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Resolution No. 97551 Pa 3 4 5 6 7 8 9 10 11 OVA 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 RESOLUTION NO. 9755 A RESOLUTION OF THE CITY COUNCIL OF THE CITY OF VERNON APPROVING AND AUTHORIZING THE EXECUTION OF AN APPLICATION FOR GROUP INSURANCE AND SAMPLE CONTRACT BY AND BETWEEN THE CITY OF VERNON AND THE LINCOLN NATIONAL LIFE INSURANCE COMPANY FOR THE PURCHASE OF LIFE INSURANCE BENEFITS AND AUTHORIZING THE CITY TO DO ALL ACTIONS DEEMED NECESSARY OR ADVISABLE CONCERNING SECURING SAID BENEFITS WHEREAS, on December 17, 2007, the City Council of the City of Vernon adopted Resolution No. 9497 ratifying and approving, in part, life benefits for eligible employees with Mutual of Omaha ("Omaha"); and WHEREAS, the Risk Manager has recommended that the City discontinue the life benefits with Omaha for 2009 due to administration tissues; and WHEREAS, the City employed the services of Gallagher Benefit Services ("Gallagher") to act as the City's broker to structure and obtain the appropriate life insurance coverage for the period January 1, 2009 through December 31, 2009; and WHEREAS, Gallagher has recommended that the City enter into an arrangement with The Lincoln National Life Insurance Company ("Lincoln") for basic life insurance at $20,000.00 per employee for an annual premium amount of $10,652.00; and WHEREAS, the City of Vernon and Lincoln desire to enter into an agreement to establish the terms and conditions necessary for the jadministration of the plan; and WHEREAS, the City Council of the City of Vernon has determined that, pursuant to the provisions of subsection (a) of 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 i6 17 18 19 20 21 22 23 24 25 26 27 28 IlSection 2.27 of the Vernon City Code, it is in the public interest and 11necessity to enter into an agreement with Lincoln. NOW, THEREFORE, BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF VERNON AS FOLLOWS: SECTION 1: The City Council of the City of Vernon hereby finds and determines that the recitals contained hereinabove are true and correct. SECTION 2: The City Council of the City of Vernon hereby approves the Application for Group Insurance, a Group Insurance Program proposal from Lincoln and Sample Contract with Lincoln, in substantially the same form as the copy which is attached hereto as Exhibit A and incorporated by reference. SECTION 3: The City Council of the City of Vernon hereby authorizes the City Administrator, or his designee, to execute the Application and Contract for, and on behalf of, the City of Vernon and the City Clerk or Deputy City Clerk is hereby authorized to attest thereto. SECTION 4: The City Council of the City of Vernon hereby authorizes the City Administrator, or his designee, to make whatever nonsubstantive, administrative and/or text changes, upon advice of counsel, to the Agreement. SECTION 5: The City Council of the City of Vernon hereby authorizes the City Administrator, or his designee, to execute any and all documents as shall be required or to take any action deemed necessary or advisable to implement the life insurance consistent with the terms of said Application and Contract approved herein. - 2 - 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 SECTION 6: The City Council of the City of Vernon hereby directs the Risk Manager to forward the required signed documents to Lincoln. SECTION 7: The City Clerk of the City of Vernon shall certify to the passage of this resolution, and thereupon and thereafter the same shall be in full force and effect. APPROVED AND ADOPTED this 3rd day of November, 2008. Name: 14ilario Gonzales Title:'Q �/ Mayor Pro-Tem AT ESTA, UELA GIRON, City Clerk - 3 - 1 STATE OF CALIFORNIA ) 2 ) ss COUNTY OF LOS ANGELES ) 3 4 I, MANUELA GIRON, City Clerk of the City of Vernon, do hereby 5 certify that the foregoing Resolution, being Resolution No. 9755, was 6 duly adopted by the City Council of the City of Vernon at a regular 7 meeting of the City Council duly held on Monday, November 3, 2008, and 8 thereafter was duly signed by the Mayor or Mayor Pro-Tem of the City of 9 Vernon. 10 11 12 MANUELA I N, City Clerk (SEAL) 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 4 - EXHIBIT A CD CD N O D r x s CD .. . • .. „; ...�.. mno �, y A)n C� m D CD 1 ' .. fD o CD CA O d w o c C CD _ • .. . G7 O i. 3 CD 1 S �i nC 0 k � CD > a r oT •• : 0 O D c y = c rt p Qo a F . CD �.. p - 0 CD T S - t! - - 6 W CD N O N � W 0 0 0 P Cfl v W O N) c - ELa �CL C)c)uloo o No Q. fl O o c c c c c c o p o 69 � ' � O S COD 0 0 0 0 0 0 Q O o 0 0 o O Q Q. 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O N CD °ail m � �(nw to o000000o to to (0 <0 (0 000Lrl 69 to- CL - 7s OOJ W CO N CSi CODA to (O -� A 0 J J W. 0 N 00DJ U(OJJ V - -� - N 00 OD - - - -. o N o 3 N N to to to to ifl to ffl 69 69 ffl w �0000000000000 o to 0 to 0 b9 0 0 0 0 0 0 0 0 0 0 0 y 0.?AAAAAA-AAAAAA N - _ _ N- f7o m 3 m 3 m CA (D • O m - o O CD (D O (D W N N CD3 CD m �D <A fA to ea to Eli ffl 0.1 to 0 fn 0 to 0 to o at H w w so 0 0 ,( - - - - OOv-(OOsj(AAJO) 899 J CL N(O CO -AJ.ON(TO V JCD - 1 � 7 o I � O O CD I E- - - (/� Oto OAAAAAAAAAAAAA O O to O O to O O to O O fir) O O to O O 69 O O to O O to O O tf)Eft O 0 O O 69 O O EA O 0' CL00 I i c m 3m 3(D m o CD om om ow o y m N N m 3 rt O (D i 1 The Lincoln National life Insurance Company fiice USe oni (D# ,. Group Insurance Service Office 8801 Indian Hills Drive Omaha, Nebraska 68114.4066 APPLICATION FOR GROUP INSURANCE is hereby made to THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (the Company). A. NAME ANY AUUM55 R. REQUESTED COVERAGES The following Group Insurance is applied for as specified in the sold case proposal(s). Complete the requested Effective Date for each coverage. [� Life & AD&D with Effective Date [] Voluntary Life with Effective Date Long Term Disability with Effective Date [] Voluntary Life & AD&D with Effective Date E Short Term Disability with Effective Date ❑ Voluntary Long Term Disability with Effective Date [❑ Dental with Effective Date 0 Voluntary Dental with Effective Date G. drUS/NtSS/NMffMA//UN 1. Nature of Business (Please specify): Years in Business Federal Tax IDlt 2. Business is Organized As (select one): HCorporation Q Non -Profit Organization Partnership [] Proprietorship [] Other 3. Financial Risk (if Yes to any part, please explain below.) Yes No Has Applicant ever filed for bankruptcy? Yes No Does Applicant anticipate ceasing or materially reducing active business operations? Yes No Has Applicant opted out (or do they anticipate opting out) of Workers' Compensation? Explanation: 4. Binder payment submitted: Amount S (if applicable) D.;, REPLACEMENT COVERAGE © Yes [_] No Will all or part of this coverage replace any similar coverage? If Yes, provide details of the prior plan below and enclose a copy of each inforce contract to be replaced. Coverage Type Prior Carrier Name Prior Plan Effective Date Termination Date E. FRAUD WARNING NOTICE: California law prohibits an HIV test from being required or used by health insurance companies as a condition of obtaining health insurance coverage. NOTICE: A person may be committing insurance fraud if he or she submits an application containing a false or deceptive statement with the intent to defraud (or knowing that he or sheds helping to defraud) an insurance company. f. AGREEMENT. The Applicant hereby applies for group insurance. The information in this Application is true and correct to the best of the Applicant's knowledge and belief. It forms the basis for this request for group insurance. Omission or misstatement of known information on this Application could affect the validity of any insurance issued and cause the denial of an otherwise valid claim. The Applicant understands that the requested group insurance will: (a) be issued only if the requested insurance is acceptable to the Company and is legally permissible; (b) be issued under a group Policy or Policies in the language'customarily used by the Company; (c) be subject to the Company's usual underwriting requirements (including Evidence of insurability, if applicable); (d) be subject to all exclusions and limitations of the Policy; and (a) take effect on the date determined by the Company. The Applicant understands that no agent or broker has the authority to guarantee the acceptability of the requested insurance. The effective date of insurance for which an employee is required to submit satisfactory Evidence of Insurability will be determined in accord with the Policy's terms, and will be subject to the Active Work requirement. The Applicant agrees not to: (a) collect or pay premiums (other than the Binder Premium, if any) for such insurance, before receiving the Company's notice of approval; or (b) distribute material describing Policy coverage to persons to be insured, without the Company's prior written consent. If dental insurance is requested, the Applicant agrees to provide employees and dependents notice of any applicable continuation rights, required by federal COBRA law or any similar state continuation law. Premium rate quotes were based on data submitted to the Company. Final premium rates will be determined by the actual composition of the group. This application and the Binder payment, if any, constitutes the consideration for any Policy issued. After receipt of the Policy, payment of the premium is deemed acceptance of the Policy's terms. If this Application is approved, it will be made a part of any Policy issued. Writing Agent Signed by Applicant's Authorized Representative: Or Broker's Signature Typed or Printed Name Signature License Number State Typed or Printed Name Title State Signed Date Must be signed prior to Effective Date GL2-APP.09102 CA PARTICIPATION AGREEMENT The Lincoln National Life Insurance Company (herein called the Company) Complete only if applying for coverage under The Lincoln National Life Insurance Company I/oluntary Insurance Trust. Note: uo not complete in AL, MN or MS. Application is hereby made to become a Participating Employer under The Lincoln National Life Insurance Company's Voluntary Insurance Trust, based on the following statements plus the attached application for group insurance coverage. The Group Employer named below (herein called the Employer) understands that if Voluntary Group Term Life and AD&D or Disability Income insurance is requested and approved, such Employer will become a Participating Employer under The Lincoln National Life Insurance Company Voluntary Insurance Trust, sitused in Kansas City, Missouri. The Employer agrees to the terms of the Trust Agreement, each group policy issued to the Trust under which the Employer's employees becomeinsured, and any amendments to them. The Employer understands that group certificates will be supplied and agrees to distribute them to each employee enrolled in the program. After receipt of the group certificates, payment of premium is deemed acceptance of the policy's terms. The Employer agrees to be responsible for all premiums payable with respect to any of my employees who will be insured under the policy. The Employer agrees to honor and administer on a timely basis the written payroll deduction request of each participant, in the amount required to pay the necessary premium to keep coverage in -force. Payroll deductions will be remitted to the Company on a timely basis, in accord with the billing schedule agreed upon. The Employer agrees to promptly furnish the Company any information reasonably required to administer the coverage and claims under it. The Employer understands that participation in the program maybe terminated at any time by giving prior written notice to the Company. The effective date of termination will be the date the notice is received by the Company's Group Insurance Service Office, or on'any later date stated in the notice. The Employer understands that the Company may terminate the Employer's participation based on the following circumstances: a) at the end of the grace period during which the required premium has not been paid; b) on any premium due date on which participation in the program falls below a minimum level of 10 employees; c) on any premium due date when the Employer has failed to perform any duties related to the policy in good faith; d) on any premium due date after the premium rate has been in effect for at least 12 months (or any longer Rate Guarantee period agreed upon by the Company). The Employer understands that the Company may change any premium rate: a) when there is a change in the terms of the policy, or in the factors bearing on the risk assumed; b) when the policy liability is changed as a result of a change in federal, state or local law; c) when a division, subsidiary or affiliate is added, removed, or relocated; , d) when the number of insured employees has changed by 25% or more since the Rate Guarantee period began; e) on any premium due date after the expiration of the Rate Guarantee period agreed upon by the Company. SIGNATURE I have read and understand the agreement above and will comply with the agreement as stated. I have reviewed, understand and agree to the proposal, rate structure, and enrollment strategy presented to me by the Company representative. I understand that no agent, broker or field representative has any right to bind the requested coverage, alter the terms of the policies or enrollment materials, adjust any claim for benefits, or waive any of the Company's rights or requirements. Group Employer Name & ID Printed Name of Authorized Company Officer Signature of Authorized Company Officer Title Date VPA2007 A GROUP INSURANCE PROGRAM Designed for CITY OF VERNON Submitted by Gallagher Benefit Services of California Glendale, CA Underwritten by THE LINCOLN NATIONAL LIFE INSURANCE COMPANY Service Office 8801 Indian Hills Drive Omaha, Nebraska 68114 - 4066 Home Office: Fort Wayne, IN Lincoln Financial Group maintains: • Strong financial history • Some of the highest ratings in the industry o AA "Very Strong" Standard & Poor Rating o A+ "Superior" A.M. Best Company Rating o AA "Very Strong" Fitch Rating • "Direct to Home Office Service" through group sales offices located nationwide • One -stop shopping for comprehensive group benefits o True group products including Life and AD&D, Short -Term Disability, Long -Term Disability(with optional Critical Illness coverage), Dental and Employee Assistance Programs o WORKSITE1 Voluntary products including Life and AD&D, STD, LTD, Dental and Vision ✓ Featuring Voluntary enrollment form customization o Exec-U-Care° Medical Reimbursement Program Real Time Online Benefit Administration with Online Services o Submit claims and check their status online o Change member information online o Enroll and terminate members and coverages online o Utilize Virtual Billing capabilities to add or terminate members, then recalculate the bill to reflect the actual amount owed, and pay the bill online o View and print group forms, administration guidelines, contracts and certificates online o Apply for group insurance coverage electronically with e-App o Continuous enhancements are being made to our Online Service capabilities to better serve both your needs and your clients' needs • Interactive Voice Response (IVR) System allows service 24 hours a day, 7 days a week o Use IVR to check on the status of claims, members and premium payments all hours of the day, everyday. WHAT THIS MEANS FOR YOU... The Lincoln Financial Group companies: ■ have a long history of strength and stability, offering you superior products — and the service to back them up. ■ focus on making life easier for the customer by doing business the way the customer wants to do business — via the Web, telephone, IVR, e-mail or fax. ■ are committed to superior service, combined with a guaranteed commitment to technology, which J means less hassle for you! The Lincoln National Life Insurance Company 2 10/29/2008 VERNONCITY 5165967 City of Vernon SCHEDULE OF INSURANCE Option 1.00 Proposed Effective Date: January 01, 2009 CLASSIFICATION Class 1 All Active Full-time Employees AMOUNT OF BENEFIT Life Accidental Death Insurance and Dismemberment (24 Hour) 20,000 20,000 The amount of Life Insurance and AD&D for Class 1 `will reduce: -35% upon the Person's attainment of age 65 -an additional 20% of the original amount at age 70 -an additional 15% of the original amount at age 75 -an additional 10% of the original amount at age 80 Benefits will terminate upon retirement. Guarantee Issue - Insurance amounts in excess of $20,000, including any increases, will require the submission and the approval of satisfactory, evidence of insurability. Minimum Hours: 30, unless otherwise agreed upon. The AD&D coverage includes the Safe Driver Benefit (Seat Belt & Air Bag Benefit) and Common Carrier Benefit. The Employer should consult a tax advisor regarding the tax implication of these benefits. The Lincoln National Life Insurance Company 6 10/29/2008 VERNONCITY 5165967 Coverage Life Insurance Number of Employees 299 299 City of Vernon SCHEDULE OF RATES AND COSTS Volume 5,959,000 5,959,000 Monthly Rate Premium $.100/per $1,000 of benefit $595.90 $.035/per $1,000 of benefit $208.57 Total Premium , $804.47 Quoted rates are guaranteed for Two Years from the effective date of the policy. Quoted rates assume: The above rates assume the Life and AD&D coverages is on a non-contributory basis and 100% participation is required. • All employees to be covered are Actively at Work on the policy's effective date. If any individual does not meet the Actively at Work