Life Insurance Services Agreement
AMENDMENT NO. 1
TO BE ATTACHED TO AND MADE PART OF GROUP POLICY NO.: 000<H0124979
ISSUED TO: City of Salina
It is agreed that the above policy be replaced with the attached Policy, which is revised and dated
January 1,2010.
The effective date of this amendment is January 1, 2010; but only with respect to losses incurred on or
after that date. Nothing contained in this amendment shall change any of the terms and conditions of
this Policy; except as stated above.
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY
~IJ,&~
Officer of the Company
I ~ day of ---L11 o..y
2010
By
Title
c.J~ ~r
GLllOO AMEND.
The Lincoln National Life Insurance Company
A Stock Company Home Office Location: Fort Wayne, Indiana
Group Insurance Service Office: 8801 Indian Hills Drive, Omaha, NE 68114-4066 (402) 361-7300
Group Policyholder:
City of Salina
In Consideration of the Group Policyholder's application for this Policy and payment of all
premiums when due, The Lincoln National Life Insurance Company agrees to make the
payments provided in this Policy. to the persons entitled to them.
The first premium for this Policy is due on its effective date. Subsequent premiums are due on
February 1, 2010, and on the same day of each month after that. Policy anniversaries will be
each January 1st; unless shown otherwise on the Premium Rate Schedule inside.
The provisions and conditions set forth on the following pages are a part of this Policy, as fully
as if recited over the signatures below.
The Lincoln National Life Insurance Company has executed this Policy at its Group Insurance
Service Office in Omaha, Nebraska. The issue date of this Policy is January 1, 2010. This
policy supercedes and replaces any previously issued policy with an effective date of January
1, 2010.
~/J,&~
O~p~
SECRETARY
PRESIDENT
GROUP INSURANCE POLICY
No. 000010124979
PROVIDING
LIFE INSURANCE
DEPENDENT LIFE INSURANCE
GLllOl-TITLE PAGE
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01/01/10
TABLE OF CONTENTS
I
Schedule of Insurance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Definitions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
General Provisions ................................... .'. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . . . . . . . . . . 5
Provisions Applicable to Participating Employers.................... .............. .........6
Eligibility and Effective Dates for Personal Insurance... ... ... .... ... ...... ....... .........7
Individual Terminations.......................................................................... 8
Premiums and Premium Rates .................................................................. 9
Grace Period........................................................................................ 10
Policy Termination................................... .;............................................ 10
Beneficiary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . , . . . . . . . . . . . . . . . .. . . . . . . . . . . . .. 11
Assignments...,..................................,.................................,.............., 12
Facility of Payment................................................................................. 13
Death Benefit....................,..........,....................................................... 13
Settlement Options ................................................................................ 13
Extension of Death Benefit .. ................. ........ .... ....... .... .... ........ ... ..... ..... ...14
Accelerated Death Benefit ........ .......... ........ ... ,..... ..... ........... ...... ,.. .......... .15
Conversion Privilege. . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 17
Dependents Life Insurance...............,......................................................, 18
Claims Procedures for Life or Accidental Death and Dismemberment Benefits ....... 20
Prior Insurance Credit Provision .... ... ..... ,........ ............. .... ,.. ................... '" 23
Notice. . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
GLllOl-1
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01/01/10
SCHEDULE OF INSURANCE
The amount of an Insured Person's insurance is determined from the following table. The initial amount of
coverage is the amount which applies to an Insured Person I s Class on the date his or her coverage takes
effect. An Insured Person may become eligible for increases in the amount of insurance in accord with the
table. Any such increase will take effect on the latest of:
(1) the first day of the Insurance Month which coincides with or follows the date on which the
Insured Person becomes eligible for the increase; provided he or she is Actively at Work on
that day;
(2) the day the Insured Person resumes Active Work, if not Actively at Work on the day the
increase would otherwise take effect; or
(3) the day any required evidence of insurability is approved by the Company.
Any decrease will take effect on the day of the change; whether or not the Insured Person is Actively at
Work.
The amount of an Insured Person's Life Insurance shall be reduced by the amount of any Life Insurance in
effect as a result of exercising the rights under the Conversion Privilege section of this Policy.
CLASSIFICATION
Class 1
All Full-Time Employees excluding Salina Airport
Authority Employees
Class 2
All Regular Part-Time Employees
Class 3
All Full-Time Salina Airport Authority Employees
Class 4
All Retired City of Salina Employees who retired
prior to December 31, 1995
WAITING PERIOD:
None (For date insurance begins, refer to "Effective Date" section)
GLllOI-2
3
01/01/10
SCHEDULE OF INSURANCE (CONTINUED)
LIFE INSURANCE
Amount of Personal
Life Insurance
Class 1
One times Basic Annual Earnings, rounded to the next higher $1,000; subject
to a minimum of $20,000 and a maximum of $200,000.
Class 2
One times Basic Annual Earnings, rounded. to the next higher $1,000; subject
to a minimum of $10,000 and a maximum of $100,000.
Class 3
One times Basic Annual Earnings, rounded to the next higher $1,000; subject
to a minimum of $20,000 and a maximum of $200,000.
Class 4
$20,000
For Classes 1, 2 and 3, Personal Life Insurance will be reduced as follows:
At age 70, benefits will reduce by 50% of the original amount.
Benefits will terminate when the Insured Person retires.
If the Insured Person first enrolls for Personal Life Insurance at age 70 or older, the above age reductions
will apply to:
Any Guarantee Issue Amount available without evidence of insurability; and
The maximum amount of insurance for which he or she is eligible.
For Class 4, Personal Life Insurance will terminate when the Insured Person attains age 70.
Basic Annual Earnings means the Insured Person's annual base salary or annualized hourly pay from the
Group Policyholder before taxes on the Determination Date.. The "Determination Date" is the last day
worked just prior to the loss.
It does not include commissions, bonuses, overtime pay, or any other extra compensation. It does not
include income from a source other than the Group Policyholder. It will not exceed the amount shown in the
Group Policyholder's financial records or the amount for which premium has been paid; whichever is less.
GLI101-2
3-2
01/01/10
SCHEDULE OF INSURANCE (CONTINUED)
Dependent
Spouse
Dependent Child
(live birth to 6 months)
Dependent Child
(age 6 months to 25 years,
25 years if a full-time student)
DEPENDENTS INSURANCE
(For Classes 1 and 3)
Amount of Life Insurance
$15,000
1,000
10,000
Spouse Life Insurance will terminate when the Insured Employee retires.
Dependent
Spouse
Dependent Child
(live birth to 6 months)
Dependent Child
(age 6 months to 25 years,
25 years if a full-time student)
DEPENDENTS INSURANCE
(For Class 2)
Amount of Life Insurance
$7,500
1,000
5,000
Spouse Life Insurance will terminate when the Insured Employee retires.
Dependent
Spouse
DEPENDENTS INSURANCE
(For Class. 4)
Amount of Life Insurance
$10,000
Spouse Life Insurance will terminate when the Spouse attains age 70.
GLllOl-2
3-3
01/01/10
SCHEDULE OF INSURANCE (CONTINUED)
Dependents Life Insurance may not exceed 50% of the Insured Person's amount of Life Insurance.
Insured Persons are not required to make contributions for Personal Life Insurance. Insured Persons are
required to make contributions for Dependent Life Insurance.
The following chart applies to the Extension of Death Benefit provision when benefits end upon attainment of
the Social Security Normal Retirement Age:
Year of Birth Normal Retirement Age
1937 and prior 65
1938 65 and 2 months
1939 65 and 4 months
1940 65 and 6 months
1941 65 and 8 months
1942 65 and 10 months
1943 - 54 66
1955 66 and 2 months
1956 66 and 4 months
1957 66 and 6 months
1958 66 and 8 months
1959 66 and 10 months
1960 and later 67
Note: Persons born on January 1 of any year should refer to the Normal Retirement Age for the previous
year.
