Certificate of InsuranceMetropolitan Life Insurance Company
200 Park Avenue, New York, New York 10166-0188
!"#$%&%!'$" (& %)*+#')!"
Metropolitan Life Insurance Company ("MetLife"), a stock company, certifies that You and Your Dependents
are insured for the benefits d escribed in this certificate, subject to the provisions of this certificate. This
certificate is issued to You under the Group Policy and it includes the terms and provisions of the Group
Policy that describe Your insurance. PLEASE READ THIS CERTIFICATE CAREFULLY.
This certificate is part of the Group Policy.The Group Policy is a contract between MetLife and the Employer
and may be changed or ended without Your consent or notice to You.
Employer:City of Salina
Group Policy Number:KM 05950251-G
Type of Insurance:Basic Term Life Insurance
MetLife Toll Free Number(s):
For General Information 1-800-275-4638
THIS CERTIFICATE ONLY DESCRIBES LIFE INSURANCE.
THE BENEFITS OF THE POLICY PROVIDING YOUR COVERAGE ARE GOVERNED PRIMARILY BY THE
LAW OF A STATE OTHER THAN FLORIDA.
THE GROUP INSURANCE POLICY PROVIDING COVERAGE UNDER THIS CERTIFICATE WAS ISSUED
IN A JURISDICTION OTHER THAN MARYLAND AND MAY NOT PROVIDE ALL THE BENEFITS
REQUIRED BY MARYLAND LAW.
For Residents of North Dakota: If you are not satisfied with your Certificate, You may return it to Us within
20 days after You receive it, unless a claim has previously been received by Us under Your Certificate. We
will refund within 30 days of o ur receipt of the returned Certificate any Premium that has been paid and the
Certificate will then be considered to have never been issued. You should be aware that, if you elect to return
the Certificate for a refund of premiums, losses which otherwise would have been covered under your
Certificate will not be covered.
WE ARE REQUIRED BY STATE LAW TO INCLUDE THE NOTICE(S) WHICH APPEAR ON THIS PAGE
AND IN THE NOTICE(S) SECTION WHICH FOLLOWS THIS PAGE. PLEASE READ THE(SE) NOTICE(S)
CAREFULLY.
GCERT2000
All Active Part-Time Employees Excluding Airport
fp
Authority Employees
NB 01/12/2018
1
IMPORTANT NOTICE AVISO IMPORTANTE
To obtain information or make a complaint:Para obtener informaci ê n o para presentar una
queja:
You may call MetLifes toll free telephone number Usted puede llamar al n ñmero de tel àfono gratuito
for information or to make a complaint at:de MetLifes para obtener informaciê n o pa ra
presentar una queja al:
1-800-275-4638 1-800-275-4638
You may contact the Texas Department of Usted puede comunicarse con el Depart amento de
Insurance to obtain information o n companies, Seguros de Texas para obtener informaciên sobre
coverages, rights,or complaints at:compa èäas, coberturas, derechos o quejas al:
1-800-252-3439 1-800-252-3439
You may write the Texas Department of Insurance:Usted puede escribir al Depart amento de Seguros
de Te xas a:
P.O. Box 14 9104 P.O. Box 149104
Austin, TX 78714-9104 Austin, TX 78714-9104
Fax:(512) 490-1007 Fax: (512) 490-1007
Web: www.tdi.texas.gov Sitio web: www.tdi.texas.gov
E-mail: ConsumerP rotection@tdi.texas.gov E-mail: ConsumerPr otection@tdi.texas.gov
PREMIUM OR CLAIM DISPUTES:Should y ou DISPUTAS POR PRIMAS DE SEGUROS O
have a dispute concerning y our premium or about a
RECLAMACIONES:Si tiene una disputa
claim,you should contact MetLife first. I f the
relacionada con su prima de seguro o con una
dispute is not resolved, y ou may contact the Texas
rec lamaciên, usted debe comunicarse con MetLife
Department of Insurance.
primero. Si la disputa no es resuelta, usted puede
comunicarse con el Depart amento de Seguros de
Texas.
ATTACH THIS NOTICE TO YOUR CERTIFICATE:
ADJUNTE ESTE AVISO A SU CERTIFICADO:
This notic e is for information only and does not
Este aviso es solamente para propêsitos
become a part or condition of the attached
informativos y no se convier te en parte o en
document.
condiciên del documento adjunto.
GCERT2000 For Texas Residents
notice/tx 02/15 2
NOTICE FOR R ESIDENTS OF TEXAS
LIFE INSURANCE: ACCELERATED BENEFIT OPTION (ABO)
The laws of the state of Texas mandate that the terms Terminally Ill and Terminal Illnesswhen used in
the LIFE INSURANCE: ACCELERATED BENEFIT OPTION (ABO)FOR YOU provisions mean that due to
injury or sickness, You expected to die within 24 months of the date You request payment of an Accelerated
Benefit.
GCERT2000
notice/tx/abo 3
NOTICE FOR RESIDENTS OF ALL STATES
LIFE INSURANCE BENEFITS WILL BE REDUCED IF AN ACCELERATED BENEFIT IS
PAID
DISCLOSURE: The Life Insurance accelerated benefit offered under this certificate is intended to qualify for
favorable tax treatment under the Internal Revenue Code of 1986. If this benefit qualifies for such favorable
tax treatment, the benefit will be e xcludable from Your income and not subject to federal taxation. Tax laws
relating to accelerated benefits are complex. You are advised to consult with a qualified tax advisor about
circumstances under which You could receive an accelerated benefit excl udable from income under federal
law.
DISCLOSURE: Receipt of an accelerated benefit may affect Your, Your Spouses or Your familys eligibility
for public assistance programs such as Medical Assistance (Medicaid), Aid to Families with Dependent
Children(AFDC), Supplementary Social Security Income (SSI), and drug assistance programs. You are
advised to consult with a qualified tax advisor and with social service agencies concerning how receipt of
such payment will affect Your, Your Spouses and Your fam ilys eligibility for public assistance.
GCERT2000
notice/abo/nw 4
)($%!" &(# #"*%,")$* (&$"-'*
The Definition of Child In The Definitions Section Of This Certificate Is Modified For The Coverage
Listed Below:
For Texas Residents (Life Insurance):
The term also includes Your grandchildren. The age limit for children and grandchildren will not be less than
25, regardless of the childs or grandchilds student status or full-time employment stat us. Your natural child,
adopted child or stepchild under age 25 will not need to be supported by You to qualify as a Child under this
insurance. In addition, grandchildren must be able to be claimed by You as a dependent for Federal Income
Tax purposes a t the time You applied for Insurance.
GCERT2000
notice/childdef 5
)($%!" &(# #"*%,")$* (& '#.')*'*
If You have a question concerning Your coverage or a claim, first contact the Policyholder or group account
administrator. If, after doing so, You still have a concern, You may call the toll free telephone number sho wn
on the Certificate Face Page.
If You are still concerned after contacting both the Policyholder and MetLife, You should feel free to contact:
Arkansas Insurance Department
Consumer Services Division
1200 West Third Street
Little Rock, Arkansas 72201
(501) 371-2640 or (800) 852-5494
GCERT2000
notice/ar 6
)($%!" &(# #"*%,")$* (& !'/%&(#)%'
IMPORTANT NOTICE
TO OBTAIN ADDITIONAL INFORMATION, OR TO MAKE A COMPLAINT, CONTACT THE
POLICYHOLDER OR THE METLIFE CLAIM OFFICE SHOWN ON THE EXPLANATION OF BENEFITS
YOU RECEIVE AFTER FILING A CLAIM.
IF, AFTER CONTACTING THE POLICYHOLDER AND/OR METLIFE, YOU FEEL THAT A SATISFACTORY
SOLUTION HAS NOT BEEN REACHED, YOU MAY FILE A COMPLAINT WITH THE CALIFORNIA
INSURANCE DEPARTMENT AT:
DEPARTMENT OF INSURANCE
300 SOUTH SPRING STREET
LOS ANGELES, CA 90013
1 (800) 927-4357
GCERT2000
notice/ca 7
)($%!" &(# #"*%,")$* (& 0"(#0%'
IMPORTANT NOTICE
The laws of the state of Georgia prohibit insurers from unfairly discriminating against any person based upon
his or her status as a victim of family violence.
GCERT2000
notice/ga 8
)($%!" &(# #"*%,")$* (& %,'1(
If You have a question concerning Your coverage or a claim, first contact t he Employer. If, after doing so,
You still have a concern, You may call the toll free telephone number shown on the Certificate Face Page.
If You are still concerned after contacting both the Employer and MetLife, You should feel free to contact:
Idaho Department of Insurance
Consumer Affairs
rd
700 West State Street, 3 Floor
PO Box 83720
Boise, Idaho 83720-0043
1-800-721-3272 or www.DOI.Idaho.gov
GCERT2000
notice/id 9
)($%!" &(# #"*%,")$* (& %//%)(%*
IMPORTANT NOTICE
To make a complaint to MetLife, You may write to:
MetLife
200 Park Avenue
New York, N ew York 10166
The address of the Illinois Department of Insurance is:
Illinois Department of Insurance
Public Services Division
Springfield, Illinois 62767
GCERT2000
notice/il 10
)($%!" &(# #"*%,")$* (& %),%')'
Questions regarding your policy or coverage should be directed to:
Metropo litan Life Insurance Company
1-800-275-4638
If you (a) need the assistance of the government agency that regulates insurance; or (b)
have a complaint you have been unable to resolve with your insurer you may contact the
Department of Insuran ce by mail, te lephone or email:
State of Indiana Department of Insurance
Consumer Services Division
311 West Washington Street, Suite 300
Indianapolis, Indiana 46204
Consumer Hotline: (800) 622-4461; (317) 232-2395
Complaint can be filed electronically at www.in.gov/idoi
GCERT2000
notice/in 11
)($%!" &(# #"*%,")$* (& 2%**(+#%
/%&" %)*+#')!"
0")"#'/3#(4%*%()*
If you reside in Missouri the suicide provision is as follows:
*567689
If You commit suicide within 1 year from the date Life Insurance for You takes effect, We will no t pay such
insurance and Our liability will be limited as follows:
·any premium paid by You will be returned to the Beneficiary.
·any premium paid by the Policyholder will be returned to the Policyholder.
If You commit suicide within 1 year from the date a n increase in Your Life Insurance takes effect, We will pay
to the Beneficiary the amount of Insurance in effect on the day before the increase. Any premium You paid
for the increase will be returned to the Beneficiary. Any premium paid by the Policyhold er for the increase will
be returned to the Policyholder.
If a Dependent commits suicide within 1 year from the date Life Insurance for such Dependent takes effect,
We will not pay such insurance and Our liability will be limited as follows:
·any premium paid by You will be returned to the Beneficiary.
·any premium paid by the Policyholder will be returned to the Policyholder.
If a Dependent commits suicide within 1 year from the date an increase in Life Insurance for such Dependent
takes effect, We will p ay to the Beneficiary the amount of Insurance in effect on the day before the increase.
Any premium You paid for the increase will be returned to the Beneficiary. Any premium paid by the
Policyholder for the increase will be returned to the Policyholder.
GCERT2000
notice/mo 12
)($%!" &(# #"*%,")$* (& $"-'*
THE INSURANCE POLICY UNDER WHICH THIS CERTIFICATE IS ISSUED IS NOT A POLICY OF
WORKERS COMPENSATION INSURANCE. YOU SHOULD CONSULT YOUR EMPLOYER TO
DETERMINE WHETHER YOUR EMPLOYER IS A SUBSCRIBER TO THE WORKERS COMPENSATION
SYSTEM.
GCERT2000
notice/tx/wc 13
)($%!" &(# #"*%,")$* (& +$'1
Notice of Protec tion Provided by
Utah Life and Health Insurance Guaranty Association
This notice provides a brief summary of the Utah Life and Health Insurance Guaranty Association
("the Association") and the protection it provides for policyholders. This safety net was created
under Utah law, which determines who and what is covered and the amounts of coverage.
The Association was established to provide protection in the unlikely event that your life, health,
or annuity insurance company becomes financially unable to me et its obligations and is taken
over by its insurance regulatory agency. If this should happen, the Association will typically
arrange to continue coverage and pay claims, in accordance with Utah law, with funding from
assessments paid by other insurance c ompanies.
The basic protections provided by the Association are:
·Life Insurance
o $500,000 in death benefits
o $200,000 in cash surrender or withdrawal values
·Health Insurance
o $500,000 in hospital, medical and surgical insurance benefits
o $500,000 in l ong-term care insurance benefits
o $500,000 in disability income insurance benefits
o $500,000 in other types of health insurance benefits
·Annuities
o $250,000 in withdrawal and cash values
The maximum amount of protection for each individual, regardless of the number of policies or
contracts, is $500,000. Special rules may apply with regard to hospital, medical and surgical
insurance benefits.
Note: Certain policies and contracts may not be covered or fully covered. For example,
coverage does not extend to any portion of a policy or contract that the insurer does not
guarantee, such as certain investment additions to the account value of a variable life insurance
policy or a variable annuity contract. Coverage is conditioned on residency in this state an d there
are substantial limitations and exclusions. For a complete description of coverage, consult Utah
Code, Title 3 lA, Chapter 28.
Insurance companies and agents are prohibited by Utah law to use the existence of the
Association or its coverage to enc ourage you to purchase insurance. When selecting an
insurance company, you should not rely on Association coverage. If there is any
inconsistency between Utah law and this notice, Utah law will control.
To learn more about the above protections, as well a s protections relating to group contracts or
retirement plans, please visit the Association's website at www.utlifega.org or contact:
Utah Life and Health Insurance Guaranty Assoc. Utah Insurance Department
60 East South Temple, Suite 500 3110 State Offi ce Building
Salt Lake City UT 84111 Salt Lake City UT 84114-6901
(801) 320-9955(801) 538-3800
A written complaint about misuse of this Notice or the improper use of the existence of the
Association may be filed with the Utah Insurance Department at the a bove address.
GTY-NOTICE-UT-0710 14
)($%!" &(# #"*%,")$* (& 4%#0%)%'
IMPORTANT INFORMATION REGARDING YOUR INSURANCE
In the event You need to contact someone about this insurance for any reason please contact Your agent. If no
agent was involved in the sale of this insurance, or if You have additional ques tions You may contact the
insurance company issuing this insurance at the following address and telephone number:
MetLife
200 Park Avenue
New York, New York 10166
Attn: Corporate Consumer Relations Department
To phone in a claim related question, You may call Claims Customer Service at:
1-800-275-4638
If You have been unable to contact or obtain satisfaction from the company or the agent, You may contact the
Virginia State Corporation Commissions Bureau of Insurance at:
The Office of the Managed Care O mbudsman
Bureau of Insurance
P.O. Box 1157
Richmond, VA 23209
1-877-310-6560 -toll-free
1-804-371-9032 -locally
www.scc.virginia.gov-web address
ombudsman@sc c.virginia.gov-email
Or:
The Virginia Department of Health (The Center for Quality Health Care Services and Consumer Protection)
3600 West Broad St
Suite 216
Richmond, VA 23230
1-800-955-1819
Written correspondence is preferable so that a record of Your inquiry is maintained. When contacting Your
agent, company or the Bureau of Insurance, have Your policy number available.
GCERT2000
notice/va 15
!%4%/ +)%() )($%!" &(# #"*%,")$* (& 4"#2()$
Vermont law provides that the following definitions apply to your certificate:
·Terms that mean or refer to a marital relati onship, or that may be construed to mean or
refer to a marital relationship, such as "marriage," "spouse," "husband," "wife,"
"dependent," "next of kin," "relative," "beneficiary," "survivor," "immediate family" and any
other such terms include the relatio nship created by a Civil Union established according
to Vermont law.
·Terms that mean or refer to the inception or dissolution of a marriage, such as "date of
marriage," "divorce decree," "termination of marriage" and any other such terms include
the incep tion or dissolution of a Civil Union established according to Vermont law.
·Terms that mean or refer to family relationships arising from a marriage, such as "family,"
"immediate family," "dependent," "children," "next of kin," "relative," "beneficiary,"
"survivor" and any other such terms include family relationships created by a Civil Union
established according to Vermont law.
·"Dependent" includes a spouse, a party to a Civil Union established according to
Vermont law, and a child or children (natural, step-child, legally adopted or a minor or
disabled child who is dependent on the insured for support and maintenance) who is born
to or brought to a marriage or to a Civil Union established according to Vermont law.
·"Child" includes a child (natural, ste pchild, legally adopted or a minor or disabled child
who is dependent on the insured for support and maintenance) who is born to or brought
to a marriage or to a Civil Union established according to Vermont law.
·"Civil Union" means a civil union establi shed pursuant to Act 91 of the 2000 Vermont
Legislative Session, entitled "Act Relating to Civil Unions".
All references in this notice to Civil Unions are limited to Civil Unions in which the parties are residents of
Vermont.
If dependent insurance f or a spouse and/or child is not provided under your certificate, such insurance is not
added by virtue of this notice.
For purposes of dependent insurance, any person who meets the definition of "dependent" as set forth in
this notice is required to mee t all other applicable requirements in order to qualify for such insurance.
This notice does not limit any definitions or terms included in your certificate. It broadens definitions and
terms only to the extent required by Vermont law.
DISCLOSURE:
Vermont law grants parties to a Civil Union the same benefits, protections and responsibilities that flow from
marriage under state law. However, some or all of the benefits, protections and responsibilities related to life
and health insurance that are ava ilable to married persons under federal law may not be available to parties
to a Civil Union. For example, a federal law, the Employee Retirement Income Security Act of 1974 known as
"ERISA", controls the employer/employee relationship with regard to de termining eligibility for enrollment in
private employer benefit plans. Because of ERISA, Act 91 does not state requirements pertaining to a private
employers enrollment of a party to a Civil Union in an ERISA employee benefit plan. However, governmenta l
employers (not federal government) are required to provide life and health benefits to the dependents of a
party to a Civil Union if the public employer provides such benefits to dependents of married persons.
Federal law also controls group health insu rance continuation rights under "COBRA" for employers with 20
or more employees as well as the Internal Revenue Code treatment of insurance premiums. As a result,
parties to a Civil Union and their families may or may not have access to certain benefits under this notice and
the certificate to which it is attached that derive from federal law. You are advised to seek expert advice to
determine your rights under this notice and the certificate to which it is attached.
GCERT 2000
notice/vt 16
)($%!" &(# #"*%,")$* (& $1" *$'$" (& :'*1%)0$()
Washington law provides that the following apply to Your certificate:
Wherever the term "Spouse" appears in this certificate it shall, unless otherwise specified, be read to include
Your Domestic Partner.
Domestic Partner means each of two people, one of whom is an Employee of the Emplo yer,who have
registered as each others domestic partner, civil union partner or reciprocal beneficiary with a government
agency where such registration is available.
Wherever the term "step-child" appears in this certificate it shall be read to include the children of Your
Domestic Partner.
GCERT2000
notice/wa
17
)($%!" &(# #"*%,")$* (& :%*!()*%)
KEEP THIS NOTICE WITH YOUR INSURANCE PAPERS
PROBLEMS WITH YOUR INSURANCE?-If you are having problems with your insurance company or
agent, do not hesitate to contact the insurance company or agent to resolve y our problem.
MetLife
Attn: Corporate Consumer Relations Department
200 Park Avenue
New York, NY 10166-0188
1-800-638-5433
You can also contact the OFFICE OF THE COMMISSIONER OF INSURANCE, a state agency which
enforces Wisconsins insurance laws, and f ile a complaint. You can contact the OFFICE OF THE
COMMISSIONER OF INSURANCE by contacting:
Office of the Commissioner of Insurance
Complaints Department
P.O. Box 7873
Madison, WI 53707-7873
1-800-236-8517 outside of Madison or 608-266-0103 in Madison.
GCERT2000
notice/wi 18
TABLE OF CONTENTS
The bottom left of each page of this certificate has a unique coding which describes the section of the
certificate that the page contains (fp = Certificate Face Page, sch = Schedule of Benefits).