requirement, we will require full disclosure of all necessary information to evaluate the risk. After reviewing this information, we reserve the right to revise or withdraw this proposal. ACTIVELY AT WORK means an/ employee's full-time performance of all customary duties of his or her occupation at: (1) the Group Policyholder's place of business; or (2) any other business location where the employee is required to travel. Unless disabled on the prior workday or on the day of absence, an employee will be considered Actively at Work on the following days; (1) a Saturday, Sunday or holiday which is not a scheduled workday; (2) a paid vacation day, or other scheduled or unscheduled non -workday; or (3) an excused or emergency leave of absence (except a medical leave). This proposal describes certain insurance coverages available from Lincoln Financial Group and should under no circumstances be construed as a contract or offer to contract for such coverages. An application must be completed and submitted to our Service Office, before a group will be considered for coverage. If the proposed policy qualifies as a replacement plan, then coverage for an otherwise eligible person who is disabled on the policy effective date will be administered in accord with any applicable state discontinuance and replacement law. The proposal is based on preliminary census data received by Lincoln Financial Group. Actual costs will be based on the final enrollment data of employees insured under the plan on its effective date. Rates quoted for the proposed benefits shown are effective for 90 days from the date shown on the proposal. A complete listing of the terms, conditions, and limitations, that will apply to your coverage, if issued, is available upon request. The Lincoln National Life Insurance Company 7 10/29/2008 VERNONCITY 5165967 City of Vernon OPTIONAL BENEFITS SCHEDULE OF INSURANCE Option 1.00 Dependents Spouse* Children 14 days but less than 6 months 6 months but less than 19 years (or 23 years if full-time student) Higher age limits may apply in certain states. Life Insurance 1,500 100 1,000 *The amount of a Spouse's benefit will terminate upon the Spouse's attainment of age 70. The amount of Dependent Life Insurance cannot exceed 50% of the insured employee's amount of insurance. The monthly rate for this benefit is $0.33 per family unit. PLEASE NOTE: Eligible dependents must satisfy the policy's non -confinement requirement. If a dependent is confined in a hospital on the date insurance would otherwise take effect, his or her insurance will become effective on the 101h day following final discharge from the hospital. PROPOSAL CONDITIONS This proposal has been prepared on the premise: - there are no known uninsurable individuals in the group to be covered; - no employee is absent from work because of sickness or injury. If any individual to be insured falls into the above categories, we will require full disclosure of all necessary information to evaluate the risk. After reviewing this information, we reserve the right to revise or withdraw our quotation. To become insured, an eligible employee must be an active, full-time employee who: - is a member of an eligible class of employees; - has completed the eligibility waiting period established by the employer; - is not a temporary or seasonal employee; - is performing all customary duties of his/her occupation at his/her usual place of business on the policy effective date (or on the effective date of his/her coverage); and - is regularly scheduled to work at least 30 hours per week, unless otherwise agreed upon. If included, any eligible dependents must satisfy a non -confinement requirement on the policy effective date (or on the date coverage becomes effective). The Lincoln National Life Insurance Company 8 10/29/2008 VERNONCITY 5165967 City of Vernon This proposal is based on the assumption that the current insurance carrier will continue coverage on any insured individual who is disabled on the date the existing contract terminates (even if it terminates while a disabled person is satisfying any applicable waiting period). The rates quoted in this proposal are a function of the characteristics of the group (i.e.: Policyholder contributions, occupations, age, gender, etc.) and the benefits requested at the time of proposal submission: If the plan is non-contributory, 100% of the eligible employees must enroll; and if the plan is contributory, 75% of the eligible employees must enroll on the effective date. We reserve the right to re-evaluate the risk, and revise or withdraw our quotation if necessary, based upon the characteristics of the group and the benefits provided on the effective date of the plan. This proposal is a description of insurance coverages available from Lincoln Financial Group and is not an offer to contract. An application must be completed before a group will be considered for coverage. This proposal outlines in general some of the important features of the proposed Group Insurance Program. The controlling provisions will be in the Group Insurance Policy, and this proposal is not intended in any way to modify the provisions or their meanings. This proposal will remain in effect until withdrawn or a new proposal is issued by Lincoln Financial Group, but in no event will this proposal remain in effect beyond 90 days from October 29, 2008. The Lincoln National Life Insurance Company 9 10/29/2008 VERNONCITY 5165967 City of Vernon EMPLOYEE GROUP LIFE INSURANCE BENEFIT: The Life Insurance Benefit is payable to the Insured Person's beneficiary upon death from any cause; except if employees contribute towards the premium, a suicide exclusion will apply to any medically underwritten amount during the first two years of coverage. The beneficiary may be changed at any time by written notice to Lincoln Financial Group. If no beneficiary survives the Insured Person, the death benefit will be payable to: - the Insured Person's surviving spouse, children, parents or siblings; or - the Insured Person's estate (as specified in the policy). CONVERSION PRIVILEGE: Conversion is available when anyone's group life insurance terminates due to: - the Insured Person's termination of employment or membership in an eligible class; or - a covered Dependent's ceasing to be an eligible dependent. That person has the option to convert all or part of the terminated insurance without Evidence of Insurability. The conversion may be made to any Individual Life Policy then provided by Lincoln Financial Group (except term insurance). To purchase a conversion policy, application and the first premium payment must be made within the time period specified in the policy. WAIVER OF PREMIUM (EXTENSION OF DEATH BENEFIT): An Insured Person's Life Insurance (and any Dependent Life Insurance) will be continued without payment of premium, if the Insured Person: - becomes Totally Disabled while insured under the policy and before age 60; - remains Totally Disabled for at least 6 months; and - submits satisfactory proof within the time period specified in the policy. Total Disability shall be defined as shown in the policy. The continued life insurance will be subject to the age reductions shown in the Schedule of Insurance. The continued life insurance will terminate when the: - ceases to be Totally Disabled; - Insured Person fails to take a required medical exam or to submit additional proof as requested; - Insured Person becomes insured under an individual conversion policy; or - attains Social Security Normal Retirement Age (SSNRA), whichever occurs first. The Lincoln National Life Insurance Company 10 10/29/2008 VERNONCITY 5165967 LIVING BENEFIT: City of Vernon An Accelerated Death Benefit is available when the Insured Person's life insurance benefit is $2,000 or more. If the Insured Person is diagnosed terminally ill due to a sickness or injury at least 12 months after life insurance takes effect or on the date of an injury which results in Terminal Illness, then part of his or her life insurance benefit can be paid prior to death (subject to state law). Terminally ill means the Insured Person's medical condition is expected to result in death within 12 months, despite appropriate medical treatment. The amount of the Accelerated Death Benefit is subject to: - a minimum of $1,000 or 10% of the Insured Person's life insurance coverage, whichever is more; and - a maximum of $250,000 or 75% of the Insured Person's life insurance coverage, whichever is less. NOTE: This is not a Long Term Care benefit. Before requesting an Accelerated Death Benefit payment, Insured Persons should seek their own tax or legal counsel concerning the effect upon taxable income or eligibility for government benefits. OTHER FEATURES: Our LINKS PROGRAM provides integrated disability management when an insured is covered under both our STD and LTD plans. LINKS helps to provide a smooth transition from STD to -LTD without claim filing, while helping the employee return to work in the most efficient and effective manner possible. Furthermore, the LINKS program identifies those claimants with group life insurance coverage with us to determine whether they're eligible for Life Waiver. The Lincoln National Life Insurance Company 11 10/29/2008 VERNONCITY 5165967 City of Vernon GROUP ACCIDENTAL DEATH & DISMEMBERMENT INSURANCE DEATH OR DISMEMBERMENT BENEFIT FOR AN INSURED PERSON: The benefit shown below will be paid if: (1) an Insured Person sustains an accidental bodily injury while insured under this provision; and (2) that injury directly causes one of the following nonfatal losses within 365 days after the date of the accident. The loss must result directly from the injury and from no other causes. LOSS Loss of Life Loss of one Member (Hand, Foot or Eye) Loss of Two or More Members BENEFIT FOR COMMON BENEFIT FOR OTHER CARRIER ACCIDENT COVERED ACCIDENT 2 Times Principal Sum Principal Sum Principal Sum Y2 Principal Sum 2 Times Principal Sum Principal Sum The Principal Sum for the Insured Person's class is shown in the Schedule of Insurance. MAXIMUM PER PERSON: If an Insured Person sustains more than one loss resulting from the same accident, the benefit: (1) will be the one largest amount listed; (2) will not exceed two times the Principal Sum for all of that person's combined losses resulting from a Common Carrier Accident; and (3) will not exceed the Principal Sum for all that person's combined losses resulting from any other covered accident. DEFINITIONS: "Common Carrier Accident" means a covered accidental bodily injury, which is sustained while riding as a fare paying passenger (not a pilot, operator or crew member) in or on, boarding or getting off from a Common Carrier. "Loss of a Member" includes the following: (1) "Loss of Hand or Foot," means complete severance through or above the wrist or ankle joint. (2) "Loss of an Eye," means total and irrevocable loss of sight in that eye. LIMITATIONS: Benefits are not payable for any loss to which a contributing cause is: - intentional self-inflicted injury or self-destruction; - disease, bodily or mental infirmity, or medical or surgical treatment of these; - duty as a member of any military, naval or air force; - war or any act of war, declared or undeclared; - the Insured Person's participation in the commission of a felony; - voluntary use of drugs except where prescribed by a Physician; - voluntary inhalation of gas; including carbon monoxide; - travel or flight in any aircraft, including balloons and gliders, except as a fare paying passenger on a regularly scheduled flight; or - the Insured Person driving while intoxicated (as defined by the jurisdiction where the accident occurred). The Lincoln National Life Insurance Company 12 10/29/2008 VERNONCITY 5165967 City of Vernon SAFE DRIVER BENEFIT (For Insured Employee) If an Insured Person dies as a direct result of a covered auto accident, for which Accidental Death and Dismemberment Benefits are payable; then (1) an additional Seat Belt Benefit will be payable provided the Insured Person was wearing a properly fastened seat belt at the time of the accident; and (2) an additional Air Bag Benefit will be payable, if the auto was equipped with airbag(s). The Seat Belt Benefit equals $10,000 or 10% of the Principal Sum, whichever is less; and the Air Bag Benefit equals $10,000 or 10% of the Principal Sum, whichever is less. The Seat Belt Benefit and Air Bag Benefit will not be less than $1,000 per Insured Person. The Principal Sum is the amount payable because of the Insured Person's accidental death. A copy of the police report must be submitted with the claim. The position of the seat belt must be certified by: (1) the official accident report; or (2) the coroner, traffic officer or other investigating officer. Upon receipt of satisfactory written proof, the additional benefit will be paid in accord with the Beneficiary section. DEFINITIONS. As used in this provision: "Auto" means a 4-wheel passenger car, station wagon, jeep, pick-up truck or van -type car. It must be licensed for use on public highways. It includes a car owned or leased by the Group Policyholder. "Intoxicated," "Impaired," or "Under the Influence of Drugs" shall be defined as by the jurisdiction where the accident occurs. "Seat Belt" means a properly installed: (1) seat belt or lap and shoulder restraint; or (2) other restraint approved by the National Highway Traffic Safety Administration. LIMITATIONS. Safe Driver Benefits will not be paid if: (1) the Accidental Death and Dismemberment Benefits is not paid under the Policy for the Insured Person's death; or (2) at the time of the accident, the Insured Person or any other person who was driving the auto in which the Insured Person was traveling: (a) was driving without a valid drivers' license; (b) was driving in excess of the legal speed limit; or (c) was driving while intoxicated, impaired, or under the influence of drugs (except for drugs taken as prescribed by a Physician for the driver's use). The above limitations will apply, whether or not the driver is convicted. The Lincoln National Life Insurance Company Seat Belt 13 10/29/2008 VERNONCITY 5165967 City of Vernon DEPENDENT GROUP LIFE INSURANCE ELIGIBLE DEPENDENT: Unless otherwise indicated in the Schedule of Insurance, a dependent means a person who meets the definition of a dependent of the Insured Person under the provision of U.S. Internal Revenue Code; and is an Insured Person's: - spouse who is not legally separated from the Insured Person; - unmarried child at least 14 days but less than 19 years of age; - unmarried child less than 23 years of age if attending an accredited educational institution for the minimum credit hours required to maintain full-time student status there; or - unmarried child who is totally and permanently disabled and who was totally and permanently disabled prior to reaching 19 years of age. A legally adopted child is considered the Insured Person's child from the date of placement in the Insured Person's home for any agency adoption, or from any later date the adoption petition is filed for a private adoption. The word 'child' includes an Insured Person's step -child or foster -child, provided the child resides in the Insured Person's household and is dependent on the Insured Person for principal support. BENEFIT: The, benefit equals the amount of the dependent life insurance in effect on the date of such death. Upon receipt of satisfactory proof of a dependent's death while insured under the policy, the death benefit will be paid to the Insured Person. CONVERSION PRIVILEGE: Conversion is available when a dependent's group life insurance terminates due to: - the Insured Person's termination of employment or membership in an eligible class; - a covered Dependent's ceasing to be an eligible dependent. The dependent has the option to convert all or part of the terminated insurance without Evidence of Insurability. The conversion may be made to any Individual Life policy then provided by Lincoln Financial Group (except term insurance). To purchase a conversion policy, application and the first premium payment must be made within the time period specified in the policy. EXTENSION OF DEATH BENEFIT: If an Insured Person becomes Totally Disabled and qualifies for an Extension of Death Benefit for personal insurance, such Insured Person's dependent life insurance will also be continued without further premium payments. The Lincoln National Life Insurance Company 14 10/29/2008 Voluntary Term Life Proposal for City of Vernon Presented by Gallagher Benefit Services of California 505 N Brand Blvd #600 Glendale, CA 91203-3944 THE LINCOLN NATIONAL LIFE INSURANCE COMPANY Service Office 8801 Indian Hills Drive Omaha, Nebraska 68114 - 4066 Home Office: Fort Wayne, IN WORKSITE I City of Vernon PORTFOLIO How WORKSITE 1 Can Work For You! Offering a comprehensive and progressive benefit package to employees is vital in today's job market. Employees appreciate and expect a benefit package that will help them meet their various insurance needs. The question is... How do you afford to provide the extra coverage and stay within your budget? We've got the answer... WORKSITE I P O R T F O L 10. WORKSITE 1 PORTFOLIO consists of a variety of voluntary benefit programs for your employees to choose from. Each program allows your employees the opportunity to select and customize the benefit program that's right for their specific needs. Since benefits are paid directly by the employee, your organization's overall benefit package is enhanced with no cost to you. Your employees will appreciate having these additional benefit choices available along with the added convenience of payment through payroll deduction. In addition, you will appreciate our simple, yet thorough approach to product design, enrollment and administration of the programs. WORKSITE I P O R T F O L 10 of benefits is a win -win situation for everyone! It is our privilege to become your partner in delivering quality benefit programs to your employees. WORKSITE 1 Programs - Voluntary Term Life - Voluntary Short -Term Disability - Voluntary Long -Term Disability - Voluntary Dental - Voluntary Vision The Lincoln National Life Insurance Company 16 10/29/2008 VERNONCITY 5165967 WORKSITE 1 City of Vernon PORTFOLIO Voluntary Term Life Voluntary Term Life is a group term life insurance program designed to provide benefits to an insured's beneficiary in the event of an untimely death or accident (if AD&D is chosen). Voluntary Term Life offers these features and advantages: - Affordability - Guaranteed Acceptance, according to underwriting guidelines - Coverage choices to meet employee needs - Spouse and Dependent Children coverage - Accidental Death Insurance - Waiver of Premium (Extension of Death Benefit) - Living Benefits - Fully Portable Coverage - Flexibility to meet an employee's changing needs - Payment convenience through payroll deduction Life insurance protection is essential for all of your employees, regardless of whether they are: Young or Old Single or Married Male or Female With or without Children Voluntary Term Life allows your employees, their spouses and their children to purchase the extra financial security they need. They'll appreciate the fact that City of Vernon realizes this benefit is valuable to them and their families in protecting their financial future. The Lincoln National Life Insurance Company 17 10/29/2008 VERNONCITY 5165967 WORKSITE I City of Vernon PORTFOLIO Voluntary Term Life Schedule Option 1.00 Proposed Effective Date: January 01, 2009 Voluntary Term Life offers your employees and their spouses the opportunity to choose the life insurance benefit(s) they want at a price they can afford. Employee - Coverage is available in $10,000 increments up to 5.00x annual salary (rounded to the next higher $10,000) - Minimum coverage is $10,000 - Maximum coverage is $500,000 - For employees age 70 & over, maximum coverage is $50,000 - Coverage reduces 35% upon the Person's attainment of age 65, an additional 20% of the original amount at age 70, an additional 15% of the original amount at age 75, an additional 10% of the original amount at age 80, and will terminate upon retirement. Voluntary Life Benefit features: - Portability. - Employee Life Insurance Premium Waiver. - Accelerated Death Benefit (Living Benefit) - maximum of $250,000 or 75% of Insured person's Life insurance coverage, whichever is less. - Conversion is available when insurance terminates. All permanent employees regularly scheduled to work at least 30 hours each week are eligible to participate. An employee must be actively at work on the date coverage takes effect. Employees who work part-time, on - call or on a seasonal basis are not eligible to participate in the program. Retirees are not eligible. Spouse - Coverage is available in $5,000 increments up to 2.50x the employee's annual salary (rounded to the next higher $5,000), not to exceed 50% of the employee's elected benefit amount - Minimum coverage is $5,000 - Maximum coverage is $100,000 - Coverage reduces 35% upon the employee's attainment of age 65, and will terminate upon the employee's attainment of age 70 or retirement, whichever occurs first. - Spouse coverage is only available if the employee is insured for voluntary coverage. Dependent Children - Dependent Coverage is only available if the employee is insured for voluntary coverage. - This benefit provides coverage for all dependent children in the following amounts: From age 6 months to 19 years old $10,000 (up to 25 years of age, if unmarried, & a full-time student) Age 14 days to 6 months $250 From birth to age 14 days No benefit The Employer should consult a tax advisor regarding the tax implication of these benefits. The Lincoln National Life Insurance Company 18 10/29/2008 VERNONCITY 5165967 WORKSITE 1 PORTFOLIO City of Vernon Rates The following Voluntary Term Life rates were developed for City of Vernon, using characteristics specific to your group. Aqe Uni-smoker with AD&D < 30 0.077 0.117 30 - 34 0.086 0.126 35 - 39 0.105 0.145 40 - 44 0.162 0.202 45 - 49 0.276 0.316 50 - 54 0.457 0.497 55 - 59 0.714 0.754 60 - 64 1.114 1.154 65 - 69 1.999 2.039 70 - 74 3.579 3.619 75 - 79 5.902 5.942 80 — 99 11.958 11.998 These rates are: - Unisex - Guaranteed for Two Years from the program effective date - Based on the employee's current age for both Employee and Spouse - Shown as a monthly rate per $1,000 of Life Insurance Coverage - Adjusted once each year on the program anniversary date - Based on 299 eligible employees Accidental Death & Dismemberment coverage is $.04 per $1,000 per month as shown above. Employee Accidental Death & Dismemberment benefit features: Seatbelt Benefit -- $10,000 or 10% of the principal sum, whichever is less. - Airbag Benefit -- $10,000 or 10% of the principal sum, whichever is less. - Common Carrier -- Two times principal sum otherwise paid for Other Covered Accidents. Dependent Children coverage is $1.00 per month for $10,000, regardless of the number of children. The Lincoln National Life Insurance Company 19 10/29/2008 VERNONCITY 5165967 WORKSITE 1 PORTFOLIO City of Vernon This proposal assumes that: • All employees to be covered are Actively at Work on the policy's effective date. Actively at Work means an employee's full-time performance of all customary duties of his or her occupation at: (1) the policyholder's place of business; or (2) any other business location where the employee is required to travel. Spouses and dependent children to be covered are not in a 'Period of Limited Activity'. Period of Limited Activity means a period when a spouse or child is confined in a health care facility; or, whether confined or not, is unable to perform the regular and usual activities of a healthy person of the same age and sex. If a spouse or child is in a Period of Limited Activity on the day his or her Dependent Life Insurance would otherwise take effect, insurance for that dependent will not take effect until the day after: (1) his or her final discharge from the health care facility; or (2) his or her resumption of the normal activities of a healthy person of the same age and sex. If any individual does not meet these requirements, we will require full disclosure of all necessary information to evaluate the risk. After reviewing this information, we reserve the right to revise or withdraw this proposal. The Lincoln National Life Insurance Company 20 10/29/2008 VERNONCITY 5165967 WORKSITE I City of Vernon PORTFOLIO Proposal Conditions This proposal contains an outline of the coverage, benefits, rates and other additional information regarding the Voluntary Term Life Program we offer. This proposal is not a contract. The controlling provisions will be in the Group Insurance Master Policy, and this proposal is not intended in anyway to modify the provisions or their meanings. If there is any conflict between the proposal and the Group Insurance Master Policy, the Group Insurance Master Policy controls. The Voluntary Term Life program is subject to the laws and rulings of the State Insurance Department having jurisdiction. This plan of insurance is not available in every state and in those states where it is available, it may be withdrawn or revised at any time prior to acceptance. The rates quoted in this proposal are a function of the characteristics of City of Vernon at the time of proposal submission. We reserve the right to re-evaluate the risk, and change the rates if necessary, based upon the characteristics of the group on the anniversary date of the program. This proposal will remain in effect until withdrawn or a new proposal is issued, but in no event will this proposal remain in effect beyond 90 days from October 29, 2008. The Lincoln National Life Insurance Company 21 10/29/2008 VERNONCITY 5165967 WORKSITE I PORTFOLIO City of Vernon Underwriting Guaranteed Acceptance Employee New employees have 31 days to enroll from the day they are first eligible in order to take advantage of the guaranteed acceptance offer. Employees must be actively at work on the day coverage takes effect. - The lesser of $150,000 or 300% of salary of coverage is available on a guaranteed acceptance basis. - Employees age 70 - 74 receive $20,000 of coverage on a guaranteed acceptance basis. - Employees age 75 and over are not eligible for coverage on a guaranteed acceptance basis. Spouse Newly eligible spouses have 31 days to enroll in the program to take advantage of the guaranteed acceptance offer. Spouses must not be in a period of limited activity on the date coverage takes effect. - $30,000 of coverage is available on a guaranteed acceptance basis. - Spouses of Employees age 60 and over are not eligible for coverage on a guaranteed acceptance basis. Dependent Children Newborn children are automatically covered when they reach 14 days of age at no additional cost if the dependent children benefit has been elected. Children must be at least 14 days old and not be in a period of limited activity on the date coverage takes effect.. - Coverage is available on a guaranteed acceptance basis. The Lincoln National Life Insurance Company 22 10/29/2008 VERNONCITY 5165967 WORKSITE 1 PORTFOLIO Simplified Underwriting: City of Vernon Underwriting (continued) When simplified underwriting is required, a completed statement of health must be submitted for coverage approval. Additional medical information may also be requested. Coverage subject to the simplified underwriting process is either approved or declined, depending on the information received. Simplified underwriting applies to the following: - Coverage amounts on any applicant in excess of the guaranteed acceptance limits up to $150,000 or 300% of salary, whichever is less. Full Underwriting: When full underwriting is required, a completed statement of health must be submitted for coverage approval. Additional medical information will be requested. Coverage subject to the full underwriting process is either approved or declined, depending on the information received. Full underwriting applies to the following: - Coverage amounts on any applicant in excess of $150,000 or 300% of salary, whichever is less. - Coverage amounts on applicants age 70 and older if applying for more than the guaranteed acceptance amount. - Coverage amounts on applicants age 75 and older. - Any coverage applied for after the established open enrollment period. - Any coverage adjustments or reinstatements. Minimum Participation: - Minimum participation rules require enrollment acceptance of at least 10 employee lives or 25% of the eligible employee group, whichever is greater. Spouse participation of at least 5 spouses or 10% of your participating employees, whichever is greater, must participate in the program. In addition, premium must total at least $100 per month. Actively at Work Definition: The full-time performance of all customary duties of an employee's occupation at your place of business or other business location to which you require the employee to travel. Period of Limited Activity Definition: Any period of time that a spouse or dependent child is confined in a health care facility or, whether confined or not, is unable to perform the regular and usual activities of a healthy person of the same age and sex. The Lincoln National Life Insurance Company 23 10/29/2008 VERNONCITY 5165967 WORKSITE 1 City of Vernon PORTFOLIO Additional Features Waiver of Premium (Extension of Death Benefit): - Automatically included with Employee coverage. - Life insurance coverage will continue without premium payment while the employee remains totally disabled up to Social Security Normal Retirement Age (SSNRA). For the benefit to become effective, total disability must begin prior to age 60 and continue for at least 6 months. The definition of total disability is "the inability, due to sickness or injury, to engage in any employment or occupation for which you are or become qualified as a result of education, training or experience." Accidental Death & Dismemberment - Optional to both employee and spouse coverage. The benefits shown below will be paid, if: (1) an employee or spouse sustains an accidental bodily injury while insured under this provision; and (2) that injury directly causes one of the following losses within 365 days after the date of the accident. 'The loss must result directly from the injury and from no other causes. LOSS Loss of Life Loss of one Member (Hand, Foot or Eye) Loss of Two or More Members BENEFIT FOR COMMON BENEFIT FOR OTHER CARRIER ACCIDENT COVERED ACCIDENT 2 Times Principal Sum Principal Sum Principal Sum 1/2 Principal Sum 2 Times Principal Sum , Principal Sum The Principal Sum for the employee or spouse is shown in the Schedule of Insurance. If an employee or spouse sustains more than one loss resulting from the same accident, the benefit: (1) will be the one largest amount listed; (2) will not exceed two times the Principal Sum for all of that person's combined losses resulting from a Common Carrier Accident; and (3) will not exceed the Principal Sum for all that person's combined losses resulting from any other covered accident. "Common Carrier Accident" means a covered accidental bodily injury, which is sustained while riding as a fare paying passenger (not a pilot, operator or crew member) in or on, boarding or getting off from a Common Carrier. The Lincoln National Life Insurance Company 24 10/29/2008 VERNONCITY 5165967 WORKSITE 1 PORTFOLIO City of Vernon Accidental Death & Dismemberment (continued) Benefits are not payable for any loss to which a contributing cause is: intentional self-inflicted injury or self-destruction; disease, bodily or mental infirmity, or medical or surgical treatment of these; duty as a member of any military, naval or air force; war or any act of war, declared or undeclared; the Insured Person's participation in the commission of a felony; voluntary use of drugs except where prescribed by a Physician; voluntary inhalation of gas; including carbon monoxide; travel or flight in any aircraft, including balloons and gliders, except as a fare paying passenger on a regularly scheduled flight; or the Insured Person driving while intoxicated (as defined by the jurisdiction where the accident occurred). Safe Driver Benefit - If an employee dies as a direct result of a covered auto accident, for which Accidental Death and Dismemberment Benefits are payable; then: (1) an additional Seat Belt Benefit will be payable, provided the Insured Person was wearing a properly fastened seat belt at the time of the accident; and (2) an additional Air Bag Benefit will by payable, if the auto was equipped with airbag(s). The Seat Belt Benefit equals $10,000 or 10% of the Principal Sum, whichever is less; and the Air Bag Benefit equals $10,000 or 10% of the Principal Sum, whichever is less. The Seat Belt Benefit and Air Bag Benefit will not be less than $1,000 per Insured Person. The Principal Sum is the amount payable because of the Insured Person's accidental death. "Seat Belt" means a properly installed: (1) seat belt or lap and shoulder restraint; or (2) other restraint approved by the National Highway Traffic Safety Administration. Safe Driver Benefits will not be paid if: (1) the Accidental Death and Dismemberment Benefits is not paid under the Policy for the Insured Person's death; or (2) at the time of the accident, the Insured Person or any other person who was driving the auto in which the Insured Person was traveling: (a) was driving without a valid driver's license; (b) was driving in excess of the legal speed limit; or (c) was driving while intoxicated, impaired, or under the influence of drugs (except for drugs taken as prescribed by a Physician for the driver's use). The above limitations will apply, whether or not the driver is convicted. The Lincoln National Life Insurance Company 25 10/29/2008 VERNONCITY 5165967 WORKSITE I PORTFOLIO City of Vernon Living Benefit (Accelerated Death Benefit) - Automatically included with both employee and spouse coverage when the life insurance benefit is $2000 or more. - If an insured is diagnosed with a terminal illness expected to result in death within 12 months, then a portion of his or her life insurance benefit can be paid prior to death (subject to state regulations). The amount of the living benefit is subject to: 1) a minimum of $1,000 or 10% of the insured's life insurance coverage, whichever is greater; and 2) a maximum of $250,000 or 75% of the insured's life insurance coverage, whichever is less. Portability - Automatically included with both employee and spouse coverage. - Allows employees and spouses to keep their Life, Accidental Death and Dismemberment and Dependent Children insurance in force even after employees leave your employment. - Life insurance coverage must be in -force at least 12 months prior to an employee's termination. - Rates remain the same as those in effect at the time of termination and will be adjusted in the same way as your group rates are adjusted. - The employee must not be terminating due to total disability or retirement at the Social Security Normal Retirement Age (SSNRA). An insured must apply for the portability option in order to actually keep the coverage. Written application along with the required premium must be made no later than 31 days after the date the insurance would normally terminate. Other Features: Our LINKS PROGRAM provides integrated disability management when an insured is covered under both our STD and LTD plans. LINKS helps to provide a smooth transition from STD to LTD without claim filing, while helping the employee return to work in the most efficient and effective manner possible. Furthermore, the LINKS program identifies those claimants with group life insurance coverage with us to determine whether they're eligible for Life Waiver. The Lincoln National Life Insurance Company 26 10/29/2008 VERNONCITY 5165967 WORKSITE 1 PORTFOLIO City of Vernon Administration All WORKSITE 1 Voluntary Benefit Programs offer City of Vernon and your employees flexible administration and superior customer service. An experienced and knowledgeable customer service representative is assigned to handle your questions and concerns -- available to you on our toll -free number. Once your program is set up, a complete administration kit will be sent to your office; this kit contains a sampling of the necessary forms for additional enrollments, coverage adjustments, and claims, as well, as billing information. Billing - Your representative will make sure that a premium statement for your program(s) is in your hands by the date required. - Billing frequency can be adjusted to meet the special needs of your company (annually, quarterly, monthly are all standard modes). Claims - Claim questions from you or your employees are directed to our claims center. Our claims center can walk your employees through the claim process and provide instruction on how to fill out the necessary claim forms. - Once a claim is received, we review it quickly and process it accurately -- usually within five business days! Customer Service - You can expect your employees to receive the same "personal touch" service that you enjoy. Your employees are free to direct their questions and concerns to us on a toll -free line. - A service representative who is knowledgeable about their program(s) awaits their calls, ready to provide guidance on adjustments, explain administrative forms and procedures, and coordinate the portability feature (if applicable). This service is available Monday through Thursday from 7:30 a.m. to 5:00 p.m. and on Friday from 7:30 a.m. to 4:30 p.m. (Central Standard Time). The Lincoln National Life Insurance Company 27 10/29/2008 nLincoln Financial Group® LINCOLN FINANCIAL GROUP® PRIVACY PRACTICES NOTICE The Lincoln Financial Group companies* are committed to protecting your privacy. To provide the products and services you expect from a financial services leader, we must collect personal information about you. We do not sell your personal information to third parties. We share your personal information with third parties as necessary to provide you with the products or services you request and to administer your business with us. This notice describes our current privacy practices. While your relationship with us continues, we will update and send our Privacy Practices Notice as required by law. Even after that relationship ends, we will continue to protect your personal information. You do not need to take any action because of this notice, but you do have certain rights as described below. INFORMATION WE MAY COLLECT AND USE We collect personal information about you to help us identify you as our customer or our former customer; to process your requests and transactions; to offer investment or insurance services to you; to pay your claim; or to tell you about our products or services we believe you may want and use. The type of personal information we collect depends on the products or services you request and may include the following: • Information from you: You give us information when you submit your application or other forms, such as your name, address, Social Security number; and your financial, health, and employment history. • Information about your transactions: We keep information about your transactions with us, such as the products you buy from us; the amount you paid for those products; your account balances; and your payment history. • Information from outside our family of companies: If you are purchasing insurance products, we may collect information from consumer reporting agencies such as your credit history; credit scores; and driving and employment records. With your authorization, we may also collect information from other individuals or businesses, such as medical information. • Information from your employer: If your employer purchases group products from us, we may obtain information about you from your employer in order to enroll you in the plan. HOW WE USE YOUR PERSONAL INFORMATION We may share your personal information within our companies and with certain service providers. They use this information to process transactions you have requested; provide customer service; and inform you of products or services we offer that you may find useful. Our service providers may or may not be affiliated with us. They include financial service providers (for example, third party administrators; broker -dealers; insurance agents and brokers, registered representatives; reinsurers; and other financial services companies with whom we have joint marketing agreements). Our service providers also include non -financial companies and individuals (for example, consultants; vendors; and companies that perform marketing services on our behalf). Information obtained from a report prepared by a service provider may be kept by the service provider and shared with other persons; however, we require our service providers to protect your personal information and to use or disclose it only for the work they are performing for us, or as permitted by law. When you apply for one of our products, we may share information about your application with credit bureaus: We also may provide information to group policy owners, regulatory authorities and law enforcement officials and to others when we believe in good faith that the law requires disclosure. In the event of a sale of all or part of our businesses, we may share customer information as part of the sale. We do not sell or share your information with outside marketers who may want to offer you their own products and services; nor do we share information we receive about you from a consumer reporting agency. You do not need to take any action for this benefit. Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates. Page 1 of 2 GB06714 7/07 SECURITY OF INFORMATION Keeping your information safe is one of our most important responsibilities. We maintain physical, electronic and procedural safeguards to protect your information. Our employees are authorized to access your information only when they need it to provide you with products and services or to maintain your accounts. Employees who have access to your personal information are required to keep it strictly confidential. We provide training to our employees about the importance of protecting the privacy of your information. Questions about your personal information should be directed to: Lincoln Financial Group Attn: Enterprise Services Compliance -Privacy, 6C-00 1300 S. Clinton St. Fort Wayne, IN 46801 *This information applies to the following Lincoln Financial Group companies: Allied Professional Advisors, Inc. First Penn -Pacific Life Insurance Company Hampshire Funding Jefferson Pilot Securities Corporation JPSC Insurance Services, Inc. Lincoln Financial Advisors Corporation Lincoln Investment Advisors Corporation Lincoln Life & Annuity Company of New York Lincoln Variable Insurance Products Trust The Lincoln National Life Insurance Company ADDITIONAL PRIVACY INFORMATION FOR INSURANCE PRODUCT CUSTOMERS CONFIDENTIALITY OF MEDICAL INFORMATION We understand you may be especially concerned about the privacy of your medical information. We do not sell or rent your medical information to anyone; nor do we share it with others for marketing purposes. We only use and share your medical information for the purpose of underwriting insurance, administering your policy or claim and other purposes permitted by law, such as disclosure to regulatory authorities or in response to a legal proceeding. MAKING SURE MEDICAL INFORMATION IS ACCURATE We want to make sure we have accurate information about you. Upon written request, we will tell you, within 30 business days, what personal information we have about you. You may see a copy of your personal information in person or receive a copy by mail, whichever you prefer. We will share with you who provided the information. In some cases we may provide your medical information to your personal physician. We will not provide you with information we have collected in connection with, or in anticipation of, a claim or legal proceeding. If you believe that any of our records are not correct, you may write and tell us of any changes you believe should be made. We will respond to your request within 30 business days. A copy of your request will be kept on file with your personal information so anyone reviewing your information in the future will be aware of your request. If we make changes to your records as a result of your request, we will notify you in writing and we will send the updated information, at your request, to any person who may have received the information within the prior two years.. We will also send the updated information to any insurance support organization that gave us the information, and any service provider that received the information within the prior 7 years. Questions about your personal medical information should be directed to: Lincoln Financial Group Attn: Medical Underwriting P.O. Box 21008 Greensboro, NC 27420-1008 The CONFIDENTIALITY OF MEDICAL INFORMATION and MAKING SURE INFORMATION IS ACCURATE sections of this Notice apply to the following Lincoln Financial Group companies: First Penn -Pacific Life Insurance Company Lincoln Life & Annuity Company of New York The Lincoln National Life Insurance Company Page 2 of 2 GB06714 7/07 The Lincoln National Life Insurance Company A Stock Company Home Office Location: Fort Wayne, Indiana Group Insurance Service Office: 8801 Indian Hills Drive, Omaha, NE 68114-4066 (402) 361-7300 Group Policyholder: Samples In Consideration of the Group Policyholder's application for this Policy and payment of all premiums when due, The Lincoln National Life Insurance Company agrees to make the payments provided in this Policy to the persons entitled to them. The first premium for this Policy is due on its effective date. Subsequent premiums are due on February 1, 2007, and on the same day of each month after that. Policy anniversaries will be each January 1st; unless shown otherwise on the Premium Rate Schedule inside. The provisions and conditions set forth on the following pages are a part of this Policy, as fully as if recited over the signatures below. The Lincoln National Life Insurance Company has executed this Policy at its Group Insurance Service Office in Omaha, Nebraska. The issue date of this Policy is January 1, 2007. IMPORTANT INFORMATION REGARDING YOUR INSURANCE. If you need to contact someone about this insurance for any reason, please contact your agent. If no agent was involved in its sale, or if you have additional questions, then you may contact the insurance company at the above address or phone them at 1-800-423-2765. If unable to obtain satisfaction from the company or agent, you may contact the state regulatory agency at California Department of Insurance, Consumer Communications Bureau, 300 South Spring Street, Los Angeles, CA 90013, or by telephone at 1-800-927-4357. Please have your policy number available. azj�/�� .z, SECRETARY PRESIDENT GROUP INSURANCE POLICY No. 000010003229 PROVIDING LIFE INSURANCE ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE DEPENDENT LIFE INSURANCE GL1101-TITLE PAGE CA 01/01/07 TABLE OF CONTENTS Schedule of Insurance.................................................................I........... 3 Definitions.......................................................................................... 4 General Provisions .................................................................... ...... 5 Provisions Applicable to Participating Employers .......................................... 6 Eligibility and Effective Dates for Personal Insurance ..................................... 7 Individual Terminations.......................................................................... 8 Continuation of Insurance During a Labor Dispute ......................................... 9 Premiums and Premium Rates.................................................................. 10 GracePeriod....................................................................................... 11 PolicyTermination.............................................................................. l l Beneficiary................................................................... ................ 12 Assignments........................................................................................ 13 Facilityof Payment............................................................................... 14 DeathBenefit...................................................................................... 14 Settlement Options................................................................................ 14 Extension of Death Benefit...................................................................... 15 Accelerated Death Benefit....................................................................... 16 Conversion Privilege ............................................................. ........... 18 Dependents Life Insurance...................................................................... 20 Claims Procedures for Life or Accidental Death and Dismemberment Benefits ...... 22 Accidental Death and Dismemberment Insurance ........................................... 25 Safe Driver Benefit ........................ ................................................ 27 Prior Insurance Credit Provision............................................................... 28 Notice............................................................................................... 29 GL1101-1 2 01/01/07 SCHEDULE OF INSURANCE The amount of an Insured Person's insurance is determined from the following table. The initial amount of coverage is the amount which applies to an Insured Person's Class on the date his or her coverage takes effect. An Insured Person may become eligible for increases in the amount of insurance in accord with the table. Any such increase will take effect on the latest of: (1) the first day of the Insurance Month which coincides with or follows the date on which the Insured Person becomes eligible for the increase; provided he or she is Actively at Work on that day; (2) the day the Insured Person resumes Active Work, if not Actively at Work on the day the increase would otherwise take effect; or (3) the day any required evidence of insurability is approved by the Company. Any decrease will take effect on the day of the change; whether or not the Insured Person is Actively at Work. The amount of an Insured Person's Life Insurance shall be reduced by the amount of any Life Insurance in effect as a result of exercising the rights under the Conversion Privilege section of this Policy. CLASSIFICATION Class 1 All Full -Time Employees WAITING PERIOD: 30 days of continuous Active Work (For date insurance begins, refer to "Effective Date" section) GL1101-2 3 01 /01 /07 SCHEDULE OF INSURANCE (CONTINUED) Class 1 LIFE AND AD&D INSURANCE Amount of Personal Life Insurance $30,000 Personal Life and AD&D Insurance will be reduced as follows: - At age 65, benefits will reduce by 35 % of the original amount; - At age 70, benefits will reduce an additional 15 % of the original amount. Benefits will terminate when the Insured Person retires. AD&D Insurance Principal Sum $30,000 If the Insured Person first enrolls for Personal Life and AD&D Insurance at age 65 or older, the above age reductions will apply to: - Any Guarantee Issue Amount available without evidence of insurability; and - The maximum amount of insurance for which he or she is eligible. Insured Persons are not required to make contributions for Personal Life Insurance and AD&D Insurance. Under the Policy Termination section on form GL1101-7, the participation rate requirements in part (3) will not apply during policy years when the Employer's premium contributions are made through a Section 125 plan. If any evidence of insurability is required, it will be provided at the Person's own expense. GL1101-2 3-2 01/01/07 DEFINITIONS ACTIVE WORK or ACTIVELY AT WORK means an employee's full-time performance of all customary duties of his or her occupation at: (1) the GROUP POLICYHOLDER'S place of business; or (2) any other business location where the employee is required to travel. Unless disabled on the prior workday or on the day of absence, an employee will be considered Actively at Work on the following days: (1) a Saturday, Sunday or holiday which is not a scheduled workday; (2) a paid vacation day, or other scheduled or unscheduled non -workday; or (3) an excused or emergency leave of absence (except a medical leave). COMPANY means The Lincoln National Life Insurance Company, an Indiana corporation, whose Group Insurance Service Office address is 8801 Indian Hills Drive, Omaha, Nebraska 68114-4066. DAY OR DATE means at 12:01 A.M., Standard Time, at the GROUP POLICYHOLDER'S place of business; when used with regard to eligibility dates and effective dates. It means 12:00 midnight, Standard Time, at the same place; when used with regard to termination dates. FULL-TIME EMPLOYEE means an employee of the GROUP POLICYHOLDER: (1) whose employment with the GROUP POLICYHOLDER is the employee's principal occupation; and (2) who is regularly scheduled to work at such occupation at least 30 hours each week. GROUP POLICYHOLDER means the person, partnership, corporation, or trust as shown on the Title Page of this Policy. INSURANCE MONTH means that period of time: (1) beginning at 12:01 A.M. Standard Time, at the GROUP POLICYHOLDER'S place of business on the first day of any calendar month; and (2) ending at 12:00 midnight on the last day of the same calendar month. INSURED PERSON means a PERSON for whom the coverages provided by this Policy are in effect. PERSON means a FULL-TIME EMPLOYEE of the GROUP POLICYHOLDER: (1) who is a member of an employee class which is eligible for coverage under this Policy; and (2) who has completed an enrollment form. PERSONAL INSURANCE means the insurance provided by this Policy on Insured Persons. PHYSICIAN means a licensed practitioner of the healing arts other than the Insured Person or a relative of the Insured Person. POLICY means this Group Insurance Policy issued by the Company to the Group Policyholder. GL1101-3 91 (REV) 4 01 /01 /07 GENERAL PROVISIONS ENTIRE CONTRACT. The entire contract between the parties consists of: (1) this Policy and the Group Policyholder's application (a copy is attached); (2) the Participating Employer's participation agreement; and (3) the Insured Persons' enrollment cards, if any. All statements made by the Group Policyholder and by Insured Persons are representations and not warranties. No statement made by an Insured Person will be used to contest the coverage provided by this Policy;. unless: (1) it is contained in a written statement signed by that Insured Person; and (2) a copy of the statement is furnished to the Insured Person or Beneficiary. Only an Officer of the Company may change this Policy or extend the time for payment of any premium. No change will be valid unless made in writing and signed by an Officer of the Company. Any change so made will be binding on all persons referred to in this Policy. INCONTESTABILITY. Except for the non-payment of premiums, the Company may not contest the validity of this Policy as to any Insured Person after it has been in force for two years during his or her lifetime. This clause will not affect the Company's right to contest claims made for disability, accidental death, or accidental dismemberment benefits. NONPARTICIPATION. This Policy will not be entitled to share in the surplus earnings of the Company. BASIS OF RESERVE. The reserve for this Policy will not be less than the reserve computed using: (1) the 1970 Intercompany Group Life Disability Valuation Table; and (2) interest at not less than three percent per annum. INFORMATION TO BE FURNISHED. The Group Policyholder and Participating Employers may be required to furnish any information needed to administer this Policy. Clerical error by the Group Policyholder or Participating Employer will not: (1) affect the amount of insurance which would otherwise be in effect; or (2) continue insurance which otherwise would be terminated. Once an error is discovered, an equitable adjustment in premium will be made. If a premium adjustment involves the return of unearned premium, the amount of the return will be limited to the twelve month period which precedes the date the Company receives proof such an adjustment should be made. The Company may inspect any of the Group Policyholder's records (and Participating Employers' records) which relate to this Policy. MISSTATEMENT OF AGE. If an Insured Person's age has been misstated, premiums will be subject to an equitable adjustment. If the amount of benefit depends upon age; then the benefit will be that which would have been payable, based upon the person's correct age. CERTIFICATES. The Group Policyholder will be furnished with individual Certificates for delivery to each Insured Person. These certificates summarize the benefits provided by this Policy. If there is a conflict between the Policy and the Certificate, the Policy will control. CONFORMITY WITH STATE STATUTES. If any provision of this Policy conflicts with any applicable law, the provision will be deemed to conform to the minimum requirements of the law. WORKER'S COMPENSATION. This Policy is not to be construed to provide benefits required by Worker's Compensation laws. GL1101-4.1 95 P.E. 5 01/01/07 PROVISIONS APPLICABLE TO PARTICIPATING EMPLOYERS A Participating Employer has no rights under this Policy except as provided in this Section. The Participating Employer will be responsible for all premiums payable with respect to any of its Employees who are Insured Persons under this Policy. PARTICIPATING EMPLOYER means an employer who has been approved by the Company for participation in the coverage provided by this Policy. The following are Participating Employers: ABC Company EFFECTIVE DATE. As it applies to any Participating Employer, the Effective Date of this Policy will be the later of: (a) the date this Policy is issued; (b) the first day of the Insurance Month following the Company's approval of the employer's Participation Agreement; or (c) a date agreed upon by the Company, the Participating Employer, and the Group Policyholder. TERMINATION: Coverage under this Policy will cease as to the employees of any Participating Employer on the date the Participating Employer: (a) no longer meets the definition of a Participating Employer; (b) suspends active business operations or is placed in bankruptcy or receivership; (c) dissolves or merges; (d) is excluded from coverage by Policy amendment; or (e) stops paying premiums as required by this Policy. If an employer ceases to be a Participating Employer, it may not be a Participating Employer again until it is re -approved as such by the Company. GL1101-4a 6 01 /01 /07 ELIGIBILITY AND EFFECTIVE DATES FOR PERSONAL INSURANCE ELIGIBILITY. A Person becomes eligible for the coverage provided by this Policy on the later of: (1) the Policy's date of issue; or (2) the date the Waiting Period is completed. WAITING PERIOD. (See Schedule of Insurance). EFFECTIVE DATE. Personal Insurance becomes effective on the latest of: (1) the first day of the Insurance Month coinciding with or next following the date the Person becomes eligible for the coverage; (2) the date the Person resumes Active Work, if not Actively at, Work on the day he or she becomes eligible; (3) the date the Person makes written application for Personal Insurance; and signs: (a) a payroll deduction order, if Insured Persons pay any part of the Policy premium; or (b) an order to pay premiums from the Person's Section 125 Plan account, if Employer contributions are made through a Section 125 Plan; or (4) the date the Company approves the Person's coverage, if evidence of insurability is required. EVIDENCE OF INSURABILITY. Evidence of insurability satisfactory to the Company must be submitted when: (1) a Person makes written application for Personal Insurance more than 31 days after becoming eligible for the coverage; or ' (2) a Person makes written application for Personal Insurance after he or she has requested: (a) to cancel Personal Insurance; (b) to stop payroll deductions for the coverage; or (c) to stop premium payments from the Section 125 Plan account. EXCEPTIONS. If an Insured Person's coverage terminates due to an approved leave of absence or military leave, the Company will waive any Waiting Period or evidence of insurability requirement upon his or her return; provided: (1) the Person returns within six months after the leave begins; (2) the Person applies or is enrolled within 31 days after resuming Active Work; and (3) the reinstated amount of insurance does not exceed the amount which terminated. If an Insured Person's coverage terminates due to a lay-off, the Company will waive any Waiting Period or evidence of insurability requirement upon his or her return; provided: (1) the Person returns within 12 months after the date the lay-off begins; (2) the Person applies or is reenrolled within 31 days after resuming Active Work; and (3) the reinstated amount of insurance does not exceed the amount which terminated. Reinstatement will take effect on the date the Insured Person returns to Active Work. If an Insured Person's coverage terminates because his or her employment ends, the Company will waive any Waiting Period or evidence of insurability requirement upon his or her return; provided: (1) the Person is rehired within 12 months after employment terminated; (2) the Person applies or is reenrolled within 31 days after resuming Active Work; and (3) the reinstated amount of insurance does not exceed the amount which terminated. Reinstatement will take effect on the date the Insured Person returns to Active Work. GL1101-5 93 (FMLA) 7 01/01/07 INDIVIDUAL TERMINATIONS An Insured Person's coverage will terminate on the earliest of: (1) the date this Policy terminates; (2) the last day of the Insurance Month in which the Insured Person requests termination; (3) the last day of the last Insurance Month for which premium payment is made on the Insured Person's behalf, (4) the date the Insured Person ceases to be in a class which is eligible for coverage under this Policy; (5) with respect to any particular insurance benefit, the date the portion of the Policy providing that benefit terminates; (6) the date on which the Insured Person's employment or membership with the Group Policyholder or Participating Employer terminates, whichever occurs first; or (7) the date the Insured Person enters the armed services of any state or country on active duty; except for duty of 30 days or less for training in the Reserves or National Guard. (If the Insured Person sends proof of military service, the Company will refund any unearned premium.) Ceasing Active Work results in termination of insurance; but coverage may be continued as follows: (1) If the Insured Person is disabled due to illness or injury, then coverage may be continued until the earliest of: (a) 12 Insurance Months after the disability begins; (b) the date the Person is no longer disabled; or (c) for Life Insurance; the date the Insured Person qualifies for any Extension of Death Benefit under this Policy; provided premium payments are made on his or her behalf. (2) If the Insured Person ceases work due to a temporary lay off, an approved leave of absence, or a military leave; then coverage may be continued: (a) for three Insurance Months after the lay off or leave begins; (b) provided premium payments are made on his or her behalf. GL1101-5 93 (FMLA) 8 01/01/07 CONTINUATION OF INSURANCE DURING A LABOR DISPUTE An Insured Person may continue his or her insurance (except for any Weekly Disability Income Insurance) for as long as six months when: (1) the Employer's premium contributions are required by a collective bargaining agreement; and (2) the Insured Person's eligibility ends because his or her employment ceases due to a labor dispute. Continued insurance will end on the earliest of: (1) the date insurance has been continued for six months; (2) the date the Insured Person begins full-time employment with another employer; (3) the date fewer than 75 % of the Insured Persons eligible for this continuation are continuing their insurance; (4) the end of the period for which the last premium has been paid; (5) the date the Conversion Privilege is exercised; or (6) the date insurance would otherwise terminate, had the Insured Person remained an active Full Time Employee. Any Weekly Disability Income Insurance will terminate on the day the Insured Person's active employment ceases, however. MONTHLY PREMIUM. The Insured Person must continue to pay the Group Policyholder the required monthly premium (including the part normally paid by the Employer). The monthly premium will be at the same rate the Company would have charged for the coverage, if the Insured Person had remained an active Full Time Employee. The Company retains the right to adjust the rates during the continuation period. ELECTION. To continue insurance, the Insured Person must send the Group Policyholder: (1) a written request to continue insurance; and (2) the first monthly premium payment. This must be done within 31 days after his or her employment ceases due to a labor dispute. An Insured Person may exercise the Conversion Privilege at any time during the period of continued coverage. GL1101-5.3 CA 9 01/01/07 PREMIUMS AND PREMIUM RATES PAYMENT OF PREMIUMS. No coverage provided by this Policy will be in effect until the first premium for such coverage is paid. For coverage to remain in effect, each subsequent premium must be paid on or before its due date. The Group Policyholder is responsible for paying all premiums as they become due. Premiums are payable on or before their due dates at the Company's Group Insurance Service Office. The premium must be paid in U.S. dollars. PREMIUM RATE CHANGE. The Company may change any premium rate on any of the following dates: (1) the date this Policy's terms are changed; (2) the date the Company's liability is changed due to a change in federal, state or local law; (3) the date the Group Policyholder (or any covered division, subsidiary or affiliated company) relocates, or is added to or removed from this Policy; (4) the date the number of Insured Persons changes by 25 % or more from the enrollment on the date this Policy took effect, or the most recent Rate Guarantee Date expired, if later; or (5) on any premium due date on or after this Policy's first anniversary, or any later Rate Guarantee Date agreed upon by the Company. Unless the Company and the Group Policyholder agree otherwise, the Company will give at least 45 days' advance written notice of any increase in premium rates. PREMIUM AMOUNT. The amount of premium due on each due date will be the sum of the products obtained by multiplying each rate shown in the Premium Rate Schedule by the amount of insurance to which the rate applies. Premium adjustments will not be pro -rated daily. Instead, premium will be adjusted as follows. (1) When an Insured Person's insurance or increase takes effect, premium will be charged from the monthly due date coinciding with or next following that change. (2) When all or part of an Insured Person's insurance terminates, the applicable premium will cease on the monthly due date coinciding with or next following that termination. (3) When premiums are paid other than monthly, increases or decreases will result in adjustment from the premium due date coinciding with or next following that change. The above manner of charging premium is for accounting purposes only. It will not extend coverage beyond a date it would have otherwise terminated. Each premium payment will include any adjustments in past premiums, which are needed due to changes that have not yet been taken into account. If a premium adjustment involves a return of unearned premium, the refund will be limited to the prior 12-month period. Monthly Group Life Rate Monthly AD&D Rate PREMIUM RATE SCHEDULE $.08 per $1,000 of insurance .02 per $1,000 of insurance For Life and AD&D Insurance, the above rates are guaranteed until January 1, 2009; and for Dependent Life Insurance, the above rate is guaranteed until January 1, 2008, unless an exception listed in the Premium Rate Change section applies. After that, any premium rate change will be as shown in the renewal letter. The Company will send the Group Policyholder a renewal letter prior to each Policy Anniversary. GL1101-6 99 10 01 /01 /07 GRACE PERIOD A grace period of 31 days from the due date will be allowed for the payment of each premium after the first. The Policy will remain in effect during the grace period; unless the Group Policyholder gives the Company advance written notice of termination. The Group Policyholder will remain liable for payment of a pro rata premium for the time this Policy remained in force during the grace period. POLICY TERMINATION TERMINATION BY THE COMPANY. To terminate this Policy, the Company must give the Group Policyholder at least 31 days' advance written notice of its intent to do so. Until the premium rate has been in effect for at least 12 months, the Company can terminate coverage only if: (1) the total number of Insured Persons is less than ten; (2) all of the premium is paid by the Group Policyholder and less than 100 % of those eligible for coverage are insured; (3) part of the premium is paid by Insured Persons and less than 75 % of those eligible for coverage are insured; (4) the Group Policyholder, without good cause: (a) fails to promptly furnish any information the Company reasonably requires; or (b) fails to perform its duties pertaining to this Policy in good faith; (5) the Company's liability is changed as a result of any change in federal, state or local law which affects this Policy; (6) the Group Policyholder (or any covered division, subsidiary or affiliated company) relocates, dissolves or merges, or is added to or removed from this Policy; (7) any coverage for one, or more classes ceases to be provided under this Policy;. or (8) the number of Insured Persons changes by 25 % or more from the enrollment on the date this Policy took effect, or the most recent Rate Guarantee Date expired, if earlier. After the premium rate has been in effect for at least 12 months, the Company can terminate coverage on any premium due date, by giving 31 days' advance written notice. Such termination may be with respect to this Policy as a whole, to any coverage(s) provided under it, or to any class of Insured Persons under it. TERMINATION BY GROUP POLICYHOLDER.. The Group Policyholder may terminate this Policy at any time, by giving the Company advance written notice. Coverage will then terminate: (1) on the date the Company receives the notice; or (2) any later date the Group policyholder and the Company have agreed upon. The Group Policyholder remains responsible for the payment of premiums to the date of termination. AUTOMATIC TERMINATION. If any premium remains unpaid at the end of the Grace Period; then this Policy will automatically terminate, without any action on the Company's part, on the last day of the Grace Period. EFFECT ON INCURRED CLAIMS. Termination of this Policy will not affect benefits otherwise payable for a claim incurred while this Policy is in force. GL1101-7 99 No Bene.-ten lives 11 01/01/07 BENEFICIARY PAYMENTS TO BENEFICIARY. At an Insured Person's death, the amount of his or her Personal Life Insurance will be paid to the surviving Beneficiary. If the Insured Person has not named a Beneficiary, or if no named Beneficiary survives the Insured Person; then payment will be made to that Insured Person's: (1) surviving spouse; or, if none (2) surviving child or children in equal shares; or, if none (3) surviving parent or parents in equal shares; or, if none (4) surviving brothers and sisters in equal shares; or, if none (5) estate, or in accord with the Facility of Payment section of this Policy. The amount payable to anyone shown above will be reduced by any amount paid in accord with the Facility of Payment section. In determining who is to receive payment, the Company may rely upon an affidavit by a member of the class of relatives to receive payment. The Company will make payment based upon the affidavit it has; unless it receives notice of a valid claim by some other person, at its Group Insurance Service Office, before paying the proceeds. Such payment will release the Company from any further obligation for the Insured Person's life insurance benefit. If an Insured Person's named Beneficiary dies: (1) within 15 days of the Insured Person's death; and (2) before the Company receives satisfactory proof of the Insured Person's death; then payment will be made as if the Insured Person had survived that Beneficiary; unless other provisions have been made. NAMING THE BENEFICIARY. An Insured Person's Beneficiary will be as shown on his or her enrollment card, unless changed. This Policy may replace a group policy providing similar coverages. In that event, the Beneficiary which the Insured Person named under the prior policy will be the Beneficiary under this Policy, until changed. CHANGING THE BENEFICIARY. Only the Insured Person, or his or her assignee, may change the Beneficiary. A new Beneficiary may be named by filing a written notice of the change with the Company at its Group Insurance Service Office. The change will be effective as of the date it was signed; subject to any action the Company takes before receiving notice of the change. When applying for a conversion policy under the Conversion Privilege Section, an Insured Person must name a Beneficiary. The Beneficiary named for the conversion policy may be someone other than the person named under this Policy. In that event, the application for the conversion policy will be treated as a written notice of change of Beneficiary. GL1101-7.1A 96 Pref. Bene. 12 01/01/07 ASSIGNMENTS Personal Life Insurance and Accidental Death Insurance may be assigned. The assignments allowed under this Policy are absolute assignments and funeral assignments as described below. No assignment will be binding on the Company unless and until: (1) it is made on a form furnished by the Company; (2) the original is completed and filed with the Company at its Group Insurance Service Office; and (3) it is approved by the Company. The Company and the Group Policyholder do not assume responsibility for the validity or effect of an assignment. ABSOLUTE ASSIGNMENTS. An Insured Person may make an irrevocable assignment of his or her Personal Life Insurance and Accidental Death Insurance as a gift (with no consideration), providing he or she has the legal capacity and the mental capacity to do so. It may be made to a trust or to one or more of the Insured Person's relatives, their estates, or to a trustee of a trust under which one of the relatives is a beneficiary. The term "relatives" includes, but is not limited to, an Insured Person's spouse, parents, grandparents, aunts, uncles, siblings, children, adopted children, stepchildren, and grandchildren. In some states, community property is an established form of ownership that must be considered in making an assignment. If an Insured Person makes an absolute assignment to two or more assignees, such assignees will be joint owners with the right of survivorship between them. An Insured Person should consult with his or her own legal advisor before making an assignment: Once the assignment has been recorded by the Company, the Insured Person can no longer change the beneficiary and cannot apply for conversion. Only the assignee can change the beneficiary designation if the previous designation is revocable. An assignment will have no effect on a prior irrevocable beneficiary designation. Only the assignee can apply for conversion but only when the Conversion Privilege provision would have been available to the Insured Person in the absence of the assignment under this Policy. An absolute assignment cannot be used as a collateral assignment. FUNERAL ASSIGNMENTS. Upon an Insured Person's death, the beneficiary may assign the Personal Life Insurance benefit and Accidental Death Insurance benefit to a funeral home for payment of burial expenses. After payment has been made for the burial expenses to the assigned funeral home, the remaining death benefit is then paid I in accord with the Beneficiary and Settlement Options sections of this Policy. GL1101-7.1C 01 13 01/01/07 FACILITY OF PAYMENT Policy benefits may become payable to an Insured Person's estate, to a minor, or to a person who the Company does not consider competent to give a valid release. In that event, the. Company has the option to pay one or more of the following: (1) a person who has assumed the care and support of the Insured Person or Beneficiary; (2) a person who has incurred expense as a result of the Insured Person's last illness or death; (3) the personal representative of the Insured Person's estate; or (4) any person related by blood or marriage to the Insured Person. No payment made under this section may exceed $2,000. Any payment made in good faith under this section will fully discharge the Company to the extent of the payment. Any remaining amount of benefit will be paid as shown in the Beneficiary section. DEATH BENEFIT AMOUNT PAYABLE ON DEATH. Upon receipt of satisfactory proof of an Insured Person's death, the Company will pay a death benefit equal to the amount of Personal Life Insurance in effect on the date of death. This amount is shown in the Schedule of Insurance. The benefit will be paid as shown in the Beneficiary, Facility of Payment, and Settlement Options sections. SETTLEMENT OPTIONS INSTALLMENTS. All or part of the death benefit may be received in installments, by making written election to the Company. ELECTION. While living, an Insured Person may direct the Company to pay the death benefit in installments. If no such direction is in effect at the time of the Insured Person's death, the Beneficiary may make such an election. CONDITIONS. Any election, whether by an Insured Person or a Beneficiary, must comply with the Company's practices at the time it is made. The amount applied under a settlement option must be at least $2,000. It must be sufficient to provide a payment of at least $20 per month. GL1101-8 96 14 01/01/07 EXTENSION OF DEATH BENEFIT BENEFIT. Life insurance will be continued, without payment of premiums, for an Insured Person who: (1) becomes Totally Disabled while insured under this policy and before reaching age 70; (2) remains Totally Disabled for at least 6 months in a row; and (3) submits satisfactory proof within the 7th through the 12th months of disability; or: (a) as soon as reasonably possible after that; but (b) not later than the 24th month of disability, unless he or she was legally incapacitated. PREMIUM PAYMENT. Premium payments must continue until: (1) the day the Insured Person is approved for this Extension of Death Benefit; or (2) the day this Policy terminates (whichever occurs first). Upon receipt of satisfactory proof, the Company will refund up to 12 months' premium paid for the Insured Person's life insurance, from the 1st day of Total Disability. DEFINITION. For this benefit, Total Disability or Totally Disabled means an Insured Person: (1) is unable, due to sickness or injury, to engage in any employment or occupation for which such Insured Person is or becomes qualified by reason of education, training, or experience; and (2) is not engaging in any gainful employment or occupation. AMOUNT CONTINUED. The life insurance continued by this section: (1) will be the amount of Personal Life Insurance and any Dependent Life Insurance in effect on the day the Insured Person's Total Disability begins; and (2) will be subject to the reductions and terminations in effect under this Policy on that day. If the Insured Person receives an Accelerated Death Benefit, the amount will be reduced in accord with that provision. Any Accidental Death and Dismemberment Benefit will not be continued. ADDITIONAL PROOF. At any time during this continuation, the Company may require the Insured Person: (1) to submit further proof of his or her continued Total Disability; and (2) to be examined by a Physician of the Company's choice, as often as reasonably necessary. After the first two years of Total Disability, the Company will not request proof or an exam more than once a year. Proof will be at the Insured Person's expense; unless the Company requests an exam by a Physician of its choice. When an Insured Person dies after submitting proof, further proof must be submitted to the Company showing that he or she remained continuously and Totally Disabled until death. When an Insured Person dies within 12 months after Total Disability begins, but before submitting proof, then his or her death benefit will still be paid under the terms of this Policy. But the Company must first receive satisfactory proof of his or her continuous Total Disability, from the last day of Active Work until the date of death. TERMINATION. Any life insurance extended under this section will terminate automatically on: (1) the day the Insured Person ceases to be Totally Disabled; (2) the day the Insured Person fails to take a required medical examination; (3) the 60th day after the Company mails a request for additional proof, if it is not given; (4) the effective date of the Insured Person's individual conversion policy, with respect to any amount of life insurance converted in accord with the Conversion Privilege section; or (5) the day the Insured Person reaches age 70 (whichever occurs first). RIGHTS AFTER TERMINATION. If Total Disability ends, and the Insured Person does not return to a class eligible for Policy coverage; then he or she may exercise the Conversion Privilege. If Total Disability ends, and the Insured Person does return to an eligible class; then his or her Policy coverage will resume when premium payments are resumed, and any conversion policy is surrendered as provided below. CONVERSION POLICIES. If the Insured Person has exercised the Conversion Privilege, and the benefits payable under this Policy and the conversion policy combined would exceed: (1) the Insured Person's original amount of Policy coverage prior to the conversion; or (2) any greater amount for which he or she later becomes insured under this Policy; then benefits will be payable under the terms of this Policy. But the conversion policy must first be surrendered to the Company; and no claim may be made under the conversion policy, except for refund of premium less any dividends and policy loans. GL1101-9 96 Stand. Ext. - Age 70 15 01 /01 /07 ACCELERATED DEATH BENEFIT BENEFIT. The Accelerated Death Benefit is an advance payment of part of the Insured Person's Personal Life Insurance. It may be paid to the Insured Person, in a lump sum, once during the Insured Person's lifetime. To qualify, a Terminal Insured Person must: (1) have satisfied the Active Work requirement under this Policy; (2) have been insured under this Policy for at least 12 months; and (3) have at least $2,000 of Personal Life Insurance under this Policy on the day before the Accelerated Death Benefit is paid. Receiving the Accelerated Death Benefit will reduce the Remaining Life Insurance and the Death Benefit payable at death, as shown on the next page. "Claimant, " as used in this section, means the Terminal Insured Person for whom the Accelerated Death Benefit is requested. "Terminal" means the Insured Person has a medical condition which is expected to result in death within 12 months, despite appropriate medical treatment. APPLYING FOR THE BENEFIT. To withdraw the Accelerated Death Benefit, the Insured Person (or his or her legal representative) must send the Company: (1) written election of the Accelerated Death Benefit, on forms supplied by the Company; and (2) satisfactory proof that the Claimant is Terminal, including a Physician's written statement. The Company reserves the right to decide whether such proof is satisfactory. Before paying an Accelerated Death Benefit, the Company must also receive the written consent of any irrevocable beneficiary, assignee or bankruptcy court with an interest in the benefit. (See Limitations 3, 4, and 5.) NOTE: THIS IS NOT A LONG-TERM CARE POLICY. RECEIVING THIS ACCELERATED DEATH BENEFIT WILL REDUCE THE BENEFIT PAYABLE AT DEATH. ANY AMOUNT WITHDRAWN MAY BE TAXABLE INCOME, SO THE INSURED PERSON SHOULD CONSULT A TAX ADVISOR BEFORE APPLYING FOR THIS BENEFIT. AMOUNT OF THE BENEFIT. The Insured Person may elect to withdraw an Accelerated Death Benefit in any $1,000 increment; subject to: (1) a minimum of $1,000 or 10% of the Claimant's amount of Life Insurance (whichever is greater); and (2) a maximum of $250,000 or 75 % of the Claimant's amount of Life Insurance (whichever is less). To determine the Accelerated Death Benefit, the Company will use the lesser of A or B below: A. the Claimant's amount of Life Insurance which is in force on the day before the Accelerated Death Benefit is paid; or B. the Claimant's amount of Life Insurance which would be in force 12 months after that date; if the coverage is scheduled to reduce, due to age, within 12 months after the Accelerated Death Benefit is paid. GL1101-9.8 01 ADB-DEP. 16 01/01/07 ADMINISTRATIVE CHARGE: NONE WITHDRAWAL FEE: NONE EFFECT ON AMOUNT OF LIFE INSURANCE. "Remaining Life Insurance" means the amount of Life Insurance which remains in force on the Claimant's life after an Accelerated Death Benefit is paid. The Remaining Life Insurance will equal: (1) the Claimant's amount of Life Insurance which was used to determine the Accelerated Death Benefit (A or B above); minus (2) any percentage by which the Claimant's coverage is scheduled to reduce, due to age; if the reduction occurs more than 12 months after the Accelerated Death Benefit is paid, and while he or she is still living; minus (3) the amount of the Accelerated Death Benefit withdrawn. PREMIUM: There is no additional charge for this benefit. Continuation of the Remaining Life Insurance will be subject to timely payment of the premium for the reduced amount; unless the Insured Person qualifies for waiver of premium under this Policy's Extension of Death Benefit provision, if included. CONDITIONS. If the Claimant exercises the Conversion Privilege after an Accelerated Death Benefit is paid, the amount of the conversion policy will not exceed the amount of his or her Remaining Life Insurance. If the Claimant has Accidental Death and Dismemberment benefits under this Policy, the Principal Sum will not be affected by the payment of an Accelerated Death Benefit. EFFECT ON DEATH BENEFIT. When the Claimant dies after an Accelerated Death Benefit is paid, the amount of Remaining Life Insurance in force on the date of death will be paid as a Death Benefit. The Insured Person's Death Benefit will be paid in accord with the Beneficiary section of this Policy. If the Claimant dies after application for an Accelerated Death Benefit has been made, but before the Company has made payment; then the request will be void and no Accelerated Death Benefit will be paid. The amount of Life Insurance in force on the date of death will be paid in accord with Policy provisions. EFFECT ON TAXES AND GOVERNMENT BENEFITS. Any Accelerated Death Benefit amount withdrawn may be taxable income to the Insured Person. Receipt of the Accelerated Death Benefit may also affect the Claimant's eligibility for Medicaid, Supplemental Security Income and other government benefits. The Claimant should consult his or her own tax and legal advisor before applying for an Accelerated Death Benefit. The Company is not responsible for any tax owed or government benefit denied, as a result of the Accelerated Death Benefit payment. LIMITATIONS. No Accelerated Death Benefit will be paid: (1) if any required premium is due and unpaid; (2) on any conversion policy purchased in accord with the Conversion Privilege; (3) without the written approval of the bankruptcy court, if the Insured Person has filed for bankruptcy; (4) without the written consent of the beneficiary, if the Insured Person has named an irrevocable beneficiary; (5) without the written consent of the assignee, if the Insured Person has assigned his or her rights under this Policy; (6) if any part of the Life Insurance must be paid to the Insured Person's child, spouse or former spouse; pursuant to a legal separation agreement, divorce decree, child support order or other court order; (7) if the Claimant is Terminal due to a suicide attempt, while sane or insane; or due to an intentionally self-inflicted injury; (8) if a government agency requires the Insured Person or the Claimant to use the Accelerated Death Benefit to apply for, receive or continue a government benefit or entitlement; or (9) if an Accelerated Death Benefit has been previously paid for the Claimant under this Policy. GL1101-9.8 01 ADB-DEP. 17 01/01/07 CONVERSION PRIVILEGE - CONVERSION BENEFITS GENERAL BENEFIT. An individual life policy, known as a conversion policy, may be purchased from the Company without evidence of insurability, if all or part of anyone's life insurance, provided by this Policy, terminates for any reason except: (1) termination or amendment of the Policy; or (2) the Insured Person's request for: (a) termination of insurance; or (b) cancellation of payroll deduction. To purchase a conversion policy, application and payment of the first premium must be made within 31 days after the life insurance is terminated. Any policy issued under the General Conversion Benefit will: (1) be for an amount not to exceed the amount of the life insurance which was terminated; (2) be on any form (except term) then issued by the Company at the age and amount for which application is made; (3) be issued at the Insured Person's age at nearest birthday; (4) be issued without disability or other supplemental benefits; and (5) require premiums based on the class of risk to which the person then belongs. CONVERSION BENEFIT -POLICY TERMINATION OR AMENDMENT. A conversion policy also may be purchased from the Company if: (1) all or a part of anyone's insurance terminates due to amendment or termination of this Policy; and (2) that person has been covered continuously under this Policy for at least five years or, in the case of an Insured Person, such Insured Person is Totally Disabled as defined in the Extension of Death Benefit Section. Any conversion policy issued due to Policy termination or amendment will be subject to the same conditions as a policy issued under the General Conversion Benefit except its amount may not exceed the lesser of: (1) $3,000 (not applicable if the Insured Person is Totally Disabled as defined in the Extension of Death Benefit Section); and (2) the Amount of Life Insurance which terminates less the amount of any group life insurance for which the Insured Person becomes eligible within 31 days after the termination. PROVISIONS APPLICABLE TO ALL CONVERSION POLICIES EFFECTIVE DATES. The coverage provided by a conversion policy issued under this Section will be effective on the later of: (1) its date of issue; or (2) 31 days after the date on which the person's life insurance terminated. DEATH DURING CONVERSION PERIOD. The Company will pay a death benefit under this Policy equal to the amount of the life insurance which could have been converted, if the person: (1) was entitled to purchase a conversion policy; and (2) dies within the 31 day conversion period. This death benefit will be paid even if no one applied for the conversion policy. If the first premium was paid for the conversion policy, the amount of the premium will be refunded and the conversion policy will be void. GL1101-10 CA DEP 18 01/01/07 NOTICE OF CONVERSION PRIVILEGES -INSURED PERSONS. When an Insured Persons Personal Insurance terminates, written notice of the right to convert will be: (1) given personally to the Insured Person; (2) mailed by the Group Policyholder to the Insured Person at his last known address; or (3) mailed by the Company to the Insured Person at his last known address as furnished by the Group Policyholder. An additional period in which to convert will be granted if this written notice is not given to the Insured Person at least 15 days before the end of the 31 day conversion period. Any such extension of the conversion period will expire on the earliest of: (1) 25 days after the Insured Person is given the written notice; and (2) 60 days after the end of the 31 day conversion period even if the Insured Person is never given such notice. No death benefit will be payable under this Policy after the 31 day conversion period has expired even though the right to convert may be extended. GL 1101-10 CA DEP (Continued) 19 01/01/07 DEPENDENTS LIFE INSURANCE BENEFIT. Upon receipt of satisfactory proof of a Dependent's death while insured under this Policy, the Company will pay the amount of the Dependents Life Insurance in effect on the date of such death. This amount is shown in the Schedule of Insurance. The death benefit will be paid: (1) to the Insured Person; or (2) if the Insured Person fails to survive the Dependent, to the Insured Person's Beneficiary or according to the Facility of Payment Section. DEPENDENT. A Dependent means a person who meets the definition of a dependent of the Insured Person under the provision of the U.S. Internal Revenue Code; and is an Insured Person's: (1) spouse who is not legally separated from the Insured Person; (2) unmarried child at least 14 days but less than 19 years of age; (3) unmarried child less than 23 years of age, if attending an accredited educational institution for the minimum credit hours required to maintain full-time student status there; or (4) unmarried child who is totally and permanently disabled and who became so disabled prior to reaching 19 years of age. A legally adopted child is considered the Insured Person's child from the date of placement in the Insured Person's home for an agency adoption; or from the date the adoption petition is filed, if later, for a private adoption. In addition to naturally born and legally adopted children, the word "child" includes an Insured Person's stepchild or foster child; provided the child resides in the Insured Person's household and is dependent on the Insured Person for principal support. The term Dependent does not include anyone serving in the armed forces of any state or country; except for duty of 30 days or less for training in the Reserves or National Guard. ELIGIBILITY. An Insured Person becomes eligible for Dependents Life Insurance on the latest of: (1) the date the Insured Person becomes eligible for Personal Insurance; (2) the effective date of this Section; or (3) the date the Insured Person first acquires a Dependent. EFFECTIVE DATES. An Insured Person's Dependents Life Insurance will become effective on the latest of the following dates: (1) the date the Insured Person becomes eligible for Dependents Life Insurance; (2) the date the Insured Person makes written application for Dependents Life Insurance and signs a payroll deduction order; and (3) the date the Company approves any required evidence of insurability on all the Insured Person's Dependents. If an Insured Person acquires a new Dependent while insured for Dependents Life Insurance, insurance for that Dependent will take effect on the date the Dependent is acquired. If a Dependent is confined in a hospital on the date his or her Dependents Life Insurance would otherwise take effect, then Dependents Life Insurance for that Dependent will not take effect until ten days after final discharge from the hospital. GL1101-11B 97 B - w/o Suicide Exclusion 20 01 /01 /07 EVIDENCE OF INSURABILITY. Each Insured Person's Dependent must submit evidence of insurability satisfactory to the Company if the Insured Person: (1) makes application for Dependents Insurance more than 31 days after the date such Insured Person becomes eligible for Dependents Insurance; or (2) elects to be insured for Dependents Insurance after such Insured Person had requested: (a) termination of the Dependents Insurance; or (b) cancellation of the payroll deduction order; or (3) makes application for Dependents Insurance after it has automatically terminated, due to failure to pay premium by the end of the grace period. INDIVIDUAL TERMINATION OF DEPENDENT INSURANCE. An Insured Person's Dependents Insurance will cease for all of the Insured Person's Dependents on the earliest of: (1) the date the Insured Person's Personal Insurance terminates; (2) the date Dependent Insurance is discontinued under this Policy; (3) the date the Insured Person ceases to be in a class of employees eligible for Dependent Insurance; (4) the date the Insured Person requests that the Dependent Insurance be terminated; or (5) the last day of the premium paying period for which the Insured Person has made any required contribution toward the cost of the Dependent Insurance. Dependents Insurance on a particular Dependent will cease on the earliest of: (1) the date he or she ceases to be a Dependent as defined in this Policy; (2) the date he or she becomes covered under this Policy as an Insured Person; or (3) the date he or she enters the armed forces of any state or country; except for duty of 30 days or less in the Reserves or National Guard. (If the Insured Person sends proof of military service, the Company will refund any unearned premium.) MISSTATEMENT OF AGE. If the age of a Dependent has been misstated, premiums will be subject to an equitable adjustment. If the amount of benefit is dependent upon age, the benefit will be that which would have been payable based upon the Dependent's correct age. ASSIGNMENT. Dependents Insurance may not be assigned. INCONTESTABILITY. Except for non-payment of premiums, the Company may not contest the validity of this Policy as to any Dependent, after it has been in force for two years during the lifetime of that Dependent. This clause will not affect the Company's right to contest claims made for accidental death, or dismemberment benefits. GL1101-12 97 21 01/01/07 CLAIMS PROCEDURES FOR LIFE OR ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS NOTE: This Policy may include an Extension of Death Benefit, an Accelerated Death Benefit or a Living Benefit. If so, please refer to that section for special claim procedures. NOTICE AND PROOF OF CLAIM Notice of Claim. Written notice of an accidental death or dismemberment claim must be given within 20 days after the loss occurs; or as soon as reasonably possible after that.* The notice must be sent to the Company's Group Insurance Service Office. It should include: (1) the Insured Person's name and address; and (2) the number of this Policy. Claim Forms. When notice of claim is received, the Company will send claim forms for filing the required proof. If the Company does not send the forms within 15 days; then the Insured Person or Beneficiary (the claimant) may send the Company written proof of claim in a letter. It should state the nature, date and cause of the loss. Proof of Claim. The Company must be given written proof of claim within 90 days after the date of the loss; or as soon as reasonably possible after that.* Proof of claim must be provided at the claimant's own expense. It must show the nature, date and cause of the loss. In addition to the information requested on the claim form, documentation must include: (1) A certified copy of the death certificate, for proof of death. (2) A copy of any police report, for proof of accidental death or dismemberment. (3) A signed authorization for the Company to obtain more information. (4) Any other items the Company may reasonably require in support of the claim. * Exception: Failure to give notice or furnish proof of claim within the required time period will not invalidate or reduce the claim; if it is shown that it was done: (1) as soon as reasonably possible; and (2) in no event more than one year after it was required. These time limits will not apply while the claimant lacks legal capacity. EXAM OR AUTOPSY. At anytime while a claim is pending, the Company may have the Insured Person examined: (1) by a Physician of the Company's choice; (2) as often as reasonably required. If the Insured Person fails to cooperate with an examiner or fails to take an exam, without good cause; then the Company may deny benefits, until the exam is completed. In case of death, the Company may also have an autopsy done, where it is not forbidden by law. Any such exam or autopsy will be at the Company's expense. TIME OF PAYMENT OF CLAIMS. Any benefits payable under this Policy will be paid immediately after the Company receives complete proof of claim and confirms liability. TO WHOM PAYABLE Death. Any benefits payable for the Insured Person's death will be paid in accord with the Beneficiary, Facility of Payment, and Settlement Options sections of this Policy. If this Policy includes Dependent Life Insurance; then any benefits payable for an insured Dependent's death will be paid to: (1) the Insured Person, if he or she survives that Dependent; or (2) the Insured Person's Beneficiary, or in accord with the Facility of Payment section; if the Insured Person does not survive that Dependent. Dismemberment. If this Policy includes Accidental Death and Dismemberment Benefits; then any benefit, other than the Insured Person's death benefit, will be paid to the Insured Person. GL1101-13A 02 CA L/ADD 22 01/01/07 CLAIMS PROCEDURES (Continued) NOTICE OF CLAIM DECISION. The Company will send the claimant a written notice of its claim decision. If the Company denies any part of the claim; then the written notice will explain: (1) the reason for the denial, under the terms of this Policy and any internal guidelines; (2) whether more information is needed to support the claim; and (3) how the claimant may request a review of the decision by the Company, or by the state Department of Insurance. It will include the address and phone number of their consumer complaint. unit. The Company will send this notice within 15 days after it receives complete proof of claim and enough information to determine liability. If reasonably possible, the Company will send it within: (1) 90 days after receiving the first proof of a death or dismemberment claim; or (2) 45 days after receiving the first proof of a claim for any Extension of Death Benefit, Living Benefit or Accelerated Death Benefit available under this Policy. Delay Notice. If the Company needs more than 15 days to process a claim, in a special case; then an extension will be permitted. If needed, the Company will send the claimant a written delay notice: (1) by the 15`h day after receiving the first proof of claim; and (2) every 30 days after that, until the claim is resolved. The notice will explain the special circumstances which require the delay, and when a decision can be expected. In any event, the Company must send written notice of its decision within: (1) 180 days after receiving the first proof of a death or dismemberment claim; or (2) 105 days after receiving the first proof of a claim for any Extension of Death Benefit, Living Benefit or Accelerated Death Benefit available under this Policy. If the Company fails to do so; then there is a right to an immediate review, as if the claim was denied. Exception: If the Company needs more information from the claimant to process a claim; then it must be supplied within 45 days after the Company requests it. The resulting delay will not count towards the above time limits for claim processing. REVIEW PROCEDURE. The claimant may request a claim review, within: (1) 60 days after receiving a denial notice of a death or dismemberment claim; or (2) 180 days after receiving a denial notice of a claim for any Extension of Death Benefit, Living Benefit or Accelerated Death Benefit available under this Policy. To request a review, the claimant must send the Company a written request, and any written comments or other items to support the claim. The claimant may review certain non -privileged information relating to the request for review. Notice of Decision. The Company will review the claim and send the claimant a written notice of its decision. The notice will explain the reasons for the Company's decision, under the terms of this Policy and any internal guidelines. If the Company upholds the denial of all or part of the claim; then the notice will also describe: (1) any further appeal procedures available under this Policy; (2) the right to access relevant claim information; and (3) the right to request a state insurance department review, or to bring legal action. For a death or dismemberment claim, the notice will be sent within 60 days after the Company receives the request for review; or within 120 days, if a special case requires more time. For a claim for any Extension of Death Benefit, Living Benefit or Accelerated Death Benefit available under this Policy, the notice will be sent within 45 days after the Company receives the request for review; or within 90 days, if a special case requires more time. GL1101-13A 02 CA L/ADD 23 01/O1/07 CLAIMS PROCEDURES (Continued) Delay Notice. If the Company needs more time to process an appeal, in a special case; then it will send the Insured Person a written delay notice, by the 30" day after receiving the request for review. The notice will explain: (1) the special circumstances which require the delay; (2) whether more information is needed to review the claim; and (3) when a decision can be expected. Exception: If the Company needs more information from the claimant to process an appeal; then it must be supplied within 45 days after the Company requests it. The resulting delay will not count towards the above time limits for appeal processing. Claims Subject to ERISA (Employee Retirement Income Security Act of 1974). Before bringing a civil legal action under the federal labor law known as ERISA, an employee benefit plan participant or beneficiary must exhaust available administrative remedies. Under this Policy, the claimant must first seek two administrative reviews of the adverse claim decision, in accord with this section. If an ERISA claimant brings legal action under Section 502(a) of ERISA after the required reviews; then the Company will waive any right to assert that he or she failed to exhaust administrative remedies. RIGHT OF RECOVERY. If benefits have been overpaid on any claim; then full reimbursement to the Company is required within 60 days. If reimbursement is not made; then the Company has the right to: (1) reduce future benefits until full reimbursement is made; and (2) recover such overpayments from the Insured Person, or from his or her Beneficiary or estate. Such reimbursement is required whether the overpayment is due to fraud, the Company's error in processing a claim, or any other reason. LEGAL ACTIONS. No legal action to recover any benefits may be brought until 60 days after the required written proof of claim has been given. No such legal action may be brought more than three years after the date written proof of claim is required. COMPANY'S DISCRETIONARY AUTHORITY. Except for the functions that this Policy clearly reserves to the Group Policyholder or Employer, the Company has the authority to: (1) manage this Policy and administer claims under it; and (2) interpret the provisions and resolve questions arising under this Policy. The Company's authority includes (but is not limited to) the right to: (1) establish and enforce procedures for administering this Policy and claims under it; (2) determine Employees' eligibility for insurance and entitlement to benefits; (3) determine what information the Company reasonably requires to make such decisions; and (4) resolve all matters when a claim review is requested. Any decision the Company makes, in the exercise of its authority, shall be conclusive and binding; subject to the Insured Person's or Beneficiary's rights to: (1) request a state insurance department review; or (2) bring legal action. GL1101-13A 02 CA L/ADD 24 01/01/07 ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE DEATH OR DISMEMBERMENT BENEFIT FOR AN INSURED PERSON. The Company will pay the benefit listed below, if: (1) an Insured Person sustains an accidental bodily injury while insured under this provision; and (2) that injury directly causes one of the following losses within 365 days after the date of the accident. The loss must result directly from the injury and from no other causes. LOSS BENEFIT FOR BENEFIT FOR COMMON CARRIER OTHER COVERED ACCIDENT ACCIDENT Loss of Life 2 Times Principal Sum Principal Sum Loss of One Member (Hand, Foot or Eye) Principal Sum 1/2 Principal Sum Loss of Two or More Members 2 Times Principal Sum Principal Sum The Principal Sum for the Insured Person's class is shown in the Schedule of Insurance. MAXIMUM PER PERSON. If an Insured Person sustains more than one loss resulting from the same accident, the benefit: (1) will be the one largest amount listed; (2) will not exceed two times the Principal Sum for all of that person's combined losses resulting from a Common Carrier Accident; and (3) will not exceed the Principal Sum for all of that. person's combined losses resulting from any other covered accident. TO WHOM PAYABLE. Benefits for the Insured Person's loss of life will be paid in accord with the Beneficiary section. All other benefits will be paid to the Insured Person. LIMITATIONS. Benefits are not payable for any loss to which a contributing cause is: (1) intentional self-inflicted injury or self-destruction; (2) disease, bodily or mental infirmity, or medical or surgical treatment of these; (3) duty as a member of any ^military, naval or air force; (4) war or any act of war, declared or undeclared; (5) participation in the commission of a felony; (6) voluntary use of drugs; except when prescribed by a Physician; (7) voluntary inhalation of gas, including carbon monoxide; (8) travel or flight in any aircraft, including balloons and gliders; except as a fare paying passenger on a regularly scheduled flight; or (9) driving a vehicle while intoxicated. GL1101-14.3A 01 CA COMMON CARRIER 25 01/01/07 ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE CONTINUED DEFINITIONS. "Beneficiary" means the person(s) named on the Insured Person's enrollment form. The Insured Person may change the Beneficiary by filing a written notice of the change with the Company at its Group Insurance Service Office. "Common Carrier Accident" means a covered accidental bodily injury, which is sustained while riding as a fare paying passenger (not a pilot, operator or crew member) in or on, boarding or getting off from a Common Carrier "Common Carrier" means any land, air or water conveyance operated under a license to transport passengers for hire. "Intoxicated" shall be defined by the jurisdiction where the accident occurs. The exclusion will apply whether or not the driver is convicted. "Loss of a Member" includes the following: (1) "Loss of Hand or Foot," means complete severance through or above ,the wrist or ankle joint. (In South Carolina, "Loss of Hand" can also mean the loss of four whole fingers from one hand.) (2) "Loss of an Eye," means total and irrevocable loss of sight in that eye. GL1101-14.3A 01 CA COMMON CARRIER 26 01/01/07 SAFE DRIVER BENEFIT BENEFIT. If an Insured Person dies as a direct result of a covered auto accident, for which Accidental Death and Dismemberment Benefits are payable; then: (1) an additional Seat Belt Benefit will be payable, if the Insured Person was wearing a properly fastened seat belt at the time of the accident; and (2) an additional Air Bag Benefit will be payable, if the auto was equipped with air bag(s). The Seat Belt Benefit equals $10,000 or 10% of the Principal Sum, whichever is less; and the Air Bag Benefit equals $10,000 or 10% of the Principal Sum, whichever is less. The Seat Belt Benefit and the Air Bag Benefit will not be less than $1,000 per Insured Person. The Principal Sum is the amount payable because of the Insured Person's accidental death. A copy of the police report must be submitted with the claim. The position of the seat belt or presence of an air bag must be certified by: (1) the official accident report; or (2) the coroner, traffic officer or other investigating officer. Upon receipt of satisfactory written proof, the additional benefit will be paid in accord with the Beneficiary section. DEFINITIONS. As used in this provision: "Auto" means a 4-wheel passenger car, station wagon, jeep, pick-up truck or van -type car. It must be licensed for use on public highways. It includes a car owned or leased by the Group Policyholder. "Intoxicated," "'Impaired," or "Under the Influence of Drugs" shall be defined as by the jurisdiction where the accident occurs. "Seat Belt" means a properly installed: (1) seat belt or lap and shoulder restraint; or (2) other restraint approved by the National Highway Traffic Safety Administration. LIMITATIONS. Safe Driver Benefits will not be paid if: (1) the Accidental Death and Dismemberment Benefit is not paid under this Policy for the Insured Person's death; or (2) at the time of the accident, the Insured Person or any other person who was driving the auto in which the Insured Person was traveling: (a) was driving without a valid drivers' license; (b) was driving in excess of the legal speed limit; or (c) was driving while intoxicated, impaired, or under the influence of drugs (except for drugs taken as prescribed by a Physician for the driver's use). The above limitations will apply, whether or not the driver is convicted. GL1101-14.15A Seat Belt & Air Bag 27 01/01/07 AMENDMENT TO BE ATTACHED TO AND MADE PART OF GROUP POLICY NO.: 000010003229 ISSUED TO: Samples The Policy is amended by the addition of the following provisions. PRIOR INSURANCE CREDIT UPON TRANSFER OF LIFE INSURANCE CARRIERS This provision prevents loss of life insurance coverage for an Insured Person, which could otherwise occur solely because of a transfer of insurance carriers. This Policy will provide the following Prior Insurance Credit, when it replaces a prior plan. "Prior Plan" means a prior carrier's group life insurance policy, which this Policy replaced within 1 day of the prior plan's termination date. FAILURE TO SATISFY ACTIVE WORK RULE. Subject to payment of premiums, this Policy will provide life coverage for a Person who: (1) was insured under the prior plan on its termination date; (2) was otherwise eligible under this Policy; but was not -Actively-At-Work due to Injury or Sickness on its Effective Date; (3) is not entitled to any extension of life insurance under the prior plan; and (4) is not Totally Disabled (as defined in the Extension of Death Benefit section of this Policy) on the date this Policy takes effect. AMOUNT OF LIFE INSURANCE. Until the Person satisfies this Policy's Active Work rule, the amount of his or her group life insurance under this Policy will not exceed the amount for which the Person was insured under the prior plan on its termination date. This Amendment takes effect on the effective date of coverage under this Policy. In all other respects, this Policy remains the same. The Lincoln National Life Insurance Company Officer of the Company GL1101-AMEND. PC 28 Prior Ins. Cred. - Life 01 /01 /07 CALIFORNIA LIFE AND HEALTH INSURANCE GUARANTY ASSOCIATION ACT SUMMARY DOCUMENT AND DISCLAIMER Residents of California who purchase life and health insurance and annuities should know that the insurance companies licensed in this state to write these type of insurance are members of the California Life and Health Insurance Guaranty Association ("CLHIGA"). The purpose of this Association is to assure that policyholders will be protected, within limits, in the unlikely event that a member insurer becomes financially unable to meet its obligations. If this should happen, the Guaranty Association will assess its other member insurance companies for the money to pay the claims of insured persons who live in this state and, in some cases, to keep coverage in force. The valuable extra protection provided through the Association is not unlimited, as noted below, and is not a substitute for consumers' care in selecting insurers. The California Life and Health Insurance Guaranty Association may not provide coverage for the policy. If coverage is provided, it may be subject to substantial limitations or exclusions, and require continued residency in California. You should not rely on coverage by the Association in selecting an insurance company or in selecting an insurance policy. Coverage is NOT provided for your policy or any portion of it that is not guaranteed by the insurer or for which you have assumed the risk, such as a variable contract sold by prospectus. Insurance companies or their agents are required by law to give or send you this notice. However, insurance companies and their agents are prohibited by law from using the existence of the Guaranty Association to induce you to purchase any kind of insurance policy. Policyholders with additional questions should first contact their insurer or agent or may then contact: California Life & Health Insurance or Consumer Communications Bureau Guaranty Association California Department of Insurance P.O. Box 16860 300 South Spring Street Beverly Hills, CA 90209-3319 Los Angeles, CA 90013 The state law that provides for this safety -net coverage is called the California Life and Health Insurance Guaranty Association Act. Below is a brief summary of this law's coverages, exclusions and limits. This summary does not cover all provisions of the law; nor does it in any way change anyone's rights or obligations under the Act or the rights or obligations of the Association. COVERAGE Generally, individuals will be protected by the California Life and Health Insurance Guaranty Association if they live in this state and hold a life or health insurance contract, or an annuity, or if they are insured under a group insurance contract, issued by a member insurer. The beneficiaries, payees or assignees of insured persons are protected as well, even if they live in another state. CA NOTICE 96 P/C-L,A&H 05 29 01/01/07 EXCLUSIONS FROM COVERAGE However, persons holding such policies are not protected by this Guaranty Association if: Their insurer was not authorized to do business in this state when it issued the policy or contract; Their policy was issued by a health care service plan (HMO, Blue Cross, Blue Shield), a charitable organization, a fraternal benefit society, a mandatory state pooling plan, a mutual assessment company, an insurance exchange, or a grants and annuities society; They are eligible for protection under the laws of another state. This may occur when the insolvent insurer was incorporated in another state whose guaranty association protects insureds who live outside that state. The Guaranty Association also does not provide coverage for: • Unallocated annuity contracts; that is, contracts which are not issued to and owned by an individual and which guarantee rights to group contractholders, not individuals; • Employer and association plans, to the extent they are self -funded or uninsured; • Any policy or portion of a policy which is not guaranteed by the insurer or for which the individual has assumed the risk, such as a variable contract sold by prospectus; • Any policy of reinsurance unless an assumption certificate was issued; • Interest rate yields that exceed an average rate; • Any portion of a contract that provides dividends or experience rating credits. LIMITS ON AMOUNT OF COVERAGE The Act limits the Association to pay as follows: LIFE AND ANNUITY BENEFITS • 80 % of what the life insurance company would owe under a life policy or annuity contract up to • $100,000 in cash surrender values, • $100,000 in present value of annuities; or • $250,000 in life insurance death benefits. • A maximum of $250,000 for any one insured life no matter how many policies and contracts there were with the same company, even if the policies provided different types of coverages. HEALTH BENEFITS A maximum of $200,000 of the contractual obligations that the health insurance company would owe were it not insolvent. The maximum may increase or decrease annually based upon changes in the health care cost component of the consumer price index. PREMIUM SURCHARGE Member insurers are required to recoup assessments paid to the Association by way of a surcharge on premiums charged for health insurance policies to which the Act applies. CA NOTICE 96 P/C-L,A&H 05 30 01 /01 /07 AMENDMENT TO BE ATTACHED TO AND MADE PART OF GROUP POLICY NO.: 000010003229 ISSUED TO: Samples It is agreed that, under the Accidental Death and Dismemberment Insurance section, the Limitation on air travel or flight is amended to read as follows: "travel or flight in any aircraft, including balloons and gliders; except: (a) as a fare -paying passenger on a regularly scheduled commercial flight; or (b) as a passenger or pilot in the Group Policyholder's aircraft while flying on the Group Policyholder's business; provided: (1) the aircraft has a valid U.S. airworthiness certificate (or foreign equivalent); and (2) the pilot has a valid pilot's certificate with a non -student rating authorizing him or her to fly the aircraft. " The effective date of this amendment is January 1, 2007; but only with respect to losses incurred on or after that date. Nothing contained in this amendment shall change any of the terms and conditions of this policy, except as stated above. The Lincoln National Life Insurance Company (i Officer of the Company GL1101-AMEND.PIL.1 01/01/07 CITY CLERK'S OFFICE INTEROFFICE MEMORANDUM DATE: November 5, 2008 TO: Willard Yamaguchi, Chief Deputy City Attorney/Risk Manager FROM: Nelly Giron, City Clerk RE: Resolution No. 9755 - A Resolution of the City Council of the City of Vernon Approving and Authorizing the Execution of ar..,' Application for Group Insurance and Sample Contract By and Between the City of Vernon and the Lincoln National Life Insurance Company for the Purchase of Life Insurance Benefits and Authorizing the City to Do All Actions Deemed Necessary or Advisable Concerning Securing Said Benefits Transmitted herewith is a copy of Resolution No. 9755 referenced above, which was approved by City Council on November 3, 2008. Thank you. NG:dr c: Karina Rueda Resolution No. 9755 {, the Lincoln National Life Insurance Company Group Insuranop Service Office 8801 Indian Hills Drive Omaha, Nebraska 68114.4066 ID# ,,,3 /lice Use On/ APPLICATION FOR GROUP INSURANCE is hereby made to THE 11NCOLN NATIONAL LIFE INSURANCE COMPANY (the Compan yJ. A. NAME AND ADDRESS 1. