.
29.8. All section headings contained in this Agreement are for convenience and reference only and are not intended to define or limit the scope of any provision of this Agreement. 29.9. This Agreement may be signed in multiple counterparts, which, when
executed by the authorized representatives of the parties, shall together constitute a single binding
agreement. SECTION 30. EXHIBITS. Each of the following exhibits, if the check box for such exhibit is selected below, is hereby attached and incorporated into this Agreement by reference as though
fully set forth herein:
EXHIBIT A: SCOPE OF SERVICES EXHIBIT A-1: BASIC & VOLUNTARY LIFE INSURANCE POLICY
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City of Palo Alto Professional Services Contract No. C22183900 Rev. Dec.15, 2020
EXHIBIT A-2: BASIC & VOLUNTARY AD&D LIFE INSURANCE POLICY EXHIBIT A-3: LONG TERM DISABILITY INSURANCE POLICY EXHIBIT B: SCHEDULE OF PERFORMANCE EXHIBIT C: COMPENSATION EXHIBIT D: INSURANCE REQUIREMENTS
THIS AGREEMENT IS NOT COMPLETE UNLESS ALL SELECTED EXHIBITS ARE ATTACHED.
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City of Palo Alto Professional Services Contract No. C22183900 Rev. Dec.15, 2020
CONTRACT No. S22183900 SIGNATURE PAGE IN WITNESS WHEREOF, the parties hereto have by their duly authorized representatives executed this Agreement as of the date first above written.
CITY OF PALO ALTO ____________________________
City Manager APPROVED AS TO FORM: __________________________
City Attorney or designee
CONSULTANT LIFE INSURANCE COMPANY OF NORTH AMERICA, A WHOLLY OWNED SUBSIDIARY OF THE CIGNA CORPORATION Officer 1 By: Name:
Title: Officer 2 (Required for Corp. or LLC) By:
Name: Title:
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Vice President of UW
Amy K. Guinan
Lauren Bradley
Corporate Vice President of UW
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City of Palo Alto Professional Services Contract No. C22183900 Rev. Dec.15, 2020
EXHIBIT A SCOPE OF SERVICES CONSULTANT shall provide the Services detailed in this Exhibit A, entitled “SCOPE OF
SERVICES”. CONSULTANT shall provide employees of CITY: BASIC AND VOLUNTARY LIFE INSURANCE, BASIC & VOLUNTARY ACCIDENTAL DEATH AND DISMEMBERMENT (AD&D) and LONG TERM DISABILITY LIFE INSURANCE (LTD) plans. CONSULTANT
shall administer the above named insurance benefits in accordance of the policies provided in this Agreement and attached as EXHIBITS “A-1”, “A-2” & “A-3”.
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CALIFORNIA LIFE AND HEALTH INSURANCE
GUARANTY ASSOCIATION ACT
SUMMARY DOCUMENT AND DISCLAIMER
Residents of California who purchase life and health insurance and annuities should know that the insurance
companies licensed in this state to write these types of insurance are members of the California Life and Health
Insurance Guaranty Association. The purpose of this Association is to assure that policyholders will be protected,
within limits, in the unlikely event that a member insurer becomes financially unable to meet its obligations. If
this should happen, the Association will assess its other member insurance companies for the money to pay the
claims of insured persons who live in this state and, in some cases, to keep coverage in force. The valuable extra
protection provided through the Association is not unlimited, as noted in the box below, and is not a substitute for
consumers' care in selecting well managed and financially stable insurers.
The California Life and Health Insurance Guaranty Association may not provide coverage for this
insurance. If coverage is provided, it may be subject to substantial limitations or exclusions, and require
continued residency in the state. 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 insurance 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 prohibited by law from using the existence of the Association
to induce you to purchase any kind of insurance policy.
If you have additional questions, you should first contact your insurer or agent and then may contact:
California Life and Health OR Consumer Service Division
Insurance Guaranty Association California Department of Insurance
P.O. Box 16860 300 South Spring Street
Beverly Hills, CA 90209 Los Angeles, CA 90013
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.
EXHIBIT "A-1"
BASIC & VOLUNTARY LIFE INSURANCE POLICYDocuSign Envelope ID: C9DE40AE-C5E8-4AD0-BF22-BA5334AA9CBA
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COVERAGE
Generally, individuals will be protected by the California Life and Health Insurance Guaranty Association
if they live in this state and 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 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
organization, 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 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 and association plans to the extent they are self-funded or uninsured;
synthetic guaranteed interest contracts;
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; and
any portion of a contract that provides dividends or experience rating credits.
LIMITS ON AMOUNT OF COVERAGE
The Act limits the Association to pay benefits as follows:
Life and Annuity Benefits
80% of what the life insurance company would owe under a life policy or annuity contract up to
$100,000 in cash surrender values;
$100,000 in present value of annuities; or
$250,000 in life insurance death benefits.
A maximum of $250,000 for any one insured life no matter how many policies and contracts there
were with the same company, even if 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.
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NOTICE
Benefits paid under the Accelerated Benefits provision will reduce the Death Benefit
payable for life insurance.
Benefits payable under the Accelerated Benefits provision may be taxable. If so, the
Employee or the Employee's beneficiary may incur a tax obligation. As with all tax
matters, an Employee should consult with a personal tax advisor to assess the impact of
this benefit. Accelerated Benefits are not payable if life insurance coverage under the
Policy is not in force.
TL-004788
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LIFE INSURANCE COMPANY OF NORTH AMERICA
1601 CHESTNUT STREET GROUP POLICY
PHILADELPHIA, PA 19192-2235
(800) 732-1603 TDD (800) 552-5744
A STOCK INSURANCE COMPANY
POLICYHOLDER:
SUBSCRIBER:
POLICY NUMBER:
POLICY EFFECTIVE DATE:
POLICY ANNIVERSARY DATE:
TRUSTEE OF THE GROUP INSURANCE
TRUST FOR EMPLOYERS IN THE PUBLIC
ADMINISTRATION INDUSTRY
City of Palo Alto
FLX-962659
January 1
January 1
This Policy describes the terms and conditions of coverage. It is issued in Delaware and shall be
governed by its laws. The Policy goes into effect on the Policy Effective Date, 12:01 a.m. at the
Policyholder's address.
In return for the required premium, the Insurance Company and the Policyholder have agreed to all the
terms of this Policy.
Deborah Young, Corporate Secretary Karen S. Rohan, President
TL-004700
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TABLE OF CONTENTS
SCHEDULE OF BENEFITS........................................................................................................................1
SCHEDULE OF BENEFITS FOR CLASS 1...............................................................................................2
SCHEDULE OF BENEFITS FOR CLASS 2...............................................................................................5
SCHEDULE OF BENEFITS FOR CLASS 3...............................................................................................2
ELIGIBILITY FOR INSURANCE ..............................................................................................................2
ENROLLING FOR INSURANCE...............................................................................................................2
EFFECTIVE DATE OF INSURANCE........................................................................................................2
TERMINATION OF INSURANCE.............................................................................................................3
CONTINUATION OF INSURANCE..........................................................................................................3
LIFE INSURANCE BENEFITS...................................................................................................................6
LIFE INSURANCE EXCLUSIONS ............................................................................................................8
CLAIM PROVISIONS.................................................................................................................................8
ADMINISTRATIVE PROVISIONS..........................................................................................................10
SCHEDULE OF RATES............................................................................................................................12
GENERAL PROVISIONS .........................................................................................................................13
DEFINITIONS............................................................................................................................................14
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1
SCHEDULE OF BENEFITS
Premium Due Date: The last day of each month
Classes of Eligible Employees
On the pages following the definition of eligible employees there is a Schedule of Benefits for each Class
of Eligible Employees listed below. For an explanation of these benefits, please see the Description of
Benefits provision.
If an Employee is eligible under one Class of Eligible Employees and later becomes eligible under a
different Class of Eligible Employees, changes in his or her insurance due to the class change will be
effective on the first of the month following the change in class.
Class 1 All active Full-time Employees of the Employer, regularly working a minimum of 20
hours per week excluding Employees who are classified as Management.
Class 2 All active Full-time Employees of the Employer, regularly working a minimum of 20
hours per week who are classified as Management.
Class 3 All active employees as defined under the prior carrier policy number 643835 and on file
with the Insurance Company. (Closed Class)
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2
SCHEDULE OF BENEFITS FOR CLASS 1
Eligibility Waiting Period
The Eligibility Waiting Period is the period of time the Employee must be in Active Service to be eligible
for coverage. It will be extended by the number of days the Employee is not in Active Service.
For Employees hired on or
before the Policy Effective Date: No Waiting Period.
For Employees hired after
the Policy Effective Date: No Waiting Period.
LIFE INSURANCE BENEFITS
Employee Benefits
Basic Benefit 1 times Annual Compensation
rounded to the next higher $1,000, if not already a multiple
thereof.
Guaranteed Issue Amount: the lesser of 1 times Annual Compensation or $325,000
Maximum Benefit: the lesser of 1 times Annual Compensation or $325,000
Voluntary Benefit 1 times Annual Compensation
rounded to the next higher $1,000, if not already a multiple
thereof.
Guaranteed Issue Amount: the lesser of 1 times Annual Compensation or $325,000
Maximum Benefit: the lesser of 1 times Annual Compensation or $325,000
Age Based Reductions Life Insurance Benefit for an Employee age 70 and over will
reduce to:
65% of the Life Insurance Benefit at age 70
50% of the Life Insurance Benefit at age 75
Continuation Options
For Layoff
Maximum Benefit Period: Coverage continues through the end of the month in which the
layoff begins
For Leave of Absence
Maximum Benefit Period: Coverage continues through the end of the month in which the
leave of absence begins
For Family Medical Leave
Maximum Benefit Period: 12 weeks
For Disability for Employees over Age 60
Maximum Benefit Period: 12 months
Applicable Coverages: Life Insurance Benefits for the Employee
Extended Death Benefit with Waiver of Premium
Extended Death Benefit
Applicable Coverages Life Insurance Benefits for the Employee
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3
Waiver of Premium
Waiver Waiting Period 9 months from the date the Employee's Active Service ends
Maximum Benefit Period To Age 65
Applicable Coverages Life Insurance Benefits for the Employee
Portability Options
For Employees See the Former Employee sections in this Schedule of Benefits
for the amounts of insurance an Insured is eligible to continue
under this option.
Terminal Illness Benefit 75% of Life Insurance Benefits in force on the date the Insured is
determined by the Insurance Company to be Terminally Ill,
subject to a Maximum Benefit of $500,000.
Automatic Increase Feature
If an Employee’s Voluntary Life Insurance Benefit is based on Annual Compensation, it will
automatically increase. The amount of the increase may be up to 25% of the Employee’s previous salary
but not more than $25,000. It will automatically increase, subject to the conditions below.
Conditions for Automatic Increase:
1. the Employer provides the Insurance Company with the required notice of an increase in Annual
Compensation; and
2. the Employee is in Active Service on the effective date of the increase.
If an Employee is not in Active Service on that date, his or her benefit will not increase until he or she
returns to Active Service.
The Employee may stop the Automatic Increase Feature at any time. If an Employee stops the feature, it
may not be restarted at a later date.
TL-004736-1
Re-solicitation Period
During a Re-solicitation Period, an Employee currently insured under the Voluntary Life Insurance
portion of this Policy may increase his or her Voluntary Life Insurance Benefits, and an Employee who is
eligible for the Voluntary Life Insurance portion of this Policy but who has not previously enrolled may
become insured under the Policy, by satisfying the Insurability Requirement. An Employee’s insurance
will be effective on the date the Insurance Company agrees in writing to insure the Employee.
An Employee may reduce Insurance Benefits at any time. A request for a Benefit reduction received
during a Re-solicitation Period will become effective on the Policy Anniversary following the Re-
solicitation Period. Any other Benefit reduction will be effective on the date the Insurance Company
receives the completed change form.
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4
Former Employee Benefits
Amount of Insurance An amount elected subject to the Maximum Benefit amount for
Life Insurance Benefits allowable to an Employee, less any
amount of conversion insurance issued under the Conversion
Privilege for Life Insurance.
Any amount elected in excess of the Life Insurance Benefits in
effect on the date he or she no longer qualifies as an Employee
will be effective on the date the Insurance Company agrees in
writing to insure him or her.
The Maximum Benefit for Basic Life Insurance Benefits is
$50,000.
Maximum Benefit Period To Age 70
Terminal Illness Benefit 75% of Life Insurance Benefits in force on the date the Insured is
determined by the Insurance Company to be Terminally Ill,
subject to a Maximum Benefit of $500,000.
TL-004774
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5
SCHEDULE OF BENEFITS FOR CLASS 2
Eligibility Waiting Period
The Eligibility Waiting Period is the period of time the Employee must be in Active Service to be eligible
for coverage. It will be extended by the number of days the Employee is not in Active Service.
For Employees hired on or
before the Policy Effective Date: No Waiting Period.
For Employees hired after
the Policy Effective Date: No Waiting Period.
LIFE INSURANCE BENEFITS
Employee Benefits
Basic Benefit 1 times Annual Compensation
rounded to the next higher $1,000, if not already a multiple
thereof.
Guaranteed Issue Amount: the lesser of 1 times Annual Compensation or $325,000
Maximum Benefit: the lesser of 1 times Annual Compensation or $325,000
Voluntary Benefit 1 or 2 times Annual Compensation
rounded to the next higher $1,000, if not already a multiple
thereof.
Guaranteed Issue Amount: the lesser of 2 times Annual Compensation or $325,000
Maximum Benefit: the lesser of 2 times Annual Compensation or $325,000
Age Based Reductions Life Insurance Benefit for an Employee age 70 and over will
reduce to:
65% of the Life Insurance Benefit at age 70
50% of the Life Insurance Benefit at age 75
Continuation Options
For Layoff
Maximum Benefit Period: Coverage continues through the end of the month in which the
layoff begins
For Leave of Absence
Maximum Benefit Period: Coverage continues through the end of the month in which the
leave of absence begins
For Family Medical Leave
Maximum Benefit Period: 12 weeks
For Disability for Employees over Age 60
Maximum Benefit Period: 12 months
Applicable Coverages: Life Insurance Benefits for the Employee
Extended Death Benefit with Waiver of Premium
Extended Death Benefit
Applicable Coverages Life Insurance Benefits for the Employee
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Waiver of Premium
Waiver Waiting Period 9 months from the date the Employee's Active Service ends
Maximum Benefit Period To Age 65
Applicable Coverages Life Insurance Benefits for the Employee
Portability Options
For Employees See the Former Employee sections in this Schedule of Benefits
for the amounts of insurance an Insured is eligible to continue
under this option.
Terminal Illness Benefit 75% of Life Insurance Benefits in force on the date the Insured is
determined by the Insurance Company to be Terminally Ill,
subject to a Maximum Benefit of $500,000.
Automatic Increase Feature
If an Employee’s Voluntary Life Insurance Benefit is based on Annual Compensation, it will
automatically increase. The amount of the increase may be up to 25% of the Employee’s previous salary
but not more than $25,000. It will automatically increase, subject to the conditions below.
Conditions for Automatic Increase:
1. the Employer provides the Insurance Company with the required notice of an increase in Annual
Compensation; and
2. the Employee is in Active Service on the effective date of the increase.
If an Employee is not in Active Service on that date, his or her benefit will not increase until he or she
returns to Active Service.
The Employee may stop the Automatic Increase Feature at any time. If an Employee stops the feature, it
may not be restarted at a later date.
TL-004736-1
Re-solicitation Period
During a Re-solicitation Period, an Employee currently insured under the Voluntary Life Insurance
portion of this Policy may increase his or her Voluntary Life Insurance Benefits, and an Employee who is
eligible for the Voluntary Life Insurance portion of this Policy but who has not previously enrolled may
become insured under the Policy, by satisfying the Insurability Requirement. An Employee’s insurance
will be effective on the date the Insurance Company agrees in writing to insure the Employee.
An Employee may reduce Insurance Benefits at any time. A request for a Benefit reduction received
during a Re-solicitation Period will become effective on the Policy Anniversary following the Re-
solicitation Period. Any other Benefit reduction will be effective on the date the Insurance Company
receives the completed change form.
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1
Former Employee Benefits
Amount of Insurance An amount elected subject to the Maximum Benefit amount for
Life Insurance Benefits allowable to an Employee, less any
amount of conversion insurance issued under the Conversion
Privilege for Life Insurance.
Any amount elected in excess of the Life Insurance Benefits in
effect on the date he or she no longer qualifies as an Employee
will be effective on the date the Insurance Company agrees in
writing to insure him or her.
The Maximum Benefit for Basic Life Insurance Benefits is
$50,000.
Maximum Benefit Period To Age 70
Terminal Illness Benefit 75% of Life Insurance Benefits in force on the date the Insured is
determined by the Insurance Company to be Terminally Ill,
subject to a Maximum Benefit of $500,000.
TL-004774
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2
SCHEDULE OF BENEFITS FOR CLASS 3
Eligibility Waiting Period
The Eligibility Waiting Period is the period of time the Employee must be in Active Service to be eligible
for coverage. It will be extended by the number of days the Employee is not in Active Service.
For Employees hired on or
before the Policy Effective Date: No Waiting Period.
For Employees hired after
the Policy Effective Date: No Waiting Period.
LIFE INSURANCE BENEFITS
Employee Benefits
Basic Benefit 1 times Annual Compensation
rounded to the next higher $1,000, if not already a multiple
thereof.
Guaranteed Issue Amount: the lesser of 1 times Annual Compensation or $325,000
Maximum Benefit: the lesser of 1 times Annual Compensation or $325,000
Voluntary Benefit 1 or 2 times Annual Compensation
rounded to the next higher $1,000, if not already a multiple
thereof.
Guaranteed Issue Amount: the greater of a) or b) below:
a)the lesser of 2 times Annual Compensation or $325,000, or
b)an amount equal to the Life Insurance Benefit in effect on
the termination date of the Prior Plan
Maximum Benefit: the lesser of 2 times Annual Compensation or $325,000
Age Based Reductions Life Insurance Benefit for an Employee age 70 and over will
reduce to:
65% of the Life Insurance Benefit at age 70
50% of the Life Insurance Benefit at age 75
Continuation Options
For Layoff
Maximum Benefit Period: Coverage continues through the end of the month in which the
layoff begins
For Leave of Absence
Maximum Benefit Period: Coverage continues through the end of the month in which the
leave of absence begins
For Family Medical Leave
Maximum Benefit Period: 12 weeks
For Disability for Employees over Age 60
Maximum Benefit Period: 12 months
Applicable Coverages: Life Insurance Benefits for the Employee
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3
Extended Death Benefit with Waiver of Premium
Extended Death Benefit
Applicable Coverages Life Insurance Benefits for the Employee
Waiver of Premium
Waiver Waiting Period 9 months from the date the Employee's Active Service ends
Maximum Benefit Period To Age 65
Applicable Coverages Life Insurance Benefits for the Employee
Portability Options
For Employees See the Former Employee sections in this Schedule of Benefits
for the amounts of insurance an Insured is eligible to continue
under this option.
Terminal Illness Benefit 75% of Life Insurance Benefits in force on the date the Insured is
determined by the Insurance Company to be Terminally Ill,
subject to a Maximum Benefit of $500,000.
Automatic Increase Feature
If an Employee’s Voluntary Life Insurance Benefit is based on Annual Compensation, it will
automatically increase. The amount of the increase may be up to 25% of the Employee’s previous salary
but not more than $25,000. It will automatically increase, subject to the conditions below.
Conditions for Automatic Increase:
1. the Employer provides the Insurance Company with the required notice of an increase in Annual
Compensation; and
2.the Employee is in Active Service on the effective date of the increase.
If an Employee is not in Active Service on that date, his or her benefit will not increase until he or she
returns to Active Service.
The Employee may stop the Automatic Increase Feature at any time. If an Employee stops the feature, it
may not be restarted at a later date.
TL-004736-1
Re-solicitation Period
During a Re-solicitation Period, an Employee currently insured under the Voluntary Life Insurance
portion of this Policy may increase his or her Voluntary Life Insurance Benefits, and an Employee who is
eligible for the Voluntary Life Insurance portion of this Policy but who has not previously enrolled may
become insured under the Policy, by satisfying the Insurability Requirement. An Employee’s insurance
will be effective on the date the Insurance Company agrees in writing to insure the Employee.
An Employee may reduce Insurance Benefits at any time. A request for a Benefit reduction received
during a Re-solicitation Period will become effective on the Policy Anniversary following the Re-
solicitation Period. Any other Benefit reduction will be effective on the date the Insurance Company
receives the completed change form.
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Former Employee Benefits
Amount of Insurance An amount elected subject to the Maximum Benefit amount for
Life Insurance Benefits allowable to an Employee, less any
amount of conversion insurance issued under the Conversion
Privilege for Life Insurance.
Any amount elected in excess of the Life Insurance Benefits in
effect on the date he or she no longer qualifies as an Employee
will be effective on the date the Insurance Company agrees in
writing to insure him or her.
The Maximum Benefit for Basic Life Insurance Benefits is
$50,000.
Maximum Benefit Period To Age 70
Terminal Illness Benefit 75% of Life Insurance Benefits in force on the date the Insured is
determined by the Insurance Company to be Terminally Ill,
subject to a Maximum Benefit of $500,000.
TL-004774
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ELIGIBILITY FOR INSURANCE
Classes of Eligible Persons
A person may be insured only once under the Basic Life portion of the Policy even though he or she may
be eligible under more than one class. A person may also be insured only once under the Voluntary Life
portion of the Policy as an Employee, even though he or she may be eligible under more than one class.
Employee
An Employee in one of the Classes of Eligible Employees shown in the Schedule of Benefits is eligible to
be insured on the Policy Effective Date or the day after he or she completes the applicable Eligibility
Waiting Period, if later.
If a person has previously converted his or her insurance under the Policy, he or she will not become
eligible until the converted policy is surrendered. This does not apply to any amount of insurance that
was previously converted under the Policy due to a reduction in the Employee's Life Insurance Benefits
based on age or a change in class unless those conditions no longer affect the amount of coverage
available to the Employee.
Except as noted in the Reinstatement Provision, if an Employee terminates coverage and later wishes to
reapply, or if a former Employee is rehired, a new Eligibility Waiting Period must be satisfied. An
Employee is not required to satisfy a new Eligibility Waiting Period if insurance ends because he or she is
no longer in a Class of Eligible Employees, but continues to be employed by the Employer, and within
one year becomes a member of an eligible class.
TL-004710
ENROLLING FOR INSURANCE
Initial Open Enrollment
During the Initial Open Enrollment Period, an Employee who was insured, or who was eligible to be
insured, under the Prior Plan may become insured under the Voluntary Life Insurance Plan provided by
this Policy for a Benefit of one times Annual Compensation up to this Policy's Guaranteed Issue Amount,
as shown in the Schedule of Benefits, without satisfying any Insurability Requirement. Any Employee
who is not actively at work, due to Injury or Sickness, on the date his or her coverage would otherwise
become effective under this Policy, may not become insured under this Policy until he or she returns to
Active Service.
An Employee may become insured for an amount in excess of the Guaranteed Issue Amount only if he or
she satisfies the Insurability Requirement. Any excess amount will be effective on the date the Insurance
Company agrees in writing to insure the Employee.
EFFECTIVE DATE OF INSURANCE
An Employee will be insured for an amount not to exceed the Guaranteed Issue Amount on the date he or
she becomes eligible, if the Employee is not required to contribute to the cost of this insurance.
An Employee who is required to contribute to the cost of this insurance may elect insurance for himself or
herself only by authorizing payroll deduction in a form approved by the Employer and the Insurance
Company. The effective date of this insurance depends on the date and amount of insurance elected.
If an individual elects coverage within 31 days after becoming eligible to enroll, or for any increases, the
Guaranteed Issue Amount will be effective on the latest of the following dates:
1. The Policy Effective Date.
2. The date payroll deduction is authorized for this insurance.
3. The date the Employer or Insurance Company receives the completed enrollment form.
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If an enrollment form for Employee coverage is received more than 31 days after becoming eligible to
elect coverage, this insurance will be effective on the date the Insurance Company agrees in writing to
insure that eligible person. The Insurance Company will require the eligible Employee to satisfy the
Insurability Requirement before it agrees to insure him or her.
If an eligible Employee is not in Active Service on the date insurance would otherwise be effective, it will
be effective on the date he or she returns to Active Service.
TL-004712
Takeover Provision
Special Terms Applicable to Previously Insured Employees Not in Active Service
Employees not in Active Service on the Policy Effective Date are not covered under the Policy.
However, the Insurance Company agrees to provide a death benefit equal to the lesser of:
1. the amount due under this Policy (without regard to the Active Service provision), or
2. the amount that would have been due under the Prior Plan had it remained in force.
The benefit amount will be reduced by any amount paid by the Prior Plan, or that would have been paid
had this Policy not been issued and had timely filing of the claim been made under the Prior Plan.
These special terms will end on the earliest of the following dates:
1. the date the Employee meets the Active Service requirements;
2. the date insurance terminates for one of the reasons stated in the Termination of Insurance
provision;
3. 12 months after the Policy Effective Date; or
4. the last day the Employee would have been covered under the Prior Plan if that plan was still in
force.
TL-009020
TERMINATION OF INSURANCE
An Insured's coverage will end on the earliest of the following dates:
1. the date the Employee is eligible for coverage under a plan intended to replace this coverage;
2. the date the Policy is terminated by the Insurance Company;
3. the date the Insured is no longer in an eligible class;
4. the date coinciding with the end of the last period for which premiums are paid;
5. the date an Employee is no longer in Active Service; and
6. for an Employee, the date the Employer cancels participation under the Policy.
TL-004714
CONTINUATION OF INSURANCE
If an Employee is no longer in Active Service, he or she may be eligible to continue insurance. The
following provisions explain the continuation options available under the Policy. Please see the Schedule
of Benefits to determine the applicability of these benefits on a class level.
Continuation for Layoff, Temporary Leave of Absence or Family Medical Leave
If an Employee's Active Service ends due to a layoff, Employer approved unpaid leave of absence, or
family medical leave of absence, insurance will continue for up to the Maximum Benefit Period shown in
the Schedule of Benefits, if the required premium is paid.
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Continuation for Disability for Employees over Age 60
If an Employee becomes Disabled and is age 60 or over, the Life Insurance Benefits shown in the
Schedule of Benefits will be continued, provided premiums are paid, until the earlier of the following
dates:
1. The date the Employee is no longer Disabled.
2. The date following the Maximum Benefit Period shown in the Schedule of Benefits.
3. The date coinciding with the end of the last period for which premiums are paid.
4. The date the Policy is terminated by the Insurance Company.
Amount of Insurance
If an Employee dies while he or she is Disabled and coverage is continued under this provision, the
Insurance Company will pay a Death Benefit equal to the amount in effect on the date the Employee
became Disabled. However, the Life Insurance Benefit will be subject to the provisions of the Policy that
reduce the coverage amount because of age, retirement, payment of an Accelerated Benefit or a change in
class. Automatic increases in Life Insurance Benefits will end while coverage is continued under this
provision. The Insurance Company will pay benefits only if due proof of the Employee’s continuous
Disability is received within one year of the date of the loss.
“Disability”/”Disabled” means because of Injury or Sickness the Employee is unable to perform all the
material duties of his or her Regular Occupation; or is receiving disability benefits under the Employer’s
plan.
“Regular Occupation” means the occupation the Employee routinely performs at the time the Disability
begins. The Insurance Company will consider the duties of the occupation as it is normally performed in
the general labor market in the national economy.
Extended Death Benefit with Waiver of Premium
Extended Death Benefit
If an Employee becomes Disabled and is less than age 60, the Life Insurance Benefits shown in the
Schedule of Benefits will be extended without premium payment until the earlier of the following dates:
1. The date the Employee is no longer Disabled.
2. The date the Employee fails to qualify for Waiver of Premium or fails to provide proof of
Disability as indicated under Waiver of Premium.
Amount of Insurance
If an Employee dies while he or she is Disabled and coverage is extended under this provision, the
Insurance Company will pay a Death Benefit equal to the amount in effect on the date the Employee
became Disabled. However, the Life Insurance Benefit will be subject to the provisions of the Policy that
reduce the coverage amount because of age, retirement, payment of an Accelerated Benefit or a change in
class. Automatic increases in Life Insurance Benefits will end while premiums are waived. The
Insurance Company will pay benefits only if due proof of the Employee’s continuous Disability is
received within one year of the date of the loss.
“Disability”/”Disabled” means because of Injury or Sickness the Employee is unable to perform all the
material duties of his or her Regular Occupation; or is receiving disability benefits under the Employer’s
plan.
“Regular Occupation” means the occupation the Employee routinely performs at the time the Disability
begins. The Insurance Company will consider the duties of the occupation as it is normally performed in
the general labor market in the national economy.
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Waiver of Premium
If the Employee submits satisfactory proof that he or she has been continuously Disabled for the Waiver
Waiting Period shown in the Schedule of Benefits, coverage will be extended up to the Maximum Benefit
Period shown in the Schedule of Benefits.
Such proof must be submitted to the Insurance Company no later than 3 months after the date the Waiver
Waiting Period ends. Premiums will be waived from the date the Insurance Company agrees in writing to
waive premiums for that Employee.
After premiums have been waived for 12 months, they will be waived for future periods of 12 months, if
the Employee remains Disabled and submits satisfactory proof that Disability continues. Satisfactory
proof must be submitted to the Insurance Company 3 months before the end of the 12-month period.
Amount of Insurance
If an Employee dies while he or she is Disabled and coverage is continued under this provision, the
Insurance Company will pay a Death Benefit equal to the amount in effect on the date the Employee
became Disabled. However, the Life Insurance Benefit will be subject to the provisions of the Policy that
reduce the coverage amount because of age, retirement, payment of an Accelerated Benefit or a change in
class. Automatic increases in Life Insurance Benefits will end while premiums are waived. The
Insurance Company will pay benefits only if due proof of the Employee’s continuous Disability is
received within one year of the date of the loss.
Termination of Waiver
Insurance will end for any Employee whose premiums are waived on the earliest of the following dates.
1. The date he or she is no longer Disabled.
2. The date he or she refuses to submit to any physical examination required by the Insurance
Company.
3. The last day of the 12-month period of Disability during which he or she fails to submit
satisfactory proof of continued Disability.
4. The date following the end of the Maximum Benefit Period shown in the Schedule of Benefits.
“Disability”/”Disabled” means because of Injury or Sickness an Employee is unable to perform all the
material duties of any occupation which he or she may reasonably become qualified based on education,
training or experience.
TL-009745
Portability Options
For Employees
If an Employee’s coverage under the Policy ends prior to age 70, for any of the following reasons:
a. termination of employment; or
b. termination of membership in an eligible class under the Policy;
Life Insurance Benefits may be continued up to the Maximum Benefit shown in the Schedule of Benefits
for this option.
The Employee must apply to the Insurance Company and pay the required premium. The application
must be submitted:
a. within 31 days of the Employee’s termination of employment or membership in an eligible class
under the Policy; or
b. during the time that the Employee has to exercise the Conversion Privilege.
Coverage under this option may not be elected at a later date.
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When applying for this option, the Employee must name a beneficiary. Any beneficiary named
previously under the Policy is no longer in effect. If there is no named or surviving beneficiary, Death
Benefits will be paid to the first surviving class of the following living relatives:
a.spouse;
b.child or children;
c.mother or father;
d.brothers or sisters; or
e.the executors or administrators of the Insured’s estate.
When coverage is continued under this option, the Employee becomes a Former Employee.
Coverage will end on the earliest of the following dates.
a.The date the Insurance Company cancels coverage for all Former Employees.
b.The end of the period for which premiums are paid.
c.The date an Insured reaches age 70.
d.The date the Maximum Benefit Period shown in the Schedule of Benefits for this option ends.
TL-004716 as modified by TL-009330
DESCRIPTION OF BENEFITS
The following provisions explain the benefits available under the Policy. Please see the Schedule of
Benefits for the applicability of these benefits on a class level.
LIFE INSURANCE BENEFITS
Death Benefit
If an Insured dies, the Insurance Company will pay the Life Insurance Benefit in force for that Insured on
the date of his or her death.
TL-004730
Accelerated Benefits
Any benefits payable under this Accelerated Benefits provision will reduce the Death Benefit payable for
Life Insurance. Any automatic increases in Life Insurance Benefits will end when benefits are payable
under this provision.
Terminal Illness Benefit
The Insurance Company will pay a Terminal Illness Benefit to an Insured who has been determined by
the Insurance Company to be Terminally Ill.
The Terminal Illness Benefit is payable only once in an Insured's lifetime.
Determination of Terminal Illness
For the purpose of determining the existence of a Terminal Illness, the Insurance Company will require
the Insured submit the following proof.
1. A written diagnosis and prognosis by two Physicians licensed to practice in the United States.
2.Supportive evidence satisfactory to the Insurance Company, including but not limited to
radiological, histological or laboratory reports documenting the Terminal Illness.
The Insurance Company may require, at its expense, an examination of the Insured and a review of the
documented evidence by a Physician of its choice.
"Terminal Illness" means a person has a prognosis of 12 months or less to live, as diagnosed by a
Physician.
TL-004748
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Conversion Privilege for Life Insurance
Each Insured may convert all or any portion of his or her Life Insurance that would end under the Policy
due to:
1. termination of employment;
2. termination of membership in an eligible class under the Policy;
3. termination of the Policy.
The Insured may apply for any type of life insurance the Insurance Company offers to persons of the
same age in the amount applied for, except the Insured may not:
1. choose term insurance;
2. apply for an amount of insurance greater than the coverage amount terminating under the Policy
(also, the conversion policy will not provide accident, disability or other benefits); or
3. apply for more than $10,000 of insurance if the Policy is terminated or amended to terminate the
insurance for any class of Insureds, or the Employer cancels participation under the Policy.
Conversion in these cases is only permitted if the Insured has been covered by the Policy or, any
group life insurance policy issued to the Employer which the Policy replaced, for at least 3 years.
If the Insured becomes eligible for coverage under any group life policy within 31 days of termination of
coverage under this Policy, the Insured may not convert an amount of insurance greater than the amount
of coverage terminating under the Policy less the amount for which he or she may be covered under the
other policy.
To apply for conversion insurance, the Insured must, within 31 days after coverage under the Policy ends:
1. submit an application to the Insurance Company; and
2. pay the required premium.
Evidence of insurability is not required.
Premium for the conversion insurance will be based on the age and class of risk of the Insured and the
type and amount of coverage issued. If the Insured has assigned ownership of his group coverage, the
owner/assignee must apply for the individual policy. Conversion insurance will become effective on the
31st day after the date coverage under the Policy ends provided the application is received by the
Insurance Company and the required premium has been paid.
If the Insured dies during the 31-day conversion period, the Life Insurance benefits will be paid under the
Policy regardless of whether he or she applied for conversion insurance. If a conversion policy is issued,
it will be in exchange for any further benefits for that type and amount of insurance from this Policy.
Extension of Conversion Period
If an Insured is eligible for conversion insurance and is not notified of this right at least 15 days prior to
the end of the 31-day conversion period, the conversion period will be extended. The Insured will have
15 days from the date notice is given to apply for conversion insurance. In no event will the conversion
period be extended beyond 90 days. Notice, for the purpose of this section, means written notice
presented to the Insured by the Employer or mailed to the Insured's last known address as reported by the
Employer.
If the Insured dies during the extended conversion period, but more than 31 days after his or her coverage
under the Policy terminates, Life Insurance benefits:
1. will not be paid under the Policy; and
2. will be payable under the conversion insurance; provided:
a. the Insured's application for conversion insurance has been received by the Insurance
Company; and
b. the required premium has been paid.
Prior Conversion Limitation
If an Insured is covered under a life insurance conversion policy previously issued by the Insurance
Company, he or she will not be eligible for this Conversion Privilege unless the prior coverage has ended.
TL-009740
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LIFE INSURANCE EXCLUSIONS
If an Insured commits suicide, while sane or insane, within 2 years from the date his or her insurance
under the Policy becomes effective, Voluntary Life Insurance Benefits will be limited to a refund of the
premiums paid on the Insured's behalf. The suicide exclusion applies from the effective date of any
additional benefits or increases in Life Insurance Benefits.
Except for any amount of benefits in excess of the Prior Plan's benefits, this exclusion will not apply to
any person covered under the Prior Plan for more than two years. If a person was not insured for two
years under the Prior Plan, credit will be given for the time he or she was insured.
TL-004752
CLAIM PROVISIONS
Notice of Claim
Written notice, or notice by any other electronic/telephonic means authorized by the Insurance Company,
must be given to the Insurance Company within 31 days after a covered loss occurs or begins or as soon
as reasonably possible. If written notice, or notice by any other electronic/telephonic means authorized
by the Insurance Company, is not given in that time, the claim will not be invalidated or reduced if it is
shown that notice was given as soon as was reasonably possible. Notice can be given at our home office
in Philadelphia, Pennsylvania or to our agent. Notice should include the Employer's Name, the Policy
Number and the claimant's name and address.
Written notice or any other electronic/telephonic means authorized by the Insurance Company of a
diagnosis of a Terminal Illness on which claim is based must be given to us within 60 days after the
diagnosis. If notice is not given in that time, the claim will not be invalidated or reduced if it is shown
that written notice or any other electronic/telephonic means authorized by the Insurance Company was
given as soon as reasonably possible.
Claim Forms
When the Insurance Company receives notice of claim, the Insurance Company will send claim forms for
filing proof of loss. If claim forms are not sent within 15 days after notice is received by the Insurance
Company, the proof requirements will be met by submitting, within the time required under the "Proof of
Loss" section, written proof, or proof by any other electronic/telephonic means authorized by the
Insurance Company, of the nature and extent of the loss.
Claimant Cooperation Provision
Failure of a claimant to cooperate with the Insurance Company in the administration of the claim may
result in termination of the claim. Such cooperation includes, but is not limited to, providing any
information or documents needed to determine whether benefits are payable or the actual benefit amount
due.
Insurance Data
The Employer is required to cooperate with the Insurance Company in the review of claims and
applications for coverage. Any information the Insurance Company provides in these areas is
confidential and may not be used or released by the Employer if not permitted by applicable privacy laws.
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Proof of Loss
Written proof of loss, or proof by any other electronic/telephonic means authorized by the Insurance
Company, must be given to the Insurance Company within 90 days after the date of the loss for which a
claim is made. If written proof of loss, or proof by any other electronic/telephonic means authorized by
the Insurance Company, is not given in that 90 day period, the claim will not be invalidated nor reduced if
it is shown that it was given as soon as was reasonably possible. In any case, written proof of loss, or
proof by any other electronic/telephonic means authorized by the Insurance Company, must be given not
more than one year after that 90 day period. If written proof of loss, or proof by any other
electronic/telephonic means authorized by the Insurance Company, is provided outside of these time
limits, the claim will be denied. These time limits will not apply while the person making the claim lacks
legal capacity.
Written proof, or any other electronic/telephonic means authorized by the Insurance Company, of loss for
Accelerated Benefits must be furnished 90 days after the date of diagnosis. This proof must describe the
occurrence, character and diagnosis for which claim is made.
In case of claim for any other loss, proof must be furnished within 90 days after the date of such loss.
If it is not reasonably possible to submit proof of loss within these time periods, the Insurance Company
will not deny or reduce any claim if proof is furnished as soon as reasonably possible. Proof must, in any
case, be furnished not more than a year later, except for lack of legal capacity.
Time of Payment
Benefits due under the Policy for a loss, other than a loss for which the Policy provides installment
payments, will be paid immediately upon receipt of due written proof of such loss.
Subject to the receipt of satisfactory written proof of loss, all accrued benefits for loss for which the
Policy provides installments will be paid monthly; any balance remaining unpaid upon the termination of
liability will be paid immediately upon receipt of due written proof, unless otherwise stated in the
Description of Benefits.
To Whom Payable
Death Benefits will be paid to the Insured's named beneficiary, if any, on file at the time of payment. If
there is no named beneficiary or surviving beneficiary, Death Benefits will be paid to the first surviving
class of the following living relatives: spouse; child or children; mother or father; brothers or sisters; or to
the executors or administrators of the Insured's estate. The Insurance Company may reduce the amount
payable by any indebtedness due.
All benefits payable under the Accelerated Benefits section are payable to the Insured, if living. If the
Insured dies prior to the payment of an eligible claim for an Accelerated Benefit, benefits will be paid in
accordance with the provisions applicable to the payment of Life Insurance proceeds, unless the Insured
has directed us otherwise in writing. However, any payment made by us prior to notice of the Insured's
death shall discharge us of any benefit that was paid.
All other benefits, unless otherwise stated in the Policy, will be payable to the Insured or the certificate
owner if other than the Insured.
Any other accrued benefits which are unpaid at the Insured's death may, at the Insurance Company's
option, be paid either to the Insured's beneficiary or to the executor or administrator of the Insured's
estate.
If the Insurance Company pays benefits to the executor or administrator of the Insured's estate or to a
person who is incapable of giving a valid release, the Insurance Company may pay up to $1,000 to a
relative by blood or marriage whom it believes is equitably entitled. This good faith payment satisfies the
Insurance Company's legal duty to the extent of that payment.
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Change of Beneficiary
The Insured may change the beneficiary at any time by giving written notice to the Employer or the
Insurance Company. The beneficiary's consent is not required for this or any other change which the
Insured may make unless the designation of beneficiary is irrevocable.
No change in beneficiary will take effect until the form is received by the Employer or the Insurance
Company. When this form is received, it will take effect as of the date of the form. If the Insured dies
before the form is received, the Insurance Company will not be liable for any payment that was made
before receipt of the form.
Physical Examination and Autopsy
The Insurance Company, at its expense, will have the right to examine any person for whom a claim is
pending as often as it may reasonably require. The Insurance Company may, at its expense, require an
autopsy unless prohibited by law.
Legal Actions
No action at law or in equity may be brought to recover benefits under the Policy less than 60 days after
written proof of loss, or proof by any other electronic/telephonic means authorized by the Insurance
Company, has been furnished as required by the Policy. No such action shall be brought more than 3
years after the time satisfactory proof of loss is required to be furnished.
Time Limitations
If any time limit stated in the Policy for giving notice of claim or proof of loss, or for bringing any action
at law or in equity, is less than that permitted by the law of the state in which the Employee lives when
the Policy is issued, then the time limit provided in the Policy is extended to agree with the minimum
permitted by the law of that state.
Physician/Patient Relationship
The Insured will have the right to choose any Physician who is practicing legally. The Insurance
Company will in no way disturb the Physician/patient relationship.
TL-004724
ADMINISTRATIVE PROVISIONS
Premiums
The premiums for this Policy will be based on the rates currently in force, the plan and the amount of
insurance in effect.
If the Insured's coverage amount is reduced due to acceleration of his or her Death Benefit, his or her
premium will be based on the amount of coverage he or she has in force on the day before the reduction
took place. If the Insured's coverage amount is reduced due to his or her attained age, premium will be
based on the amount of coverage in force on the day after the reduction took place.
Changes in Premium Rates
The premium rates may be changed by the Insurance Company from time to time with at least 31 days
advance written notice. No change in rates will be made until 48 months after the Policy Effective Date.
An increase in rates will not be made more often than once in a 12 month period. However, the Insurance
Company reserves the right to change the rates even during a period for which the rate is guaranteed if
any of the following events take place.
1. The terms of the Policy change.
2. A division, subsidiary, affiliated company or eligible class is added or deleted from the Policy.
3. There is a change in the factors bearing on the risk assumed.
4. Any federal or state law or regulation is amended to the extent it affects the Insurance Company's
benefit obligation.
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5. The Insurance Company determines that the Employer has failed to promptly furnish any
necessary information requested by the Insurance Company, or has failed to perform any other
obligations in relation to the Policy.
If an increase or decrease in rates takes place on a date that is not a Premium Due Date, a pro rata
adjustment will apply from the date of the change to the next Premium Due Date.
Reporting Requirements
The Employer must, upon request, give the Insurance Company any information required to determine
who is insured, the amount of insurance in force and any other information needed to administer the plan
of insurance.
Payment of Premium
The first premium is due on the Policy Effective Date. After that, premiums will be due monthly unless
the Employer and the Insurance Company agree on some other method of premium payment.
If any premium is not paid when due, the plan will be canceled as of the Premium Due Date, except as
provided in the Policy Grace Period section.
Notice of Cancellation
The Employer or the Insurance Company may cancel the Policy as of any Premium Due Date by giving
31 days advance written notice. If a premium is not paid when due, the Policy will automatically be
canceled as of the Premium Due Date, except as provided in the Policy Grace Period section.
Policy Grace Period
A Policy Grace Period of 60 days will be granted for the payment of the required premiums under this
Policy. This Policy will be in force during the Policy Grace Period. The Employer is liable to the
Insurance Company for any unpaid premium for the time this Policy was in force.
Grace Period for the Insured
If the required premium is not paid on the Premium Due Date, there is a 60 day grace period after each
premium due date after the first. If the required premium is not paid during the grace period, insurance
will end on the last day for which premium was paid.
If benefits are paid during the Grace Period for the Insured, the Insurance Company will deduct any
overdue premium from the proceeds payable under the Policy.
Reinstatement of Insurance
Coverage may be reinstated without satisfying the Insurability Requirement, if an Employee's insurance
ends because he or she is on an unpaid leave of absence and he or she applies for Reinstatement within 31
days of his return to Active Service.
After an Insured's coverage has ceased, it may be reinstated at any date prior to five years after the date of
termination if the following conditions are met:
1. The Policy is still in force.
2. The Insured is eligible under the Policy.
3. A written request for reinstatement and a new enrollment form are sent to the Insurance
Company.
4. The required premium is paid.
5. The Insurability Requirement, if any, is satisfied.
TL-004720
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SCHEDULE OF RATES
The following monthly rates apply to all Classes of Eligible Persons unless otherwise indicated.
FOR EMPLOYEE BENEFITS
Basic Life Insurance $.13 Per $1,000
Voluntary Life Insurance $.24 Per $1,000
FOR FORMER EMPLOYEE BENEFITS
Monthly Rates are based on units of $1,000.
Under Age 20 $.153 Age 45 - 49 $.384
Age 20 - 24 $.144 Age 50 - 54 $.726
Age 25 - 29 $.153 Age 55 - 59 $1.347
Age 30 - 34 $.177 Age 60 - 64 $2.461
Age 35 - 39 $.19 Age 65 - 69 $4.065
Age 40 - 44 $.243
A change in rates due to a change in the Former Employee's age will become effective on the Policy
Anniversary Date coinciding with or following the Former Employee's birthday.
TL-004718
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GENERAL PROVISIONS
Entire Contract
The entire contract will be made up of the Policy, the application of the Employer, a copy of which is
attached to the Policy, and the applications, if any, of the Insureds.
Incontestability
All statements made by the Employer or by an Insured are representations not warranties. No statement
will be used to deny or reduce benefits or as a defense to a claim, unless a copy of the instrument
containing the statement has been furnished to the claimant. In the event of death or legal incapacity, the
beneficiary or representative must receive the copy.
After two years from an Insured's effective date of insurance, or from the effective date of any added or
increased benefits, no such statement will cause insurance to be contested except for fraud or eligibility
for coverage.
Misstatement of Age
If an Insured's age has been misstated, the Insurance Company will adjust all benefits to the amounts that
would have been purchased for the correct age.
Policy Changes
No change in the Policy will be valid until approved by an executive officer of the Insurance Company.
This approval must be endorsed on, or attached to, the Policy. No agent may change the Policy or waive
any of its provisions.
Workers' Compensation Insurance
The Policy is not in lieu of and does not affect any requirements for insurance under any Workers'
Compensation Insurance Law.
Certificates
A certificate of insurance will be delivered to the Employer for delivery to Insureds. Each certificate will
list the benefits, conditions and limits of the Policy. It will state to whom benefits will be paid.
Assignment of Benefits
The Insurance Company will not be affected by the assignment of an Insured's certificate until the
original assignment or a certified copy of the assignment is filed with the Insurance Company. The
Insurance Company will not be responsible for the validity or sufficiency of an assignment. An
assignment of benefits will operate so long as the assignment remains in force provided insurance under
the Policy is in effect. This insurance may not be levied on, attached, garnisheed, or otherwise taken for a
person's debts. This prohibition does not apply where contrary to law.
Clerical Error
A person's insurance will not be affected by error or delay in keeping records of insurance under the
Policy. If such an error is found, the premium will be adjusted fairly.
Agency
The Employer and Plan Administrator are agents of the Employee for transactions relating to insurance
under the Policy. The Insurance Company is not liable for any of their acts or omissions.
TL-004726
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DEFINITIONS
Please note, certain words used in this document have specific meanings. These terms will be capitalized
throughout this document. The definition of any word, if not defined in the text where it is used, may be
found either in this Definitions section or in the Schedule of Benefits.
Accident
An Accident is a sudden, unforeseeable external event that causes bodily Injury to an Insured while
coverage is in force under the Policy.
Active Service
An Employee will be considered in Active Service with the Employer on a day which is one of the
Employer's scheduled work days if either of the following conditions are met.
1.He or she is actively at work. This means the Employee is performing his or her regular
occupation for the Employer on a Full-time basis, either at one of the Employer's usual places of
business or at some location to which the Employer's business requires the Employee to travel.
2.The day is a scheduled holiday, vacation day or period of Employer approved paid leave of
absence, other than disability or sick leave after 7 days.
An Employee is considered in Active Service on a day which is not one of the Employer's scheduled
work days only if he or she was in Active Service on the preceding scheduled work day.
Annual Compensation
An Employee's annual wage or salary as reported by the Employer for work performed for the Employer
as of the date the covered loss occurs. It includes earnings received as commissions, but not bonuses,
overtime pay or other extra compensation.
Commissions will be averaged for the 12 months just prior to the date the covered loss occurs, or the
months employed, if less than 12 months.
Employee
For eligibility purposes, an Employee is an employee of the Employer in one of the "Classes of Eligible
Employees." Otherwise, Employee means an employee of the Employer who is insured under the Policy.
Employer
The Employer who has subscribed to the Policyholder and for the benefit of whose Employees this policy
has been issued. The Employer, named as the Subscriber on the front of this Policy, includes any
affiliates or subsidiaries covered under the Policy. The Employer is acting as an agent of the Insured for
transactions relating to this insurance. The actions of the Employer shall not be considered the actions of
the Insurance Company.
Full-time
Full-time means the number of hours set by the Employer as a regular work day for Employees in the
Employee's eligibility class.
Initial Open Enrollment Period
The period in the calendar year when an eligible Employee who was hired on or before the Policy
Effective Date may enroll for the first time for Insurance Benefits under this Policy. This period must be
agreed upon by the Employer and the Insurance Company. Refer to Initial Open Enrollment under the
Enrolling for Insurance section of the Policy.
Injury
Any accidental loss or bodily harm which results directly and independently of all other causes from an
Accident.
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Insurability Requirement
An eligible person will satisfy the Insurability Requirement for an amount of coverage on the day the
Insurance Company agrees in writing to accept him or her as insured for that amount. To determine a
person's acceptability for coverage, the Insurance Company will require evidence of good health and may
require it be provided at the Employee's expense.
Insurance Company
The Insurance Company underwriting the Policy is named on the Policy cover page.
Insured
A person who is eligible for insurance under the Policy, for whom insurance is elected, the required
premium is paid and coverage is in force under the Policy.
Physician
Physician means a licensed doctor practicing within the scope of his or her license and rendering care and
treatment to an Insured that is appropriate for the condition and locality. The term does not include an
Employee, an Employee's spouse, the immediate family (including parents, children, siblings or spouses
of any of the foregoing, whether the relationship derives from blood or marriage), of an Employee or
spouse, or a person living in an Employee's household.
Prior Plan
The Prior Plan refers to the plan of insurance providing similar benefits sponsored by the Employer in
effect directly prior to the Policy Effective Date.
Sickness
Any physical or mental illness.
TL-004708
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IMPORTANT CHANGES FOR STATE REQUIREMENTS
If an Employee resides in one of the following states, the provisions of the certificate are modified for
residents of the following states. The modifications listed apply only to residents of that state.
California Residents:
Conversion Privilege for Life Insurance
Insured Employees and Insured Spouses may convert to an individual policy of life insurance for an
amount not greater than the Conversion Amount shown below when the Policy ends, without regard
to any requirement that the person be insured under the policy for a specified period of time, if all of
the following apply.
a. The Insured became Totally Disabled while covered for the Life Benefit of the Policy.
Totally Disabled means the person is unable to perform all the material duties of any
occupation for which he or she may reasonably be qualified based on training, education and
experience.
b. The Insured remained Totally Disabled until the Policy ended while covered for the Life
Benefit of this Policy.
c. The Policy does not provide a Waiver of Premium, Extended Death Benefit Provision or
monthly payments to Totally Disabled Insureds for the Life Benefit.
d. The person meets all other conditions for converting the insurance.
Conversion Amount - Insured’s life insurance amount under the Policy on the date the Policy ends
minus the amount for which the Insured is insured under a group policy that provides life coverage to
employees of the Insured Employee’s Employer covered under this Policy. The dollar limit that
applies to the amount for conversion at Policy termination does not apply.
The requirement that the Insured be covered under the Policy for the stated number of years in order
to convert life insurance does not apply.
Missouri residents:
Regardless of any language to the contrary in the Policy, suicide is no defense to payment of life
insurance benefits. However, if an Insured commits suicide within 2 years from the date their
insurance under the Policy becomes effective, and the Insurance Company can show that the Insured
intended suicide at the time they applied for the insurance, life insurance benefits will be limited to a
refund of premium paid on the Insured's behalf.
North Dakota residents:
The Suicide exclusion, if any, is limited to one year from the effective date of insurance. The suicide
exclusion with respect to any increase in death benefits which results from an application of the
insured subsequent to the effective date, if any, is limited to one year from the effective date of the
increase.
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LIFE INSURANCE COMPANY OF NORTH AMERICA
PHILADELPHIA, PA 19192-2235
We, City of Palo Alto, whose main office address is Palo Alto, CA, hereby approve and accept the terms of
Group Policy Number FLX-962659 issued by the LIFE INSURANCE COMPANY OF NORTH AMERICA
to the TRUSTEE OF THE GROUP INSURANCE TRUST FOR EMPLOYERS IN THE PUBLIC
ADMINISTRATION INDUSTRY.
This form is to be signed in duplicate. One part is to be retained by City of Palo Alto; the other part is to be
returned to the LIFE INSURANCE COMPANY OF NORTH AMERICA.
City of Palo Alto
Signature and Title: _________________________________________ Date:__________________________
(This Copy Is To Be Returned To Life Insurance Company of North America)
--------------------------------------------------------------------------------------------------------------------------------------
LIFE INSURANCE COMPANY OF NORTH AMERICA
PHILADELPHIA, PA 19192-2235
We, City of Palo Alto, whose main office address is Palo Alto, CA, hereby approve and accept the terms of
Group Policy Number FLX-962659 issued by the LIFE INSURANCE COMPANY OF NORTH AMERICA
to the TRUSTEE OF THE GROUP INSURANCE TRUST FOR EMPLOYERS IN THE PUBLIC
ADMINISTRATION INDUSTRY.
This form is to be signed in duplicate. One part is to be retained by City of Palo Alto; the other part is to be
returned to the LIFE INSURANCE COMPANY OF NORTH AMERICA.
City of Palo Alto
Signature and Title: _________________________________________ Date:__________________________
(This Copy Is To Be Retained By City of Palo Alto)
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LIFE INSURANCE COMPANY OF NORTH AMERICA
(herein called the Company)
Amendment to be attached to and made a part of the Group Policy
A Contract between the Company and
Policyholder: Trustee of the Group Insurance Trust for Employers in the Public Administration Industry
Participating Subscriber: City of Palo Alto
(herein called the Subscriber)
Policy No.: FLX - 962659
The Company and the Subscriber hereby agree that the Policy is amended as follows:
Effective January 1, 2022, the rates shown on the attached Schedule of Rates will be in force for coverage under the Policy.
No change in rates will be made until 36 months after the effective date of this Amendment. However, the Company
reserves the right to change the rates at any time during a period for which the rates are guaranteed if the conditions
described in the Changes in Premium Rates provision under the Administrative Provisions section of the Policy apply.
Except for the above, this Amendment does not change the Policy in any way.
FOR THE COMPANY
William J. Smith, President
Date: November 10, 2021 (revised)
Amendment No. 03a
TL-004780
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SCHEDULE OF RATES
The following monthly rates apply to all Classes of Eligible Persons unless otherwise indicated.
FOR EMPLOYEE BENEFITS
Basic Life Insurance $.090 Per $1,000
Voluntary Life Insurance $.24 Per $1,000
FOR FORMER EMPLOYEE BENEFITS
Monthly Rates are based on units of $1,000.
Under Age 20 $.153 Age 45 - 49 $.384
Age 20 - 24 $.144 Age 50 - 54 $.726
Age 25 - 29 $.153 Age 55 - 59 $1.347
Age 30 - 34 $.177 Age 60 - 64 $2.461
Age 35 - 39 $.19 Age 65 - 69 $4.065
Age 40 - 44 $.243
A change in rates due to a change in the Former Employee's age will become effective on the Policy Anniversary Date
coinciding with or following the Former Employee's birthday.
TL-004718
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LIFE INSURANCE COMPANY OF NORTH AMERICA
(herein called the Company)
Amendment to be attached to and made a part of the Group Policy
A Contract between the Company and
Policyholder: Trustee of the Group Insurance Trust for Employers in the Public Administration Industry
Participating Subscriber: City of Palo Alto
(herein called the Subscriber)
Policy No.: LK - 961943
The Company and the Subscriber hereby agree that the Policy is amended as follows:
1. Effective January 1, 2022, the following rates will be in force for Classes 1 for coverage under the Policy:
Option 1
$1.07 per $100 of Covered Payroll
Covered Payroll for an Employee will mean his or her Covered Earnings for the insurance month prior to the date the
determination is made. However, an Employee's Covered Payroll will not include any part of his or her monthly
Covered Earnings which exceed $6,000.
Option 2
$.51 per $100 of Covered Payroll
Covered Payroll for an Employee will mean his or her Covered Earnings for the insurance month prior to the date the
determination is made. However, an Employee's Covered Payroll will not include any part of his or her monthly
Covered Earnings which exceed $3,000.
2. Effective January 1, 2022, the following rates will be in force for Class 2 and 3 for coverage under the Policy:
$.56 per $100 of Covered Payroll
Covered Payroll for an Employee will mean his or her Covered Earnings for the insurance month prior to the date the
determination is made. However, an Employee's Covered Payroll will not include any part of his or her monthly
Covered Earnings which exceed $15,000.
No change in rates will be made until 36 months after the effective date of this Amendment. However, the Company
reserves the right to change the rates at any time during a period for which the rates are guaranteed if the conditions
described in the Changes in Premium Rates provision under the Administrative Provisions section of the Policy apply.
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Except for the above, this Amendment does not change the Policy in any way.
FOR THE COMPANY
William J. Smith, President
Date: August 26, 2021
Amendment No. 03a
TL-004780
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Life Insurance Company of North America
1601 Chestnut Street
Philadelphia, Pennsylvania 19192-2235
AMENDMENT
Policyholder: Trustee of the Group Insurance Trust for Employers in the Public Administration Industry
Subscriber: City of Palo Alto Policy No.: OK - 964302
This Amendment is attached to and made part of the Policy specified above. It is subject to all of the policy provisions that
do not conflict with its provisions.
Subscriber and We hereby agree that the Policy is amended as follows:
Effective January 1, 2022, the following rates will be in force for Classes 1, 2 and 3 for coverage under the Policy:
Premium Rate: Basic Insurance
Employee Rate: $0.015 per $1,000
Voluntary Insurance
Employee Rate: $0.02 per $1,000
No change in rates will be made until 36 months after the effective date of this Amendment. However, the Company
reserves the right to change the rates at any time during a period for which the rates are guaranteed if the conditions
described in the Changes in Premium Rates provision under the Administrative Provisions section of the Policy apply.
Except for the above, this Amendment does not change the Policy in any way.
Life Insurance Company of North America
William J. Smith, President
Date: August 26, 2021
Amendment No. 04ri0215
GA -00-4000.00
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CALIFORNIA LIFE AND HEALTH INSURANCE
GUARANTY ASSOCIATION ACT
SUMMARY DOCUMENT AND DISCLAIMER
Residents of California who purchase life and health insurance and annuities should know that the insurance
companies licensed in this state to write these types of insurance are members of the California Life and Health
Insurance Guaranty Association. The purpose of this Association is to assure that policyholders will be protected,
within limits, in the unlikely event that a member insurer becomes financially unable to meet its obligations. If
this should happen, the Association will assess its other member insurance companies for the money to pay the
claims of insured persons who live in this state and, in some cases, to keep coverage in force. The valuable extra
protection provided through the Association is not unlimited, as noted in the box below, and is not a substitute for
consumers' care in selecting well managed and financially stable insurers.
The California Life and Health Insurance Guaranty Association may not provide coverage for this
insurance. If coverage is provided, it may be subject to substantial limitations or exclusions, and
require continued residency in the state. 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 insurance 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 prohibited by law from using the existence of the Association
to induce you to purchase any kind of insurance policy.
If you have additional questions, you should first contact your insurer or agent and then may contact:
California Life and Health OR Consumer Service Division
Insurance Guaranty Association California Department of Insurance
P.O. Box 16860 300 South Spring Street
Beverly Hills, CA 90209 Los Angeles, CA 90013
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.
EXHIBIT "A-2"
BASIC & VOLUNTARY AD&D LIFE INSURANCE POLICY
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COVERAGE
Generally, individuals will be protected by the California Life and Health Insurance Guaranty Association if they
live in this state and 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 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
organization, 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 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 and association plans to the extent they are self-funded or uninsured;
• synthetic guaranteed interest contracts;
• 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; and
• any portion of a contract that provides dividends or experience rating credits.
LIMITS ON AMOUNT OF COVERAGE
The Act limits the Association to pay benefits as follows:
Life and Annuity Benefits
• 80% of what the life insurance company would owe under a life policy or annuity contract up to
• $100,000 in cash surrender values;
• $100,000 in present value of annuities; or
• $250,000 in life insurance death benefits.
• A maximum of $250,000 for any one insured life no matter how many policies and contracts there were with
the same company, even if 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.
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Life Insurance Company of North America
1601 Chestnut Street, Philadelphia, Pennsylvania 19192-2235
A Stock Insurance Company
GROUP ACCIDENT POLICY
POLICYHOLDER:
POLICY NUMBER:
POLICY EFFECTIVE DATE:
POLICY ANNIVERSARY DATE:
STATE OF ISSUE:
Trustee of the Group Insurance Trust for
Employers in the Public Administration
Industry
OK 964302
January 1
January 1
Delaware
This Policy describes the terms and conditions of insurance. This Policy goes into effect subject to its applicable terms and
conditions at 12:01 AM on the Policy Effective Date shown above at the Policyholder’s address. The laws of the State of
Issue shown above govern this Policy.
We and the Policyholder agree to all of the terms of this Policy.
THIS IS A GROUP ACCIDENT ONLY INSURANCE POLICY.
IT DOES NOT PAY BENEFITS FOR LOSS CAUSED BY SICKNESS.
THIS IS A LIMITED POLICY.
PLEASE READ IT CAREFULLY.
Deborah Young, Corporate Secretary Karen S. Rohan, President
Countersigned________________________________________
Where Required By Law
GA-00-1000.00
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TABLE OF CONTENTS
SECTION PAGE NUMBER
SCHEDULE OF AFFILIATES 1
SCHEDULE OF BENEFITS 2
GENERAL DEFINITIONS 15
ELIGIBILITY AND EFFECTIVE DATE PROVISIONS 18
COMMON EXCLUSIONS 19
CONVERSION PRIVILEGE 20
CLAIM PROVISIONS 22
ADMINISTRATIVE PROVISIONS 24
GENERAL PROVISIONS 25
ACCIDENTAL DEATH AND DISMEMBERMENT COVERAGE 27
EXPOSURE AND DISAPPEARANCE COVERAGE 28
CHILD CARE CENTER BENEFIT 28
COMMON CARRIER BENEFIT 29
FELONIOUS ASSAULT AND VIOLENT CRIME BENEFIT 29
SEATBELT AND AIRBAG BENEFIT 30
SPECIAL EDUCATION BENEFIT 30
SPOUSE RETRAINING BENEFIT 32
GA-00-1000.00
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1
SCHEDULE OF AFFILIATES
The following affiliates are covered under this Policy on the effective dates listed below.
AFFILIATE NAME LOCATION EFFECTIVE DATE
None
GA-00-1000.00
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SCHEDULE OF BENEFITS
This Policy is intended to be read in its entirety. In order to understand all the conditions, exclusions and limitations
applicable to its benefits, please read all the policy provisions carefully.
The Schedule of Benefits provides a brief outline of the coverage and benefits provided by this Policy. Please read
the Description of Coverages and Benefits Section for full details.
Subscriber: City of Palo Alto
Effective Date of Subscriber Participation: January 1, 2009
Covered Classes:
Class 1 All active, full-time Employees of the Employer, regularly working a minimum of 20 hours per week
excluding Employees who are classified as Management.
Class 2 All active, full-time Employees of the Employer, regularly working a minimum of 20 hours per week
who are classified as Management.
Class 3 All active, Full-time Employees of the Employer as defined under the prior carrier policy number
643835, and on file with the Insurance Company, and who are regularly working a minimum of 20 hours
per week. (Closed Class)
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SCHEDULE OF BENEFITS FOR CLASS 1
This Schedule of Benefits shows maximums, benefit periods and any limitations applicable to benefits provided in
this Policy for each Covered Person unless otherwise indicated. Principal Sum, when referred to in this Schedule,
means the Employee’s Principal Sum in effect on the date of the Covered Accident causing the Covered Injury or
Covered Loss unless otherwise specified.
Eligibility Waiting Period
The Eligibility Waiting Period is the period of time the Employee must be in a Covered Class to be eligible for coverage.
For Employees hired on or before the Policy Effective Date: No Waiting Period
For Employees hired after the Policy Effective Date: No Waiting Period
Time Period for Loss:
Any Covered Loss must occur within: 365 days of the Covered Accident
Maximum Age for Insurance: None
BASIC ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS
Employee Principal Sum: 1 times Annual Compensation rouinded to the next higher $1,000
if not already a multiple thereof, subject to a maximum of
$325,000.
Changes in the Covered Person's amount of insurance resulting from a change in the Employee's amount of
Annual Compensation take effect, subject to any Active Service requirement, on the first day of the month
following the change in Annual Compensation.
SCHEDULE OF COVERED LOSSES
Covered Loss Benefit
Loss of Life 100% of the Principal Sum
Loss of Two or More Hands or Feet 100% of the Principal Sum
Loss of Sight of Both Eyes 100% of the Principal Sum
Loss of One Hand or One Foot and Sight in One Eye 100% of the Principal Sum
Loss of Speech and Hearing (in both ears) 100% of the Principal Sum
Quadriplegia 100% of the Principal Sum
Paraplegia 75% of the Principal Sum
Hemiplegia 50% of the Principal Sum
Uniplegia 25% of the Principal Sum
Coma
Monthly Benefit 1% of the Principal Sum
Number of Monthly Benefits 11
Lump Sum Benefit 100% of the Principal Sum
When Payable Beginning of the 12th month
Loss of One Hand or Foot 50% of the Principal Sum
Loss of Sight in One Eye 50% of the Principal Sum
Loss of Speech 50% of the Principal Sum
Loss of Hearing (in both ears) 50% of the Principal Sum
Loss of all Four Fingers of the Same Hand 25% of the Principal Sum
Loss of Thumb and Index Finger of the Same Hand 25% of the Principal Sum
Loss of all the Toes of the Same Foot 25% of the Principal Sum
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Age Reductions
A Covered Person's Principal Sum will be reduced to the percentage of his Principal Sum in effect on the date
preceding the first reduction, as shown below.
Age Percentage of Benefit Amount
70 but less than 75 65%
75 and over 50%
ADDITIONAL ACCIDENTAL DEATH AND DISMEMBERMENT COVERAGES
Accidental Death and Dismemberment benefits are provided under the following coverages. Any benefits payable under
them are as shown in the Schedule of Covered Losses and are not paid in addition to any other Accidental Death and
Dismemberment benefits.
EXPOSURE AND DISAPPEARANCE COVERAGE Principal Sum multiplied by the percentage applicable to the
Covered Loss, as shown in the Schedule of Covered Losses.
ADDITIONAL ACCIDENT BENEFITS
Any benefits payable under these Additional Accident Benefits shown below are paid in addition to any other Accidental
Death and Dismemberment benefits payable.
CHILD CARE CENTER BENEFIT
Benefit Amount $5,000
Maximum Benefit Period the earlier of 4 years or until the child turns 13 for each
surviving Dependent Child
COMMON CARRIER BENEFIT 100% multiplied by the percentage of the Principal Sum
applicable to the Covered Loss, as shown in the Schedule of
Covered Losses, subject to a maximum of $200,000
FELONIOUS ASSAULT AND VIOLENT CRIME BENEFIT
Accidental Death and Dismemberment Benefit 50% multiplied by the percentage of the Principal Sum
applicable to the Covered Loss, as shown in the Schedule of
Covered Losses, subject to a maximum of $25,000
Hospital Stay Benefit $100 per day
Maximum Benefit Period 365 days per Hospital Stay per Covered Accident
SEATBELT AND AIRBAG BENEFIT
Seatbelt Benefit $10,000
Airbag Benefit $5,000
Default Benefit $1,000
SPECIAL EDUCATION BENEFIT
Surviving Dependent Child Benefit $5,000
Maximum Number of Annual Payments
For Each Surviving Dependent Child 4
Default Benefit $1,000
SPOUSE RETRAINING BENEFIT
Benefit $5,000
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VOLUNTARY ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS
Employee Principal Sum: Voluntary Benefits match the Voluntary Life Benefits under
policy number FLX 962659. Only Employees covered for the
Voluntary Life can elect Voluntary AD&D.
Changes in the Covered Person's amount of insurance resulting from a change in the Employee's amount of
Annual Compensation take effect, subject to any Active Service requirement, on the first day of the month
following the change in Annual Compensation.
SCHEDULE OF COVERED LOSSES
Covered Loss Benefit
Loss of Life 100% of the Principal Sum
Loss of Two or More Hands or Feet 100% of the Principal Sum
Loss of Sight of Both Eyes 100% of the Principal Sum
Loss of One Hand or One Foot and Sight in One Eye 100% of the Principal Sum
Loss of Speech and Hearing (in both ears) 100% of the Principal Sum
Quadriplegia 100% of the Principal Sum
Paraplegia 75% of the Principal Sum
Hemiplegia 50% of the Principal Sum
Uniplegia 25% of the Principal Sum
Coma
Monthly Benefit 1% of the Principal Sum
Number of Monthly Benefits 11
Lump Sum Benefit 100% of the Principal Sum
When Payable Beginning of the 12th month
Loss of One Hand or Foot 50% of the Principal Sum
Loss of Sight in One Eye 50% of the Principal Sum
Loss of Speech 50% of the Principal Sum
Loss of Hearing (in both ears) 50% of the Principal Sum
Loss of all Four Fingers of the Same Hand 25% of the Principal Sum
Loss of Thumb and Index Finger of the Same Hand 25% of the Principal Sum
Loss of all the Toes of the Same Foot 25% of the Principal Sum
Age Reductions
A Covered Person's Principal Sum will be reduced to the percentage of his Principal Sum in effect on the date
preceding the first reduction, as shown below.
Age Percentage of Benefit Amount
70 but less than 75 65%
75 and over 50%
ADDITIONAL ACCIDENTAL DEATH AND DISMEMBERMENT COVERAGES
Accidental Death and Dismemberment benefits are provided under the following coverages. Any benefits payable under
them are as shown in the Schedule of Covered Losses and are not paid in addition to any other Accidental Death and
Dismemberment benefits.
EXPOSURE AND DISAPPEARANCE COVERAGE Principal Sum multiplied by the percentage applicable to the
Covered Loss, as shown in the Schedule of Covered Losses.
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ADDITIONAL ACCIDENT BENEFITS
Any benefits payable under these Additional Accident Benefits shown below are paid in addition to any other Accidental
Death and Dismemberment benefits payable.
CHILD CARE CENTER BENEFIT
Benefit Amount $5,000
Maximum Benefit Period the earlier of 4 years or until the child turns 13 for each
surviving Dependent Child
COMMON CARRIER BENEFIT 100% multiplied by the percentage of the Principal Sum
applicable to the Covered Loss, as shown in the Schedule of
Covered Losses, subject to a maximum of $200,000
FELONIOUS ASSAULT AND VIOLENT CRIME BENEFIT
Accidental Death and Dismemberment Benefit 50% multiplied by the percentage of the Principal Sum
applicable to the Covered Loss, as shown in the Schedule of
Covered Losses, subject to a maximum of $25,000
Hospital Stay Benefit $100 per day
Maximum Benefit Period 365 days per Hospital Stay per Covered Accident
SEATBELT AND AIRBAG BENEFIT
Seatbelt Benefit $10,000
Airbag Benefit $5,000
Default Benefit $1,000
SPECIAL EDUCATION BENEFIT
Surviving Dependent Child Benefit $5,000
Maximum Number of Annual Payments
For Each Surviving Dependent Child 4
Default Benefit $1,000
SPOUSE RETRAINING BENEFIT
Benefit $5,000
INITIAL PREMIUM RATES
Premium Rate: Basic Insurance
Employee Rate: $0.02 per $1,000
Voluntary Insurance
Employee Rate: $0.02 per $1,000
Mode of Premium Payment: Monthly
Contributions: The cost of the coverage is paid by the Subscriber and the Employee
Premium Due Dates: The Policy Effective Date and the first day of each succeeding modal
period
Premium rates are subject to change in accordance with the Changes in Premium Rates section contained in the
Administrative Provisions section of this Policy.
GA-00-1100.00
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SCHEDULE OF BENEFITS FOR CLASS 2
This Schedule of Benefits shows maximums, benefit periods and any limitations applicable to benefits provided in
this Policy for each Covered Person unless otherwise indicated. Principal Sum, when referred to in this Schedule,
means the Employee’s Principal Sum in effect on the date of the Covered Accident causing the Covered Injury or
Covered Loss unless otherwise specified.
Eligibility Waiting Period
The Eligibility Waiting Period is the period of time the Employee must be in a Covered Class to be eligible for coverage.
For Employees hired on or before the Policy Effective Date: No Waiting Period
For Employees hired after the Policy Effective Date: No Waiting Period
Time Period for Loss:
Any Covered Loss must occur within: 365 days of the Covered Accident
Maximum Age for Insurance: None
BASIC ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS
Employee Principal Sum: 1 times Annual Compensation rouinded to the next higher $1,000
if not already a multiple thereof, subject to a maximum of
$325,000.
Changes in the Covered Person's amount of insurance resulting from a change in the Employee's amount of
Annual Compensation take effect, subject to any Active Service requirement, on the first day of the month
following the change in Annual Compensation.
SCHEDULE OF COVERED LOSSES
Covered Loss Benefit
Loss of Life 100% of the Principal Sum
Loss of Two or More Hands or Feet 100% of the Principal Sum
Loss of Sight of Both Eyes 100% of the Principal Sum
Loss of One Hand or One Foot and Sight in One Eye 100% of the Principal Sum
Loss of Speech and Hearing (in both ears) 100% of the Principal Sum
Quadriplegia 100% of the Principal Sum
Paraplegia 75% of the Principal Sum
Hemiplegia 50% of the Principal Sum
Uniplegia 25% of the Principal Sum
Coma
Monthly Benefit 1% of the Principal Sum
Number of Monthly Benefits 11
Lump Sum Benefit 100% of the Principal Sum
When Payable Beginning of the 12th month
Loss of One Hand or Foot 50% of the Principal Sum
Loss of Sight in One Eye 50% of the Principal Sum
Loss of Speech 50% of the Principal Sum
Loss of Hearing (in both ears) 50% of the Principal Sum
Loss of all Four Fingers of the Same Hand 25% of the Principal Sum
Loss of Thumb and Index Finger of the Same Hand 25% of the Principal Sum
Loss of all the Toes of the Same Foot 25% of the Principal Sum
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Age Reductions
A Covered Person's Principal Sum will be reduced to the percentage of his Principal Sum in effect on the date
preceding the first reduction, as shown below.
Age Percentage of Benefit Amount
70 but less than 75 65%
75 and over 50%
ADDITIONAL ACCIDENTAL DEATH AND DISMEMBERMENT COVERAGES
Accidental Death and Dismemberment benefits are provided under the following coverages. Any benefits payable under
them are as shown in the Schedule of Covered Losses and are not paid in addition to any other Accidental Death and
Dismemberment benefits.
EXPOSURE AND DISAPPEARANCE COVERAGE Principal Sum multiplied by the percentage applicable to the
Covered Loss, as shown in the Schedule of Covered Losses.
ADDITIONAL ACCIDENT BENEFITS
Any benefits payable under these Additional Accident Benefits shown below are paid in addition to any other Accidental
Death and Dismemberment benefits payable.
CHILD CARE CENTER BENEFIT
Benefit Amount $5,000
Maximum Benefit Period the earlier of 4 years or until the child turns 13 for each
surviving Dependent Child
COMMON CARRIER BENEFIT 100% multiplied by the percentage of the Principal Sum
applicable to the Covered Loss, as shown in the Schedule of
Covered Losses, subject to a maximum of $200,000
FELONIOUS ASSAULT AND VIOLENT CRIME BENEFIT
Accidental Death and Dismemberment Benefit 50% multiplied by the percentage of the Principal Sum
applicable to the Covered Loss, as shown in the Schedule of
Covered Losses, subject to a maximum of $25,000
Hospital Stay Benefit $100 per day
Maximum Benefit Period 365 days per Hospital Stay per Covered Accident
SEATBELT AND AIRBAG BENEFIT
Seatbelt Benefit $10,000
Airbag Benefit $5,000
Default Benefit $1,000
SPECIAL EDUCATION BENEFIT
Surviving Dependent Child Benefit $5,000
Maximum Number of Annual Payments
For Each Surviving Dependent Child 4
Default Benefit $1,000
SPOUSE RETRAINING BENEFIT
Benefit $5,000
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VOLUNTARY ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS
Employee Principal Sum: Voluntary Benefits match the Voluntary Life Benefits under
policy number FLX 962659. Only Employees covered for the
Voluntary Life can elect Voluntary AD&D.
Changes in the Covered Person's amount of insurance resulting from a change in the Employee's amount of
Annual Compensation take effect, subject to any Active Service requirement, on the first day of the month
following the change in Annual Compensation.
SCHEDULE OF COVERED LOSSES
Covered Loss Benefit
Loss of Life 100% of the Principal Sum
Loss of Two or More Hands or Feet 100% of the Principal Sum
Loss of Sight of Both Eyes 100% of the Principal Sum
Loss of One Hand or One Foot and Sight in One Eye 100% of the Principal Sum
Loss of Speech and Hearing (in both ears) 100% of the Principal Sum
Quadriplegia 100% of the Principal Sum
Paraplegia 75% of the Principal Sum
Hemiplegia 50% of the Principal Sum
Uniplegia 25% of the Principal Sum
Coma
Monthly Benefit 1% of the Principal Sum
Number of Monthly Benefits 11
Lump Sum Benefit 100% of the Principal Sum
When Payable Beginning of the 12th month
Loss of One Hand or Foot 50% of the Principal Sum
Loss of Sight in One Eye 50% of the Principal Sum
Loss of Speech 50% of the Principal Sum
Loss of Hearing (in both ears) 50% of the Principal Sum
Loss of all Four Fingers of the Same Hand 25% of the Principal Sum
Loss of Thumb and Index Finger of the Same Hand 25% of the Principal Sum
Loss of all the Toes of the Same Foot 25% of the Principal Sum
Age Reductions
A Covered Person's Principal Sum will be reduced to the percentage of his Principal Sum in effect on the date
preceding the first reduction, as shown below.
Age Percentage of Benefit Amount
70 but less than 75 65%
75 and over 50%
ADDITIONAL ACCIDENTAL DEATH AND DISMEMBERMENT COVERAGES
Accidental Death and Dismemberment benefits are provided under the following coverages. Any benefits payable under
them are as shown in the Schedule of Covered Losses and are not paid in addition to any other Accidental Death and
Dismemberment benefits.
EXPOSURE AND DISAPPEARANCE COVERAGE Principal Sum multiplied by the percentage applicable to the
Covered Loss, as shown in the Schedule of Covered Losses.
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ADDITIONAL ACCIDENT BENEFITS
Any benefits payable under these Additional Accident Benefits shown below are paid in addition to any other Accidental
Death and Dismemberment benefits payable.
CHILD CARE CENTER BENEFIT
Benefit Amount $5,000
Maximum Benefit Period the earlier of 4 years or until the child turns 13 for each
surviving Dependent Child
COMMON CARRIER BENEFIT 100% multiplied by the percentage of the Principal Sum
applicable to the Covered Loss, as shown in the Schedule of
Covered Losses, subject to a maximum of $200,000
FELONIOUS ASSAULT AND VIOLENT CRIME BENEFIT
Accidental Death and Dismemberment Benefit 50% multiplied by the percentage of the Principal Sum
applicable to the Covered Loss, as shown in the Schedule of
Covered Losses, subject to a maximum of $25,000
Hospital Stay Benefit $100 per day
Maximum Benefit Period 365 days per Hospital Stay per Covered Accident
SEATBELT AND AIRBAG BENEFIT
Seatbelt Benefit $10,000
Airbag Benefit $5,000
Default Benefit $1,000
SPECIAL EDUCATION BENEFIT
Surviving Dependent Child Benefit $5,000
Maximum Number of Annual Payments
For Each Surviving Dependent Child 4
Default Benefit $1,000
SPOUSE RETRAINING BENEFIT
Benefit $5,000
INITIAL PREMIUM RATES
Premium Rate: Basic Insurance
Employee Rate: $0.02 per $1,000
Voluntary Insurance
Employee Rate: $0.02 per $1,000
Mode of Premium Payment: Monthly
Contributions: The cost of the coverage is paid by the Subscriber and the Employee
Premium Due Dates: The Policy Effective Date and the first day of each succeeding modal
period
Premium rates are subject to change in accordance with the Changes in Premium Rates section contained in the
Administrative Provisions section of this Policy.
GA-00-1100.00
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SCHEDULE OF BENEFITS FOR CLASS 3
This Schedule of Benefits shows maximums, benefit periods and any limitations applicable to benefits provided in
this Policy for each Covered Person unless otherwise indicated. Principal Sum, when referred to in this Schedule,
means the Employee’s Principal Sum in effect on the date of the Covered Accident causing the Covered Injury or
Covered Loss unless otherwise specified.
Eligibility Waiting Period
The Eligibility Waiting Period is the period of time the Employee must be in a Covered Class to be eligible for coverage.
For Employees hired on or before the Policy Effective Date: No Waiting Period
For Employees hired after the Policy Effective Date: No Waiting Period
Time Period for Loss:
Any Covered Loss must occur within: 365 days of the Covered Accident
Maximum Age for Insurance: None
BASIC ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS
Employee Principal Sum: 1 times Annual Compensation rouinded to the next higher $1,000
if not already a multiple thereof, subject to a maximum of
$325,000.
Changes in the Covered Person's amount of insurance resulting from a change in the Employee's amount of
Annual Compensation take effect, subject to any Active Service requirement, on the first day of the month
following the change in Annual Compensation.
SCHEDULE OF COVERED LOSSES
Covered Loss Benefit
Loss of Life 100% of the Principal Sum
Loss of Two or More Hands or Feet 100% of the Principal Sum
Loss of Sight of Both Eyes 100% of the Principal Sum
Loss of One Hand or One Foot and Sight in One Eye 100% of the Principal Sum
Loss of Speech and Hearing (in both ears) 100% of the Principal Sum
Quadriplegia 100% of the Principal Sum
Paraplegia 75% of the Principal Sum
Hemiplegia 50% of the Principal Sum
Uniplegia 25% of the Principal Sum
Coma
Monthly Benefit 1% of the Principal Sum
Number of Monthly Benefits 11
Lump Sum Benefit 100% of the Principal Sum
When Payable Beginning of the 12th month
Loss of One Hand or Foot 50% of the Principal Sum
Loss of Sight in One Eye 50% of the Principal Sum
Loss of Speech 50% of the Principal Sum
Loss of Hearing (in both ears) 50% of the Principal Sum
Loss of all Four Fingers of the Same Hand 25% of the Principal Sum
Loss of Thumb and Index Finger of the Same Hand 25% of the Principal Sum
Loss of all the Toes of the Same Foot 25% of the Principal Sum
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Age Reductions
A Covered Person's Principal Sum will be reduced to the percentage of his Principal Sum in effect on the date
preceding the first reduction, as shown below.
Age Percentage of Benefit Amount
70 but less than 75 65%
75 and over 50%
ADDITIONAL ACCIDENTAL DEATH AND DISMEMBERMENT COVERAGES
Accidental Death and Dismemberment benefits are provided under the following coverages. Any benefits payable under
them are as shown in the Schedule of Covered Losses and are not paid in addition to any other Accidental Death and
Dismemberment benefits.
EXPOSURE AND DISAPPEARANCE COVERAGE Principal Sum multiplied by the percentage applicable to the
Covered Loss, as shown in the Schedule of Covered Losses.
ADDITIONAL ACCIDENT BENEFITS
Any benefits payable under these Additional Accident Benefits shown below are paid in addition to any other Accidental
Death and Dismemberment benefits payable.
CHILD CARE CENTER BENEFIT
Benefit Amount $5,000
Maximum Benefit Period the earlier of 4 years or until the child turns 13 for each
surviving Dependent Child
COMMON CARRIER BENEFIT 100% multiplied by the percentage of the Principal Sum
applicable to the Covered Loss, as shown in the Schedule of
Covered Losses, subject to a maximum of $200,000
FELONIOUS ASSAULT AND VIOLENT CRIME BENEFIT
Accidental Death and Dismemberment Benefit 50% multiplied by the percentage of the Principal Sum
applicable to the Covered Loss, as shown in the Schedule of
Covered Losses, subject to a maximum of $25,000
Hospital Stay Benefit $100 per day
Maximum Benefit Period 365 days per Hospital Stay per Covered Accident
SEATBELT AND AIRBAG BENEFIT
Seatbelt Benefit $10,000
Airbag Benefit $5,000
Default Benefit $1,000
SPECIAL EDUCATION BENEFIT
Surviving Dependent Child Benefit $5,000
Maximum Number of Annual Payments
For Each Surviving Dependent Child 4
Default Benefit $1,000
SPOUSE RETRAINING BENEFIT
Benefit $5,000
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VOLUNTARY ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS
Employee Principal Sum: Voluntary Benefits match the Voluntary Life Benefits under
policy number FLX 962659. Only Employees covered for the
Voluntary Life can elect Voluntary AD&D.
Changes in the Covered Person's amount of insurance resulting from a change in the Employee's amount of
Annual Compensation take effect, subject to any Active Service requirement, on the first day of the month
following the change in Annual Compensation.
SCHEDULE OF COVERED LOSSES
Covered Loss Benefit
Loss of Life 100% of the Principal Sum
Loss of Two or More Hands or Feet 100% of the Principal Sum
Loss of Sight of Both Eyes 100% of the Principal Sum
Loss of One Hand or One Foot and Sight in One Eye 100% of the Principal Sum
Loss of Speech and Hearing (in both ears) 100% of the Principal Sum
Quadriplegia 100% of the Principal Sum
Paraplegia 75% of the Principal Sum
Hemiplegia 50% of the Principal Sum
Uniplegia 25% of the Principal Sum
Coma
Monthly Benefit 1% of the Principal Sum
Number of Monthly Benefits 11
Lump Sum Benefit 100% of the Principal Sum
When Payable Beginning of the 12th month
Loss of One Hand or Foot 50% of the Principal Sum
Loss of Sight in One Eye 50% of the Principal Sum
Loss of Speech 50% of the Principal Sum
Loss of Hearing (in both ears) 50% of the Principal Sum
Loss of all Four Fingers of the Same Hand 25% of the Principal Sum
Loss of Thumb and Index Finger of the Same Hand 25% of the Principal Sum
Loss of all the Toes of the Same Foot 25% of the Principal Sum
Age Reductions
A Covered Person's Principal Sum will be reduced to the percentage of his Principal Sum in effect on the date
preceding the first reduction, as shown below.
Age Percentage of Benefit Amount
70 but less than 75 65%
75 and over 50%
ADDITIONAL ACCIDENTAL DEATH AND DISMEMBERMENT COVERAGES
Accidental Death and Dismemberment benefits are provided under the following coverages. Any benefits payable under
them are as shown in the Schedule of Covered Losses and are not paid in addition to any other Accidental Death and
Dismemberment benefits.
EXPOSURE AND DISAPPEARANCE COVERAGE Principal Sum multiplied by the percentage applicable to the
Covered Loss, as shown in the Schedule of Covered Losses.
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ADDITIONAL ACCIDENT BENEFITS
Any benefits payable under these Additional Accident Benefits shown below are paid in addition to any other Accidental
Death and Dismemberment benefits payable.
CHILD CARE CENTER BENEFIT
Benefit Amount $5,000
Maximum Benefit Period the earlier of 4 years or until the child turns 13 for each
surviving Dependent Child
COMMON CARRIER BENEFIT 100% multiplied by the percentage of the Principal Sum
applicable to the Covered Loss, as shown in the Schedule of
Covered Losses, subject to a maximum of $200,000
FELONIOUS ASSAULT AND VIOLENT CRIME BENEFIT
Accidental Death and Dismemberment Benefit 50% multiplied by the percentage of the Principal Sum
applicable to the Covered Loss, as shown in the Schedule of
Covered Losses, subject to a maximum of $25,000
Hospital Stay Benefit $100 per day
Maximum Benefit Period 365 days per Hospital Stay per Covered Accident
SEATBELT AND AIRBAG BENEFIT
Seatbelt Benefit $10,000
Airbag Benefit $5,000
Default Benefit $1,000
SPECIAL EDUCATION BENEFIT
Surviving Dependent Child Benefit $5,000
Maximum Number of Annual Payments
For Each Surviving Dependent Child 4
Default Benefit $1,000
SPOUSE RETRAINING BENEFIT
Benefit $5,000
INITIAL PREMIUM RATES
Premium Rate: Basic Insurance
Employee Rate: $0.02 per $1,000
Voluntary Insurance
Employee Rate: $0.02 per $1,000
Mode of Premium Payment: Monthly
Contributions: The cost of the coverage is paid by the Subscriber and the Employee
Premium Due Dates: The Policy Effective Date and the first day of each succeeding modal
period
Premium rates are subject to change in accordance with the Changes in Premium Rates section contained in the
Administrative Provisions section of this Policy.
GA-00-1100.00
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GENERAL DEFINITIONS
Please note that certain words used in this Policy have specific meanings. The words defined below and capitalized within
the text of this Policy have the meanings set forth below.
Active Service An Employee will be considered in Active Service with his employer on any day
that is either of the following:
1. one of the Employer’s scheduled work days on which the Employee is
performing his regular duties on a full-time basis, either at one of the
Employer’s usual places of business or at some other location to which the
Employer’s business requires the Employee to travel;
2. a scheduled holiday, vacation day or period of Employer-approved paid leave
of absence, other than sick leave, only if the Employee was in Active Service
on the preceding scheduled workday.
Age A Covered Person’s Age, for purposes of initial premium calculations, is his Age
attained on the date coverage becomes effective for him under this Policy.
Thereafter, it is his Age attained on his last birthday.
Aircraft A vehicle which:
1. has a valid certificate of airworthiness; and
2. is being flown by a pilot with a valid license to operate the Aircraft.
Annual Compensation An Employee's annual earnings for normal work established by the Subscriber for
his job classification, including commissions averaged over 12 months, excluding
bonuses or overtime.
Covered Accident A sudden, unforeseeable, external event that results, directly and independently of
all other causes, in a Covered Injury or Covered Loss and meets all of the
following conditions:
1. occurs while the Covered Person is insured under this Policy;
2. is not contributed to by disease, Sickness, mental or bodily infirmity;
3. is not otherwise excluded under the terms of this Policy.
Covered Injury Any bodily harm that results directly and independently of all other causes from a
Covered Accident.
Covered Loss A loss that is all of the following:
1. the result, directly and independently of all other causes, of a Covered
Accident;
2. one of the Covered Losses specified in the Schedule of Covered Losses;
3. suffered by the Covered Person within the applicable time period specified in
the Schedule of Benefits.
Covered Person An eligible person, as defined in the Schedule of Benefits, for whom an enrollment
form has been accepted by Us and required premium has been paid when due and
for whom coverage under this Policy remains in force.
Employee For eligibility purposes, an Employee of the Employer who is in one of the
Covered Classes.
Employer The Subscriber and any affiliates, subsidiaries or divisions shown in the Schedule
of Covered Affiliates and which are covered under this Policy on the date of issue
or subsequently agreed to by Us.
He, His, Him Refers to any individual, male or female.
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Hospital An institution that meets all of the following:
1. it is licensed as a Hospital pursuant to applicable law;
2. it is primarily and continuously engaged in providing medical care and
treatment to sick and injured persons;
3. it is managed under the supervision of a staff of medical doctors;
4. it provides 24-hour nursing services by or under the supervision of a graduate
registered nurse (R.N.);
5. it has medical, diagnostic and treatment facilities, with major surgical facilities
on its premises, or available on a prearranged basis;
6. it charges for its services.
The term Hospital does not include a clinic, facility, or unit of a Hospital for:
1. rehabilitation, convalescent, custodial, educational or nursing care;
2. the aged, drug addicts or alcoholics;
3. a Veteran’s Administration Hospital or Federal Government Hospital unless
the Covered Person incurs an expense.
Inpatient A Covered Person who is confined for at least one full day’s Hospital room and
board. The requirement that a person be charged for room and board does not
apply to confinement in a Veteran’s Administration Hospital or Federal
Government Hospital and in such case, the term 'Inpatient' shall mean a Covered
Person who is required to be confined for a period of at least a full day as
determined by the Hospital.
Nurse A licensed graduate Registered Nurse (R.N.), a licensed practical Nurse (L.P.N.) or
a licensed vocational Nurse (L.V.N.) and who is not:
1. employed or retained by the Subscriber;
2. living in the Covered Person’s household; or
3. a parent, sibling, spouse or child of the Covered Person.
Outpatient A Covered Person who receives treatment, services and supplies while not an
Inpatient in a Hospital.
Prior Plan The plan of insurance providing similar benefits, sponsored by the Employer in
effect immediately prior to this Policy’s Effective Date.
Physician A licensed health care provider practicing within the scope of his license and
rendering care and treatment to a Covered Person that is appropriate for the
condition and locality and who is not:
1. employed or retained by the Subscriber;
2. living in the Covered Person’s household;
3. a parent, sibling, spouse or child of the Covered Person.
Sickness A physical or mental illness.
Subscriber Any participating organization that subscribes to the trust to which this Policy is
issued.
Terrorist Act Any hostile or violent act carried out by a group of persons having political or
military goals but not operating on behalf of a foreign state and whose purpose is to
compel an act or omission by any other person or governmental entity.
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Totally Disabled or Totally Disabled or Total Disability means either:
Total Disability 1. inability of the Covered Person who is currently employed to do any type of
work for which he is or may become qualified by reason of education, training
or experience; or
2. inability of the Covered Person who is not currently employed to perform all
of the activities of daily living including eating, transferring, dressing,
toileting, bathing, and continence, without human supervision or assistance.
We, Us, Our Life Insurance Company of North America.
GA-00-1200.00
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ELIGIBILITY AND EFFECTIVE DATE PROVISIONS
Subscriber Effective Date
Accident Insurance Benefits become effective for each Subscriber in consideration of the Subscriber’s application,
Subscription Agreement and payment of the initial premium when due. Insurance coverage for the Subscriber becomes
effective on the Effective Date of Subscriber Participation.
Eligibility
An Employee becomes eligible for insurance under this Policy on the date he meets all of the requirements of one of the
Covered Classes and completes any Eligibility Waiting Period, as shown in the Schedule of Benefits.
Effective Date for Individuals
Basic Accidental Death and Dismemberment Benefits
Insurance becomes effective for an eligible Employee, subject to the Deferred Effective Date provision below, on the latest
of the following dates:
1. the effective date of this Policy;
2. the date the Employee becomes eligible.
Voluntary Accidental Death and Dismemberment Benefits
Insurance becomes effective for an eligible Employee who applies and agrees to make required contributions within 31
days of eligibility, and subject to the Deferred Effective Date provision below, on the latest of the following dates:
1. the effective date of this Policy;
2. the date the Employee becomes eligible;
3. the date We receive the Employee’s completed enrollment form and the required first premium, during his
lifetime.
DEFERRED EFFECTIVE DATE
Active Service
The effective date of insurance will be deferred for any Employee who is not in Active Service on the date coverage would
otherwise become effective. Coverage will become effective on the later of the date he returns to Active Service and the
date coverage would otherwise have become effective.
Effective Date of Changes
Any increase or decrease in the amount of insurance for the Covered Person resulting from:
1. a change in benefits provided by this Policy; or
2. a change in the Employee’s Covered Class will take effect on the date of such change.
Increases will take effect subject to any Active Service requirement.
TERMINATION OF INSURANCE
The insurance on a Covered Person will end on the earliest date below:
1. the date this Policy or insurance for a Covered Class is terminated;
2. the next premium due date after the date the Covered Person is no longer in a Covered Class or satisfies eligibility
requirements under this Policy;
3. the last day of the last period for which premium is paid;
4. the next premium due date after the Covered Person attains the maximum Age for insurance under this Policy.
Termination will not affect a claim for a Covered Loss or Covered Injury that is the result, directly and independently of all
other causes, of a Covered Accident that occurs while coverage was in effect.
Continuation for Layoff, Leave of Absence or Family Medical Leave
Insurance for an Employee may be continued until the earliest of the following dates if: (a) an Employee is on a temporary
layoff, an Employer-approved leave of absence or an Employer-approved family medical leave; and (b) required premium
contributions are paid when due.
1. for a layoff: coverage continues through the end of the month in which the layoff begins;
2. for an Employer-approved leave of absence: coverage continues through the end of the month in which the leave
begins;
3. for an Employer-approved family medical leave: 12 weeks in a consecutive 12-month period.
GA-00-1300.00
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COMMON EXCLUSIONS
In addition to any benefit-specific exclusions, benefits will not be paid for any Covered Injury or Covered Loss which,
directly or indirectly, in whole or in part, is caused by or results from any of the following unless coverage is specifically
provided for by name in the Description of Benefits Section:
1. intentionally self-inflicted injury, suicide or any attempt thereat while sane or insane;
2. commission or attempt to commit a felony or an assault;
3. commission of or active participation in a riot, insurrection or Terrorist Act;
4. bungee jumping; parachuting; skydiving; parasailing; hang-gliding;
5. declared or undeclared war or act of war;
6. flight in, boarding or alighting from an Aircraft or any craft designed to fly above the Earth’s surface:
a. except as a passenger on a regularly scheduled commercial airline;
b. being flown by the Covered Person or in which the Covered Person is a member of the crew;
c. being used for:
i. crop dusting, spraying or seeding, giving and receiving flying instruction, fire fighting, sky
writing, sky diving or hang-gliding, pipeline or power line inspection, aerial photography or
exploration, racing, endurance tests, stunt or acrobatic flying; or
ii. any operation that requires a special permit from the FAA, even if it is granted (this does not
apply if the permit is required only because of the territory flown over or landed on);
d. designed for flight above or beyond the earth’s atmosphere;
e. an ultra-light or glider;
f. being used for the purpose of parachuting or skydiving;
g. being used by any military authority, except an Aircraft used by the Air Mobility Command or its foreign
equivalent;
7. Sickness, disease, bodily or mental infirmity, bacterial or viral infection or medical or surgical treatment thereof,
except for any bacterial infection resulting from an accidental external cut or wound or accidental ingestion of
contaminated food;
8. travel in any Aircraft owned, leased or controlled by the Subscriber, or any of its subsidiaries or affiliates. An
Aircraft will be deemed to be ''controlled'' by the Subscriber if the Aircraft may be used as the Subscriber wishes
for more than 10 straight days, or more than 15 days in any year;
9. a Covered Accident that occurs while engaged in the activities of active duty service in the military, navy or air
force of any country or international organization. Covered Accidents that occur while engaged in Reserve or
National Guard training are not excluded until training extends beyond 31 days;
10. operating any type of vehicle while under the influence of alcohol or any drug, narcotic or other intoxicant
including any prescribed drug for which the Covered Person has been provided a written warning against
operating a vehicle while taking it. Under the influence of alcohol, for purposes of this exclusion, means
intoxicated, as defined by the law of the state in which the Covered Accident occurred;
11. voluntary ingestion of any narcotic, drug, poison, gas or fumes, unless prescribed or taken under the direction of a
Physician and taken in accordance with the prescribed dosage;
12. in addition, benefits will not be paid for services or treatment rendered by a Physician, Nurse or any other person
who is:
a. employed or retained by the Subscriber;
b. providing homeopathic, aroma-therapeutic or herbal therapeutic services;
c. living in the Covered Person’s household;
d. a parent, sibling, spouse or child of the Covered Person.
GA-00-1403.00
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CONVERSION PRIVILEGE
1. If the Covered Person’s insurance or any portion of it ends for any of the following reasons:
a. employment or membership ends;
b. eligibility ends (except for age for the Employee);
the Covered Person may have Us issue converted accident insurance on an individual policy or an individual certificate
under a designated group policy. The Covered Person may apply for an amount of coverage that is:
a. in $1,000 increments;
b. not less than $25,000, regardless of the amount of insurance under the group policy; and
c. not more than the amount of insurance he had under the group policy, except as provided above, up to a maximum
amount of $250,000.
The Covered Person must be under age 70 to get a converted policy.
If the Covered Person’s insurance or any portion of it ends for non-payment of premium, he may not convert. If the
Covered Person’s insurance ends for a reason described in 2. below, conversion is subject to that section.
The converted policy or certificate will cover accidental death and dismemberment. The policy or certificate will not
contain disability or other additional benefits. The Covered Person need not show Us that he is insurable.
If the Covered Person has converted his group coverage and later becomes insured under the same group plan as
before, he may not convert a second time unless he provides, at his own expense, proof of insurability or proof the
prior converted policy is no longer in force.
The Covered Person must apply for the individual policy within 31 days after his coverage under this Group Policy
ends and pay the required premium, based on Our table of rates for such policies, his Age and class of risk. If the
Covered Person has assigned ownership of his group coverage, the owner/assignee must apply for the individual
policy.
If the Covered Person suffers a Covered Loss or dies during this 31-day period as the result of an accident that would
have been covered under this Group Policy, We will pay as a claim under this Group Policy the amount of insurance
that the Covered Person was entitled to convert. It does not matter whether the Covered Person applied for the
individual policy or certificate. If such policy or certificate is issued, it will be in exchange for any other benefits under
this Group Policy.
The individual policy or certificate will take effect on the day following the date coverage under the Group Policy
ended; or, if later, the date application is made.
Exclusions
The converted policy may exclude the hazards or conditions that apply to the Covered Person’s group coverage at the
time it ends. We will reduce payment under the converted policy by the amount of any benefits paid under the group
policy if both cover the same loss.
2. If the Covered Person’s insurance ends because this Group Policy is terminated or is amended to terminate insurance
for the Covered Person’s class, and he has been covered under this Group Policy or, any group accident insurance
issued to the Employer which the Group Policy replaced, for at least five years, the Covered Person may have Us issue
an individual policy or certificate of accident insurance subject to the same terms, conditions and limitations listed
above. However, the amount he may apply for will be limited to the lesser of the following:
a. coverage under this Group Policy less any amount of group accident insurance for which he is eligible on the date
this Group Policy is terminated or for which he became eligible within 31 days of such termination, or
b. $10,000.
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Extension of Conversion Period
If the Covered Person is eligible to convert and is not notified of this right at least 15 days prior to the end of the 31 day
conversion period, the conversion period will be extended. The Covered Person will have 15 days from the date notice is
given to apply for a converted policy or certificate. In no event will the conversion period be extended beyond 90 days.
Notice, for the purpose of this section, means written notice presented to the Covered Person by the Subscriber or mailed to
the Covered Person’s last known address as reported by the Subscriber.
If the Covered Person sustains a Covered Loss or dies during the extended conversion period, but more than 31 days after
his coverage under the Group Policy terminates, benefits will not be paid under the Group Policy. If the Covered Person’s
application for a converted policy or certificate is received by Us and the required premium is paid, benefits may be payable
under the converted policy or certificate.
GA-01-1505.00
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CLAIM PROVISIONS
Notice of Claim
Written or authorized electronic/telephonic notice of claim must be given to Us within 31 days after a Covered Loss occurs
or begins or as soon as reasonably possible. If written or authorized electronic/telephonic notice is not given in that time,
the claim will not be invalidated or reduced if it is shown that written or authorized electronic/telephonic notice was given
as soon as was reasonably possible. Notice can be given to Us at Our Home Office in Philadelphia, Pennsylvania, such
other place as We may designate for the purpose, or to Our authorized agent. Notice should include the Subscriber's name
and policy number and the Covered Person’s name, address, policy and certificate number.
Claim Forms
We will send claim forms for filing proof of loss when We receive notice of a claim. If such forms are not sent within 15
days after We receive notice, the proof requirements will be met by submitting, within the time fixed in this Policy for
filing proof of loss, written or authorized electronic proof of the nature and extent of the loss for which the claim is made.
Claimant Cooperation Provision
Failure of a claimant to cooperate with Us in the administration of the claim may result in termination of the claim. Such
cooperation includes, but is not limited to, providing any information or documents needed to determine whether benefits
are payable or the actual benefit amount due.
Proof of Loss
Written or authorized electronic proof of loss satisfactory to Us must be given to Us at Our office, within 90 days of the
loss for which claim is made. If (a) benefits are payable as periodic payments and (b) each payment is contingent upon
continuing loss, then proof of loss must be submitted within 90 days after the termination of each period for which We are
liable. If written or authorized electronic notice is not given within that time, no claim will be invalidated or reduced if it is
shown that such notice was given as soon as reasonably possible. In any case, written or authorized electronic proof must
be given not more than one year after the time it is otherwise required, except if proof is not given solely due to the lack of
legal capacity.
Time of Payment of Claims
We will pay benefits due under this Policy for any loss other than a loss for which this Policy provides any periodic
payment immediately upon receipt of due written or authorized electronic proof of such loss. Subject to due written or
authorized electronic proof of loss, all accrued benefits for loss for which this Policy provides periodic payment will be
paid monthly unless otherwise specified in the benefits descriptions and any balance remaining unpaid at the termination of
liability will be paid immediately upon receipt of proof satisfactory to Us.
Payment of Claims
All benefits will be paid in United States currency. Benefits for loss of life will be payable in accordance with the
Beneficiary provision and these Claim Provisions. All other proceeds payable under this Policy, unless otherwise stated,
will be payable to the covered Employee or to his estate.
If We are to pay benefits to the estate or to a person who is incapable of giving a valid release, We may pay $1,000 to a
relative by blood or marriage whom We believe is equitably entitled. Any payment made by Us in good faith pursuant to
this provision will fully discharge Us to the extent of such payment and release Us from all liability.
Payment of Claims to Foreign Employees
The Subscriber may, in a fiduciary capacity, receive and hold any benefits payable to covered Employees whose place of
employment is other than the United States of America.
We will not be responsible for the application or disposition by the Subscriber of any such benefits paid. Our payments to
the Subscriber will constitute a full discharge of Our liability for those payments under this Policy.
Physical Examination and Autopsy
We, at Our own expense, have the right and opportunity to examine the Covered Person when and as often as We may
reasonably require while a claim is pending and to make an autopsy in case of death where it is not forbidden by law.
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Legal Actions
No action at law or in equity may be brought to recover under this Policy less than 60 days after written or authorized
electronic proof of loss has been furnished as required by this Policy. No such action will be brought more than three years
after the time such written proof of loss must be furnished.
Beneficiary
The beneficiary is the person or persons the Employee names or changes on a form executed by him and satisfactory to Us.
This form may be in writing or by any electronic means agreed upon between Us and the Subscriber. Consent of the
beneficiary is not required to affect any changes, unless the beneficiary has been designated as an irrevocable beneficiary,
or to make any assignment of rights or benefits permitted by this Policy.
A beneficiary designation or change will become effective on the date the Employee executes it. However, We will not be
liable for any action taken or payment made before We record notice of the change at our Home Office.
If more than one person is named as beneficiary, the interests of each will be equal unless the Employee has specified
otherwise. The share of any beneficiary who does not survive the Covered Person will pass equally to any surviving
beneficiaries unless otherwise specified.
If there is no named beneficiary or surviving beneficiary, or if the Employee dies while benefits are payable to him, We
may make direct payment to the first surviving class of the following classes of persons:
1. spouse;
2. child or children;
3. mother or father;
4. sisters or brothers;
5. estate of the Covered Person.
Recovery of Overpayment
If benefits are overpaid, We have the right to recover the amount overpaid by either of the following methods.
1. A request for lump sum payment of the overpaid amount.
2. A reduction of any amounts payable under this Policy.
If there is an overpayment due when the Covered Person dies, We may recover the overpayment from the Covered Person’s
estate.
GA-00-1600.00
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ADMINISTRATIVE PROVISIONS
Premiums
All premium rates are expressed in, and all premiums are payable in, United States currency. The premiums for this Policy
will be based on the rates set forth in the Schedule of Benefits, the plan and amounts of insurance in effect. If a Covered
Person’s insurance amounts are reduced due to age, premium will be based on the amounts of insurance in force on the day
after the reduction took place.
Changes in Premium Rates
We may change the premium rates from time to time with at least 31 days advance written notice to the Subscriber. No
change in rates will be made until 48 months after the Policy Effective Date. An increase in rates will not be made more
often than once in a 12-month period. However, We reserve the right to change rates at any time if any of the following
events take place:
1. the terms of this Policy change;
2. the terms of the Subscriber's participation change;
3. a division, subsidiary, affiliated company or eligible class is added or deleted from this Policy;
4. there is a change in the factors bearing on the risk assumed;
5. any federal or state law or regulation is amended to the extent it affects Our benefit obligation.
Payment of Premium
The first premium is due on the Subscriber's effective date of participation under this Policy. Thereafter, premiums are due
on the Premium Due Dates agreed upon between Us and the Subscriber. If any premium is not paid when due, the
Subscriber's participation under this Policy will be terminated as of the Premium Due Date on which premium was not paid.
Grace Period
A Grace Period of 60 days will be granted to each Subscriber for payment of required premiums under this Policy. A
Subscriber's participation under this Policy will remain in effect during the Grace Period. The Subscriber is liable to Us for
any unpaid premium for the time its participation under this Policy was in force.
A Grace Period of 60 days will be granted for payment of required premiums under this Policy. A Covered Person’s
insurance under this Policy will remain in force during the Grace Period. We will reduce any benefits payable for any
claims incurred during the grace period by the amount of premium due. If no such claims are incurred and premium is not
paid during the grace period, insurance will end on the last day of the period for which premiums were paid.
GA-00-1701.00
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GENERAL PROVISIONS
Entire Contract; Changes
This Policy, including the endorsements, amendments and any attached papers constitutes the entire contract of insurance.
No change in this Policy will be valid until approved by one of Our executive officers and endorsed on or attached to this
Policy. No agent has authority to change this Policy or to waive any of its provisions.
Subscriber Participation Under This Policy
An organization may elect to participate under this Policy by submitting a signed Subscriber participation agreement to the
Policyholder. No participation by an organization is in effect until approved by Us.
Misstatement of Fact
If the Covered Person has misstated any fact, all amounts payable under this Policy will be such as the premium paid would
have purchased had such fact been correctly stated.
Certificates
Where required by law, We will provide a certificate of insurance for delivery to the Covered Person. Each certificate will
list the benefits, conditions and limits of this Policy. It will state to whom benefits will be paid.
30 Day Right To Examine Certificate
If a Covered Person does not like the Certificate for any reason, it may be returned to Us within 30 days after receipt. We
will return any premium that has been paid and the Certificate will be void as if it had never been issued.
Multiple Certificates
The Covered Person may have in force only one certificate at a time under this Policy. If at any time the Covered Person
has been issued more than one certificate, then only the largest shall be in effect. We will refund premiums paid for the
others for any period of time that more than one certificate was issued.
Assignment
We will be bound by an assignment of a Covered Person's insurance under this Policy only when the original assignment or
a certified copy of the assignment, signed by the Covered Person and any irrevocable beneficiary, is filed with Us. The
assignee may exercise all rights and receive all benefits assigned only while the assignment remains in effect and insurance
under this Policy and the Covered Person’s certificate remains in force.
Incontestability
1. Of This Policy or Participation Under This Policy
All statements made by the Subscriber to obtain this Policy or to participate under this Policy are considered representations
and not warranties. No statement will be used to deny or reduce benefits or be used as a defense to a claim, or to deny the
validity of this Policy or of participation under this Policy unless a copy of the instrument containing the statement is, or
has been, furnished to the Subscriber.
After two years from the Policy Effective Date, no such statement will cause this Policy to be contested except for fraud.
2. Of A Covered Person's Insurance
All statements made by a Covered Person are considered representations and not warranties. No statement will be used to
deny or reduce benefits or be used as a defense to a claim, unless a copy of the instrument containing the statement is, or
has been, furnished to the claimant.
After two years from the Covered Person’s effective date of insurance, or from the effective date of increased benefits, no
such statement will cause insurance or the increased benefits to be contested except for fraud or lack of eligibility for
insurance.
In the event of death or incapacity, the beneficiary or representative shall be given a copy.
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Policy Termination
We may terminate coverage on or after the first anniversary of the policy effective date. The Subscriber may terminate
coverage on any premium due date. Written or authorized electronic notice must be given at least 31 days prior to such
premium due date.
Termination will not affect a claim for a Covered Loss that is the result, directly and independently of all other causes, of a
Covered Accident that occurs while coverage was in effect.
Reinstatement
This Policy may be reinstated if it lapsed for nonpayment of premium. Requirements for reinstatement are written
application of the Subscriber satisfactory to Us and payment of all overdue premiums. Any premium accepted in
connection with a reinstatement will be applied to a period for which premium was not previously paid.
Clerical Error
A Covered Person's insurance will not be affected by error or delay in keeping records of insurance under this Policy. If
such error or delay is found, We will adjust the premium fairly.
Conformity with Statutes
Any provisions in conflict with the requirements of any state or federal law that apply to this Policy are automatically
changed to satisfy the minimum requirements of such laws.
Policy Changes
We may agree with the Subscriber to modify a plan of benefits without the Covered Person’s consent.
Workers’ Compensation Insurance
This Policy is not in place of and does not affect any requirements for coverage under any Workers’ Compensation law.
Examination of the Policy
This Group Policy will be available for inspection at the Subscriber's office during regular business hours.
Examination of Records
We will be permitted to examine all of the Subscriber's records relating to this Group Policy. Examination may occur at
any reasonable time while the Group Policy is in force; or it may occur:
1. at any time for two years after the expiration of this Group Policy; or, if later,
2. upon the final adjustment and settlement of all Group Policy claims.
The Subscriber is acting as an agent of the Covered Person for transactions relating to this insurance. The actions of the
Subscriber will not be considered Our actions.
GA-00-1800.00
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DESCRIPTION OF COVERAGES AND BENEFITS
This Description of Coverages and Benefits Section describes the Accident Coverages and Benefits provided to You.
Benefit amounts, benefit periods and any applicable aggregate and benefit maximums are shown in the Schedule of
Benefits. Certain words capitalized in the text of these descriptions have special meanings within this Certificate
and are defined in the General Definitions section. Please read these and the Common Exclusions sections in order to
understand all of the terms, conditions and limitations applicable to these coverages and benefits.
ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS
Covered Loss We will pay the benefit for any one of the Covered Losses listed in the Schedule of Benefits, if the
Covered Person suffers a Covered Loss resulting directly and independently of all other causes from a
Covered Accident within the applicable time period specified in the Schedule of Benefits.
If the Covered Person sustains more than one Covered Loss as a result of the same Covered Accident,
benefits will be paid for the Covered Loss for which the largest available benefit is payable. If the loss
results in death, benefits will only be paid under the Loss of Life benefit provision. Any Loss of Life
benefit will be reduced by any paid or payable Accidental Dismemberment benefit. However, if such
Accidental Dismemberment benefit equals or exceeds the Loss of Life benefit, no additional benefit will
be paid.
Definitions Loss of a Hand or Foot means complete Severance through or above the wrist or ankle joint.
Loss of Sight means the total, permanent loss of all vision in one eye which is irrecoverable by natural,
surgical or artificial means.
Loss of Speech means total and permanent loss of audible communication which is irrecoverable by
natural, surgical or artificial means.
Loss of Hearing means total and permanent loss of ability to hear any sound in both ears which is
irrecoverable by natural, surgical or artificial means.
Loss of a Thumb and Index Finger of the Same Hand or Four Fingers of the Same Hand means
complete Severance through or above the metacarpophalangeal joints of the same hand (the joints
between the fingers and the hand).
Loss of Toes means complete Severance through the metatarsalphalangeal joint.
Paralysis or Paralyzed means total loss of use of a limb. A Physician must determine the loss of use to
be complete and irreversible.
Quadriplegia means total Paralysis of both upper and both lower limbs.
Hemiplegia means total Paralysis of the upper and lower limbs on one side of the body.
Paraplegia means total Paralysis of both lower limbs or both upper limbs.
Uniplegia means total Paralysis of one upper or one lower limb.
Coma means a profound state of unconsciousness which resulted directly and independently from all
other causes from a Covered Accident, and from which the Covered Person is not likely to be aroused
through powerful stimulation. This condition must be diagnosed and treated regularly by a Physician.
Coma does not mean any state of unconsciousness intentionally induced during the course of treatment of
a Covered Injury unless the state of unconsciousness results from the administration of anesthesia in
preparation for surgical treatment of that Covered Accident.
Severance means the complete and permanent separation and dismemberment of the part from the body.
Exclusions The exclusions that apply to this benefit are in the Common Exclusions section.
GA-00-2100.00
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ADDITIONAL ACCIDENTAL DEATH AND DISMEMBERMENT COVERAGES
Accidental Death and Dismemberment benefits are provided under the following coverages. Any benefits payable under
them are shown in the Schedule of Covered Losses and will not be paid in addition to any other Accidental Death and
Dismemberment benefits payable.
EXPOSURE AND DISAPPEARANCE COVERAGE
Benefits for Accidental Death and Dismemberment, as shown in the Schedule of Covered Losses, will be payable if a
Covered Person suffers a Covered Loss which results directly and independently of all other causes from unavoidable
exposure to the elements following a Covered Accident.
If the Covered Person disappears and is not found within one year from the date of the wrecking, sinking or disappearance
of the conveyance in which the Covered Person was riding in the course of a trip which would otherwise be covered under
this Policy, it will be presumed that the Covered Person’s death resulted directly and independently of all other causes from
a Covered Accident.
Exclusions The exclusions that apply to this coverage are in the Common Exclusions Section.
GA-00-2202.00
ADDITIONAL ACCIDENT BENEFITS
Accidental Death and Dismemberment benefits are provided under the following Additional Benefits. Any benefits
payable under them will be paid in addition to any other Accidental Death and Dismemberment benefit payable.
CHILD CARE CENTER BENEFIT
We will pay benefits shown in the Schedule of Benefits for the care of each surviving Dependent Child in a Child Care
Center if death of the covered Employee results directly and independently of all other causes from a Covered Accident and
all of the following conditions are met:
1. coverage for his Dependent Children was in force on the date of the Covered Accident causing his death; and
2. one or more surviving Dependent Children is under Age 13 and:
a. was enrolled in a Child Care Center on the date of the Covered Accident; or
b. enrolls in a Child Care Center within 90 days from the date of the Covered Accident.
This benefit will be payable to the Surviving Spouse if the Spouse has custody of the child. If the Surviving Spouse does
not have custody of the child, benefits will be paid to the child’s legally appointed guardian. Payments will be made at the
end of each 12 month period that begins after the date of the covered Employee’s death. A claim must be submitted to Us
at the end of each 12 month period. A 12 month period begins:
1. when the Dependent Child enters a Child Care Center for the first time, within the period specified in (2b) above,
after the covered Employee’s death; or
2. on the first of the month following the covered Employee’s death, if the Dependent Child was enrolled in a Child
Care Center before the covered Employee’s death.
Each succeeding 12 month period begins on the day immediately following the last day of the preceding period. Pro rata
payments will be made for periods of enrollment in a Child Care Center of less than 12 months.
Definitions For purposes of this benefit:
Child Care Center is a facility which:
1. is licensed and run according to laws and regulations applicable to child care facilities; and
2. provides care and supervision for children in a group setting on a regular, daily basis.
A Child Care Center does not include any of the following:
1. a Hospital;
2. the child’s home;
3. care provided during normal school hours while a child is attending grades one through twelve.
Exclusions The exclusions that apply to this benefit are in the Common Exclusions Section.
GA-00-2222.00
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COMMON CARRIER BENEFIT
We will pay the benefit shown in the Schedule of Benefits if the Covered Person suffers a Covered Loss that results directly
and independently of all other causes from a Covered Accident that occurs while riding as a fare-paying passenger in, or
being struck by, a Common Carrier. Riding includes getting into and out of the Common Carrier.
Definition For purposes of this benefit:
Common Carrier means:
1. a public conveyance, including Aircraft, licensed for hire to carry fare-paying
passengers; or
2. a transport Aircraft operated by the Air Mobility Command of the United States of
America or a similar air transport service of another country.
Exclusions The exclusions that apply to this benefit are in the Common Exclusions Section.
GA-00-2225.00
FELONIOUS ASSAULT AND VIOLENT CRIME BENEFIT
We will pay the amount shown in the Schedule of Benefits, subject to the following conditions and exclusions, when the
Covered Employee suffers a Covered Loss resulting directly and independently of all other causes from a Covered Accident
that occurs during a violent crime or felonious assault as described below. A police report detailing the felonious assault or
violent crime must be provided before any benefits will be paid. The Covered Accident must occur while the Covered
Person is on the business or premises of the Employer.
To qualify for benefit payment, the Covered Accident must occur during any of the following:
1. actual or attempted robbery or holdup;
2. actual or attempted kidnapping;
3. any other type of intentional assault that is a crime classified as a felony by the governing statute or common law
in the state where the felony occurred.
We will pay a Hospital Stay Benefit, subject to the following conditions and exclusions, when the Covered Person suffers a
Covered Loss resulting directly and independently of all other causes from a Covered Accident that occurs during a violent
crime or felonious assault if all of the following conditions are met:
1. the Covered Person is covered for Hospital Stay benefits under this Policy;
2. the Hospital Stay begins within 30 days of the violent crime/felonious assault;
3. the Hospital Stay is at the direction and under the care of a Physician;
4. the Covered Person provides proof satisfactory to Us that his Hospital Stay was necessitated to treat Covered
Injuries sustained in a Covered Accident caused solely by a violent crime or felonious assault;
5. the Hospital Stay begins while the Covered Person’s insurance is in effect.
The benefit will be paid for each day of a continuous Hospital Stay.
Definitions For purposes of this benefit:
Family Member means the Covered Person’s parent, step-parent, Spouse or former Spouse,
son, daughter, brother, sister, mother-in-law, father-in-law, son-in-law, daughter-in-law, brother-
in-law, sister-in-law, aunt, uncle, cousins, grandparent, grandchild and stepchild.
Fellow Employee means a person employed by the same Employer as the Covered Person or by
an Employer that is an affiliated or subsidiary corporation. It shall also include any person who
was so employed, but whose employment was terminated not more than 45 days prior to the date
on which the defined violent crime/felonious assault was committed.
Member of the Same Household means a person who maintains residence at the same address
as the Covered Person.
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Exclusions Benefits will not be paid for treatment of any Covered Injury sustained or Covered Loss incurred during
any:
1. violent crime or felonious assault committed by the Covered Person; or
2. felonious assault or violent crime committed upon the Covered Person by a Fellow
Employee, Family Member, or Member of the Same Household.
Other exclusions that apply to this benefit are in the Common Exclusions Section.
GA-00-2234.00
SEATBELT AND AIRBAG BENEFIT
We will pay the benefit shown in the Schedule of Benefits, subject to the conditions and exclusions described below, when
the Covered Person dies directly and independently of all other causes from a Covered Accident while wearing a seatbelt
and operating or riding as a passenger in an Automobile. An additional benefit is provided if the Covered Person was also
positioned in a seat protected by a properly-functioning and properly deployed Supplemental Restraint System (Airbag).
Verification of proper use of the seatbelt at the time of the Covered Accident and that the Supplemental Restraint System
properly inflated upon impact must be a part of an official police report of the Covered Accident or be certified, in writing,
by the investigating officer(s) and submitted with the Covered Person’s claim to Us.
If such certification or police report is not available or it is unclear whether the Covered Person was wearing a seatbelt or
positioned in a seat protected by a properly functioning and properly deployed Supplemental Restraint System, We will pay
a default benefit shown in the Schedule of Benefits to the Covered Person’s beneficiary.
In the case of a child, seatbelt means a child restraint, as required by state law and approved by the National Highway
Traffic Safety Administration, properly secured and being used as recommended by its manufacturer for children of like
Age and weight at the time of the Covered Accident.
Definitions For purposes of this benefit:
Supplemental Restraint System means an airbag that inflates upon impact for added protection to the
head and chest areas.
Automobile means a self-propelled, private passenger motor vehicle with four or more wheels which is a
type both designed and required to be licensed for use on the highway of any state or country.
Automobile includes, but is not limited to, a sedan, station wagon, sport utility vehicle, or a motor vehicle
of the pickup, van, camper, or motor-home type. Automobile does not include a mobile home or any
motor vehicle which is used in mass or public transit.
Exclusions The exclusions that apply to this benefit are in the Common Exclusions Section.
GA-00-2251.00
SPECIAL EDUCATION BENEFIT
We will pay the benefit, up to the Maximum Benefit shown in the Schedule of Benefits, for each qualifying Dependent
Child. The Covered Person’s death must result, directly and independently of all other causes from a Covered Accident for
which an Accidental Death Benefit is payable under this Policy. This benefit is subject to the conditions and exclusions
described below.
A qualifying Dependent Child must:
1. enroll as a full-time student at an accredited school of higher learning before reaching the limiting Age for
dependent eligibility stated in this Policy;
2. continue his education as a full-time student; and
3. incur expenses for tuition, fees, books, room and board, transportation and any other costs payable directly to, or
approved and certified by, such school.
A qualifying surviving Spouse must:
1. enroll in any accredited school for the purpose of retraining or refreshing skills needed for employment within one
year of the date of the covered Employee’s Covered Accident;
2. remain enrolled in such accredited school; and
3. incur expenses payable directly to, or approved by, such school.
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Payments will be made to each qualifying Dependent Child or to the child’s legal guardian, if the child is a minor at the end
of each year for the number of years shown in the Schedule of Benefits. We must receive proof satisfactory to Us of the
Dependent Child’s enrollment and attendance within 31 days of the end of each year. The first year for which a Special
Education Benefit is payable will begin on the first of the month following the date the covered Employee died, if the
surviving Dependent Child was enrolled on that date in an accredited school of higher learning beyond the 12th grade;
otherwise on the date he enrolls in such school. Each succeeding year for which benefits are payable will begin on the date
following the end of the preceding year.
If no Dependent Child qualifies for Special Education Benefits within 365 days of the covered Employee’s death, We will
pay the default benefit shown in the Schedule of Benefits to the covered Employee’s beneficiary.
Payments will be made to the surviving Spouse at the end of each year for the number of years shown in the Schedule of
Benefits. We must receive proof satisfactory to Us of the Spouse’s enrollment and attendance within 31 days of the end of
each year. The first year for which a Special Education Benefit is payable will begin on the date the surviving Spouse
enrolls in an accredited school for the first time following the date the Employee died. Each succeeding year for which
benefits are payable will begin on the date following the end of the preceding year.
If a surviving Spouse does not qualify for Special Education Benefits within 365 days of the covered Employee’s death, We
will pay the default benefit shown in the Schedule of Benefits to the covered Employee’s beneficiary.
Definitions For the purposes of this benefit:
Dependent Child(ren) An Employee’s unmarried child who meets the following requirements:
1. A child from live birth to 19 years old;
2. A child who is 19 or more years old but less than 25 years old, enrolled in a school as a full-time
student and primarily supported by the Employee;
3. A child who is 19 or more years old, primarily supported by the Employee and incapable of self-
sustaining employment by reason of mental or physical handicap. Proof of the child’s condition
and dependence must be submitted to Us within 31 days after the date the child ceases to qualify
as a Dependent Child for the reasons listed above. During the next two years, We may, from
time to time, require proof of the continuation of such condition and dependence. After that, We
may require proof no more than once a year.
A child, for purposes of this provision, includes an Employee’s:
1. natural child;
2. adopted child, beginning with any waiting period pending finalization of the child’s adoption;
3. stepchild who resides with the Employee;
4. child for whom the Employee is legal guardian, as long as the child resides with the Employee
and depends on the Employee for financial support. Financial support means that the Employee
is eligible to claim the dependent for purposes of Federal and State income tax returns.
Spouse the Employee’s lawful spouse under age 70.
Exclusions The exclusions that apply to this benefit are in the Common Exclusions Section.
GA-00-2252a.00
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SPOUSE RETRAINING BENEFIT
We will pay expenses incurred, as described below, up to the Maximum Benefit shown in the Schedule of Benefits, to
enable the covered Employee’s Spouse to obtain occupational or educational training needed for employment if the covered
Employee dies directly and independently of all other causes from a Covered Accident. This benefit is subject to the
conditions and exclusions described below.
This benefit will be payable if the covered Employee dies within one year of a Covered Accident and is survived by his
Spouse who:
1. enrolls, within three years after the covered Employee’s death in any accredited school for the purpose of
retraining or refreshing skills needed for employment; and
2. incurs expenses payable directly to, or approved and certified by, such school.
If there is no surviving Spouse at the time of the covered Employee’s Covered Accidental Death, the Default Benefit shown
in the Schedule of Benefits will be paid to the covered Employee’s beneficiary.
Definitions For the purposes of this benefit:
Spouse will include the Employee’s lawful spouse under age 70.
Exclusions The exclusions that apply to this benefit are in the Common Exclusions Section.
GA-00-2254a.00
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LIFE INSURANCE COMPANY OF NORTH AMERICA
Philadelphia, PA 19192-2235
We, City of Palo Alto, whose main office address is Palo Alto, CA, hereby approve and accept the terms of Group Policy
Number OK 964302 issued by the LIFE INSURANCE COMPANY OF NORTH AMERICA to the TRUSTEE OF THE
GROUP INSURANCE TRUST FOR EMPLOYERS IN THE PUBLIC ADMINISTRATION INDUSTRY.
This form is to be signed in duplicate. One part is to be retained by City of Palo Alto; the other part is to be returned to the
LIFE INSURANCE COMPANY OF NORTH AMERICA.
City of Palo Alto
Signature and Title:____________________________________________ Date: __________________________
(This Copy Is To Be Returned To Life Insurance Company of North America)
-------------------------------------------------------------------------------------------------------------------------------------------
LIFE INSURANCE COMPANY OF NORTH AMERICA
Philadelphia, PA 19192-2235
We, City of Palo Alto, whose main office address is Palo Alto, CA, hereby approve and accept the terms of Group Policy
Number OK 964302 issued by the LIFE INSURANCE COMPANY OF NORTH AMERICA to the TRUSTEE OF THE
GROUP INSURANCE TRUST FOR EMPLOYERS IN THE PUBLIC ADMINISTRATION INDUSTRY.
This form is to be signed in duplicate. One part is to be retained by City of Palo Alto; the other part is to be returned to the
LIFE INSURANCE COMPANY OF NORTH AMERICA.
City of Palo Alto
Signature and Title:____________________________________________ Date: __________________________
(This Copy Is To Be Retained By City of Palo Alto)
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LIFE INSURANCE COMPANY OF NORTH AMERICA
(herein called the Company)
Amendment to be attached to and made a part of the Group Policy
A Contract between the Company and
Policyholder: Trustee of the Group Insurance Trust for Employers in the Public Administration Industry
Participating Subscriber: City of Palo Alto
(herein called the Subscriber)
Policy No.: LK - 961943
The Company and the Subscriber hereby agree that the Policy is amended as follows:
1. Effective January 1, 2022, the following rates will be in force for Classes 1 for coverage under the Policy:
Option 1
$1.07 per $100 of Covered Payroll
Covered Payroll for an Employee will mean his or her Covered Earnings for the insurance month prior to the date the
determination is made. However, an Employee's Covered Payroll will not include any part of his or her monthly
Covered Earnings which exceed $6,000.
Option 2
$.51 per $100 of Covered Payroll
Covered Payroll for an Employee will mean his or her Covered Earnings for the insurance month prior to the date the
determination is made. However, an Employee's Covered Payroll will not include any part of his or her monthly
Covered Earnings which exceed $3,000.
2. Effective January 1, 2022, the following rates will be in force for Class 2 and 3 for coverage under the Policy:
$.56 per $100 of Covered Payroll
Covered Payroll for an Employee will mean his or her Covered Earnings for the insurance month prior to the date the
determination is made. However, an Employee's Covered Payroll will not include any part of his or her monthly
Covered Earnings which exceed $15,000.
No change in rates will be made until 36 months after the effective date of this Amendment. However, the Company
reserves the right to change the rates at any time during a period for which the rates are guaranteed if the conditions
described in the Changes in Premium Rates provision under the Administrative Provisions section of the Policy apply.
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Except for the above, this Amendment does not change the Policy in any way.
FOR THE COMPANY
William J. Smith, President
Date: August 26, 2021
Amendment No. 03a
TL-004780
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CALIFORNIA LIFE AND HEALTH INSURANCE
GUARANTY ASSOCIATION ACT
SUMMARY DOCUMENT AND DISCLAIMER
Residents of California who purchase life and health insurance and annuities should know that the insurance
companies licensed in this state to write these types of insurance are members of the California Life and Health
Insurance Guaranty Association. The purpose of this Association is to assure that policyholders will be protected,
within limits, in the unlikely event that a member insurer becomes financially unable to meet its obligations. If
this should happen, the Association will assess its other member insurance companies for the money to pay the
claims of insured persons who live in this state and, in some cases, to keep coverage in force. The valuable extra
protection provided through the Association is not unlimited, as noted in the box below, and is not a substitute for
consumers' care in selecting well managed and financially stable insurers.
The California Life and Health Insurance Guaranty Association may not provide coverage for this
insurance. If coverage is provided, it may be subject to substantial limitations or exclusions, and require
continued residency in the state. 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 insurance 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 prohibited by law from using the existence of the Association
to induce you to purchase any kind of insurance policy.
If you have additional questions, you should first contact your insurer or agent and then may contact:
California Life and Health OR Consumer Service Division
Insurance Guaranty Association California Department of Insurance
P.O. Box 16860 300 South Spring Street
Beverly Hills, CA 90209 Los Angeles, CA 90013
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.
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COVERAGE
Generally, individuals will be protected by the California Life and Health Insurance Guaranty Association
if they live in this state and 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 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
organization, 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 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 and association plans to the extent they are self-funded or uninsured;
synthetic guaranteed interest contracts;
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; and
any portion of a contract that provides dividends or experience rating credits.
LIMITS ON AMOUNT OF COVERAGE
The Act limits the Association to pay benefits as follows:
Life and Annuity Benefits
80% of what the life insurance company would owe under a life policy or annuity contract up to
$100,000 in cash surrender values;
$100,000 in present value of annuities; or
$250,000 in life insurance death benefits.
A maximum of $250,000 for any one insured life no matter how many policies and contracts there
were with the same company, even if 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.
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LIFE INSURANCE COMPANY OF NORTH AMERICA
1601 CHESTNUT STREET GROUP POLICY
PHILADELPHIA, PA 19192-2235
(800) 732-1603 TDD (800) 552-5744
A STOCK INSURANCE COMPANY
POLICYHOLDER:
SUBSCRIBER:
POLICY NUMBER:
POLICY EFFECTIVE DATE:
POLICY ANNIVERSARY DATE:
TRUSTEE OF THE GROUP INSURANCE
TRUST FOR EMPLOYERS IN THE PUBLIC
ADMINISTRATION INDUSTRY
City of Palo Alto
LK-961943
January 1
January 1
This Policy describes the terms and conditions of coverage. It is issued in Delaware and shall be
governed by its laws. The Policy goes into effect on the Policy Effective Date, 12:01 a.m. at the
Policyholder's address.
In return for the required premium, the Insurance Company and the Policyholder have agreed to all the
terms of this Policy.
Deborah Young, Corporate Secretary Karen S. Rohan, President
TL-004700 O/O v-2
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TABLE OF CONTENTS
SCHEDULE OF BENEFITS........................................................................................................................1
SCHEDULE OF BENEFITS FOR CLASS 1...............................................................................................2
SCHEDULE OF BENEFITS FOR CLASS 2...............................................................................................5
SCHEDULE OF BENEFITS FOR CLASS 3...............................................................................................8
ELIGIBILITY FOR INSURANCE ............................................................................................................11
EFFECTIVE DATE OF INSURANCE......................................................................................................11
TERMINATION OF INSURANCE...........................................................................................................11
CONTINUATION OF INSURANCE........................................................................................................12
DESCRIPTION OF BENEFITS.................................................................................................................13
EXCLUSIONS............................................................................................................................................18
CLAIM PROVISIONS...............................................................................................................................18
ADMINISTRATIVE PROVISIONS..........................................................................................................20
GENERAL PROVISIONS .........................................................................................................................21
DEFINITIONS............................................................................................................................................22
DOMESTIC PARTNER RIDER................................................................................................................25
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SCHEDULE OF BENEFITS
Premium Due Date: The last day of each month
Classes of Eligible Employees
On the pages following the definition of eligible employees there is a Schedule of Benefits for each Class
of Eligible Employees listed below. For an explanation of these benefits, please see the Description of
Benefits provision.
If an Employee is eligible under one Class of Eligible Employees and later becomes eligible under a
different Class of Eligible Employees, changes in his or her insurance due to the class change will be
effective on the first of the month following the change in class.
Class 1 All active, Full-time Service Employees International Union Employees/Members of the
Employer regularly working a minimum of 20 hours per week.
Class 2 All active, Full-time Employees of the Employer regularly working a minimum of 20
hours per week who are classified as Management, Confidential and Council Officer.
Class 3 All active, Full-time Employees of the Employer as defined under the prior carrier policy,
number 643835, and on file with the Insurance Company, regularly working a minimum
of 20 hours per week. (Closed Class)
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SCHEDULE OF BENEFITS FOR CLASS 1
Eligibility Waiting Period
For Employees hired on or before the Policy Effective Date: No Waiting Period
For Employees hired after the Policy Effective Date: No Waiting Period
Definition of Disability/Disabled
The Employee is considered Disabled if, solely because of Injury or Sickness, he or she is:
1. unable to perform the material duties of his or her Regular Occupation; and
2. unable to earn 80% or more of his or her Indexed Earnings from working in his or her Regular
Occupation.
After Disability Benefits have been payable for 24 months, the Employee is considered Disabled if, solely
due to Injury or Sickness, he or she is:
1. unable to perform the material duties of any occupation for which he or she is, or may reasonably
become, qualified based on education, training or experience; and
2. unable to earn 60% or more of his or her Indexed Earnings.
The Insurance Company will require proof of earnings and continued Disability.
Definition of Covered Earnings
Covered Earnings means an Employee's wage or salary as reported by the Employer for work performed
for the Employer as in effect just prior to the date Disability begins. It includes earnings received from
commissions but not bonuses, overtime pay and other extra compensation. Covered Earnings are
determined initially on the date an Employee applies for coverage. A change in the amount of Covered
Earnings is effective on the date of the change, if the Employer gives us written notice of the change and
the required premium is paid.
Commissions will be averaged for the 12 months just prior to the date Disability begins, or the months
employed, if less than 12 months.
Any increase in an Employee's Covered Earnings will not be effective during a period of continuous
Disability.
Elimination Period 60 days
Gross Disability Benefit
Option 1 The lesser of 66.67% of an Employee's monthly Covered
Earnings rounded to the nearest dollar or the Maximum
Disability Benefit.
Option 2 The lesser of 60% of an Employee's monthly Covered Earnings
rounded to the nearest dollar or the Maximum Disability Benefit.
Maximum Disability Benefit
Option 1 $4,000 per month
Option 2 $1,800 per month
Minimum Disability Benefit $100 per month
Disability Benefit Calculation
The Disability Benefit payable to the Employee is figured using the Gross Disability Benefit, Other
Income Benefits and the Return to Work Incentive. Monthly Benefits are based on a 30-day month. The
Disability Benefit will be prorated if payable for any period less than a month.
During any month the Employee has no Disability Earnings, the monthly benefit payable is the Gross
Disability Benefit less Other Income Benefits. During any month the Employee has Disability Earnings,
benefits are determined under the Return to Work Incentive. Benefits will not be less than the minimum
benefit shown in the Schedule of Benefits except as provided under the section Minimum Benefit.
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"Other Income Benefits" means any benefits listed in the Other Income Benefits provision that an
Employee receives on his or her own behalf or for dependents, or which the Employee's dependents
receive because of the Employee's entitlement to Other Income Benefits.
Return to Work Incentive
During any month the Employee has Disability Earnings, his or her benefits will be calculated as
follows.
The Employee's monthly benefit payable will be calculated as follows during the first 24 months
disability benefits are payable and the Employee has Disability Earnings:
1.Add the Employee's Gross Disability Benefit and Disability Earnings.
2.Compare the sum from 1. to the Employee's Indexed Earnings.
3.If the sum from 1. exceeds 100% of the Employee's Indexed Earnings, then subtract the
Indexed Earnings from the sum in 1.
4.The Employee's Gross Disability Benefit will be reduced by the difference from 3., as
well as by Other Income Benefits.
5.If the sum from 1. does not exceed 100% of the Employee's Indexed Earnings, the
Employee's Gross Disability Benefit will be reduced by Other Income Benefits.
After disability benefits are payable for 24 months, the monthly benefit payable is the Gross
Disability Benefit reduced by Other Income Benefits and 50% of Disability Earnings.
No Disability Benefits will be paid, and insurance will end if the Insurance Company determines
the Employee is able to work under a modified work arrangement and he or she refuses to do so
without Good Cause.
Additional Benefits
Survivor Benefit
Benefit Waiting Period: After 3 Monthly Benefits are payable.
Amount of Benefit: 100% of the sum of the last full Disability Benefit plus the
amount of any Disability Earnings by which the benefit had been
reduced for that month.
Maximum Benefit Period A single lump sum payment equal to 3 monthly Survivor
Benefits.
Maximum Benefit Period
The later of the Employee’s SSNRA* or the Maximum Benefit Period listed below.
Age When Disability Begins Maximum Benefit Period
Age 62 or under The Employee's 65th birthday or the date the 42nd Monthly
Benefit is payable, if later.
Age 63 The date the 36th Monthly Benefit is payable.
Age 64 The date the 30th Monthly Benefit is payable.
Age 65 The date the 24th Monthly Benefit is payable.
Age 66 The date the 21st Monthly Benefit is payable.
Age 67 The date the 18th Monthly Benefit is payable.
Age 68 The date the 15th Monthly Benefit is payable.
Age 69 or older The date the 12th Monthly Benefit is payable.
*SSNRA means the Social Security Normal Retirement Age in effect under the Social Security Act on the
Policy Effective Date.
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Initial Premium Rates – Option 1
$1.23 per $100 of Covered Payroll
Covered Payroll for an Employee will mean his or her Covered Earnings for the insurance month prior to
the date the determination is made. However, an Employee's Covered Payroll will not include any part of
his or her monthly Covered Earnings which exceed $6,000.
Initial Premium Rates – Option 2
$.575 per $100 of Covered Payroll
Covered Payroll for an Employee will mean his or her Covered Earnings for the insurance month prior to
the date the determination is made. However, an Employee's Covered Payroll will not include any part of
his or her monthly Covered Earnings which exceed $3,000.
TL-004774
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SCHEDULE OF BENEFITS FOR CLASS 2
Eligibility Waiting Period
For Employees hired on or before the Policy Effective Date: No Waiting Period
For Employees hired after the Policy Effective Date: No Waiting Period
Definition of Disability/Disabled
The Employee is considered Disabled if, solely because of Injury or Sickness, he or she is:
1. unable to perform the material duties of his or her Regular Occupation; and
2. unable to earn 80% or more of his or her Indexed Earnings from working in his or her Regular
Occupation.
After Disability Benefits have been payable for 24 months, the Employee is considered Disabled if, solely
due to Injury or Sickness, he or she is:
1. unable to perform the material duties of any occupation for which he or she is, or may reasonably
become, qualified based on education, training or experience; and
2. unable to earn 60% or more of his or her Indexed Earnings.
The Insurance Company will require proof of earnings and continued Disability.
Definition of Covered Earnings
Covered Earnings means an Employee's wage or salary as reported by the Employer for work performed
for the Employer as in effect just prior to the date Disability begins. It includes earnings received from
commissions but not bonuses, overtime pay and other extra compensation. Covered Earnings are
determined initially on the date an Employee applies for coverage. A change in the amount of Covered
Earnings is effective on the date of the change, if the Employer gives us written notice of the change and
the required premium is paid.
Commissions will be averaged for the 12 months just prior to the date Disability begins, or the months
employed, if less than 12 months.
Any increase in an Employee's Covered Earnings will not be effective during a period of continuous
Disability.
Elimination Period 60 days
Gross Disability Benefit The lesser of 66.67% of an Employee's monthly Covered
Earnings rounded to the nearest dollar or the Maximum
Disability Benefit.
Maximum Disability Benefit $10,000 per month
Minimum Disability Benefit $100 per month
Disability Benefit Calculation
The Disability Benefit payable to the Employee is figured using the Gross Disability Benefit, Other
Income Benefits and the Return to Work Incentive. Monthly Benefits are based on a 30-day month. The
Disability Benefit will be prorated if payable for any period less than a month.
During any month the Employee has no Disability Earnings, the monthly benefit payable is the Gross
Disability Benefit less Other Income Benefits. During any month the Employee has Disability Earnings,
benefits are determined under the Return to Work Incentive. Benefits will not be less than the minimum
benefit shown in the Schedule of Benefits except as provided under the section Minimum Benefit.
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"Other Income Benefits" means any benefits listed in the Other Income Benefits provision that an
Employee receives on his or her own behalf or for dependents, or which the Employee's dependents
receive because of the Employee's entitlement to Other Income Benefits.
Return to Work Incentive
During any month the Employee has Disability Earnings, his or her benefits will be calculated as
follows.
The Employee's monthly benefit payable will be calculated as follows during the first 24 months
disability benefits are payable and the Employee has Disability Earnings:
1. Add the Employee's Gross Disability Benefit and Disability Earnings.
2. Compare the sum from 1. to the Employee's Indexed Earnings.
3. If the sum from 1. exceeds 100% of the Employee's Indexed Earnings, then subtract the
Indexed Earnings from the sum in 1.
4. The Employee's Gross Disability Benefit will be reduced by the difference from 3., as
well as by Other Income Benefits.
5. If the sum from 1. does not exceed 100% of the Employee's Indexed Earnings, the
Employee's Gross Disability Benefit will be reduced by Other Income Benefits.
After disability benefits are payable for 24 months, the monthly benefit payable is the Gross
Disability Benefit reduced by Other Income Benefits and 50% of Disability Earnings.
No Disability Benefits will be paid, and insurance will end if the Insurance Company determines
the Employee is able to work under a modified work arrangement and he or she refuses to do so
without Good Cause.
Additional Benefits
Survivor Benefit
Benefit Waiting Period: After 3 Monthly Benefits are payable.
Amount of Benefit: 100% of the sum of the last full Disability Benefit plus the
amount of any Disability Earnings by which the benefit had been
reduced for that month.
Maximum Benefit Period A single lump sum payment equal to 3 monthly Survivor
Benefits.
Maximum Benefit Period
The later of the Employee’s SSNRA* or the Maximum Benefit Period listed below.
Age When Disability Begins Maximum Benefit Period
Age 62 or under The Employee's 65th birthday or the date the 42nd Monthly
Benefit is payable, if later.
Age 63 The date the 36th Monthly Benefit is payable.
Age 64 The date the 30th Monthly Benefit is payable.
Age 65 The date the 24th Monthly Benefit is payable.
Age 66 The date the 21st Monthly Benefit is payable.
Age 67 The date the 18th Monthly Benefit is payable.
Age 68 The date the 15th Monthly Benefit is payable.
Age 69 or older The date the 12th Monthly Benefit is payable.
*SSNRA means the Social Security Normal Retirement Age in effect under the Social Security Act on the
Policy Effective Date.
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Initial Premium Rates
$.62 per $100 of Covered Payroll
Covered Payroll for an Employee will mean his or her Covered Earnings for the insurance month prior to
the date the determination is made. However, an Employee's Covered Payroll will not include any part of
his or her monthly Covered Earnings which exceed $15,000.
TL-004774
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SCHEDULE OF BENEFITS FOR CLASS 3
Eligibility Waiting Period
For Employees hired on or before the Policy Effective Date: No Waiting Period
For Employees hired after the Policy Effective Date: No Waiting Period
Definition of Disability/Disabled
The Employee is considered Disabled if, solely because of Injury or Sickness, he or she is:
1. unable to perform the material duties of his or her Regular Occupation; and
2. unable to earn 80% or more of his or her Indexed Earnings from working in his or her Regular
Occupation.
After Disability Benefits have been payable for 24 months, the Employee is considered Disabled if, solely
due to Injury or Sickness, he or she is:
1. unable to perform the material duties of any occupation for which he or she is, or may reasonably
become, qualified based on education, training or experience; and
2. unable to earn 60% or more of his or her Indexed Earnings.
The Insurance Company will require proof of earnings and continued Disability.
Definition of Covered Earnings
Covered Earnings means an Employee's wage or salary as reported by the Employer for work performed
for the Employer as in effect just prior to the date Disability begins. It includes earnings received from
commissions but not bonuses, overtime pay and other extra compensation. Covered Earnings are
determined initially on the date an Employee applies for coverage. A change in the amount of Covered
Earnings is effective on the date of the change, if the Employer gives us written notice of the change and
the required premium is paid.
Commissions will be averaged for the 12 months just prior to the date Disability begins, or the months
employed, if less than 12 months.
Any increase in an Employee's Covered Earnings will not be effective during a period of continuous
Disability.
Elimination Period 60 days
Gross Disability Benefit The lesser of 66.67% of an Employee's monthly Covered
Earnings rounded to the nearest dollar or the Maximum
Disability Benefit.
Maximum Disability Benefit $10,000 per month
Minimum Disability Benefit $100 per month
Disability Benefit Calculation
The Disability Benefit payable to the Employee is figured using the Gross Disability Benefit, Other
Income Benefits and the Return to Work Incentive. Monthly Benefits are based on a 30-day month. The
Disability Benefit will be prorated if payable for any period less than a month.
During any month the Employee has no Disability Earnings, the monthly benefit payable is the Gross
Disability Benefit less Other Income Benefits. During any month the Employee has Disability Earnings,
benefits are determined under the Return to Work Incentive. Benefits will not be less than the minimum
benefit shown in the Schedule of Benefits except as provided under the section Minimum Benefit.
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"Other Income Benefits" means any benefits listed in the Other Income Benefits provision that an
Employee receives on his or her own behalf or for dependents, or which the Employee's dependents
receive because of the Employee's entitlement to Other Income Benefits.
Return to Work Incentive
During any month the Employee has Disability Earnings, his or her benefits will be calculated as
follows.
The Employee's monthly benefit payable will be calculated as follows during the first 24 months
disability benefits are payable and the Employee has Disability Earnings:
1. Add the Employee's Gross Disability Benefit and Disability Earnings.
2. Compare the sum from 1. to the Employee's Indexed Earnings.
3. If the sum from 1. exceeds 100% of the Employee's Indexed Earnings, then subtract the
Indexed Earnings from the sum in 1.
4. The Employee's Gross Disability Benefit will be reduced by the difference from 3., as
well as by Other Income Benefits.
5. If the sum from 1. does not exceed 100% of the Employee's Indexed Earnings, the
Employee's Gross Disability Benefit will be reduced by Other Income Benefits.
After disability benefits are payable for 24 months, the monthly benefit payable is the Gross
Disability Benefit reduced by Other Income Benefits and 50% of Disability Earnings.
No Disability Benefits will be paid, and insurance will end if the Insurance Company determines
the Employee is able to work under a modified work arrangement and he or she refuses to do so
without Good Cause.
Additional Benefits
Survivor Benefit
Benefit Waiting Period: After 3 Monthly Benefits are payable.
Amount of Benefit: 100% of the sum of the last full Disability Benefit plus the
amount of any Disability Earnings by which the benefit had been
reduced for that month.
Maximum Benefit Period A single lump sum payment equal to 3 monthly Survivor
Benefits.
Maximum Benefit Period
The later of the Employee’s SSNRA* or the Maximum Benefit Period listed below.
Age When Disability Begins Maximum Benefit Period
Age 62 or under The Employee's 65th birthday or the date the 42nd Monthly
Benefit is payable, if later.
Age 63 The date the 36th Monthly Benefit is payable.
Age 64 The date the 30th Monthly Benefit is payable.
Age 65 The date the 24th Monthly Benefit is payable.
Age 66 The date the 21st Monthly Benefit is payable.
Age 67 The date the 18th Monthly Benefit is payable.
Age 68 The date the 15th Monthly Benefit is payable.
Age 69 or older The date the 12th Monthly Benefit is payable.
*SSNRA means the Social Security Normal Retirement Age in effect under the Social Security Act on the
Policy Effective Date.
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Initial Premium Rates
$.62 per $100 of Covered Payroll
Covered Payroll for an Employee will mean his or her Covered Earnings for the insurance month prior to
the date the determination is made. However, an Employee's Covered Payroll will not include any part of
his or her monthly Covered Earnings which exceed $15,000.
TL-004774
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ELIGIBILITY FOR INSURANCE
An Employee in one of the Classes of Eligible Employees shown in the Schedule of Benefits is eligible to
be insured on the Policy Effective Date, or the day after he or she completes the Eligibility Waiting
Period, if later. The Eligibility Waiting Period is the period of time the Employee must be in Active
Service to be eligible for coverage. It will be extended by the number of days the Employee is not in
Active Service.
Except as noted in the Reinstatement Provision, if an Employee terminates coverage and later wishes to
reapply, or if a former Employee is rehired, a new Eligibility Waiting Period must be satisfied. An
Employee is not required to satisfy a new Eligibility Waiting Period if insurance ends because he or she is
no longer in a Class of Eligible Employees, but continues to be employed and within one year becomes a
member of an eligible class.
TL-004710
EFFECTIVE DATE OF INSURANCE
An Employee will be insured on the date he or she becomes eligible, if the Employee is not required to
contribute to the cost of this insurance.
An Employee who is required to contribute to the cost of this insurance may elect to be insured only by
authorizing payroll deduction in a form approved by the Employer and the Insurance Company. The
effective date of this insurance depends on the date coverage is elected.
Insurance for an Employee who applies for insurance within 31 days after he or she becomes eligible is
effective on the latest of the following dates.
1. The Policy Effective Date.
2. The date payroll deduction is authorized.
3. The date the Insurance Company receives the Employee's completed enrollment form.
If an Employee's enrollment form is received more than 31 days after he or she is eligible for this
insurance, the Insurability Requirement must be satisfied before this insurance is effective. If approved,
this insurance is effective on the date the Insurance Company agrees in writing to insure the Employee.
If an Employee is not in Active Service on the date insurance would otherwise be effective, it will be
effective on the date he or she returns to any occupation for the Employer on a Full-time basis.
TL-004712
TERMINATION OF INSURANCE
An Employee's coverage will end on the earliest of the following dates:
1. the date the Employee is eligible for coverage under a plan intended to replace this coverage;
2. the date the Policy is terminated;
3. the date the Employee is no longer in an eligible class;
4. the day after the end of the period for which premiums are paid;
5. the date the Employee is no longer in Active Service;
6. the date benefits end for failure to comply with the terms and conditions of the Policy.
Disability Benefits will be payable to an Employee who is entitled to receive Disability Benefits when the
Policy terminates, if he or she remains disabled and meets the requirements of the Policy. Any period of
Disability, regardless of cause, that begins when the Employee is eligible under another group disability
coverage provided by any employer, will not be covered.
TL-007505.00
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CONTINUATION OF INSURANCE
This Continuation of Insurance provision modifies the Termination of Insurance provision to allow
insurance to continue under certain circumstances if the Insured Employee is no longer in Active Service.
Insurance that is continued under this provision is subject to all other terms of the Termination of
Insurance provisions.
Disability Insurance continues if an Employee's Active Service ends due to a Disability for which benefits
under the Policy are or may become payable. Premiums for the Employee will be waived while
Disability Benefits are payable. If the Employee does not return to Active Service, this insurance ends
when the Disability ends or when benefits are no longer payable, whichever occurs first.
If an Employee’s Active Service ends due to personal or family medical leave approved timely by the
Employer, insurance will continue for an Employee for up to 12 weeks, if the required premium is paid
when due.
If an Employee’s Active Service ends due to any other leave of absence approved in writing by the
Employer prior to the date the Employee ceases work insurance will continue for an Employee until the
end of the month in which the leave begins if the required premium is paid. An approved leave of
absence does not include termination of employment.
If an Employee’s Active Service ends due to a layoff, insurance will continue for an Employee until the
end of the month in which the leave begins if the required premium is paid.
If an Employee’s Active Service ends due to any other excused short term absence from work that is
reported to the Employer timely in accordance with the Employer’s reporting requirements for such short
term absence, insurance for an Employee will continue until the earlier of:
a. the date the Employee’s employment relationship with the Employer terminates;
b. the date premiums are not paid when due;
c. the end of the 30 day period that begins with the first day of such excused absence;
d. the end of the period for which such short term absence is excused by the Employer.
Notwithstanding any other provision of this policy, if an Employee’s Active Service ends due to
termination of employment, or any other termination of the employment relationship, insurance will
terminate and Continuation of Insurance under this provision will not apply.
If an Employee’s insurance is continued pursuant to this Continuation of Insurance provision, and he or
she becomes Disabled during such period of continuation, Disability Benefits will not begin until the later
of the date the Elimination Period is satisfied or the date he or she is scheduled to return to Active
Service.
TL-004716
TAKEOVER PROVISION
This provision applies only to Employees eligible under this Policy who were covered for long term
disability coverage on the day prior to the effective date of this Policy under the Prior Plan provided by
the Policyholder or by an entity that has been acquired by the Policyholder.
A. This section A applies to Employees who are not in Active Service on the day prior to the effective
date of this Policy due to a reason for which the Prior Plan and this Policy both provide for
continuation of insurance. If required premium is paid when due, the Insurance Company will insure
an Employee to which this section applies against a disability that occurs after the effective date of
this Policy for the affected employee group. This coverage will be provided until the earlier of the
date: (a) the employee returns to Active Service, (b) continuation of insurance under the Prior Plan
would end but for termination of that plan; or (c) the date continuation of insurance under this Policy
would end if computed from the first day the employee was not in Active Service. The Policy will
provide this coverage as follows:
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1. If benefits for a disability are covered under the Prior Plan, no benefits are payable under this
Plan.
2. If the disability is not a covered disability under the Prior Plan solely because the plan terminated,
benefits payable under this Policy for that disability will be the lesser of: (a) the disability benefits
that would have been payable under the Prior Plan; and (b) those provided by this Policy. Credit
will be given for partial completion under the Prior Plan of Elimination Periods and partial
satisfaction of pre-existing condition limitations.
B. The Elimination Period under this Policy will be waived for a Disability which begins while the
Employee is insured under this Policy if all of the following conditions are met:
1. The Disability results from the same or related causes as a Disability for which monthly benefits
were payable under the Prior Plan;
2. Benefits are not payable for the Disability under the Prior Plan solely because it is not in effect;
3. An Elimination Period would not apply to the Disability if the Prior Plan had not ended;
4. The Disability begins within 6 months of the Employee’s return to Active Service and the
Employee’s insurance under this Policy is continuous from this Policy’s Effective Date.
C. Except for any amount of benefit in excess of a Prior Plan's benefits, the Pre-existing Condition
Limitation will not apply to an Employee covered under a Prior Plan who satisfied the pre-existing
condition limitation, if any, under that plan. If an Employee, covered under a Prior Plan, did not fully
satisfy the pre-existing condition limitation of that plan, credit will be given for any time that was
satisfied under the Prior Plan's pre-existing condition limitation.
Benefits will be determined based on the lesser of: (1) the amount of the gross disability benefit under
the Prior Plan and any applicable maximums; and (2) those provided by this Policy.
If benefits are payable under the Prior Plan for the Disability, no benefits are payable under this
Policy.
TL-005108
DESCRIPTION OF BENEFITS
The following provisions explain the benefits available under the Policy. Please see the Schedule of
Benefits for the applicability of these benefits to each class of Insureds.
Disability Benefits
The Insurance Company will pay Disability Benefits if an Employee becomes Disabled while covered
under this Policy. The Employee must satisfy the Elimination Period, be under the Appropriate Care of a
Physician, and meet all the other terms and conditions of the Policy. He or she must provide the
Insurance Company, at his or her own expense, satisfactory proof of Disability before benefits will be
paid. The Disability Benefit is shown in the Schedule of Benefits.
The Insurance Company will require continued proof of the Employee’s Disability for benefits to
continue.
Elimination Period
The Elimination Period is the period of time an Employee must be continuously Disabled before
Disability Benefits are payable. The Elimination Period is shown in the Schedule of Benefits.
A period of Disability is not continuous if separate periods of Disability result from unrelated causes.
Disability Benefit Calculation
The Disability Benefit Calculation is shown in the Schedule of Benefits. Monthly Disability Benefits are
based on a 30 day period. They will be prorated if payable for any period less than a month. If an
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Employee is working while Disabled, the Disability Benefit Calculation will be the Return to Work
Incentive.
Return to Work Incentive
The Return to Work Incentive is shown in the Schedule of Benefits. An Employee may work for wage or
profit while Disabled. In any month in which the Employee works and a Disability Benefit is payable,
the Return to Work Incentive applies.
The Insurance Company will, from time to time, review the Employee's status and will require
satisfactory proof of earnings and continued Disability.
Minimum Benefit
The Insurance Company will pay the Minimum Benefit shown in the Schedule of Benefits despite any
reductions made for Other Income Benefits. The Minimum Benefit will not apply if benefits are being
withheld to recover an overpayment of benefits.
Other Income Benefits
An Employee for whom Disability Benefits are payable under this Policy may be eligible for benefits
from Other Income Benefits. If so, the Insurance Company may reduce the Disability Benefits by the
amount of such Other Income Benefits.
Other Income Benefits include:
1. any amounts received (or assumed to be received*) by the Employee or his or her dependents
under:
- the Canada and Quebec Pension Plans;
- the Railroad Retirement Act;
- any local, state, provincial or federal government disability or retirement plan or law
payable for Injury or Sickness provided as a result of employment with the Employer;
- any sick leave or salary continuation plan of the Employer;
- any work loss provision in mandatory "No-Fault" auto insurance.
2. any Social Security disability or retirement benefits the Employee or any third party receives (or
is assumed to receive*) on his or her own behalf or for his or her dependents; or which his or her
dependents receive (or are assumed to receive*) because of his or her entitlement to such benefits.
3. any Retirement Plan benefits funded by the Employer. "Retirement Plan" means any defined
benefit or defined contribution plan sponsored or funded by the Employer. It does not include an
individual deferred compensation agreement; a profit sharing or any other retirement or savings
plan maintained in addition to a defined benefit or other defined contribution pension plan, or any
employee savings plan including a thrift, stock option or stock bonus plan, individual retirement
account or 40l(k) plan.
4. any proceeds payable under any franchise or group insurance or similar plan. If other insurance
applies to the same claim for Disability, and contains the same or similar provision for reduction
because of other insurance, the Insurance Company will pay for its pro rata share of the total
claim. "Pro rata share" means the proportion of the total benefit that the amount payable under
one policy, without other insurance, bears to the total benefits under all such policies.
5. any amounts received (or assumed to be received*) by the Employee or his or her dependents
under any workers' compensation, occupational disease, unemployment compensation law or
similar state or federal law payable for Injury or Sickness arising out of work with the Employer,
including all permanent and temporary disability benefits. This includes any damages,
compromises or settlement paid in place of such benefits, whether or not liability is admitted.
6. any amounts paid because of loss of earnings or earning capacity through settlement, judgment,
arbitration or otherwise, where a third party may be liable, regardless of whether liability is
determined.
Dependents include any person who receives (or is assumed to receive*) benefits under any applicable
law because of an Employee’s entitlement to benefits.
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*See the Assumed Receipt of Benefits provision.
Increases in Other Income Benefits
Any increase in Other Income Benefits during a period of Disability due to a cost of living adjustment
will not be considered in calculating the Employee’s Disability Benefits after the first reduction is made
for any Other Income Benefits. This section does not apply to any cost of living adjustment for Disability
Earnings.
Lump Sum Payments
Other Income Benefits or earnings paid in a lump sum will be prorated over the period for which the sum
is given. If no time is stated, the lump sum will be prorated over five years.
If no specific allocation of a lump sum payment is made, then the total payment will be an Other Income
Benefit.
Assumed Receipt of Benefits
The Insurance Company will assume the Employee (and his or her dependents, if applicable) are
receiving benefits for which they are eligible from Other Income Benefits. The Insurance Company will
reduce the Employee’s Disability Benefits by the amount from Other Income Benefits it estimates are
payable to the Employee and his or her dependents.
The Insurance Company will waive Assumed Receipt of Benefits, except for Disability Earnings for work
the Employee performs while Disability Benefits are payable, if the Employee:
1. provides satisfactory proof of application for Other Income Benefits;
2. signs a Reimbursement Agreement;
3. provides satisfactory proof that all appeals for Other Income Benefits have been made unless the
Insurance Company determines that further appeals are not likely to succeed; and
4. submits satisfactory proof that Other Income Benefits were denied.
The Insurance Company will not assume receipt of any pension or retirement benefits that are actuarially
reduced according to applicable law, until the Employee actually receives them.
Social Security Assistance
The Insurance Company may help the Employee in applying for Social Security Disability Income
(SSDI) Benefits, and may require the Employee to file an appeal if it believes a reversal of a prior
decision is possible.
The Insurance Company will reduce Disability Benefits by the amount it estimates the Employee will
receive, if the Employee refuses to cooperate with or participate in the Social Security Assistance
Program.
Recovery of Overpayment
The Insurance Company has the right to recover any benefits it has overpaid. The Insurance Company
may use any or all of the following to recover an overpayment:
1. request a lump sum payment of the overpaid amount;
2. reduce any amounts payable under this Policy; and/or
3. take any appropriate collection activity available to it.
The Minimum Benefit amount will not apply when Disability Benefits are reduced in order to recover any
overpayment.
If an overpayment is due when the Employee dies, any benefits payable under the Policy will be reduced
to recover the overpayment.
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Successive Periods of Disability
A separate period of Disability will be considered continuous:
1. if it results from the same or related causes as a prior Disability for which benefits were payable;
and
2. if, after receiving Disability Benefits, the Employee returns to work in his or her Regular
Occupation for less than 6 consecutive months; and
3. if the Employee earns less than the percentage of Indexed Earnings that would still qualify him or
her to meet the definition of Disability/Disabled during at least one month.
Any later period of Disability, regardless of cause, that begins when the Employee is eligible for coverage
under another group disability plan provided by any employer will not be considered a continuous period
of Disability. For any separate period of disability which is not considered continuous, the Employee
must satisfy a new Elimination Period.
LIMITATIONS
Limited Benefit Periods for Mental or Nervous Disorders
The Insurance Company will pay Disability Benefits on a limited basis during an Employee's lifetime for
a Disability caused by, or contributed to by, any one or more of the following conditions. Once 24
monthly Disability Benefits have been paid, no further benefits will be payable for any of the following
conditions.
1) Anxiety disorders
2) Delusional (paranoid) disorders
3) Depressive disorders
4) Eating disorders
5) Mental illness
6) Somatoform disorders (psychosomatic illness)
If, before reaching his or her lifetime maximum benefit, an Employee is confined in a hospital for more
than 14 consecutive days, that period of confinement will not count against his or her lifetime limit. The
confinement must be for the Appropriate Care of any of the conditions listed above.
Limited Benefit Periods for Alcoholism and Drug Addiction or Abuse
The Insurance Company will pay Disability Benefits on a limited basis during an Employee's lifetime for
a Disability caused by, or contributed to by, any one or more of the following conditions. Once 24
monthly Disability Benefits have been paid, no further benefits will be payable for any of the following
conditions.
1) Alcoholism
2) Drug addiction or abuse
If, before reaching his or her lifetime maximum benefit, an Employee is confined in a hospital for more
than 14 consecutive days, that period of confinement will not count against his or her lifetime limit. The
confinement must be for the Appropriate Care of any of the conditions listed above.
Pre-Existing Condition Limitation
The Insurance Company will not pay benefits for any period of Disability caused or contributed to by, or
resulting from, a Pre-existing Condition. A "Pre-existing Condition" means any Injury or Sickness for
which the Employee incurred expenses, received medical treatment, care or services including diagnostic
measures, took prescribed drugs or medicines, or for which a reasonable person would have consulted a
Physician within 3 months before his or her most recent effective date of insurance.
The Pre-existing Condition Limitation will apply to any added benefits or increases in benefits. This
limitation will not apply to a period of Disability that begins after an Employee is covered for at least 12
months after his or her most recent effective date of insurance, or the effective date of any added or
increased benefits.
TL-007500.00
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ADDITIONAL BENEFITS
Rehabilitation During a Period of Disability
If the Insurance Company determines that a Disabled Employee is a suitable candidate for rehabilitation,
the Insurance Company may require the Employee to participate in a Rehabilitation Plan and assessment
at our expense. The Insurance Company has the sole discretion to approve the Employee's participation
in a Rehabilitation Plan and to approve a program as a Rehabilitation Plan. The Insurance Company will
work with the Employee, the Employer and the Employee's Physician and others, as appropriate, to
perform the assessment, develop a Rehabilitation Plan, and discuss return to work opportunities.
The Rehabilitation Plan may, at the Insurance Company's discretion, allow for payment of the Employee's
medical expense, education expense, moving expense, accommodation expense or family care expense
while he or she participates in the program.
If an Employee fails to fully cooperate in all required phases of the Rehabilitation Plan and assessment
without Good Cause, no Disability Benefits will be paid, and insurance will end.
TL-007501.00
Survivor Benefit
The Insurance Company will pay a Survivor Benefit if an Employee dies while Monthly Benefits are
payable. The Employee must have been continuously Disabled for the Survivor Benefit Waiting Period
before the first benefit is payable. These benefits will be payable for the Maximum Benefit Period for
Survivor Benefits.
Benefits will be paid to the Employee's Spouse. If there is no Spouse, benefits will be paid in equal
shares to the Employee's surviving Children. If there are no Spouse and no Children, benefits will be paid
to the Employee's estate.
"Spouse" means an Employee's lawful spouse. "Children" means an Employee's unmarried children
under age 21 who are chiefly dependent upon the Employee for support and maintenance. The term
includes a stepchild living with the Employee at the time of his or her death.
TL-005107
TERMINATION OF DISABILITY BENEFITS
Benefits will end on the earliest of the following dates:
1. the date the Employee earns from any occupation, more than the percentage of Indexed Earnings
set forth in the definition of Disability applicable to him or her at that time;
2. the date the Insurance Company determines he or she is not Disabled;
3. the end of the Maximum Benefit Period;
4. the date the Employee dies;
5. the date the Employee refuses, without Good Cause, to fully cooperate in all required phases of
the Rehabilitation Plan and assessment;
6. the date the Employee is no longer receiving Appropriate Care;
7. the date the Employee fails to cooperate with the Insurance Company in the administration of the
claim. Such cooperation includes, but is not limited to, providing any information or documents
needed to determine whether benefits are payable or the actual benefit amount due.
Benefits may be resumed if the Employee begins to cooperate fully in the Rehabilitation Plan within 30
days of the date benefits terminated.
TL-007502.00
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EXCLUSIONS
The Insurance Company will not pay any Disability Benefits for a Disability that results, directly or
indirectly, from:
1. suicide, attempted suicide, or self-inflicted injury while sane or insane.
2. war or any act of war, whether or not declared.
3. active participation in a riot.
4. commission of a felony.
5. the revocation, restriction or non-renewal of an Employee’s license, permit or certification
necessary to perform the duties of his or her occupation unless due solely to Injury or Sickness
otherwise covered by the Policy.
In addition, the Insurance Company will not pay Disability Benefits for any period of Disability during
which the Employee is incarcerated in a penal or corrections institution.
TL-007503.00
CLAIM PROVISIONS
Notice of Claim
Written notice, or notice by any other electronic/telephonic means authorized by the Insurance Company,
must be given to the Insurance Company within 31 days after a covered loss occurs or begins or as soon
as reasonably possible. If written notice, or notice by any other electronic/telephonic means authorized
by the Insurance Company, is not given in that time, the claim will not be invalidated or reduced if it is
shown that notice was given as soon as was reasonably possible. Notice can be given at our home office
in Philadelphia, Pennsylvania or to our agent. Notice should include the Employer's Name, the Policy
Number and the claimant's name and address.
Claim Forms
When the Insurance Company receives notice of claim, the Insurance Company will send claim forms for
filing proof of loss. If claim forms are not sent within 15 days after notice is received by the Insurance
Company, the proof requirements will be met by submitting, within the time required under the "Proof of
Loss" section, written proof, or proof by any other electronic/telephonic means authorized by the
Insurance Company, of the nature and extent of the loss.
Claimant Cooperation Provision
Failure of a claimant to cooperate with the Insurance Company in the administration of the claim may
result in termination of the claim. Such cooperation includes, but is not limited to, providing any
information or documents needed to determine whether benefits are payable or the actual benefit amount
due.
Insurance Data
The Employer is required to cooperate with the Insurance Company in the review of claims and
applications for coverage. Any information the Insurance Company provides in these areas is
confidential and may not be used or released by the Employer if not permitted by applicable privacy laws.
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Proof of Loss
Written proof of loss, or proof by any other electronic/telephonic means authorized by the Insurance
Company, must be given to the Insurance Company within 90 days after the date of the loss for which a
claim is made. If written proof of loss, or proof by any other electronic/telephonic means authorized by
the Insurance Company, is not given in that 90 day period, the claim will not be invalidated nor reduced if
it is shown that it was given as soon as was reasonably possible. In any case, written proof of loss, or
proof by any other electronic/telephonic means authorized by the Insurance Company, must be given not
more than one year after that 90 day period. If written proof of loss, or proof by any other
electronic/telephonic means authorized by the Insurance Company, is provided outside of these time
limits, the claim will be denied. These time limits will not apply while the person making the claim lacks
legal capacity.
Written proof, or proof by any other electronic/telephonic means authorized by the Insurance Company,
that the loss continues must be furnished to the Insurance Company at intervals required by us. Within 30
days of a request, written proof of continued Disability and Appropriate Care by a Physician must be
given to the Insurance Company.
Time of Payment
Disability Benefits will be paid at regular intervals of not less frequently than once a month. Any
balance, unpaid at the end of any period for which the Insurance Company is liable, will be paid at that
time.
To Whom Payable
Disability Benefits will be paid to the Employee. If any person to whom benefits are payable is a minor
or, in the opinion of the Insurance Company, is not able to give a valid receipt, such payment will be
made to his or her legal guardian. However, if no request for payment has been made by the legal
guardian, the Insurance Company may, at its option, make payment to the person or institution appearing
to have assumed custody and support.
If an Employee dies while any Disability Benefits remain unpaid, the Insurance Company may, at its
option, make direct payment to any of the following living relatives of the Employee: spouse, mother,
father, children, brothers or sisters; or to the executors or administrators of the Employee's estate. The
Insurance Company may reduce the amount payable by any indebtedness due.
Payment in the manner described above will release the Insurance Company from all liability for any
payment made.
Physical Examination and Autopsy
The Insurance Company, at its expense, will have the right to examine any person for whom a claim is
pending as often as it may reasonably require. The Insurance Company may, at its expense, require an
autopsy unless prohibited by law.
Legal Actions
No action at law or in equity may be brought to recover benefits under the Policy less than 60 days after
written proof of loss, or proof by any other electronic/telephonic means authorized by the Insurance
Company, has been furnished as required by the Policy. No such action shall be brought more than 3
years after the time satisfactory proof of loss is required to be furnished.
Time Limitations
If any time limit stated in the Policy for giving notice of claim or proof of loss, or for bringing any action
at law or in equity, is less than that permitted by the law of the state in which the Employee lives when
the Policy is issued, then the time limit provided in the Policy is extended to agree with the minimum
permitted by the law of that state.
Physician/Patient Relationship
The Insured will have the right to choose any Physician who is practicing legally. The Insurance
Company will in no way disturb the Physician/patient relationship.
TL-004724
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ADMINISTRATIVE PROVISIONS
Premiums
The premiums for this Policy will be based on the rates currently in force, the plan and the amount of
insurance in effect.
Changes in Premium Rates
The premium rates may be changed by the Insurance Company from time to time with at least 31 days
advance written notice. No change in rates will be made until 36 months after the Policy Effective Date.
An increase in rates will not be made more often than once in a 12 month period. However, the Insurance
Company reserves the right to change the rates even during a period for which the rate is guaranteed if
any of the following events take place.
1. The terms of the Policy change.
2. A division, subsidiary, affiliated company or eligible class is added or deleted from the Policy.
3. There is a change in the factors bearing on the risk assumed.
4. Any federal or state law or regulation is amended to the extent it affects the Insurance Company's
benefit obligation.
5. The Insurance Company determines that the Employer has failed to promptly furnish any
necessary information requested by the Insurance Company, or has failed to perform any other
obligations in relation to the Policy.
If an increase or decrease in rates takes place on a date that is not a Premium Due Date, a pro rata
adjustment will apply from the date of the change to the next Premium Due Date.
Reporting Requirements
The Employer must, upon request, give the Insurance Company any information required to determine
who is insured, the amount of insurance in force and any other information needed to administer the plan
of insurance.
Payment of Premium
The first premium is due on the Policy Effective Date. After that, premiums will be due monthly unless
the Employer and the Insurance Company agree on some other method of premium payment.
If any premium is not paid when due, the plan will be canceled as of the Premium Due Date, except as
provided in the Policy Grace Period section.
Notice of Cancellation
The Employer or the Insurance Company may cancel the Policy as of any Premium Due Date by giving
31 days advance written notice. If a premium is not paid when due, the Policy will automatically be
canceled as of the Premium Due Date, except as provided in the Policy Grace Period section.
Policy Grace Period
A Policy Grace Period of 60 days will be granted for the payment of the required premiums under this
Policy. This Policy will be in force during the Policy Grace Period. The Employer is liable to the
Insurance Company for any unpaid premium for the time this Policy was in force.
Grace Period for the Insured
If the required premium is not paid on the Premium Due Date, there is a 60 day grace period after each
premium due date after the first. If the required premium is not paid during the grace period, insurance
will end on the last day for which premium was paid.
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Reinstatement of Insurance
An Employee's insurance may be reinstated if it ends because the Employee is on an unpaid leave of
absence.
An Employee's insurance may be reinstated only if reinstatement occurs within 12 weeks from the date
insurance ends due to an Employer approved unpaid leave of absence or must be returning from military
service pursuant to the Uniformed Services Employment and Reemployment Rights Act of 1994
(USERRA). For insurance to be reinstated the following conditions must be met.
1. An Employee must be in a Class of Eligible Employees.
2. The required premium must be paid.
3. A written request for reinstatement must be received by the Insurance Company within 31 days
from the date an Employee returns to Active Service.
Reinstated insurance will be effective on the date the Employee returns to Active Service. If an
Employee did not fully satisfy the Eligibility Waiting Period or the Pre-Existing Condition Limitation (if
any) before insurance ended due to an unpaid leave of absence, credit will be given for any time that was
satisfied.
TL-004720
GENERAL PROVISIONS
Entire Contract
The entire contract will be made up of the Policy, the application of the Employer, a copy of which is
attached to the Policy, and the applications, if any, of the Insureds.
Incontestability
All statements made by the Employer or by an Insured are representations not warranties. No statement
will be used to deny or reduce benefits or as a defense to a claim, unless a copy of the instrument
containing the statement has been furnished to the claimant. In the event of death or legal incapacity, the
beneficiary or representative must receive the copy.
After two years from an Insured's effective date of insurance, or from the effective date of any added or
increased benefits, no such statement will cause insurance to be contested except for fraud or eligibility
for coverage.
Misstatement of Age
If an Insured's age has been misstated, the Insurance Company will adjust all benefits to the amounts that
would have been purchased for the correct age.
Policy Changes
No change in the Policy will be valid until approved by an executive officer of the Insurance Company.
This approval must be endorsed on, or attached to, the Policy. No agent may change the Policy or waive
any of its provisions.
Workers' Compensation Insurance
The Policy is not in lieu of and does not affect any requirements for insurance under any Workers'
Compensation Insurance Law.
Certificates
A certificate of insurance will be delivered to the Employer for delivery to Insureds. Each certificate will
list the benefits, conditions and limits of the Policy. It will state to whom benefits will be paid.
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Assignment of Benefits
The Insurance Company will not be affected by the assignment of an Insured's certificate until the
original assignment or a certified copy of the assignment is filed with the Insurance Company. The
Insurance Company will not be responsible for the validity or sufficiency of an assignment. An
assignment of benefits will operate so long as the assignment remains in force provided insurance under
the Policy is in effect. This insurance may not be levied on, attached, garnisheed, or otherwise taken for a
person's debts. This prohibition does not apply where contrary to law.
Clerical Error
A person's insurance will not be affected by error or delay in keeping records of insurance under the
Policy. If such an error is found, the premium will be adjusted fairly.
Agency
The Employer and Plan Administrator are agents of the Employee for transactions relating to insurance
under the Policy. The Insurance Company is not liable for any of their acts or omissions.
TL-004726
Certain Internal Revenue Code (IRC) & Internal Revenue Service (IRS) Functions
The Insurer may agree with the Subscriber to perform certain functions required by the Internal Revenue
Code and IRS regulations. Such functions may include the preparation and filing of wage and tax
statements (Form W-2) for disability benefit payments made under this Policy. In consideration of the
payment of premiums by the Subscriber, the Insurer waives the right to transfer liability with respect to
the employer taxes imposed on the Insurer by IRS Regulation 32.1(e)(1) for monthly Disability payments
made under this Policy. Employee money may not be used to fund the Premium for the services and
payments of this section.
TL-009230.00
DEFINITIONS
Please note, certain words used in this document have specific meanings. These terms will be capitalized
throughout this document. The definition of any word, if not defined in the text where it is used, may be
found either in this Definitions section or in the Schedule of Benefits.
Active Service
An Employee is in Active Service on a day which is one of the Employer's scheduled work days if either
of the following conditions are met.
1. The Employee is performing his or her regular occupation for the Employer on a full-time basis.
He or she must be working at one of the Employer's usual places of business or at some location
to which the employer's business requires an Employee to travel.
2. The day is a scheduled holiday or vacation day and the Employee was performing his or her
regular occupation on the preceding scheduled work day.
An Employee is in Active Service on a day which is not one of the Employer's scheduled work days only
if he or she was in Active Service on the preceding scheduled work day.
Appropriate Care
Appropriate Care means the determination of an accurate and medically supported diagnosis of the
Employee’s Disability by a Physician, or a plan established by a Physician of ongoing medical treatment
and care of the Disability that conforms to generally accepted medical standards, including frequency of
treatment and care.
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Consumer Price Index (CPI-W)
The Consumer Price Index for Urban Wage Earners and Clerical Workers published by the U.S.
Department of Labor. If the index is discontinued or changed, another nationally published index that is
comparable to the CPI-W will be used.
Disability Earnings
Any wage or salary for any work performed for any employer during the Employee’s Disability,
including commissions, bonus, overtime pay or other extra compensation.
Employee
For eligibility purposes, an Employee is an employee of the Employer in one of the "Classes of Eligible
Employees." Otherwise, Employee means an employee of the Employer who is insured under the Policy.
Employer
The Employer who has subscribed to the Policyholder and for the benefit of whose Employees this policy
has been issued. The Employer, named as the Subscriber on the front of this Policy, includes any
affiliates or subsidiaries covered under the Policy. The Employer is acting as an agent of the Insured for
transactions relating to this insurance. The actions of the Employer shall not be considered the actions of
the Insurance Company.
Full-time
Full-time means the number of hours set by the Employer as a regular work day for Employees in the
Employee's eligibility class.
Good Cause
A medical reason preventing participation in the Rehabilitation Plan. Satisfactory proof of Good Cause
must be provided to the Insurance Company.
Indexed Earnings
For the first 12 months Monthly Benefits are payable, Indexed Earnings will be equal to Covered
Earnings. After 12 Monthly Benefits are payable, Indexed Earnings will be an Employee's Covered
Earnings plus an increase applied on each anniversary of the date Monthly Benefits became payable. The
amount of each increase will be the lesser of:
1. 10% of the Employee's Indexed Earnings during the preceding year of Disability; or
2. the rate of increase in the Consumer Price Index (CPI-W) during the preceding calendar year.
Injury
Any accidental loss or bodily harm which results directly and independently of all other causes from an
Accident.
Insurability Requirement
An eligible person will satisfy the Insurability Requirement for an amount of coverage on the day the
Insurance Company agrees in writing to accept him or her as insured for that amount. To determine a
person's acceptability for coverage, the Insurance Company will require evidence of good health and may
require it be provided at the Employee's expense.
Insurance Company
The Insurance Company underwriting the Policy is named on the Policy cover page.
Insured
A person who is eligible for insurance under the Policy, for whom insurance is elected, the required
premium is paid and coverage is in force under the Policy.
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Physician
Physician means a licensed doctor practicing within the scope of his or her license and rendering care and
treatment to an Insured that is appropriate for the condition and locality. The term does not include an
Employee, an Employee's spouse, the immediate family (including parents, children, siblings or spouses
of any of the foregoing, whether the relationship derives from blood or marriage), of an Employee or
spouse, or a person living in an Employee's household.
Prior Plan
The Prior Plan refers to the plan of insurance providing similar benefits sponsored by the Employer in
effect directly prior to the Policy Effective Date. A Prior Plan will include the plan of a company in
effect on the day prior to that company's addition to this Policy after the Policy Effective Date.
Regular Occupation
The occupation the Employee routinely performs at the time the Disability begins. In evaluating the
Disability, the Insurance Company will consider the duties of the occupation as it is normally performed
in the general labor market in the national economy. It is not work tasks that are performed for a specific
employer or at a specific location.
Rehabilitation Plan
A written plan designed to enable the Employee to return to work. The Rehabilitation Plan will consist of
one or more of the following phases:
1. rehabilitation, under which the Insurance Company may provide, arrange or authorize
educational, vocational or physical rehabilitation or other appropriate services;
2. work, which may include modified work and work on a part-time basis.
Sickness
Any physical or mental illness.
TL-007500.00
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Life Insurance Company of North America
a stock insurance company
Rider to Group Policy No. LK-961943
Effective Date of Rider: January 1, 2009
Eligible Classes to which this Rider applies: All Classes
MODIFICATION OF GROUP DISABILITY POLICY
TO ADD DOMESTIC PARTNER AS AN ELIGIBLE SURVIVOR UNDER THE SURVIVOR
BENEFIT
The Survivor Benefit are modified in the Policy as follows:
1. All references to the term “Spouse” are replaced by "Spouse or Domestic Partner" except for the
following references:
a. The first reference to “Spouse” in the benefit text is changed to “Spouse, or Domestic Partner
if there is no Spouse,”
b. The text pertaining to the definition of “Spouse" remains unchanged.
2. The following definition of Domestic Partner is added.
“Domestic Partner” means a person who is registered as the Employee’s domestic partner with
the California Secretary of State.
Except for the above, this Rider does not change the Group Policy to which it is attached.
Life Insurance Company of North America
By:
Karen S. Rohan, President
TL-007152-1.05
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IMPORTANT CHANGES FOR STATE REQUIREMENTS
If an Employee resides in one of the following states, the provisions of the certificate are modified for
residents of the following states. The modifications listed apply only to residents of that state.
Louisiana residents:
The percentage of Indexed Earnings, if any, that qualifies an insured to meet the definition of
Disability/Disabled may not be less than 80%.
Minnesota residents:
The Pre-existing Condition Limitation, if any, may not be longer than 24 months from the insured’s
most recent effective date of insurance.
Texas residents:
Any provision offsetting or otherwise reducing any benefit by an amount payable under an individual
or franchise policy will not apply.
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LIFE INSURANCE COMPANY OF NORTH AMERICA
PHILADELPHIA, PA 19192-2235
We, City of Palo Alto, whose main office address is Palo Alto, CA, hereby approve and accept the terms of
Group Policy Number LK-961943 issued by the LIFE INSURANCE COMPANY OF NORTH AMERICA
to the TRUSTEE OF THE GROUP INSURANCE TRUST FOR EMPLOYERS IN THE PUBLIC
ADMINISTRATION INDUSTRY.
This form is to be signed in duplicate. One part is to be retained by City of Palo Alto; the other part is to be
returned to the LIFE INSURANCE COMPANY OF NORTH AMERICA.
City of Palo Alto
Signature and Title: _________________________________________ Date:__________________________
(This Copy Is To Be Returned To Life Insurance Company of North America)
--------------------------------------------------------------------------------------------------------------------------------------
LIFE INSURANCE COMPANY OF NORTH AMERICA
PHILADELPHIA, PA 19192-2235
We, City of Palo Alto, whose main office address is Palo Alto, CA, hereby approve and accept the terms of
Group Policy Number LK-961943 issued by the LIFE INSURANCE COMPANY OF NORTH AMERICA
to the TRUSTEE OF THE GROUP INSURANCE TRUST FOR EMPLOYERS IN THE PUBLIC
ADMINISTRATION INDUSTRY.
This form is to be signed in duplicate. One part is to be retained by City of Palo Alto; the other part is to be
returned to the LIFE INSURANCE COMPANY OF NORTH AMERICA.
City of Palo Alto
Signature and Title: _________________________________________ Date:__________________________
(This Copy Is To Be Retained By City of Palo Alto)
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Life Insurance Company of North America
1601 Chestnut Street
Philadelphia, Pennsylvania 19192-2235
AMENDMENT
Policyholder: Trustee of the Group Insurance Trust for Employers in the Public Administration Industry
Subscriber: City of Palo Alto Policy No.: OK - 964302
This Amendment is attached to and made part of the Policy specified above. It is subject to all of the policy provisions that
do not conflict with its provisions.
Subscriber and We hereby agree that the Policy is amended as follows:
Effective January 1, 2022, the following rates will be in force for Classes 1, 2 and 3 for coverage under the Policy:
Premium Rate: Basic Insurance
Employee Rate: $0.015 per $1,000
Voluntary Insurance
Employee Rate: $0.02 per $1,000
No change in rates will be made until 36 months after the effective date of this Amendment. However, the Company
reserves the right to change the rates at any time during a period for which the rates are guaranteed if the conditions
described in the Changes in Premium Rates provision under the Administrative Provisions section of the Policy apply.
Except for the above, this Amendment does not change the Policy in any way.
Life Insurance Company of North America
William J. Smith, President
Date: August 26, 2021
Amendment No. 04ri0215
GA -00-4000.00
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City of Palo Alto Professional Services Contract No. C22183900 Rev. Dec.15, 2020
EXHIBIT B SCHEDULE OF PERFORMANCE CONSULTANT shall provide Insurance benefits as specified in EXHIBIT “A” Scope of Services. Claims shall be processed in a timely manner to the reasonable satisfaction of the
CITY.
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City of Palo Alto Professional Services Contract No. C22183900 Rev. Dec.15, 2020
EXHIBIT C COMPENSATION
The CITY agrees to compensate the CONSULTANT for professional services performed in accordance with the terms and conditions of this Agreement based on the rate schedules within Exhibits A-1, A-2 and A-3.
The compensation to be paid to CONSULTANT under this Agreement for all services described
in Exhibit “A” (“Services”) and reimbursable expenses shall not exceed $1,920,000.00. CONSULTANT agrees to complete all Services, including reimbursable expenses, within this amount. Any work performed or expenses incurred for which payment would result in a total exceeding the maximum amount of compensation set forth herein shall be at no cost to the CITY.
REIMBURSABLE EXPENSES CITY’S sole financial obligation to CONSULTANT shall be the payment of premiums as provided in the Policies.
ADDITIONAL SERVICES
The CONSULTANT shall provide additional services only by advanced, written authorization from the CITY. The CONSULTANT, at the CITY’s project manager’s request, shall submit a detailed written proposal including a description of the scope of services, schedule, level of effort, and CONSULTANT’s proposed maximum compensation, including reimbursable expenses, for
such services based on the rates set forth in such proposal. The additional services scope, schedule
and maximum compensation shall be negotiated and agreed to in writing by the CITY’s Project Manager and CONSULTANT prior to commencement of the services. Payment for additional services is subject to all requirements and restrictions in this Agreement.
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City of Palo Alto Professional Services Contract No. C22183900 Rev. Dec.15, 2020
EXHIBIT D INSURANCE REQUIREMENTS
CONSULTANTS TO THE CITY OF PALO ALTO (CITY), AT THEIR SOLE EXPENSE, SHALL FOR THE TERM OF THE CONTRACT OBTAIN AND MAINTAIN INSURANCE IN THE AMOUNTS FOR THE COVERAGE SPECIFIED BELOW, AFFORDED BY COMPANIES WITH AM BEST’S KEY RATING OF A-:VII, OR HIGHER, LICENSED OR AUTHORIZED TO TRANSACT INSURANCE BUSINESS IN THE STATE OF CALIFORNIA. AWARD IS CONTINGENT ON COMPLIANCE WITH CITY’S INSURANCE REQUIREMENTS AS SPECIFIED HEREIN.
REQUIRED TYPE OF COVERAGE REQUIREMENT
MINIMUM LIMITS
EACH OCCURRENCE AGGREGATE
YES YES WORKER’S COMPENSATION EMPLOYER’S LIABILITY STATUTORY STATUTORY STATUTORY STATUTORY
YES
GENERAL LIABILITY, INCLUDING PERSONAL INJURY, BROAD FORM PROPERTY DAMAGE BLANKET CONTRACTUAL, AND FIRE LEGAL LIABILITY
BODILY INJURY PROPERTY DAMAGE BODILY INJURY & PROPERTY DAMAGE COMBINED.
$1,000,000 $1,000,000 $1,000,000
$1,000,000 $1,000,000 $1,000,000
YES
AUTOMOBILE LIABILITY, INCLUDING ALL OWNED, HIRED, NON-OWNED
BODILY INJURY - EACH PERSON - EACH OCCURRENCE PROPERTY DAMAGE BODILY INJURY AND PROPERTY DAMAGE, COMBINED
$1,000,000 $1,000,000 $1,000,000 $1,000,000 $1,000,000
$1,000,000 $1,000,000 $1,000,000 $1,000,000 $1,000,000
YES
PROFESSIONAL LIABILITY, INCLUDING, ERRORS AND OMISSIONS, MALPRACTICE (WHEN APPLICABLE), AND NEGLIGENT PERFORMANCE
ALL DAMAGES $1,000,000
YES
THE CITY OF PALO ALTO IS TO BE NAMED AS AN ADDITIONAL INSURED: CONSULTANT, AT ITS SOLE COST AND EXPENSE, SHALL OBTAIN AND MAINTAIN, IN FULL FORCE AND EFFECT THROUGHOUT THE ENTIRE TERM OF ANY RESULTANT AGREEMENT, THE INSURANCE COVERAGE HEREIN DESCRIBED, INSURING NOT ONLY CONSULTANT AND ITS SUBCONSULTANTS, IF ANY, BUT ALSO, WITH THE EXCEPTION OF WORKERS’ COMPENSATION, EMPLOYER’S LIABILITY AND PROFESSIONAL INSURANCE, NAMING AS ADDITIONAL INSUREDS CITY, ITS COUNCIL MEMBERS, OFFICERS, AGENTS, AND EMPLOYEES.
I. INSURANCE COVERAGE MUST INCLUDE: A. A CONTRACTUAL LIABILITY ENDORSEMENT PROVIDING INSURANCE COVERAGE FOR CONSULTANT’S AGREEMENT TO INDEMNIFY CITY. II. THE CONSULTANT MUST SUBMIT CERTIFICATES(S) OF INSURANCE EVIDENCING REQUIRED COVERAGE AT THE FOLLOWING URL: HTTPS://WWW.PLANETBIDS.COM/PORTAL/PORTAL.CFM?COMPANYID=25569 III. ENDORSEMENT PROVISIONS WITH RESPECT TO THE INSURANCE AFFORDED TO ADDITIONAL INSUREDS: A. PRIMARY COVERAGE WITH RESPECT TO CLAIMS ARISING OUT OF THE OPERATIONS OF THE NAMED INSURED, INSURANCE AS AFFORDED BY THIS POLICY IS PRIMARY AND IS NOT ADDITIONAL TO OR CONTRIBUTING WITH ANY OTHER INSURANCE CARRIED BY OR FOR THE BENEFIT OF THE ADDITIONAL INSUREDS.
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City of Palo Alto Professional Services Contract No. C22183900 Rev. Dec.15, 2020
B. CROSS LIABILITY THE NAMING OF MORE THAN ONE PERSON, FIRM, OR CORPORATION AS INSUREDS UNDER THE POLICY SHALL NOT, FOR THAT REASON ALONE, EXTINGUISH ANY RIGHTS OF THE INSURED AGAINST ANOTHER, BUT THIS ENDORSEMENT, AND THE NAMING OF MULTIPLE INSUREDS, SHALL NOT INCREASE THE TOTAL LIABILITY OF THE COMPANY UNDER THIS POLICY. C. NOTICE OF CANCELLATION 1. IF THE POLICY IS CANCELED BEFORE ITS EXPIRATION DATE FOR ANY REASON OTHER THAN THE NON-PAYMENT OF PREMIUM, THE CONSULTANT SHALL PROVIDE CITY AT LEAST A THIRTY (30) DAY WRITTEN NOTICE BEFORE THE EFFECTIVE DATE OF CANCELLATION. 2. IF THE POLICY IS CANCELED BEFORE ITS EXPIRATION DATE FOR THE NON-PAYMENT OF PREMIUM, THE CONSULTANT SHALL PROVIDE CITY AT LEAST A TEN (10) DAY WRITTEN NOTICE BEFORE THE EFFECTIVE DATE OF CANCELLATION. EVIDENCE OF INSURANCE AND OTHER RELATED NOTICES ARE REQUIRED TO BE FILED WITH THE CITY OF PALO ALTO
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