If any evidence of insurability is required, it will be provided at the Person's own expense.
GLI101-2
I
3-4
01/01/10
DEFINITIONS
ACTIVE WORK or ACTIVELY AT WORK means an employee's full-time performance of all customary
duties of his or her occupation at:
(1) the GROUP POLICYHOLDER'S place of business; or
(2) any other business location where the employee is required to travel.
Unless disabled on the prior workday or on the day of absence, an employee will be considered Actively at
Work on the following days:
(1) a Saturday, Sunday or holiday which is not a scheduled workday;
(2) a paid vacation day, or other scheduled or unscheduled non-workday; or
(3) an excused or emergency leave of absence (except a medical leave).
COMPANY means The Lincoln National Life Insurance Company, an Indiana corporation, whose Group
Insurance Service Office address is 8801 Indian Hills Drive, Omaha, Nebraska 68114-4066.
DAY OR DATE means at 12:01 A.M., Standard Time, at the GROUP POLICYHOLDER'S place of
business; when used with regard to eligibility dates and effective dates. It means 12:00 midnight, Standard
Time, at the same place; when used with regard to termination dates.
FULL-TIME EMPLOYEE means an employee of the GROUP POLICYHOLDER:
(1) whose employment with the GROUP POLICYHOLDER is the employee's principal
occupation;
(2) who is not a temporary or seasonal employee; and
(3) who is regularly scheduled to work at such occupation at least 40 hours each week.
GROUP POLICYHOLDER means the person, partnership, corporation, or trust as shown on the Title Page
of this Policy.
INSURANCE MONTH means that period of time:
(1) beginning at 12:01 A.M. Standard Time, at the GROUP POLICYHOLDER'S place of
business on the first day of any calendar month; and
(2) ending at 12:00 midnight on the last day of the same calendar month.
INSURED PERSON means a PERSON for whom the coverages provided by this Policy are in effect.
PERSON means a FULL-TIME EMPLOYEE, REGULAR PART-TIME EMPLOYEE or RETIREE of the
GROUP POLICYHOLDER:
(1) who is a member of an employee class which is eligible for coverage under this Policy; and
(2) who has completed an enrollment form.
PERSONAL INSURANCE means the insurance provided by this Policy on Insured Persons.
PHYSICIAN means a licensed practitioner of the healing arts other than the Insured Person or a relative of
the Insured Person. In Kansas, the term includes a medical doctor, dentist, optometrist, podiatrist, duly
certified psychologist, osteopath, chiropractor, licensed special clinical social worker, and any other duly
licensed practitioner acting within the scope of his or her license.
POLICY means this Group Insurance Policy issued by the Company to the Group Policyholder.
REGULAR PART-TIME EMPLOYEE means an employee of the GROUP POLICYHOLDER who is
regularly scheduled to work at least 20 hours each week.
RETIREE means a former FULL-TIME EMPLOYEE of the GROUP POLICYHOLDER who is eligible for
retirement benefits.
GLI101-3 KS
4
(REV)
01101110
GENERAL PROVISIONS
ENTIRE CONTRACT. The entire contract between the parties consists of:
(1) this Policy and the Group Policyholder's application (a copy is attached);
(2) the Participating Employer's participation agreement; and
(3) the Insured Persons' enrollment cards, if any.
All statements made by the Group Policyholder and qy Insured Persons are representations and not
warranties. No statement made by an Insured Person will, be used to contest the coverage provided by this
Policy; unless:
(1) it is contained in a written statement signed by that Insured Person; and
(2) a copy of the statement is furnished to the Insured Person or Beneficiary.
Only an Officer of the Company may change this Policy or 'extend the time for payment of any premium. No
change will be valid unless made in writing and signed by an Officer of the Company. Any change so made
will be binding on all persons referred to in this Policy.
INCONTESTABILITY. Except for the non-payment of premiums, the Company may not contest the validity
of this Policy as to any Insured Person after it has been in force for two years during his or her lifetime. This
clause will not affect the Company's right to contest claims made for disability, accidental death, or
accidental dismemberment benefits.
NONP ARTICIP A TION. This Policy will not be entitled to share in the surplus earnings of the Company.
BASIS OF RESERVE. The reserve for this Policy will not; be less than the reserve computed using:
(1) the 1970 Intercompany Group Life Disability Valuation Table; and
(2) interest at not less than three percent per annum.
INFORMATION TO BE FURNISHED. The Group Policyholder and Participating Employers may be
required to furnish any information needed to administer this Policy. Clerical error by the Group
Policyholder or Participating Employer will not:
(1) affect the amount of insurance which otherwise would be in effect; or
(2) continue insurance which otherwise would be terminated.
Once an error is discovered, an equitable adjustment in premium will be made. If a premium adjustment
involves the return of unearned premium, the amount of the return will be limited to the twelve month period
which precedes the date the Company receives proof such' an adjustment should be made.
The Company may inspect any of the Group Policyholder's records or Participating Employers I records
which relate to this Policy.
MISSTATEMENT OF AGE. If an Insured Person's age lias been misstated, premiums will be subject to an
equitable adjustment. If the amount of benefit depends upon age; then the benefit will be that which would
have been payable, based upon the person's correct age.
CERTIFICATES. The Group Policyholder will be furnished with individual Certificates for delivery to each
Insured Person. These certificates summarize the benefits provided by this Policy. If there is a conflict
between the Policy and the Certificate, the Policy will control.
CONFORMITY WITH STATE STATUTES. If any provision of this Policy conflicts with any applicable
law, the provision will be deemed to conform to the minimum requirements of the law.
WORKER'S COMPENSATION. This Policy is not to be construed to provide benefits required by Worker's
Compensation laws.
5
P.E.
01/01/10
GLllOI-4.195
PROVISIONS APPLICABLE TO PARTICIPATING EMPLOYERS
A Participating Employer has no rights under this Policy except as provided in this Section. The
Participating Employer will be responsible for all premiums payable with respect to any of its Employees
who are Insured Persons under this Policy.
P ARTICIP A TING EMPLOYER means an employer who has been approved by the Company for
participation in the coverage provided by this Policy. The following are Participating Employers:
Salina Airport Authority
EFFECTIVE DATE. As it applies to any Participating Employer, the Effective Date of this Policy will be
the later of:
(a) the date this Policy is issued;
(b) the first day of the Insurance Month following the Company's approval of the employer's
Participation Agreement; or
(c) a date agreed upon by the Company, the Participating Employer, and the Group
Policyholder.
TERMINATION: A Participating Employer's participation under this Policy ends on the earliest of the
following dates: .
(a) the date the employer no longer meets the definition of a Participating Employer;
(b) the date the Participating Employer has fewer than 10 Insured Persons;
(c) the date the Participating Employer suspends active business operations, is placed in
bankruptcy or receivership, dissolves, merges or relocates;
(d) the date the Participating Employer, without good cause, fails to:
(a) promptly furnish the Company any information it may reasonably require; or
(b) perform its duties pertaining to this Policy in good faith;
(e) the last day of the Insurance Month for which premium is paid;
(t) the last day of the Insurance Month in which the Company receives the Participating
Employer's written request to cease participation; or
(g) the date the Company terminates the coverage under this Policy for all Participating
Employer's in this state.
On the day participation ends, Policy coverage will terminate for all the Participating Employer's employees
and their Dependents. If an employer ceases to be a Participating Employer, it may not be a Participating
Employer again; until the Company reapproves it as such.
GLllOl-4a 04
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01/01/10
ELIGIBILITY AND EFFECTIVE DATES FOR PERSONAL INSURANCE
ELIGIBILITY. A Person becomes eligible for the coverage provided by this Policy on the later of:
(1) the Policy's date of issue; or
(2) the date the Waiting Period is completed.