Section Page
!"#$%&%!'$" &'!" (')"*******************************************************************************************************************************+
,-$%!".************************************************************************************************************************************************************/
$'01" -& !-,$",$.************************************************************************************************************************************+2
.!3"451" -& 0","&%$.******************************************************************************************************************************/6
4"&%,%$%-,.****************************************************************************************************************************************************/7
"1%)%0%1%$8 (#-9%.%-,.: %,.5#',!" &-# 8-5**************************************************************************************/;
Eligible Classes.............................................................................................................................................26
Date You Are Eligible For Insurance.............................................................................................................26
Enrollment Process........................................................................................................................................26
Date Your Insurance Ta kes Effect.................................................................................................................26
Date Your Insurance Ends............................................................................................................................28
"1%)%0%1%$8 (#-9%.%-,.: %,.5#',!" &-# 8-5# 4"(",4",$.*********************************************************/2
Eligible Classes For Dependent Insurance...................................................................................................29
Date You Are Eligible For Dependent Insurance..........................................................................................29
Enrollment Process ......................................................................................................................................29
Date Insurance For Your Dependents Take Effect.......................................................................................29
Date Your Insurance For Your Dependents Ends.........................................................................................32
!-,$%,5'$%-, -& %,.5#',!" <%$3 (#"=%5= ('8=",$********************************************************************77
For Mentally Or Physically Handicapped Children........................................................................................33
For Family And Medical Leave......................................................................................................................33
At Your Option: Portability.............................................................................................................................33
At The Employe r's Option..............................................................................................................................36
"9%4",!" -& %,.5#'0%1%$8************************************************************************************************************************7>
1%&" %,.5#',!": &-# 8-5**************************************************************************************************************************72
1%&" %,.5#',!": &-# 8-5# 4"(",4",$.**********************************************************************************************?6
1%&" %,.5#',!": '!!"1"#'$"4 0","&%$ -($%-, @'0-A &-# 8-5****************************************************?+
1%&" %,.5#',!": !-,9"#.%-, -($%-, &-# 8-5**********************************************************************************?7
1%&" %,.5#',!": !-,9"#.%-, -($%-, &-# 8-5# 4"(",4",$.*****************************************************?B
"1%)%0%1%$8 &-# !-,$%,5'$%-, -&!"#$'%, %,.5#',!" <3%1" 8-5 '#" $-$'118 4%.'01"4**?C
&%1%,) ' !1'%=***********************************************************************************************************************************************B6
)","#'1 (#-9%.%-,.**********************************************************************************************************************************B+
Assignment....................................................................................................................................................51
Beneficiary.....................................................................................................................................................51
Entire Contract...............................................................................................................................................52
Incontestability: Statements Made By You....................................................................................................52
Misstatement of Age......................................................................................................................................52
Conformity With Law.....................................................................................................................................52
Autopsy..........................................................................................................................................................52
GCERT2000
toc 19
SCHEDULE OF BENE FITS
This schedule shows the benefits that are available under the Group Policy. You and Your Dependents will
only be insured for the benefits:
·for which You and Your Dependents become and remai n eligible, and
·which You elect, if subject to election; and
·which are in effect.
;")"&%$ '2(+)$
;")"&%$
'), 1%01/%01$*
1<=:9 :6>> 3?@;9A9B6CD
Unless the Beneficiary requests payment by check, when the Certificate states that We will pay benefits in
"one sum" or a "single sum", We may pay the full benefit amount:
1.by check;
2.by establishing an account that earns interest and provides the Beneficiary with immediate access to
the full benefit amount; or
3.by any other method that provides the Beneficiary with immediate access to the full benefit amount.
Other modes of payment may be available upon request. For details, call Our toll free number shown on the
Certificate Face Page.
/6B9 %AD5E?A79 &<E F<5
;?D67 /6B9 %AD5E?A79
Basic Life Insurance for You is Portability Eligible Insurance
For All Active Part-Time Employees Excluding Airport An amount equal to 1
Authority Employees.................................................................times Your Basic Annual
Earnings, rounded to the
next higher $1,000.
Minimum Basic Life Benefit...$20,000
Maximum Life Benefit..$100,000
Non-Medical Issue Amount....$100,000
Accelerated Benefit Option.......................................................Up to 80% of Your Basic
Life amount not to exceed
$500,000.
If You Are Age 70 Or Older
If You are age 70 or older on Your effective date of insurance, the appropriate percentage from the following
table will be applied to the amount of Your Basic Life Insurance on Your effective date of insurance, adjusted
for any later changes in Your salary.
If You are under age 70 on Your effective date of insurance, the amounts of Your Basic Life Insurance on and
after age 70 will be determined by applying the appropriate percentage from the following table to the amount
th
of Your insurance in effect on the day before Your 70 birthday, adjusted for any later changes in Your salary.
Age of Employee Percentage
70 or older 50%
GCERT2000
sch 20
SCHEDULE OF BENE FITS
/6B9 %AD5E?A79 &<E F<5E ,9G9A89ACD
Basic Life Insurance
Dependent Basic Life Insurance is Portability Eligible Insurance
For All Active Part-Time Employe es Excluding Airport
Authority Employees who elect:
For Your Spouse.......................................................................$15,000
Non-Medical Issue Amount$15,000
For All Active Part-Time Employees Excluding Airport
Authority Employees who elect:
For Your Child from age 15 days but less than 6 months........$100
For Your Child 6 months and over............................................$10,000
Non-Medical Issue Amount.......................................................$10,000
3<EC?H6>6C@">6I6H>9 /6B9 %AD5E?A79
/6B9 %AD5E?A79 &<E F<5J
Portability Eligible Life Insurance For You:
Basic Life Insurance:
Minimum Portability Eligible Life Insurance Amount......................$10,000
Maximum Portability Eligible Life Insurance Amount.....................The lesser of Your total Life
Insurance in effect on the
date You elect to Port or
$2,000,000.
If Your Portability Eligible Insurance ends due to the end of the Group Policy or the amendment of the Group
Policy to end the Portability Eligible Insurance for an eligible class of which You are a member, the maximum
amount of insurance that You may Port is the lesser of:
·the amount of Your Portability Eligible Insurance that ends under the Group Policy less the amount of Life
insurance for which You become eligible under any group policy issued to replace this Group Policy; or
·$10,000.
Life Insurance For Your Spouse
Portability Eligible Dependent Spouse Life Insurance
GCERT2000
sch 21
SCHEDULE OF BENE FITS
When Porting Dependent Spouse Life Insurance along wit h Insurance for You
Minimum Portability Eligible
Dependent Spouse Life Insurance Amount...................................$2,500
Maximum Portability Eligible
Dependent Spouse Life Insurance Amount...................................The lesser of Your total
Dependent Spouse Life
Insurance in effect on the
date You elect to Port or
$250,000.
When Porting Dependent Spouse Life Insurance alone
Minimum Portability Eligible
Dependent Spouse Life Insurance Amount...................................$10,000
Maximum Portability Eligible
Dependent Spouse Life Insurance Amount...................................The lesser of Your total
Dependent Spouse Life
Insurance in effect on the
date You elect to Port or
$250,000.
If Your Portability Eligible Insurance or Your Portability Eligible Dependent Insurance ends due to the end of
the Group Policy or the amendment of the Group Poli cy to end the Portability Eligible Insurance or Your
Portability Eligible Dependent Insurance for an eligible class of which You are a member, the maximum
amount of insurance that You may Port is the lesser of:
·the amount of Your Portability Eligible Insu rance or Portability Eligible Dependent Insurance that ends
under the Group Policy less the amount of Life insurance for which You become eligible under any group
policy issued to replace this Group Policy; or
·$10,000.
GCERT2000
sch 22
DEFINITIONS
As used in this certificate, the terms listed below will have the meanings set forth below. When defined terms
are used in this certificate, they will appear with initial capitalization. The plural use of a term defined in the
singular will share the same meaning.
Actively at Work or Active Work means that You are performing all of the usual and customary duties of
Your job on a Full-Time basis. This must be done at:
·the Employer's place of business;
·an alternate place approved by the Employer; or
·a location to which the Employer's business requires You to travel.
You will be deemed to be Actively at Work during weekends or Employer-approved vacations, holidays or
business closures if You were Actively at Work on the last scheduled work day preceding such time off.
Basic Annual Earnings means Your gross annual rate of pay as determined by Your Employer, excluding
overtime and other extra pay.
Beneficiary means the person(s) to whom We will pay insurance as determined in accordance with the
General Provisions section.
Child means the following: (for residents of Texas, the Child Definition is modified as explained in the Notice
pages of this certificate please consult the Notice)
For Life Insurance, Your natural child, adopted child (including a child from the date of placement with the
adopting parents until the legal adoption) or stepchild and who, in each case, is at least 15 days old, under
age 26, unmarried and supported by You.
The term does not include any person who:
·is on active duty in the military of any country or international authority; however, active
duty for this purpose does not include weekend o r summer training for the reserve forces
of the United States, including the National Guard; or
·is insured under the Group Policy as an employee.
Contributory Insurance means insurance for which the Employer requires You to pay any part of the
premium.
Dependent(s)means Your Spouse and/or Child.
Full-Time means Active Work on the Employer's regular work schedule for the class of employees to which
You belong. The work schedule must be at leas t 20 hours a week. Full-Time does not include temporary or
seasonal employees.
Hospital means a facility which is licensed as such in the jurisdiction in which it is located and:
·provides a broad range of medical and surgical services on a 24 hour a day basis for
injured and sick persons by or under the supervision of a staff of Physicians; and
·provides a broad range of nursing care on a 24 hour a day basis by or under the direction
of a registered professional nurse.
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DEFINITIONS
Hospitalized means:
·admission for inpatient care in a Hospital;
·receipt of care in the following:
·a hospice facility; or
·an intermediate care facility; or
·a long term care facility; or
·receipt of the following treatment, wherever performed:
·chemotherapy; or
·radiation therapy; or
·dialysis.
Noncontributory Insurance means insurance for which the Employer does not require You to pay any part
of the premium.
Physician means:
·a person licensed to practice medicine in the jurisdiction where such services are
performed; or
·any other person whose services, according to applicable law, must be treated as
Physician's services for purposes of the Group Policy. Each such person must be
licensed in the jurisdiction where the service is performed and must act within the scope
of that license. Such person must also be certified and/or registered if require d by such
jurisdiction.
The term does not include:
·You;
·Your Spouse; or
·any member of Your immediate family including Your and/or Your spouses parents; children (natural,
step or adopted); siblings; grandparents; or grandchildren.
Proof means Written evidence satisfactory to Us that a person has satisfied the conditions and requirements
for any benefit described in this certificate. When a claim is made for any benefit described in this certificate,
Proof must establish:
·the nature and extent of the l oss or condition;
·Our obligation to pay the claim; and
·the claimants right to receive payment.
Proof must be provided at the claimants expense.
Sickness means illness, disease or pregnancy, including complications of pregnancy.
Signed means any symbol or method executed or adopted by a person with the present intention to
authenticate a record, which is on or transmitted by paper or electronic media which is acceptable to Us and
consistent with applicable law.
Spouse means Your lawful Spouse.
The term does not include any person who:
·is on active duty in the military of any country or international authority; however, active
duty for this purpose does not include weekend or summer training for the reserve forces
of the United States, includi ng the National Guard; or
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DEFINITIONS
·is insured under the Group Policy as an employee.
We,Us and Our mean MetLife.
Written or Writing means a record which is on or transmitted by paper or electronic media which is
acceptable to Us and consistent with applicable l aw.
You and Your mean an employee who is insured under the Group Policy for the insurance described in this
certificate.
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ELIGIBILITY PROVISIONS: INSURANCE FOR YOU
ELIGIBLE CLASS(ES)
All Active Part-Time Employees Ex cluding Airport Authority Employees
DATE YOU ARE ELIGIBLE FOR INSURANCE
You may only become eligible for the insurance available for Your class as shown in the SCHEDULE OF
BENEFITS.
All Active Part-Time Emp loyees Excluding Airport Authority Employees
Basic Life Insurance
If You are in an eligible class on January 01, 2018,You will be eligible for insurance on that date.
If You enter an eligible class after January 01, 2018, You will be eligible for insur ance on the first day of the
month coincident with or next following the date You enter that class.
Waiting Period means the period of continuous membership in an eligible class that You must wait before
You become eligible for insurance. This period beg ins on the date You enter an eligible class and ends on
the date You complete the period(s) specified.
ENROLLMENT PROCESS
If You are eligible for insurance, You may enroll for such insurance by completing the required form. In
addition, You must give evidence of Your insurability satisfactory to Us at Your expense if You are required to
do so under the section entitled EVIDENCE OF INSURABILITY. If you enroll for Contributory Insurance, You
must also give the Employer written permission to deduct premiums from Your pay for such insurance. You
will be notified by the Employer how much You will be required to contribute.
If Your Employer establishes an annual enrollment period for Life Insurance, You may enrol l for Life
Insurance only when You are first eligible or during an annual enrollment period or If You have a Qualifying
Event. You should contact the Employer for more information regarding the annual enrollment period.
DATE YOUR INSURANCE TAKES EFFECT
Rules for Noncontributory Insurance
When You complete the enrollment process for Noncontributory Insurance, such insurance will take effect as
follows:
·if You are not required to give evidence of Your insurabi lity, such insurance will take
effect on the date You become eligible, provided You are Actively at Work on that date;
or
·if You are required to give evidence of Your insurability and We determine that You are
insurable, such insurance will take effect o n the date We state in Writing, provided You
are Actively at Work on that date.
If You are not Actively at Work on the date the Noncontributory Insurance benefit would otherwise take effect,
the insurance will take effect on the day You resume Active Work.
Rules for Contributory Insurance
If You request Contributory Insurance before the date You become eligible for such insurance, such
insurance will take effect as follows:
·if You are not required to give evidence of Your insurability, such insurance will take
effect on the date You become eligible, provided You are Actively at Work on that date.
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ELIGIBILITY PROVISIONS: INSURANCE FOR YOU
·if You are required to give evidence of Your insurability and We determine that You are
insurable, such insurance will take effect on the date We state in Writing, provided You
are Actively at Work on that date.
If You request Contributory Insurance within 12 months of the date You become eligible for such insurance, or
during the Employers next annual enrollment period, whichever occurs first, such insurance will take effect as
follows:
·if You are not required to give evidence of Your insura bility, such insurance will take
effect on the later of:
·the date You become eligible for such insurance; and
·the date You enroll provided You are Actively at Work on that date.
·if You are required to give evidence of Your insurability and We determine that You are
insurable, such insurance will take effect on the date We state in Writing, provided You
are Actively at Work on that date.
·If You request Contributory Insur ance more than 12 months after the date You become
eligible for such insurance or after the first annual enrollment period for which You may
enroll, whichever occurs first,You must give such evidence at Your expense. If We
determine that You are insurabl e, such insurance will take effect on the date We state in
Writing, if You are Actively at Work on that date.
If You are not Actively at Work on the date insurance would otherwise take effect, insurance will take effect on
the day You resume Active Work.
See the DEFINITIONS section of this certificate for a complete list of Contributory Insurance benefits.
Increase in Insurance
An increase in insurance due to a change in class of employee, an increase in Your earnings, or a requested
increase in insurance will take effect as follows:
·if You are required to give evidence of insurability for the entire incr ease and We approve
Your evidence of insurability, the increase will take effect on the date We state in Writing.
If We do not approve Your evidence of insurability, or You do not submit evidence of
insurability, the increase in insurance will not take ef fect.
·if You are required to give evidence of insurability for a portion of the increase:
·the portion of the increase that is not subject to evidence of insurability will take effect on the first day
of the month coincident with or next following the da te of Your request or the date of the increase in Your
earnings.
·if We approve Your evidence of insurability, the portion of the increase that is subject to evidence of
insurability will take effect on the date We state in Writing. If We do not approve Your evidence of
insurability or You do not submit evidence o f insurability, the increase in insurance will not take effect.
·if You are not required to give evidence of insurability, the increase will take effect on the
first day of the month coincident with or next following the date of Your request or the
date of the increase in Your earnings.
You must be Actively at Work on that date. If You are not Actively at Work on the date the increase would
otherwise take effect, the increase will take effect on the day You resume Active Work.
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ELIGIBILITY PROVISIONS: INSURANCE FOR YOU
Decrease in Insurance
A decrease in insurance due to a change in class of employee or a decrease in Your earnings will take effect
on the first day of the month coincident with or next following the date of change.
If You make a Written application to decrease Your insurance, that decrease will take effect as of the date of
Your application.
Enrollment Due to a Qualifying Event
You may enroll for insurance for which You are eligible or change the amount of Your insurance between
annual enrollment periods only if You have a Qualifying Event.
If You have a Qualifying Event, You will have 12 months from the date of that change or the Employers next
annual enrollment period following the date of that change to make a request, whichever occurs first*
This request must be consistent with the nature of the Qua lifying Event. The insurance enrolled for or
changes to Your insurance made as a result of a Qualifying Event will take effect on the first day of the month
coincident with or next following the date of Your request, if You are Actively at Work on that dat e.
If You are not Actively at Work on the date insurance would otherwise take effect, insurance will take effect on
the day You resume Active Work.
Qualifying Event includes:
marriage; or
the birth, adoption or placement for adoption of a dependent chil d; or
divorce, legal separation or annulment; or
the death of a dependent; or
You previously did not enroll for life coverage for You or Your dependent because You had other group
coverage, but that coverage has ceased due to loss of eligibility for the ot her group coverage; or
Your dependent's ceasing to qualify as a dependent under this insurance or under other group coverage.
DATE YOUR INSURANCE ENDS
Your insurance will end on the earliest of:
1.the date the Group Pol icy ends;
2.the date insurance ends for Your class;
3.the end of the period for which the last premium has been paid for You; or
4.for Basic Life Insurance, the last day of the calendar month in which Your employment ends; Your
employment will end if You cease t o be Actively at Work in any eligible class, except as stated in the
section entitled CONTINUATION OF INSURANCE WITH PREMIUM PAYMENT; or
5.for Basic Life Insurance, the last day of the calendar month in which You retire in accordance with the
Employers ret irement plan.
Please refer to the section entitled ELIGIBILITY FOR CONTINUATION OF CERTAIN INSURANCE WHILE
YOU ARE TOTALLY DISABLED for information concerning continuation of Your Life Insurance if insurance
ends while You are Totally Disabled. Please refer to the section entitled LIFE INSURANCE: CONV ERSION
OPTION FOR YOU for information concerning the option to convert to an individual policy of life insurance if
Your Life Insurance ends.
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ELIGIBILITY PROVISIONS: INSURANCE FOR YOUR DEPENDENTS
ELIGIBLE CLASS(ES) FOR DEPENDENT INSURANCE
All Active Part-Time Employees Excluding Airport Authority Employees
DATE YOU ARE ELIGIBLE FOR DEPENDENT INSURANCE
You may only become eligible for the Dependent insurance available for Your eligible class as shown in the
SCHEDULE OF BENEFITS.
All Active Part-Time Employees Excluding Airport Authority Employees
Basic Life Insurance for Your Dependent s
If You are in an eligible class on January 01, 2018, You will be eligible for Dependent insurance on that date.
If You enter an eligible class after January 01, 2018, You will be eligible for Dependent insurance on the first
day of the month coincident with or next following the date You enter that class.
No person may be insured as a Dependent of more than one employee.
Waiting Period means the period of continuous membership in an eligible class that You must wait before
You become eligible for Depe ndent Insurance. This period begins on the later of:
·the date You enter an eligible class; and
·the date You obtain a Dependent.
This period ends on the date You complete the period(s) specified.
ENROLLMENT PROCESS
In order to enroll for Basic Life Insurance for Your Dependents, You must either (a) already be enrolled for
Basic Life Insurance for You or (b) enroll at the same time for Basic Life Insurance for You.
If Your Employer establishes an annual enrollment period for Life Insurance, You may enroll for Dependent
Life Insurance only when You are first eligible or during an annual enrollment period or If You have a
Qualifying Event. You should contact the Empl oyer for more information regarding the annual enrollment
period.
If You are eligible for Dependent insurance, You may enroll for such insurance by completing the required
form for each Dependent to be insured. In addition, each of Your Dependents must give evidence of his
insurability satisfactory to Us at Your expense if required to do so under the section entitled EVIDENCE OF
INSURABILITY.
DATE INSURANCE FOR YOUR DEPENDENTS TAKES EFFECT
Rules for Noncontributory Dependent Insurance
For Dependents You Have When You Become Eligible For De pendent Insurance
If You complete the enrollment process for Noncontributory Dependent Insurance, the insurance will take
effect for each enrolled Dependent as follows:
·if the Dependent is not required to give evidence of his insurability, the insurance for
each enrolled Dependent will take effect on the date You become eligible for such
insurance, if You are Actively at Work on that day and the Dependent satisfies the
Additional Requirement stated below.
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ELIGIBILITY PROVISIONS: INSURANCE FOR YOUR DEPENDENTS
·if the Dependent is required to give evidence of his insurability and We determine that
the Dependent is insurable, the insurance will take effect on the date We state in Writing,
if You are Actively at Work on that day and the dependent satis fies the Additional
Requirement stated below.
If You are not Actively at Work on the date the Noncontributory Dependent Insurance benefit would otherwise
take effect, the insurance will take effect on the day You resume Active Work and the Additi onal Requirement
stated below is satisfied.
Rules for Contributory Dependent Insurance
For Dependents You Have When You Become Eligible For Dependent Insurance
If You complete the enrollment process for Contributory Dependent Insurance before the date You become
eligible for such insurance, such insurance will take effect for each enrolled Dependent as follows:
·if the Dependent is not required to give evidence of his insurability, such insurance will
take effect on the date You become eligible, provide d You are Actively at Work on that
date and the Dependent satisfies the Additional Requirement stated below.
·if the Dependent is required to give evidence of insurability and We determine that the
Dependent is insurable, such insurance will take effect on the date We state in Writing, if
You are Actively at Work on that date.
If You complete the enrollment process for Contributory Dependent Insurance, within 12 months of the date
You become eligible for such insurance or during the Empl oyers next annual enrollment period following the
date You become eligible for such insurance, whichever occurs first, such insurance will take effect for each
enrolled Dependent as follows:
·If the Dependent is not required to give evidence of his insura bility, such insurance will
take effect on the later of:
·the date You become eligible for such insurance; and
·the date You enroll if You are Actively at Work on that date and the Dependent satisfies the Additional
Requirement stated below.
·if the Dependent is required to give evidence of his insurability and We determine that the
Dependent is insurable, such insurance will take effect on the date We state in Writing, if
You are Actively at Work on that date the Dependent satisfies the Additional Requirement
stated below.
If You complete the enrollment process for Contributory Dependent Life Insurance more than 12 months after
the date You become eligible for such insurance or after the Employers next annual enrollment pe riod
following the date You become eligible for such insurance, whichever occurs first, each Dependent must give
evidence of his insurability satisfactory to us. You must give such evidence at Your expense. If We
determine that the Dependent is insurable, such insurance will take effect on the date We state in Writing, if
You are Actively at Work on that date and the Dependent satisfies the Additional Requirement stated below.
If You are not Actively at Work on the date benefits would otherwise take effe ct, benefits will take effect on the
day You resume Active Work.
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ELIGIBILITY PROVISIONS: INSURANCE FOR YOUR DEPENDENTS
For Dependents You Obtain After You Become Eligible For Dependent Insurance
If You obtain a Dependent after You become eligible for Dependent insurance, You may enroll the Dependent
for suc h insurance within 12 months of the date he qualifies as a Dependent, or during the Employer's next
annual enrollment period following date he qualifies as a Dependent, whichever occurs first. The Dependent
must give evidence of his insurability satisfact ory to Us at Your expense if required to do so under the section
entitled EVIDENCE OF INSURABI LITY. The Dependent insurance for the Dependent will take effect as
follows:
·if Dependents were not required to give evidence of insurability, the benefit for t hose
Dependents will take effect on the later of:
·the date You become eligible for such insurance; and
·the date You enroll provided You are Actively at Work on that day and the Additional Requirement
stated below is satisfied.
·if Dependents were required to give evidence of insurability and We determine that all
Dependents are insurable, the insurance will take effect on the date We state in Writing,
provided You are Actively at Work on that day and the Additional R equirement stated
below is satisfied.
If You complete the enrollment process for any Dependent more than 12 months after the date he qualifies as
a Dependent, or after the Employer's next annual enrollment period following date he qualifies as a
Dependent, whichever comes first, the Dependent must give evidence of his insurability satisfactory to Us at
Your expense. If We determine that the Dependent is insurable, the insurance will take effect on the date We
state in Writing, if the Dependent sa tisfies the Additional Requirement stated below.
Once You have enrolled one Child for Dependent insurance, each succeeding Child will automatically be
insured for such insurance on the date he qualifies as a Dependent.
If You are not Actively at Work on the date the Noncontributory Dependent Insurance would otherwise take
effect, the insurance will take effect on the day You resume Active Work and the Additional Requirement
stated below is satisfied.
Additional Requirement
On the date a Dependent insura nce is scheduled to take effect, the Dependent must not be:
·confined at home under a Physician's care;
·receiving or applying to receive disability insurance from any source; or
·Hospitalized.
If the Dependent does not meet this requirement on such date, insurance for the Dependent will take effect on
the date he is no longer:
·confined;
·receiving or applying to receive disability insurance from any source; or
·Hospitalized.
Enrollment Due to a Qualifying Event
You may enroll for dependent insurance for w hich You are eligible or change the amount of Your dependent
insurance between annual enrollment periods only if You have a Qualifying Event.
If You have a Qualifying Event, You will have 12 months from the date of that change or the Employers next
annua l enrollment period following the date of that change to make a request, whichever occurs first*
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ELIGIBILITY PROVISIONS: INSURANCE FOR YOUR DEPENDENTS
This request must be consistent with the nature of the Qualifying Event. The insurance enrolled for or
changes to Your insurance made as a result of a Qualify ing Event will take effect on the first day of the month
coincident with or next following the date of Your request, if You are Actively at Work on that date.
If You are not Actively at Work on the date insurance would otherwise take effect, insurance wil l take effect on
the day You resume Active Work.
Qualifying Event includes:
marriage; or
the birth, adoption or placement for adoption of a dependent child; or
divorce, legal separation or annulment; or
the death of a dependent; or
You previously did not enroll for life coverage for You or Your dependent because You had other group
coverage, but that coverage has ceased due to loss of eligibility for the other group coverage; or
Your dependent's ceasing to qualify as a dependent under this insurance or un der other group coverage.
DATE YOUR INSURANCE FOR YOUR DEPENDENTS ENDS
A Dependent's insurance will end on the earliest of:
1.for Dependent Life Insurance, the date all Your Life Insurance under the Group Policy ends;
2.the date You die;
3.the date the Group Policy ends;
4.the date insurance for Your Dependents ends under the Group Policy;
5.the date insurance for Your Dependents ends for Your class;
6.the date the person ceases to be a Dependent;
7.for Utah residents, the last day of the calendar month the person ceases to be a Dependent;
8.the last day of the calendar month in which Your employment ends; Your employment will end if You
cease to be Actively at Work in any eligible class, except as s tated in the section entitled
CONTINUATION WITH PR EMIUM PAYMENT;
9.the last day of the calendar month in which You retire in accordance with the Employers retirement plan;
or
10.the end of the period for which the last premium has been paid for the Dependent.
Please refer to the section entitled LIFE INSURANCE: CON VERSION OPTION FOR Y OUR DEPENDENTS
for information concerning the option to convert to an individual policy of life insurance if Life Insurance for a
Dependent ends.
Please refer to the section ent itled CONTINUATION OF INSU RANCE WITH PREMIUM P AYMENT for
information concerning Continuation For Family and Medical Leave.
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FOR MENTALLY OR PHYSICALLY HANDICAPPED CHILDREN
Insurance for a Dependent Child may be continued past the age limit if that child is incapable of self-
sustaining employment because of a mental or physical handicap as defined by applicable law. Proof of such
handicap must be sent to Us within 31 days after the date the Child attains the age limit and at reasonable
intervals after such date.
Subject to the DATE YOUR INSURANCE FOR YOUR DEPENDENTS E NDS subsection of the section
entitled ELIGIBILITY PROVISIONS: INSURANCE FOR YOUR DEPENDENTS, insurance will continue while
such Child:
·remains incapable of self-sustaining employment because of a mental or physical
handicap; and
·continues to qualify as a Child, except for the age limit.
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Certain leaves of absence may qualify for continuation of insurance under the Family and Medical Leave Act
of 1993 (FMLA), or other legally mandated leave of absence or similar laws. Please contact the Employer for
information regarding such legally mandated leave of absence laws.
AT YOUR OPTION: PORTABILITY
For Basic Life Insurance
If Your Portability Eligible Insurance or Portability Eligible Dependent Insur ance ends for any of the reasons
stated below, You have the option to continue that insurance under another group policy in accordance with
the conditions and requirements of this section. This is referred to as Porting. Evidence of Your insurability
will not be required.
For purposes of this subsection the term Portability Eligible Insurance refers to Your Basic Life benefits for
which the Portability Eligible Insurance is shown as available in the SCHEDULE OF BENEFITS.
If Insurance for Your Dependen ts is in effect, the term Portability Eligible Dependent Insurance refers to
Your Basic Life Insurance for Your Dependents for which the Portability Eligible Dependent Insurance is
shown as available in the SCHEDULE OF BENEFITS.
When Porting is an Optio n
Porting may only be exercised by a request in Writing during the Request Period specified below.
If You choose not to Port, Life Insurance benefits may be converted in accordance with the section entitled
LIFE INSURANCE: CONVERSION OPTION FOR YOU or th e section entitled LIFE INSURANCE:
CONVERSION OPTION FOR YOUR DEPENDENTS.
1.You may choose to Port if Portability Eligible Insurance and/or Portability Eligible Dependent Insurance
ends while You are Actively at Work or on an approved leave of absence becau se:
·You retired from active service with the Employer; or
·Your employment ends, due to a reason other than retirement; or
·You cease to be in a class that is eligible for such insurance; or
·The Policy is amended to end the Portability Eligible Insurance an d/or Portability Eligible Dependent
Insurance, unless such insurance is replaced by similar insurance under another group insurance
policy issued to the Policyholder or its successor; or
·This Policy has ended, unless such insurance is replaced by similar i nsurance under another group
insurance policy issued to the Policyholder or its successor.
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2.You may choose to Port the reduced amount of insurance if Your Portability Eligible Insurance is reduced
due to:
·Your age; or
·An amendment to the Plan which affects the amount of insurance for Your class.
3.Your former Dependent Spouse may choose to Port if their Portability Eligible Dependent Insurance on
his or her own life ends because:
·You die; or
·Your marriage ends in divorce or annulment;
provided that former Dependent Spouse satisfies the Additional Requirement subsection of the
ELIGIBILITY PROVISIONS: INSURANCE FOR YOUR DEPENDENTS.
4.Your former Dependent Spouse may also Port Portability Eligible Dependent Insurance on Your
Dependent Child if Your former Depen dent Spouse Ports insurance on his or her own life. If Your former
Dependent Spouse Ports that insurance on that Dependent Child, that Porting will have no effect on the
insurance You may have on that Dependent Child.
5.Your former Dependent Child may requ est to Port Portability Eligible Dependent Insurance on his or her
own life if that insurance ends because Your former Dependent Child no longer meets the definition of
Child.
If a request is made under this subsection, We will issue a new certificate of insurance which will explain the
new insurance benefits. The insurance benefits under the new certificate may not be the same as those that
ended under this Policy.
A request under this subsection may be made, if on the date the Portability Eligible Insu rance ended, the
following requirements are met:
·the Group Policy is in effect;
·With respect to any amount of Portability Eligible Life Insurance or Portability Eligible
Dependent Life Insurance that is to be Ported, no application has been made to conve rt
that amount of insurance to an individual policy of life insurance as provided in the
section entitled LIFE INSURANCE: CONVERSION OPTION FOR YOU or the section
entitled LIFE INSURANCE: CONVERSION OPTION FOR YOUR DEPENDENTS; and
·the person making the re quest resides in a jurisdiction that permits this Portability feature.
Request Period
For You or a former Dependent to Port, We must receive a completed request form within the Request Period
as described below.
If written notice of the option to Port i s given within 15 days before or after the date such insurance ends, the
Request Period:
·begins on the date the insurance ends, and
·expires 31 days after the date.
If written notice of the option to Port is given more than 15 days after but within 90 day s of the date such
insurance ends, the Request Period:
·begins on the date the insurance ends, and
·expires 45 days after the date of the notice.
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If written notice of the option to Port is not given within 91 days of the date such insurance ends, the Reque st
Period:
·begins on the date the insurance ends, and
·expires at the end of such 91 day period.
Amount of the New Certificate
The amount of Ported Insurance for You and for Your Dependents that may be continued is shown in the
SCHEDULE OF BENEFITS. How ever, at the time of Porting You may change the amount of Portability
Eligible Insurance in the following circumstances:
Your Increase in Amount
For Portability Eligible Life Insurance
At the time of Porting, You may increase the amount of Your Portabi lity Eligible Life Insurance. This
may be done in increments of $25,000, up to a maximum ported amount of $2,000,000. To be
eligible for this increased amount, You must provide evidence of Your insurability satisfactory to us, at
Your expense. If We app rove the increase, it will take effect on the date We state in Writing.
Dependent Spouse Increase in Amount
For Portability Eligible Dependent Life Insurance
At the time of Porting, the amount of Your Spouses (or Your former Dependent Spouses) Portability
Eligible Dependent Life Insurance may be increased. This may be done in increments of $25,000, up
to a maximum ported amount of $250,000. To be eligible for this increased amount, Your Spouse (or
Your former Dependent Spouse) must provide evidence of insurability satisfactory to us, at Your
Spouses (or Your former Dependent Spouses) expense. If We app rove the increase, it will take
effect on the date We state in Writing.
Dependent Child Increase in Amount
For Portability Eligible Dependent Life Insurance
At the time of Porting, if Your former Dependent Child is making the request to continue Portability
Eligible Dependent Life Insurance because he or she no longer meets the definition of a Child, that
former Dependent Child is eligible to increase coverage by $25,000. To be eligible for this increased
amount, Your former Dependent Child must give evidence of insurability satisfactory to Us at Your
former Dependent Childs expense. If we approve the inc rease, it will take effect on the date We
state in Writing.
You and/or Your Dependent(s) Decrease in Amount
If We receive a request to decrease an amount of insurance, any such decrease will take place on the date
We state in Writing.
Premiums for the N ew Certificate
All premium payments must be made directly to Us. When We issue the new certificate, We will also provide
a schedule of premiums and payment instructions.
You are not required to provide evidence of insurability to Port Your existing amou nt of Portability Eligible
Basic Life. However, to qualify for a lower premium rate, You may give us, at Your expense, evidence of Your
insurability satisfactory to Us. If We determine that the evidence satisfies Us, We will notify You that the lower
prem ium rates will apply to You.
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35
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Your former Dependents are not required to provide evidence of insurability to Port their existing amount of
Portability Eligible Dependent Life Insurance. However, to qualify for a lower premium rate, they may give us,
at their expense, evidence of their insurability satisfactory to Us. If We determine that the evidence satisfies
Us, We will notify them that the lower premium rates will apply to them.
Right to Convert Life Insurance Amounts Not Ported
Any amount of Life In surance not Ported under this subsection may be converted under the section entitled
LIFE INSURANCE: CONVERSION OPTION FOR YOU or the section entitled LIFE INSURANCE:
CONVERSION OPTION FOR YOUR DEPENDENTS.
If You Die Within 31 Days of the Date Portability Eligible Life Insurance Ends
If You die within 31 days of the date Portability Eligible Life Insurance ends and an application to Port is not
received by Us during such period, We will determine whether Your life insurance qualifies for payment. This
de termination will be made in accordance with the section entitled LIFE INSURANCE: CONVERSION
OPTION FOR YOU.
If a former Dependent Dies Within 31 Days of the Date Portability Eligible Life Dependent Insurance
Ends
If a former Dependent dies within 31 day s of the date Portability Eligible Dependent Life Insurance ends and
an application for a new certificate is not received by Us during such period, We will determine whether Your
life insurance qualifies for payment. This determination will be made in acc ordance with the section entitled
LIFE INSURANCE: CONVERSION OPTION FOR YOUR DEPENDENTS.
If You are Totally Disabled on the Date Your Employment Ends.
If You are Totally Disabled on the date Your employment ends and You elect to continue Portability E ligible
Insurance and/or Portability Eligible Dependent Insurance as provided in this subsection, You may at a later
date become approved for continuation of insurance under the section entitled ELIGIBILITY FOR
CONTINUATION OF CERTAIN INSURANCE WHILE YOU ARE TOTALLY DISABLED. If You are so
approved, all insurance continued under this subsection or any new certificate provided under this subsection
will end and We will return any premium paid by You for such insurance.
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The Employer has elected to continue insurance by paying premiums for employees who cease Active Work
in an eligible class for any of the reasons specified below. If Your insurance is continued, insurance for Your
Dependent s may also be continued. You will be notified by the Employer how much You will be required to
contribute.
Insurance will continue for the following periods:
1. for the period You cease Active Work in an eligible class due to injury or Sickness, up t o 9 months;
2. for the period You cease Active Work in an eligible class due to part-time work, layoff or strike, up to 2
months;
3. for the period You cease Active Work in an eligible class due to any other Employer approved leave of
absence, up to 2 months.
4. for the period You cease Active Work in an eligible class due to any Employer approved leave of absence
because of a call-up to active military service, up to 24 months.
At the end of any of the c ontinuation periods listed above, Your insurance will be affected as follows:
GCERT2000
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36
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·if You resume Active Work in an eligible class at this time, You will continue to be insured
under the Group Policy;
·if You do not resume Active Work in an eligible class at th is time, Your employment will
be considered to end and Your insurance will end in accordance with the DATE YOUR
INSURANCE ENDS subsection of the section entitled ELIGIBILITY PROVISIONS:
INSURANCE FOR YOU.
If Your insurance ends, Your Dependents insurance will also end in accordance with the DATE YOUR
INSURANCE FOR YOUR DEPENDENTS ENDS subsection of the section entitled ELIGIBILITY
PROVISIONS: INSURANCE FOR YOUR DEPENDENTS.
Option to Convert
In addition to the Continuation of Insurance options described above, You may have the right to convert to a
policy of individual life insurance. We urge You to read the section entitled LIFE INSURANCE: CONVERSION
OPTION FOR YOU or the section entitled LIFE INSURANCE: CONVERSION OPTION FOR YOUR
DEPENDENTS.
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EVIDENCE OF INSURABILITY
We require evidence of insurability satisfactory to Us as follows:
1.In order to receive an increase in the amount of Life Insurance of $50,000 or more due to an increase in
Your Basic Annual Earnings.
If You do not give Us evi dence of insurability or the evidence of insurability is not accepted by Us as
satisfactory, Your Life Insurance will not be increased.
2.In the case of transferred business, if You did not elect coverage under the prior plan for which You were
eligible.
If You do not give Us evidence of insurability or the evidence of insurability is not accepted by Us as
satisfactory, You will not be covered for Life Insurance.
3.In the case of transferred business, if You did not elect coverage under the prior plan for w hich Your
Dependents were eligible.
If You do not give Us evidence of insurability or the evidence of insurability is not accepted by Us as
satisfactory, Your Dependents will not be covered for Life Insurance.
The evidence of insurability is to be given at Your expense.
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LIFE INSURANCE: FOR YOU
If You die, Proof of Your death must be sent to Us. When We receive such Proof with the claim, We will
review the claim and if We approve it, will pay the Beneficiary the Life Insurance in effect on the date of Your
death.
PAYMENT OPTIONS
We will pay the Life Insurance in one sum.Other modes of payment may be available upon request. For
details, call Our toll free number shown on the Certificate Face Page.
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LIFE INSURANCE: FOR YOUR DEPENDENTS
If a Dependent dies, Proof of the Dependents death must be sent to Us. When We receive such Proof with
the claim, We will review the claim and if We approve it, will pay the Beneficiary the Life Insurance amount in
effect on the date of the Dependents death.
PAYMENT OPTIONS
We will pay the Life Insurance in one sum.Othe r modes of payment may be available upon request. For
details, call Our toll free number shown on the Certificate Face Page.
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LIFE INSURANCE: ACCELERATED BENEFIT OPTION (ABO) FOR YOU
For purposes of this section, the term ABO Eligible Life Insurance refers to each of Your Life Insurance
benefits for which the Accelerated Benefit Option is shown as available in the Schedule of Benefits.