WAITING PERIOD. (See Schedule of Insurance).
EFFECTIVE DATE. Personal Insurance becomes effective on the latest of:
(1) the date the Person becomes eligible for the coverage;
(2) the date the Person resumes Active Work, if not Actively at Work on the day he or she
becomes eligible;
(3) the date the Person makes written application for Personal Insurance; and signs:
(a) a payroll deduction order, if Insured Persons pay any part of the Policy
premium; or
(b) an order to pay premiums from the Person's Section 125 Plan account, if
Employer contributions are made through a Section 125 Plan; or
(4) the date the Company approves the Person's coverage, if evidence of insurability is required.
EVIDENCE OF INSURABILITY. Evidence of insurability satisfactory to the Company must be submitted
when:
(1)
(2)
a Person makes written application for Personal Insurance more than 31 days after becoming
eligible for the coverage; or
a Person makes written application for Personal Insurance after he or she has requested:
(a) to cancel Personal Insurance;
(b) to stop payroll deductions for the coverage; or
(c) to stop premium payments from the Section 125 Plan account.
EXCEPTIONS. If an Insured Person's coverage terminates due to an approved leave of absence or military
leave, the Company will waive any Waiting Period or evidence of insurability requirement upon his or her
return; provided:
(1) the Person returns within six months after the leave begins;
(2) the Person applies or is enrolled within 31 days after resuming Active Work; and
(3) the reinstated amount of insurance does not exceed the amount which terminated.
If an Insured Person's coverage terminates due to a lay-off, the Company will waive any Waiting Period or
evidence of insurability requirement upon his or her return; provided:
(1) the Person returns within 12 months after the date the lay-off begins;
(2) the Person applies or is reenrolled within 31 days after resuming Active Work; and
(3) the reinstated amount of insurance does not exceed the amount which terminated.
Reinstatement will take effect on the date the Insured Person returns to Active Work.
If an Insured Person's coverage terminates because his or her employment ends, the Company will waive any
Waiting Period or.evidence of insurability requirement upon his or her return; provided:
(1) the Person is rehired within 12 months after employment terminated;
(2) the Person applies or is reenrolled within 31 days after resuming Active Work; and
(3) the reinstated amount of insurance does not exceed the amount which terminated.
Reinstatement will take effect on the date the Insured Person returns to Active Work.
GLllOI-593
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(FMLA)
01/01110
INDIVIDUAL TERMINATIONS
An Insured Person's coverage will terminate on the earliest of:
(1) the date this Policy terminates;
(2) the last day of the Insurance Month in which the Insured Person requests termination;
(3) the last day of the last Insurance Month for which premium payment is made on the Insured
Person's behalf;
(4) the date the Insured Person ceases to be in a class of employees which is eligible for
coverage under this Policy;
(5) with respect to any particular insurance benefit, the date the portion of the Policy providing
that benefit terminates;
(6) the date on which the Insured Person's employment with the Group Policyholder or
Participating Employer terminates, unless the Insured Person is eligible for Retirement
Benefits; or
(7) the date the Insured Person enters the armed services of any state or country on active duty;
except for duty of 30 days or less for training in the Reserves or National Guard. (If the
Insured Person sends proof of military service, the Company will refund any unearned
premium. )
Ceasing Active Work results in termination of insurance; but coverage may be continued as follows:
(1) If the Insured Person is disabled due to illness or injury, then coverage may be continued
until the earliest of:
(a) 12 Insurance Months after the disability begins;
(b) the date the Person is no longer disabled; or
(c) for Life Insurance; the date the Insured Person qualifies for any Extension of
Death Benefit under this Policy;
provided premium payments are made on his or her behalf.
(2) If the Insured Person ceases work due to a temporary layoff, an approved leave of absence,
or a military leave; then coverage may be continued:
(a) for three Insurance Months after the layoff or leave begins;
(b) provided premium payments are made on his or her behalf.
GL1101-593
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(FMLA)
01/01/10
PREMIUMS AND PREMIUM RATES
PAYMENT OF PREMIUMS. No coverage provided by this Policy will be in effect until the first premium
for such coverage is paid. For coverage to remain in effect, each subsequent premium must be paid on or
before its due date. The Group Policyholder is responsible for paying all premiums as they become due.
Premiums are payable on or before their due dates at the Company's Group Insurance Service Office. The
premium must be paid in U.S. dollars.
PREMIUM RATE CHANGE. The Company may change any premium rate on any of the following dates:
(1) the date this Policy's terms are changed;
(2) the date the Company's liability is changed due to a change in federal, state or local law;
(3) the date the Group Policyholder (or any covered division, subsidiary or affiliated company)
relocates, dissolves or merges, or is added to or removed from this Policy;
(4) the date any coverage for one or more classes ceases to be provided under this Policy;
(5) the date the number of Insured Persons changes by 25 % or more from the enrollment on the
date this Policy took effect, or the most recent Rate Guarantee Date expired, if later; or
(6) on any premium due date on or after this Policy's first anniversary, or any later rate
guarantee date agreed upon by the Company.
Unless the Company and the Group Policyholder agree otherwise, the Company will give at least 31 days'
advance written notice of any increase in premium rates.
PREMIUM AMOUNT. The amount of premium due on each due date will be the sum of the products
obtained by multiplying each rate shown in the Premium Rate Schedule by the amount of insurance to which
the rate applies.
Premium adjustments will not be pro-rated daily. Instead, premium will be adjusted as follows.
(1) When an Insured Person's insurance or increase takes effect, premium will be charged from
the monthly due date coinciding with or next following that change.
(2) When all or part of an Insured Person's insurance terminates, the applicable premium will
cease on the monthly due date coinciding with or next following that termination.
(3) When premiums are paid other than monthly, increases or decreases will result in adjustment
from the premium due date coinciding with or next following that change.
The above manner of charging premium is for accounting purposes only. It will not extend coverage beyond
a date it would have otherwise terminated. Each premium payment will include any adjustments in past
premiums, which are needed due to changes that have not yet been taken into account. If a premium
adjustment involves a return of unearned premium, the refund will be limited to the prior 12-month period.
PREMIUM RATE SCHEDULE
Monthly Group Life Rate
$.14 per $1,000 of insurance
Monthly Dependent Life Rate
Classes 1 and 3 2.99 per Family Unit
Class 2 1.82 per Family Unit
Class 4 2.00 per Family Unit
The above rates are guaranteed until January 1, 2013, unless an exception listed in the Premium Rate Change
section applies.
After that, any premium rate change will be as shown in the renewal letter. The Company will send the
Group Policyholder a renewal letter prior to each Policy Anniversary.
GLll01-604
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01/01/10
GRACE PERIOD
A grace period of 31 days from the due date will be allowed for the payment of each premium after the first.
This Policy will remain in effect during the grace period; unless the Group Policyholder gives the Company
advance written notice of termination. The Group Policynolder will remain liable for payment of a pro rata
premium for the time this Policy remained in force during the grace period.
POLICY TERMINATION
TERMINATION BY THE COMPANY. To terminate this Policy, the Company must give the Group
Policyholder at least 31 days' advance written notice of its intent to do so. The Company may terminate this
Policy coverage on the due date of any premium; if:
(1) the total number of Insured Persons is less than 10;
(2) all of the premium is paid by the Group Policyholder and less than 100 % of those eligible for
coverage are insured;
(3) part of the premium is paid by Insured Persons and less than 75 % of those eligible for
coverage are insured;
(4) the Group Policyholder, without good cause, fails to:
(a) promptly furnish any information the Company reasonably requires; or
(b) perform its duties pertaining to this Policy in good faith;
(5) the Company terminates all other policies where permitted by their terms, which provide life
insurance or weekly disability income insurance in the same state in which this Policy was
issued; or
(6) state law otherwise requires this Policy to be terminated.
TERMINATION BY GROUP POLICYHOLDER. The Group Policyholder may terminate this Policy at any
time, by giving the Company advance written notice. Coverage will then terminate:
(1) on the date the Company receives the notice; or
(2) any later date the Group Policyholder and the Company have agreed upon.
The Group Policyholder remains responsible for the payment of premiums to the date of termination.
AUTOMATIC TERMINATION. If any premium remains unpaid at the end of the Grace Period; then this
Policy will automatically terminate, without any action on the Company's part, on the last day of the Grace
Period. The Group Policyholder remains responsible for the payment of premiums to the date of termination.
EFFECT ON INCURRED CLAIMS. Termination of this Policy will not affect benefits otherwise payable
for a claim incurred while this Policy is in force.
GLI101-704
10
No Bene.-lO lives
01/01/10
BENEFICIARY
PAYMENTS TO BENEFICIARY. At an Insured Person's death, the amount of his or her Personal Life
Insurance will be paid to the surviving Beneficiary. If the Insured Person has not named a Beneficiary, or if
no named Beneficiary survives the Insured Person; then payment will be made to that Insured Person's:
(1) surviving spouse; or, if none
(2) surviving child or children in equal shares; or, if none
(3) surviving parent or parents in equal shares; or, if none
(4) surviving brothers and sisters in equal shares; or, if none
(5) estate, or in accord with the Facility of Payment section of this Policy.
The amount payable to anyone shown above will be reduced by any amount paid in accord with the Facility
of Payment section.
In determining who is to receive payment, the Company may rely upon an affidavit by a member of the class
of relatives to receive payment. The Company will make payment based upon the affidavit it has; unless it
receives notice of a valid claim by some other person, at its Group Insurance Service Office, before paying
the proceeds. Such payment will release the Company from any further obligation for the Insured Person's
life insurance benefit.
If an Insured Person's named Beneficiary dies:
(1) within 15 days of the Insured Person's death; and
(2) before the Company receives satisfactory proof of the Insured Person's death;
then payment will be made as if the Insured Person had survived that Beneficiary; unless other provisions
have been made.
NAMING THE BENEFICIARY. An Insured Person's Beneficiary will be as shown on his or her enrollment
card, unless changed. This Policy may replace a group policy providing similar coverages. In that event, the
Beneficiary which the Insured Person named under the prior policy will be the Beneficiary under this Policy,
until changed.
CHANGING THE BENEFICIARY. Only the Insured Person, or his or her assignee, may change the
Beneficiary. A new Beneficiary may be named by filing a written notice of the change with the Company at
its Group Insurance Service Office. The change will be effective as of the date it was signed; subject to any
action the Company takes before receiving notice of the change.
When applying for a conversion policy under the Conversion Privilege Section, an Insured Person must name
a Beneficiary. The Beneficiary named for the conversion policy may be someone other than the person
named under this Policy. In that event, the application for the conversion policy will be treated as a written
notice of change of Beneficiary.
GLllOI-7.1A 96
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Pref. Bene.
01101110
ASSIGNMENTS
Personal Life Insurance may be assigned. The assignments allowed under this Policy are absolute
assignments and funeral assignments as described below.
No assignment will be binding on the Company unless and until:
(1) it is made on a form furnished by the Company;
(2) the original is completed and filed with the Company at its Group Insurance Service Office;
and
(3) it is approved by the Company.
The Company and the Group Policyholder do not assume responsibility . for the validity or effect of an
assignment.
ABSOLUTE ASSIGNMENTS. An Insured Person may make an irrevocable assignment of his or her
Personal Life Insurance as a gift (with no consideration), providing he or she has the legal capacity and the
mental capacity to do so. It may be made to a trust or to one or more of the Insured Person's relatives, their
estates, or to a trustee of a trust under which one of the relatives is a beneficiary.
The term "relatives" includes, but is not limited to, an Insured Person's spouse, parents, grandparents, aunts,
uncles, siblings, children, adopted children, stepchildren, and grandchildren.
In some states, community property is an established form of ownership that must be considered in making an
assignment. If an Insured Person makes an absolute assignment to two or more assignees, such assignees will
be joint owners with the right of survivorship between them. An Insured Person should consult with his or
her own legal advisor before making an assignment.
Once the assignment has been recorded by the Company, the Insured Person can no longer change the
beneficiary and cannot apply for conversion. Only the assignee can change the beneficiary designation if the
previous designation is revocable. An assignment will have no effect on a prior irrevocable beneficiary
designation. Only the assignee can apply for conversion but only when the Conversion Privilege provision
would have been available to the Insured Person in the absence of the assignment under this Policy.
An absolute assignment cannot be used as a collateral assignment.
FUNERAL ASSIGNMENTS. Upon an Insured Person's death, the beneficiary may assign the Personal Life
Insurance benefit to a funeral home for payment of burial expenses. After payment has been made for the
burial expenses to the assigned funeral home, the remaining death benefit is then paid in accord with the
Beneficiary and Settlement Options sections of this Policy.
GLll01-7.1C 01 KS
12
01/01/10
FACILITY OF PAYMENT
If any benefit under this Policy becomes payable by reason of death of the Insured Person, but no designated
beneficiary is then living, the Company may, at its option, pay a sum not exceeding $250.00 to any person
appearing to the Company equitably entitled by reason of having incurred funeral or other expenses incident
to the last illness or death of the Insured Person.
Any payment made in good faith under this Section will fully discharge the Company to the extent of the
payment.
DEATH BENEFIT
AMOUNT PAYABLE ON DEATH. Upon receipt of satisfactory proof of an Insured Person's death, the
Company will pay a death benefit equal to the amount of Personal Life Insurance in effect on the date of
death. This amount is shown in the Schedule of Insurance. The benefit will be paid as shown in the
Beneficiary, Facility of Payment, and Settlement Options sections.
SETTLEMENT OPTIONS
INSTALLMENTS. All or part of the death benefit may be received in installments, by making written
election to the Company.
ELECTION. While living, an Insured Person may direct the Company to pay the death benefit in
installments. If no such direction is in effect at the time of the Insured Person's death, the Beneficiary may
make such an election.
CONDITIONS. Any election, whether by an Insured Person or a Beneficiary, must comply with the
Company's practices at the time it is made. The amount applied under a settlement option must be at least
$2,000. It must be sufficient to provide a payment of at least $20 per month.
GLl101-8 96 KS
13
01/01110
EXTENSION OF DEATH BENEFIT
BENEFIT. Life insurance will be continued, without payment of premiums, for an Insured Person who:
(1) becomes Totally Disabled while insured under this policy and before reaching age 60;
(2) remains Totally Disabled for at least 6 months in a row; and
(3) submits satisfactory proof within the 7th through the 12th months of disability; or:
(a) as soon as reasonably possible after that; but
(b) not later than the 24th month of disability, unless he or she was legally incapacitated.
PREMIUM PAYMENT. Premium payments must continue until:
(1) the day the Insured Person is approved for this Extension of Death Benefit; or
(2) the day this Policy terminates (whichever occurs first).
Upon receipt of satisfactory proof, the Company will refund up to 12 months' premium paid for the Insured
Person's life insurance, from the 1st day of Total Disability.
DEFINITION. For this benefit, Total Disability or Totally Disabled means an Insured Person:
(1) is unable, due to sickness or injury, to engage in any employment or occupation for which such
Insured Person is or becomes qualified by reason of education, training, or experience; and
(2) is not engaging in any gainful employment or occupation.
AMOUNT CONTINUED. The life insurance continued by this section:
(1) will be the amount of Personal Life Insurance and any Dependent Life Insurance in effect on
the day the Insured Person's Total Disability begins; and
(2) will be subject to the reductions and terminations in effect under this Policy on that day.
If the Insured Person receives an Accelerated Death Benefit, the amount will be reduced in accord with that
provision. Any Accidental Death and Dismemberment Benefit will not be continued.
ADDITIONAL PROOF. At any time during this continuation, the Company may require the Insured Person:
(1) to submit further proof of his or her continued Total Disability; and
(2) to be examined by a Physician of the Company's choice, as often as reasonably necessary.
After the first two years of Total Disability, the Company will not request proof or an exam more than once a
year. Proof will be at the Insured Person's expense; unless the Company requests an exam by a Physician of
its choice.
When an Insured Person dies after submitting proof, further proof must be submitted to the Company
showing that he or she remained continuously and Totally Disabled until death. When an Insured Person dies
within 12 months after Total Disability begins, but before submitting proof; then his or her death benefit will
still be paid under the terms of this Policy. But the Company must first receive satisfactory proof of his or
her continuous Total Disability, from the last day of Active Work until the date of death.
TERMINATION. Any life insurance extended under this section will terminate automatically on:
(1) the day the Insured Person ceases to be Totally Disabled;
(2) the day the Insured Person fails to take a required medical examination;
(3) the 60th day after the Company mails a request for additional proof, if it is not given;
(4) the effective date of the Insured Person's individual conversion policy, with respect to any
amount of life insurance converted in accord with the Conversion Privilege section; or
(5) the day the Insured Person reaches Social Security Normal Retirement Age (SSNRA), as
shown in the Schedule of Insurance (whichever occurs first).
RIGHTS AFTER TERMINATION. If Total Disability ends, and the Insured Person does not return to a
class eligible for Policy coverage; then he or she may exercise the Conversion Privilege. If Total Disability
ends, and the Insured Person does return to an eligible class; then his or her Policy coverage will resume
when premium payments are resumed, and any conversion policy is surrendered as provided below.
CONVERSION POLICIES. If the Insured Person has exercised the Conversion Privilege, and the benefits
payable under this Policy and the conversion policy combined would exceed:
(1) the Insured Person's original amount of Policy coverage prior to the conversion; or
(2) any greater amount for which he or she later becomes insured under this Policy;
then benefits will be payable under the terms of this Policy. But the conversion policy must first be
surrendered to the Company; and no claim may be made under the conversion policy, except for refund of
premium less any dividends and policy loans.
14
Stand. Ext. - SSNRA
01/01/10
GLllOl-996
ACCELERATED DEATH BENEFIT
BENEFIT. The Accelerated Death Benefit is an advance payment of part of the Insured Person's Personal
Life Insurance. It may be paid to the Insured Person, in a lump sum, once during the Insured Person's
lifetime.
To qualify, a Terminal Insured Person must:
(1) have satisfied the Active Work requirement under this Policy;
(2) have been insured under this Policy:
(a) on the date of an injury which results in a Terminal condition; or
(b) for 30 days before being diagnosed Terminal' as a result of sickness; and
(3) have at least $2,000 of Personal Life Insurance under this Policy on the day before the
Accelerated Death Benefit is paid.
Receiving the Accelerated Death Benefit will reduce the Remaining Life Insurance and the Death Benefit
payable at death, as shown on the next page.
"Claimant," as used in this section, means the Terminal Insured Person for whom the Accelerated Death
Benefit is requested.
"Terminal" means the Insured Person has a medical condition which is expected to result in death within 12
months, despite appropriate medical treatment.
APPLYING FOR THE BENEFIT. To withdraw the Accelerated Death Benefit, the Insured Person (or his or
her legal representative) must send the Company:
(1) written election of the Accelerated Death Benefit, on forms supplied by the Company; and
(2) satisfactory proof that the Claimant is Terminal, including a Physician's written statement.
The Company reserves the right to decide whether such proof is satisfactory.
Before paying an Accelerated Death Benefit, the Company must also receive the written consent of any
irrevocable beneficiary, assignee or bankruptcy court with an interest in the benefit. (See Limitations 3, 4,
and 5.)
NOTE: THIS IS NOT A LONG-TERM CARE POLICY. RECEIVING THIS ACCELERATED
DEATH BENEFIT WILL REDUCE THE BENEFIT PAYABLE AT DEATH. ANY AMOUNT
WITHDRAWN MAY BE TAXABLE INCOME, SO THE INSURED PERSON SHOULD CONSULT A
TAX ADVISOR BEFORE APPLYING FOR THIS BENEFIT.
AMOUNT OF THE BENEFIT. The Insured Person may elect to withdraw an Accelerated Death Benefit in
any $1,000 increment; subject to:
(1) a minimum of $1,000 or 10% of the Claimant's amount of Life Insurance (whichever is
greater); and
(2) a maximum of $250,000 or 75% of the Claimant's amount of Life Insurance (whichever is
less) .
To determine the Accelerated Death Benefit, the Company will use the lesser of A orB below:
A. the Claimant's amount of Life Insurance which is in force on the day before the Accelerated
Death Benefit is paid; or
B. the Claimant's amount of Life Insurance which would be in force 12 months after that date;
if the coverage is scheduled to reduce, due to age, within 12 months after the Accelerated
Death Benefit is paid.
15
ADB-DEP.
01/01/10
GLll01-9.8 01 DAY
ADMINISTRATIVE CHARGE: NONE
WITHDRAWAL FEE: NONE
EFFECT ON AMOUNT OF LIFE INSURANCE. "Remaining Life Insurance" means the amount of Life
Insurance which remains in force on the Claimant's life after an Accelerated Death Benefit is paid. The
Remaining Life Insurance will equal:
(1) the Claimant's amount of Life Insurance which was used to determine the Accelerated Death
Benefit (A or B above); minus
(2) any percentage by which the Claimant's coverage is scheduled to reduce, due to age; if the
reduction occurs more than 12 months after the Accelerated Death Benefit is paid, and while
he or she is still living; minus
(3) the amount of the Accelerated Death Benefit withdrawn.
PREMIUM: There is no additional charge for this benefit. Continuation of the Remaining Life Insurance
will be subject to timely payment of the premium for the reduced amount; unless the Insured Person qualifies
for waiver of premium under this Policy's Extension of Death Benefit provision, if included.
CONDITIONS. If the Claimant exercises the Conversion Privilege after an Accelerated Death Benefit is
paid, the amount of the conversion policy will not exceed the amount of his or her Remaining Life Insurance.
If the Claimant has Accidental Death and Dismemberment benefits under this Policy, the Principal Sum will
not be affected by the payment of an Accelerated Death Benefit.
EFFECT ON DEATH BENEFIT. When the Claimant dies after an Accelerated Death Benefit is paid, the
amount of Remaining Life Insurance in force on the date of death will be paid as a Death Benefit. The
Insured Person's Death Benefit will be paid in accord with the Beneficiary section of this Policy. If the
Claimant dies after application for an Accelerated Death Benefit has been made, but before the Company has
made payment; then the request will be void and no Accelerated Death Benefit will be paid. The amount of
Life Insurance in force on the date of death will be paid in accord with Policy provisions.
EFFECT ON TAXES AND GOVERNMENT BENEFITS. Any Accelerated Death Benefit amount
withdrawn may be taxable income to the Insured Person. Receipt of the Accelerated Death Benefit may also
affect the Claimant's eligibility for Medicaid, Supplemental Security Income and other government benefits.
The Claimant should consult his or her own tax and legal advisor before applying for an Accelerated Death
Benefit. The Company is not responsible for any tax owed or government benefit denied, as a result of the
Accelerated Death Benefit payment.
LIMITATIONS. No Accelerated Death Benefit will be paid:
(1) if any required premium is due and unpaid;
(2) on any conversion policy purchased in accord with the Conversion Privilege;
(3) without the written approval of the bankruptcy court, if the Insured Person has filed for
bankruptcy;
(4) without the written consent of the beneficiary, if the Insured Person has named an
irrevocable beneficiary;
(5) without the written consent of the assignee, if the Insured Person has assigned his or her
rights under this Policy;
(6) if any part of the Life Insurance must be paid to the Insured Person's child, spouse or former
spouse; pursuant to a legal separation agreement, divorce decree, child support order or
other court order;
(7) if the Claimant is Terminal due to a suicide attempt, while sane or insane; or due to an
intentionally self-inflicted injury;
(8) if a government agency requires the Insured Person or the Claimant to use the Accelerated
Death Benefit to apply for, receive or continue a government benefit or entitlement; or
(9) if an Accelerated Death Benefit has been previously paid for the Claimant under this Policy.
GLllOI-9.8 01 DAY
16
ADB-DEP.
01/01/10
CONVERSION PRIVILEGE - CONVERSION BENEFITS
GENERAL BENEFIT. An individual life policy, known as a conversion policy, may be purchased from the
Company without evidence of insurability, if all or part of anyone's life insurance, provided by this Policy,
terminates for any reason except:
(1) termination or amendment of the Policy; or
(2) the Insured Person's request for:
(a) termination of insurance; or
(b) cancellation of payroll deduction.
To purchase a conversion policy, application and payment of the first premium must be made within 31 days
after the life insurance is terminated.
Any policy issued under the General Conversion Benefit will:
(1) be for an amount not to exceed the amount of the life insurance which was terminated;
(2) be on any form (except term) then issued by the Company at the age and amount for which
application is made;
(3) be issued at the Insured Person's age at nearest birthday;
(4) be issued without disability or other supplemental benefits; and
(5) require premiums based on the class of risk to which the person then belongs.
CONVERSION BENEFIT-POLICY TERMINATION OR AMENDMENT. A conversion policy also may
be purchased from the Company if:
(1) all or a part of anyone's insurance terminates due to amendment or termination of this
Policy; and
(2) that person has been covered continuously under this Policy for at least five years.
Any conversion policy issued due to Policy termination or amendment will be subject to the same conditions
as a policy issued under the General Conversion Benefit except its amount may not exceed the lesser of:
(1) $10,000; or
(2) the Amount of Life Insurance which terminates less the amount of any group life insurance
for which the Insured Person becomes eligible within 31 days after the termination.
PROVISIONS APPLICABLE TO ALL CONVERSION POLICIES
EFFECTIVE DATES. The coverage provided by a conversion policy issued under this Section will be
effective on the later of:
(1) its date of issue; or
(2) 31 days after the date on which the person's life insurance terminated.
DEATH DURING CONVERSION PERIOD. The Company will pay a death benefit under this Policy equal
to the amount of the life insurance which could have been converted, if the person:
(1) was entitled to purchase a conversion policy; and
(2) dies within the 31 day conversion period.
This death benefit will be paid even if no one applied for the conversion policy. If the first premium was
paid for the conversion policy, the amount of the premium will be refunded and the conversion policy will be
void.
NOTICE OF CONVERSION PRIVILEGES-INSURED PERSONS. When an Insured Person's Personal
Insurance terminates, written notice of the right to convert will be:
(1) given personally to the Insured Person;
(2) mailed by the Group Policyholder to the Insured Person at his last known address; or
(3) mailed by the Company to the Insured Person at his last known address as furnished by the
Group Policyholder.
An additional period in which to convert will be granted if this written notice is not given to the Insured
Person at least 15 days before the end of the 31 day conversion period. Any such extension of the conversion
period will expire on the earliest of:
(1) 15 days after the Insured Person is given the written notice; or
(2) 60 days after the end of the 31 day conversion period even if the Insured Person is never
given such notice.
No death benefit will be payable under this Policy after the 31 day conversion period has expired even though
the right to convert may be extended.
GLllOl-lO DEP.
17
01101110
DEPENDENTS LIFE INSURANCE
BENEFIT. Upon receipt of satisfactory proof of a Dependent's death while insured under this Policy, the
Company will pay the amount of the Dependents Life Insurance in effect on the date of such death. This
amount is shown in the Schedule of Insurance. The death benefit will be paid:
(1) to the Insured Person; or
(2) if the Insured Person fails to survive the Dependent, to the Insured Person's Beneficiary or
according to the Facility of Payment Section. .
DEPENDENT. A Dependent means a person who meets the definition of a dependent of the Insured Person
under the provision of the U.S. Internal Revenue Code; and is an Insured Person's:
(1) spouse who is not legally separated from the Insured Person;
(2) unmarried child less than 25 years of age;
(3) unmarried child less than 25 years of age, if attending an accredited educational institution
for the minimum credit hours required to maintain full-time student status there; or
(4) unmarried child who is totally and permanently disabled and who became so disabled prior to
reaching 25 years of age.
A legally adopted child is considered the Insured Person's child from the date of placement in the Insured
Person's home for an agency adoption; or from the date the adoption petition is filed, if later, for a private
adoption.
In addition to naturally born and legally adopted children, the word "child" includes an Insured Person's
stepchild or foster child; provided the child resides in the Insured Person's household and is dependent on the
Insured Person for principal support.
The term Dependent does not include anyone serving in the armed forces of any state or country; except for
duty of 30 days or less for training in the Reserves or National Guard.
ELIGIBILITY. An Insured Person becomes eligible for Dependents Life Insurance on the latest of:
(1) the date the Insured Person becomes eligible for Personal Insurance;
(2) the effective date of this Section; or
(3) the date the Insured Person first acquires a Dependent.
EFFECTIVE DATES. An Insured Person's Dependents Life Insurance will become effective on the latest of
the following dates:
(1) the date the Insured Person becomes eligible for Dependents Life Insurance;
(2) the date the Insured Person makes written application for Dependents Life Insurance and
signs a payroll deduction order; and
(3) the date the Company approves any required evidence of insurability on all the Insured
Person's Dependents.
If an Insured Person acquires a new Dependent while insured for Dependents Life Insurance, insurance for
that Dependent will take effect on the date the Dependent is acquired.
If a Dependent is confined in a hospital on the date his or her Dependents Life Insurance would otherwise
take effect, then Dependents Life Insurance for that Dependent will not take effect until ten days after fmal
discharge from the hospital.
GLlI01-lIB 97
18
B - wlo Suicide Exclusion
01101110
EVIDENCE OF INSURABILITY. Each Insured Person's Dependent must submit evidence of insurability
satisfactory to the Company if the Insured Person:
(1) makes application for Dependents Insurance more than 31 days after the date such Insured
Person becomes eligible for Dependents Insurance; or
(2) elects to be insured for Dependents Insurance after such Insured Person had requested:
(a) termination of the Dependents Insurance; or
(b) cancellation of the payroll deduction order; or
(3) makes application for Dependents Insurance after it has automatically terminated, due to
failure to pay premium by the end of the grace period.
INDIVIDUAL TERMINATION OF DEPENDENT INSURANCE. An Insured Person's Dependents
Insurance will cease for all of the Insured Person's Dependents on the earliest of:
(I) the date the Insured Person's Personal Insurance terminates;
(2) the date Dependent Insurance is discontinued under this Policy;
(3) the date the Insured Person ceases to be in a class of employees eligible for Dependent
Insurance;
(4) the date the Insured Person requests that the Dependent Insurance be terminated; or
(5) the last day of the premium paying period for which the Insured Person has made any
required contribution toward the cost of the Dependent Insurance.
Dependents Insurance on a particular Dependent will cease on the earliest of:
(1) the date he or she ceases to be a Dependent as defmed in this Policy;
(2) the date he or she becomes covered under this Policy as an Insured Person; or
(3) the date he or she enters the armed forces of any state or country; except for duty of 30 days
or less in the Reserves or National Guard. (If the Insured Person sends proof of military
service, the Company will refund any unearned premium.)
MISSTATEMENT OF AGE. If the age of a Dependent has been misstated, premiums will be subject to an
equitable adjustment. If the amount of benefit is dependent upon age, the benefit will be that which would
have been payable based upon the Dependent's correct age.
ASSIGNMENT. Dependents Insurance may not be assigned.
INCONTESTABILITY. Except for non-payment of premiums, the Company may not contest the validity of
this Policy as to any Dependent, after it has been in force for two years during the lifetime of that Dependent.
This clause will not affect the Company's right to contest claims made for accidental death, or
dismemberment benefits.
GLllOI-1297
19
01101110
CLAIMS PROCEDURES
FOR LIFE OR ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS
NOTE: This Policy may include an Extension of Death Benefit, an Accelerated Death Benefit or a
Living Benefit. If so, please refer to that section for special claim procedures.
NOTICE AND PROOF OF CLAIM
Notice of Claim. Written notice of an accidental death or dismemberment claim must be given within 20
days after the loss occurs; or as soon as reasonably possible after that. * The notice must be sent to the
Company's Group Insurance Service Office. It should include:
(1) the Insured Person's name and address; and
(2) the number of this Policy.
Claim Forms. When notice of claim is received, the Company will send claim forms for filing the required
proof. If the Company does not send the forms within 15 days; then the Insured Person or Beneficiary (the
claimant) may send the Company written proof of claim in a letter. It should state the nature, date and cause
of the loss.
Proof of Claim. The Company must be given written proof of claim within 90 days after the date of the
, loss; or as soon as reasonably possible after that. * Proof of claim must be provided at the claimant's own
expense. It must show the nature, date and cause of the loss. In addition to the information requested on the
claim form, documentation must include:
(1) A certified copy of the death certificate, for proof of death.
(2) A copy of any police report, for proof of accidental death or dismemberment.
(3) A signed authorization for the Company to obtain more information.
(4) Any other items the Company may reasonably require in support of the claim.
* Exception: Failure to give notice or furnish proof of claim within the required time period will not
invalidate or reduce the claim; if it is shown that it was done:
(1) as soon as reasonably possible; and
(2) in no event more than one year after it was required.
These time limits will not apply while the claimant lacks legal capacity.
EXAM OR AUTOPSY. At anytime while a claim is pending, the Company may have the Insured Person
examined:
(1) by a Physician of the Company's choice;
(2) as often as reasonably required.
If the Insured Person fails to cooperate with an examiner or fails to take an exam, without good cause; then
the Company may deny benefits, until the exam is completed. In case of death, the Company may also have
an autopsy done, where it is not forbidden by law. Any such exam or autopsy will be at the Company's
expense.
TIME OF PAYMENT OF CLAIMS. Any benefits payable under this Policy will be paid immediately after
the Company receives complete proof of claim and confirms liability.
TO WHOM PAYABLE
Death. Any benefits payable for the Insured Person's death will be paid in accord with the Beneficiary,
Facility of Payment, and Settlement Options sections of this Policy. If this Policy includes Dependent Life
Insurance; then any benefits payable for an insured Dependent's death will be paid to:
(1) the Insured Person, if he or she survives that Dependent; or
(2) the Insured Person's Beneficiary, or in accord with the Facility of Payment section; if the
Insured Person does not survive that Dependent.
Dismemberment. If this Policy includes Accidental Death and Dismemberment Benefits; then any benefit,
other than the Insured Person's death benefit, will be paid to the Insured Person.
20
L/ADD
01101110
GLllOI-13A 02 KS REV
CLAIMS PROCEDURES
(Continued)
NOTICE OF CLAIM DECISION. The Company will send the claimant a written notice of its claim
decision. If the Company denies any part of the claim; then the written notice will explain:
(1) the reason for the denial, under the terms of this Policy and any internal guidelines;
(2) how the claimant may request a review of the Company's decision; and
(3) whether more information is needed to support the claim.
The Company will send this notice within 15 days after resolving the claim. If reasonably possible, the
Company will send it within:
(1) 90 days after receiving the first proof of a death or dismemberment claim; or
(2) 45 days after receiving the first proof of a claim for any Extension of Death Benefit, Living
Benefit or Accelerated Death Benefit available under this Policy.
Delay Notice. If the Company needs more than 15 days to process a claim, in a special case; then an
extension will be permitted. If needed, the Company will send the claimant a written delay notice:
(1) by the 15th day after receiving the first proof of claim; and
(2) every 30 days after that, until the claim is resolved.
The notice will explain the special circumstances which require the delay, and when a decision can be
expected.
In any event, the Company must send written notice of its decision within:
(1) 180 days after receiving the first proof of a death or dismemberment claim; or
(2) 105 days after receiving the first proof of a claim for any Extension of Death Benefit, Living
Benefit or Accelerated Death Benefit available under this Policy.
If the Company fails to do so; then there is a right to an immediate review, as if the claim was denied.
Exception: If the Company needs more information from the claimant to process a claim; then it must be
supplied within 45 days after the Company requests it. The resulting delay will not count towards the above
time limits for claim processing.
REVIEW PROCEDURE. The claimant may request a claim review, within:
(1) 60 days after receiving a denial notice of a death or dismemberment claim; or
(2) 180 days after receiving a denial notice of a claim for any Extension of Death Benefit, Living
Benefit or Accelerated Death Benefit available under this Policy.
To request a review, the claimant must send the Company a written request, and any written comments or
other items to support the claim. The claimant may review certain non-privileged information relating to the
request for review.
Notice of Decision. The Company will review the claim and send the claimant a written notice of its
decision. The notice will explain the reasons for the Company's decision, under the terms of this Policy and
any internal guidelines. If the Company upholds the denial of all or part of the claim; then the notice will
also describe:
(1) any further appeal procedures available under this Policy;
(2) the right to access relevant claim information; and
(3) the right to request a state insurance department review, or to bring legal action.
For a death or dismemberment claim, the notice will be sent within 60 days after the Company receives the
request for review; or within 120 days, if a special case requires more time. For a claim for any Extension of
Death Benefit, Living Benefit or Accelerated Death Benefit available under this Policy, the notice will be sent
within 45 days after the Company receives the request for review; or within 90 days, if a special case requires
more time.
GLllOI-13A 02 KS REV
21
LlADD
01/01/10
CLAIMS PROCEDURES
(Continued)
Delay Notice. If the Company needs more time to process an appeal, in a special case; then it will send the
Insured Person a written delay notice, by the 30th day after receiving the request for review. The notice will
explain:
(1) the special circumstances which require the delay;
(2) whether more information is needed to review the claim; and
(3) when a decision can be expected.
Exception: If the Company needs more information from the claimant to process an appeal; then it must be
supplied within 45 days after the Company requests it. The resulting delay will not count. towards the above
time limits for appeal processing.
Claims Subject to ERISA (Employee Retirement Income Security Act of 1974). Before bringing a civil
legal action under the federal labor law known as ERISA, an employee benefit plan participant or beneficiary
must exhaust available administrative remedies. Under this Policy, the claimant must first seek two
administrative reviews of the adverse claim decision, in accord with this section. If an ERISA claimant
brings legal action under Section 502(a) of ERISA after the required reviews; then the Company will waive
any right to assert that he or she failed to exhaust administrative remedies.
ERRORS RELATED TO THE INSURED PERSON'S COVERAGE. The Company has the right to
correct benefit payments that are made in error. The Insured Person, Beneficiary or estate has the
responsibility to return any overpayments to the Company. The Company has the responsibility to make
additional payments, if any underpayments have been made.
LEGAL ACTIONS. No legal action to recover any benefits may be brought until 60 days after the required
written proof of claim has been given. No such legal action may be brought more than five years after the
date written proof of claim is required.
COMPANY'S AUTHORITY TO ADMINISTER ERISA PLAN. Policy coverage may be provided under
an employee benefit plan, which is subject to federal ERISA law. In that event, the Company has the
discretionary authority to determine eligibility and to administer claims, in accord with Policy provisions.
The Company will do so on the Group Policyholder's or Employer's behalf.
GLllOl-13A 02 KS REV
22
L/ADD
01/01/10
I
AMENDMENT TO BE ATTACHED TO AND MADE PART OF GROUP POLICY NO.: 000010124979
ISSUED TO: City of Salina
The Policy is amended by the addition of the following provisions.
PRIOR INSURANCE CREDIT UPON TRANSFER OF
LIFE INSURANCE CARRIERS
This provision prevents loss of life insurance coverage for an Insured Person, which could otherwise occur
solely because of a transfer of insurance carriers. This Policy will provide the following Prior Insurance
Credit, when it replaces a prior plan.
"Prior Plan" means a prior carrier's group life insurance policy, which this Policy replaced within 1 day of
the prior plan's termination date.
FAILURE TO SATISFY ACTIVE WORK RULE. Subject to payment of premiums, this Policy will provide
life coverage for a Person who:
(1) was insured under the prior plan on its termination date;
(2) was otherwise eligible under this Policy; but was not Actively-At-Work due to Injury or
Sickness on its Effective Date;
(3) is not entitled to any extension of life insurance under the prior plan; and
(4) is not Totally Disabled (as defmed in the Extension of Death Benefit section of this Policy)
on the date this Policy takes effect.
AMOUNT OF LIFE INSURANCE. Until the Person satisfies this Policy's Active Work rule, the amount of
his or her group life insurance under this Policy will not exceed the amount for which the Person was insured
under the prior plan on its termination date.
This Amendment takes effect on the effective date of coverage under this Policy. In all other respects, this
Policy remains the same.
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY
~Il,&~
Officer of the Company
Countersigned By:
A Licensed Resident Agent
23
Prior Ins. Credo - Life
01/01/10
GLllOl-AMEND. PC1 KS
GENERAL PURPOSES AND LIMITATIONS OF THE KANSAS
LIFE AND HEALTH INSURANCE
GUARANTY ASSOCIATION
K.S.A.40-3001 et. seq.
DISCLAIMER
THE KANSAS LIFE AND HEALTH INSURANCE GUARANTY ASSOCIATION MAY NOT PROVIDE
COVERAGE FOR ALL OR A PORTION OF THIS POLICY. IF COVERAGE IS PROVIDED, IT MAY
BE SUBJECT TO SUBSTANTIAL LIMITATIONS OR EXCLUSIONS, AND IS DEPENDENT UPON
CONTINUED RESIDENCE IN KANSAS. THEREFORE, YOU SHOULD NOT RELY UPON
COVERAGE BY THE KANSAS LIFE AND HEALTH INSURANCE GUARANTY ASSOCIATION IN
SELECTING AN INSURANCE COMPANY OR IN SELECTING AN INSURANCE POLICY.
INSURANCE COMPANIES AND THEIR AGENTS ARE PROHIBITED BY LAW FROM USING THE
EXISTENCE OF THE KANSAS LIFE AND HEALTH . INSURANCE GUARANTY ASSOCIATION IN
SELLING YOU ANY FORM OF AN INSURANCE POLICY, OR TO INDUCE YOU TO PURCHASE
ANY FORM OF AN INSURANCE POLICY. EITHER THE KANSAS LIFE AND HEALTH
INSURANCE GUARANTY ASSOCIATION OR THE KANSAS INSURANCE DEPARTMENT WILL
RESPOND TO ANY QUESTIONS YOU MAY HA VE REGARDING THIS DOCUMENT.
THE KANSAS LIFE AND HEALTH
INSURANCE GUARANTY ASSOCIATION
2909 SW Maupin Lane
Topeka, Kansas 66614-4139
THE KANSAS INSURANCE DEPARTMENT
420 Southwest 9th Street
Topeka, Kansas 66612-1678
This is a summary of the basic provisions of the Kansas Life and Health Insurance Guaranty Association Act.
It is only a summary, and does not provide an in depth analysis of that act. Nothing in this summary
modifies the rights of persons who are protected by the act, or the rights or duties of the association.
The purpose of the Kansas Life and Health Insurance Guaranty Association Act is to protect certain
individuals who purchase life insurance, annuities or health insurance in Kansas. The act provides for the
establishment of a funding mechanism to pay benefits or provide insurance coverage to individuals when a
life or health insurance company is unable to meet its obligations by reason of insolvency or financial
impairment.
However, not all individuals with a right to recover under life or health insurance policies are protected by
the act. An individual is only provided protection when:
(1) the individual, regardless of where they reside, except for nonresident certificateholders
under group policies or contracts, is the beneficiary, assignee or payee of a covered policy or
contractholder;
(2) the individual policy or contractholder is a resident of the state of Kansas;
(3) the individual is not a resident of the state of Kansas, but only with respect to an annuity
contract which has been awarded pursuant to a judgment or settlement agreement in a
medical malpractice liability action;
(4) the individual is not a resident of the state of Kansas, but only under all of the following
conditions: -
(a) the impaired or insolvent insurer was a Kansas domestic insurer; and
(b) the insurer never had a license to do business in the state in which the individual
resides; and
(c) the state in which the individual resides has an association similar to this state's;
and
(d) the individual is not eligible for coverage by the association of the state in which
the individual resides.
KS NOTICE-PIC 98
24
01101110
Additionally, the association may not provide coverage for.the entire amount the individual expects to receive
from the policy. The association does not provide coverage for any portion of the policy where the individual
has assumed the risk, for any policy of reinsurance, for interest rates that exceed a specified average rate, for
employer's plans that are self funded, for parts of plans thfit provide dividends or credits in connection with
the administration of the policy, for policies sold by companies not authorized to do business in Kansas, or
for any unallocated annuity contract. Also, the association will not provide coverage where any guaranty
protection is provided to the individual under the laws of the insolvent or impaired insurer's state of domicile.
The act also limits the amount the association is obligated to pay individuals on various policies. The
association does not pay more than the amount of the contractual obligation of the insurance company.
Regardless of the number of policies or contracts the association is not obligated to pay amounts over
$300,000 in life insurance death benefits; $100,000 in net cash surrender and net cash withdrawal values for
life insurance; $100,000 in health insurance benefits, including net cash surrender and net cash withdrawal
values; $100,000 in the present value of annuity benefits, including net cash surrender and net cash
withdrawal values, unless the annuity contract is awarded pursuant to a judgment or settlement agreement in a
medical malpractice liability action; or more than $300,000 in the aggregate for the above coverages with
respect to anyone life.
KS NOTICE-PIC 98
25
01/01/10
I
n Lincoln
Financial Group@
Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates.
March 25, 2010
The Lincoln National Life
Insurance Company
8801 Indian Hills Drive
Omaha, NE 68114-4066
toll free (800) 423-2765
www.LFG.com
Jennifer Perry
City of Salina
300 West Ash
Salina, KS 67401
Re: Policy No. 000010124979 (Life/ AD&D)
Group LD. CITYOFSA
Dear Jennifer Perry:
Enclosed you will find Amendment No.1 and a revised policy. As requested, we have added a
$10,000 dependent spouse benefit for Class 4 emploY,ees. Billing adjustments will be reflected on
your next statement changes made due to this amendment. This amendment was effective January 1,
2010.
Revised generic certificates for class 4 are located on The Lincoln National Life Insurance Company
website, www.jpfic.com. A supply of printed certificates can be requested from Client Services at
the telephone number below.
It is very important that we receive a signed copy of Amendment No.1 for our records. Please fax
the signed copy to 877-573-6177. If we do not hear from you within 30 days, payment of the
required premium will be considered acceptance of the amendment as issued. .
If you have any questions on this change, please feel free to contact your broker or your Customer
Service Representative at 800-423-2765. Thank you for giving The Lincoln National Life Insurance
Company an opportunity to serve you.
Sincerely,
The Lincoln National Life Insurance Company
Enclosures