If You become Terminally Ill, You or Your legal representative have the option to request Us to pay ABO
Eligible Life Insurance before Your death. This is called an accelerated benefit. The request must be made
while ABO Eligible Life Insurance is in effect.
Terminally Ill or Terminal Illness means that due to injury or sickness, You are expected to die within 12
months.
Requirements For Payment of an Accelerated Benefit
Subject to the conditions and requirements of this section, We will pay an accelerated benefit to You or Your
legal representative if:
·the amount of each ABO Eligible Life Insurance benefit to be accelerated equals or
exceeds $20,000; and
·the ABO Eligible Life Insurance to be accelerated has not been assigned; and
·We have received Proof that You are Terminally Ill.
We will only pay an accelerated benefit for each ABO Eligible Life I nsurance benefit once.
Proof of Your Terminal Illness
We will require the following Proof of Your Terminal Illness:
·a completed accelerated benefit claim form;
·a signed Physicians certification that You are Terminally Ill; and
·an examination by a Physician of Our choice, at Our expense, if We request it.
You or Your legal representative should contact the Employer to obtain a claim form and information
regarding the accelerated benefit.
Upon Our receipt of Your request to accelerate benefits, We will send You a letter with information about the
accelerated benefit payment You requested. Our letter will describe the amount of the accelerated benefits
We will pay and the amount of Life Insurance remaining after the accelerated benefit is pai d.
Accelerated Benefit Amount
We will pay an accelerated benefit up to the percentage shown in the SCHEDULE OF BENEFITS for each
ABO Eligible Life Insurance benefit in effect for You, subject to the following:
Maximum accelerated benefit amount.The maximum amount We will pay for each ABO Eligible Life
Insurance benefit is shown in the SCHEDULE OF BENEFITS.
Scheduled reduction of an ABO Eligible Life Insurance Benefit.If an ABO Eligible Life Insurance
benefit is scheduled to reduce within the 12 mo nth period after the date You or Your legal representative
request an accelerated benefit, We will calculate the accelerated benefit using the amount of such ABO
Eligible Life Insurance that will be in effect immediately after the reduction(s) scheduled for such period.
Scheduled end of ABO Eligible Life Insurance Benefit. If an ABO Eligible Life Insurance benefit is
scheduled to end within 12 months after the date You or Your legal representative request an accelerated
benefit, We will not pay an accelerated benefit for such ABO Eligible Life Insurance benefit.
Previous conversi on of an ABO Eligible Life Insurance Benefit. We will not pay an accelerated
benefit for any amount of ABO Eligible Life Insurance which You previously converted under the section
entitled LIFE INSURANCE: CONV ERSION OPTION FOR YO U.
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LIFE INSURANCE: ACCELERATED BENEFIT OPTION (ABO) FOR YOU
We will pay the accel erated benefit in one sum unless You or Your legal representative select another
payment mode.
Effect of Payment of an Accelerated Benefit
On premium for Your Life Insurance. After We pay the accelerated benefit, any premium You are
required to pay w ill be based upon the amount of Your Life Insurance remaining after the accelerated
benefit is paid.
On Your Life Insurance at Your death. The amount of Life Insurance that We will pay at Your death will
be decreased by:
·the amount of the accelerated benefit paid by Us.
On Your Life Insurance at conversion. The amount to which You are entitled to convert under the
section entitled LIFE INSURANCE: CONV ERSION OPTION FOR YO U, will be decreased by:
·the amount of the accelerated benefit paid by Us.
Date Your Option to Accelerate Benefits Ends
The accelerated benefit option will end on the earliest of:
·the date ABO Eligible Life Insurance ends;
·the date You or Your legal representative assign all ABO Eligible Life Insurance; or
·the date You or Your legal representative have accelerated all ABO Eligible Life
Insurance benefits.
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LIFE INSURANCE: CONVERSION OPTION FOR YOU
If Your Life Insurance ends for any of the reasons stated below, You have the option to buy an individual
policy of life insurance (new policy) from Us during the Application Period in accordance with the conditions
and requirements of this section. This is referred to as the option to convert. Evidence of Your insurability
will not be required.
When You Will Have the Option to Convert
You will have the option to convert when:
·Your Life Insurance ends because:
·You cease to be in an eligible class; or
·Your employment ends; or
·the Group Policy ends provided You have been insured for Life Insurance for at least 5 years; or
·the Group Policy is amended to end Life Insurance for an eligible class of which You are a member,
provided You have been insu red for Life Insurance for at least 5 years.
A reduction in the amount of Your Life Insurance as a result of the payment of an accelerated benefit will not
give rise to a right to convert under this section.
Application Period
If You opt to convert Yo ur Life Insurance for any of the reasons stated above, We must receive a completed
conversion application form from You within the Application Period described below.
If You are given Written notice of the option to convert within 15 days before or after the date Your Life
Insurance ends, the Application Period begins on the date that such Life Insurance ends and expires 31 days
after such date.
If You are given Written notice of the option to convert more than 15 days after the date Your Life Insurance
ends, the Application Period b egins on the date such Life Insurance ends and expires 15 days from the date
of such notice. In no event will the Application Period exceed 91 days from the date Your Life Insurance ends.
Option Conditions
The option to convert is subject to these co nditions:
1. Our receipt within the Application Period of:
·Your Written application for the new policy; and
·the premium due for such new policy;
2. The premium rates for the new policy will be based on:
·Our rates then in use;
·the form and amount of insurance;
·Your class of risk; and
·Your attained age when Your Life Insurance ends;
3. the new policy may be on any form then customarily offered by Us excluding term insurance;
4. the new policy will be issued without an accidental death and dismemberment benefit, a continuation
benefit, an accelerated benefit option, a waiver of premium benefit or any other rider or additional benefit;
and
nd
5. the new policy will take effect on the 32 day after the date Your Life Insurance ends; this will be the case
regardless of the duration of the Application Period.
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LIFE INSURANCE: CONVERSION OPTION FOR YOU
Maximum Amount of the New Policy
If Your Life Insurance ends due to the end of the Group Policy or the amendment of the Group Policy to end
Life Insurance for an eligible class of which You are a member, the maximum amount of insurance that You
may elect for the new polic y is the lesser of:
·the amount of Your Life Insurance that ends under the Group Policy less the amount of
life insurance for which You become eligible under any group policy within 31 days after
the date insurance ends under the Group Policy; or
·$2,000
If Your Life Insurance ends for any other reason, the maximum amount of insurance that You may elect for
the new policy is the amount of Your Life Insurance that ends under the Group Policy.
If You Die Within 31 Days After Your Life Insuran ce Ends
If You die within 31 days after Your Life Insurance ends, Proof of Your death must be sent to Us. When We
receive such Proof with the claim, We will review the claim and if We approve it will pay the Beneficiary the
amount of Life Insurance You w ere entitled to convert.
Effect of Previous Conversion
If You obtained a new policy through this conversion option and Your Life Insurance is later continued under
the section entitled ELIGIBILITY FOR CONTINUATION OF CERTAIN INSURANCE WHILE YOU ARE
TOTALLY DISABLED. We will only pay Your Life Insurance under such section if the new pol icy is returned
to Us. If the new policy is returned to us, We will refund to Your estate the premium paid for such policy
without interest, less any debt incurred under such policy. If the new policy is not returned to Us, We will only
pay the life insu rance in effect under such new policy.
We will not pay insurance under both the Group Policy and the new policy.
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LIFE INSURANCE: CONVERSION OPTION FOR YOUR DEPENDENTS
If Life Insurance for a Dependent ends for any of the reasons stated below, You or the dependent will have
the option to buy from Us an individual policy of life insurance (new policy) during the Application Period in
accordance with the conditions and requirements of this section. This i s referred to as the option to convert.
Evidence of the Dependents insurability will not be required.
When You or a Dependent Will Have the Option to Convert
You will have the option to convert Life Insurance for a Dependent when:
·Life Insurance for the Dependent ends because:
·You cease to be in an eligible class ; or
·Your employment ends ; or
·the Group Policy ends provided You have been insured for Life Insurance for the Dependent for at
least 5 years; or
·the Group Policy is amended to end Life Insurance for Dependents for an eligible class of which You
are a me mber, provided You have been insured for Life Insurance for the Dependent for at least 5
years.
A Dependent will have the option to convert when Life Insurance ends because such Dependent ceases to
qualify as a Dependent as defined in this certificate.
You must notify the Employer in the event that a Dependent ceases to qualify as a Dependent as defined in
this certificate.
Application Period
If You or a Dependent opt to convert as stated above, We must receive a completed conversion application
form within the Application Period described below.
If Written notice of the option to convert is given within 15 days before or after the date Life Insurance for the
Dependent ends, the Application Period begins on the date that such Life Insurance ends and expires 31
days after such date.
If Written notice of the option to convert is given more than 15 days after the date Life Insurance for the
Dependent ends, the Application Period begins on the date such Life Insurance ends and expires 15 days
from the date of such notice. In no event will the Application Period exceed 91 days from the date Life
Insurance for the Dependent ends.
Option Conditions
The option to convert is subject to these conditions:
1. Our receipt within the Application Period of:
·a Written application for the new policy for the Dependent; and
·the premium due for such new policy;
2. the premium rates for the new policy will be based on:
·Our rates then in use;
·the form and amount of insurance;
·the Dependents class of risk;and
·the Dependents attained age when Life Insurance for such Dependent ends;
3. the new policy may be on any form then customarily offered by Us excluding term insurance;
GCERT2000
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LIFE INSURANCE: CONVERSION OPTION FOR YOUR DEPENDENTS
4. the new policy will be issued without an accidental death and dismemberme nt benefit, a continuation
benefit, an accelerated benefit option, waiver of premium benefit or any other rider or additional benefit;
and
nd
5. the new policy will take effect on the 32 day after the date Life Insurance for the Dependent ends; this
will be the case regardless of the duration of the Application Period.
Maximum Amount of the New Policy
If Life Insurance for a Dependent ends due to the end of the Group Policy or the amendment of the Group
Policy to end Life Insurance for Dependents for an eligible class of which You are a member, the maximum
amount of insurance that may be elected for the new policy is the lesser of:
·the amount of Life Insurance for the Dependent that ends under the Group Policy less the
amount of life insurance for de pendents for which You become eligible under any group
policy within 31 days after the date insurance ends under the Group Policy; or
·$2,000
If Life Insurance for a Dependent ends for any other reason , the maximum amount of insurance that may be
elected for the new policy is the amount of Life Insurance for the Dependent that ends under the Group
Policy.
If a Dependent Dies Within the 31 Days After Life Insurance for a Dependent Ends
If a Dependent dies within 31 days after the date Life Insuranc e for the Dependent ends, Proof of the
Dependents death must be sent to Us. When we receive such Proof with the claim, We will review the claim
and if We approve it, will pay the Beneficiary the amount of Life Insurance for the Dependent that could have
been converted.
GCERT2000
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For All Active Part-Time Employees Excluding Airport Authority Employees:
If You become Totally Disabled while You are insured for Continuatio n Eligible Insurance under this policy,
You may qualify to continue certain insurance under this section. If continued, premium payment will not be
required. We will determine if You qualify for this continuation after We receive Proof that You have sati sfied
the conditions of this section.
Total Disability must start before You attain age 60 and while You are insured for Continuation Eligible
Insurance.
Your Total Disability must continue without interruption from the date You became Totally Disabled through
the end of the Continuation Waiting Period.
DEFINITIONS
For the purpose of this section, Continuation Eligible Insurance means Your
·Basic Life Insurance;
·Dependent Basic Life Insurance if You continue Basic Life Insurance;
to the extent that such insurance was in effect for You on the date Your Total Disability began.
Continuation Eligible Insurance does not include Life Insurance amounts accelerated under the section
entitled LIFE INSURANCE: ACCELERATED BENEFIT OPTION FOR YOU.
Continuation Waiting Period means the period which starts on the date You become Totall y Disabled and
ends 9 consecutive months later.
Total Disability or Totally Disabled means, for purposes of this section, that due to an injury or sickness:
·You are unable to perform the material and substantial duties of Your regular job; and
·You are unable to perf orm any other job for which You are fit by education, training or
experience.
TOTAL DISABILITY AND PROOF REQUIREMENTS
If You become disabled You should contact Us as soon as reasonably possible. After the Continuation
Waiting Period ends,You must send Us Proof that You were Totally Disabled with no interruption throughout
the Continuation Waiting Period. You must do this within the time frame specified in the section entitled
FILING A CLAIM.
As part of such Proof, We may choose a Physic ian to examine You to verify that You are Totally Disabled.
We will pay for the exam.
After We receive and review Your Proof, We will determine if You qualify. We will notify You in writing of Our
decision.
To verify that You continue to be Totally Di sabled without interruption, We may require from time to time that
You send Us Proof that You continue to be Totally Disabled. We will not ask for Proof more than once each
year.
IF YOU OR YOUR DEPENDENT DIE DURING CONTINUATION
If You or Your Dependent die during the continuation, Proof of the death must be sent to Us. In addition to
the Proof which is otherwise required for the insurance, the Proof must show that Your Total Disability
GCERT2000
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continued with no i nterruption from the date We informed You that the continuation was approved until the
date of the death.
When We receive such Proof with the claim, We will review the claim and if We approve it, will pay any
benefit payable under the insurance continued under this section.
EFFECT OF PREVIOUS CONVERSION
If You converted any portion of Your Continuation Eligible Life Insurance to an individual policy, We will only
pay the life insurance under this section if the individual policy is returned to Us. If it is returned to Us, We will
refund to Your estate the premiums paid for such policy without interest, less any debt incurred under such
policy.
If such individual policy is not returned to Us, We will pay the life insurance in effect under the individua l
policy.
We will not pay insurance under both the Group Policy and the individual policy.
EFFECT OF PREVIOUS ELECTION TO PORT COVERAGE
If You ported any portion of Your Continuation Eligible Insurance to a certificate under another policy, We will
only pay insurance under this section if the other policys certificate is surrendered to Us. If it is returned to
Us, We will refund to Your estate the premiums paid under such policy without interest.
If that certificate is not returned to Us, We will pay any insurance which applies under the other policys
certificate.
We will not pay insurance under both this Group Policy and the other policy.
DATE CONTINUATION ENDS
The Continuation Eligible Insuranc e continued under this section may be continued in a reduced amount on
account of Your age or the payment of accelerated benefits and will end at the earliest of:
1.the date You die;
2.the date Your Total Disability ends;
3.the date You do not give Us Proof of Total Disability, as required;
4.the date You refuse to be examined by Our Physician, as required;
5.with respect to Depend ent Life Insurance, the date You no longer have any Dependents;
6.if You become Totally Disabled before age 60, the date You reach age 65.
Option To Convert Your Continuation Eligible Life Insurance
When a continuation under this section ends, You may bu y an individual policy of life insurance from Us. The
details of this option are described in the section entitled LIFE INSURANCE: CONVERSION OPTION FOR
YOU and LIFE INSURANCE: CONVERSION OPTION FOR YOUR DEPENDENTS. For the purpose of that
section, the e nd of this continuation will be considered the end of Your employment. You may not use the
conversion option described in those sections if before the end of the Application Period for conversion You
return to Active Work in an eligible class and become i nsured under the Group Policy. You will not be able to
convert any of Your Continuation Eligible Life Insurance which You have already converted to an individual
policy.
Option To Port Your Continuation Eligible Insurance
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When a continuation under this section ends, You may elect to port to a different policy the insurance which
has been continued under this section. The details of this option are described in the At Your Option:
Portability subsection of the CONTINUATION OF INSURANCE WITH PREMIUM PAYME NT section. For the
purpose of that section, the end of this continuation will be considered the end of Your employment. You may
not use the portability option described in that section if before the end of the Portability Request Period, You
return to Ac tive Work in an eligible class and become insured under the Group Policy. You will not be able to
port any of Your Continuation Eligible Insurance which You have already converted to an individual policy.
GCERT2000
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FILING A CLAIM
The Employer should have a supply of claim forms. Obtain a claim form from the Employer and fill it out
carefully. Return the completed claim form with the required Proof to the Employer. The Employer will certify
Your insurance under the Group Policy and s end the certified claim form and Proof to Us.
When we receive the claim form and Proof We will review the claim and, if We approve it, We will pay benefits
subject to the terms and provisions of this certificate and the Group Policy.
CLAIMS FOR LIFE INSU RANCE BENEFITS
When a claimant files a claim for Life Insurance benefits, Proof should be sent to Us as soon as is
reasonably possible after the death of an insured.
GCERT2000
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50
GENERAL PROVISIONS
Assignment
You may assign Your Life Insurance rights and benefits under the Group Policy as a gift or as a viatical
assignment.
We will recognize the assignee(s) under such assignment as owner(s) of Your right, title and interest in the
Group Policy if:
1. a Written form satisfactory to Us, affirming this assignment, has been completed;
2. the W ritten form has been Signed by You and the assignee(s);
3. the Employer acknowledges that the Life Insurance being assigned is in force on the life of the assignor;
and
4. the Written form is delivered to Us for recording.
Viatical assignments may only be made after Your Life Insurance has been in effect under this certificate for 2
years. However, you may make a viatical assignment before the end of the 2 year period if you are Terminally
Ill.
Terminally Ill means that You are expected to die wit hin 6 months. As Proof of Your Terminal Illness You or
Your legal representative must send Us a signed Physicians certification that You are Terminally Ill. We may
also request an exam by a Physician of Our choice, at Our expense.
Beneficiary
You may designate a Beneficiary in Your application or enrollment form. You may change Your Beneficiary at
any time. To do so, You must send a Signed and dated, Written request to the Employer using a form
satisfactory to Us. Your Written r equest to change the Beneficiary must be sent to the Employer within 30
days of the date You Sign such request.
You do not need the Beneficiarys consent to make a change. When We receive the change, it will take effect
as of the date You Signed it. Th e change will not apply to any payment made in good faith by Us before the
change request was recorded.
If two or more Beneficiaries are designated and their shares are not specified, they will share the insurance
equally.
If there is no Beneficiary desi gnated or no surviving designated Beneficiary at Your death, We will determine
the Beneficiary to be one or more of the following who survive You:
1. Your Spouse;
2. Your child(ren);
3. Your parent(s);
4. Your siblings(s); or
5. Your estate, if there is no surviving sibling.
For Your Life Insurance for Your Dependents, We will pay You as the Beneficiary, if alive. If You are not alive,
We will deter mine the Beneficiary to be one or more of the following who survive You:
1. Your Spouse;
2. Your child(ren);
3. Your parent(s);
4. Your sibling(s); or
5. Your estate, if there is no surviving sibling.
If You and any Dependent die within a 24 hour period, We will pay the Dependents Life Insurance to Your
estate.
·Any payment made in good faith will discharge our liability to the extent of such payment.
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gp 10/04 51
GENERAL PROVISIONS (CONTINUED)
If a Beneficiary or payee is a minor or incompetent to receive payment, We will pay that persons guardian.
Entire Contract
Your insurance is provided under a contract of group insurance with the Employer. The entire contract with
the Employer is made up of the following:
1. the Group Policy and its Exh ibits, which include the certificate(s);
2. the Employer's application; and
3. any amendments and/or endorsements to the Group Policy.
Incontestability: Statements Made by You
Any statement made b y You will be considered a representation and not a warranty. We will not use such
statement to avoid insurance, reduce benefits or defend a claim unless the following requirements are met:
1. the statement is in a Written application or enrollment for m;
2. You have Signed the application or enrollment form; and
3. a copy of the application or enrollment form has been given to You or Your Beneficiary.
We will not use Your statements which relate to insurability to contest life insurance after it h as been in force
for 2 years during Your life. In addition, We will not use such statements to contest an increase or benefit
addition to such insurance after the increase or benefit has been in force for 2 years during Your life.
Misstatement of Age
If Your or Your Dependents age is misstated, the correct age will be used to determine if insurance is in
effect and, as appropriate, We will adjust the benefits and/or premiums.
Conformity with Law
If the terms and provisions of this certificate do not conform to any applicable law, this certificate shall be
interpreted to so conform.
Autopsy
We have the right to make a reasonable request for an autopsy where permitted by law. Any such request
will set forth the reasons We are requesting the autopsy. We will pay the cost of such autopsy.
GCERT2 000
gp 10/04 52
"THIS IS THE END OF THE CERT IFICATE. THE FOLLOWING IS ADDITIONAL INFORMATION"
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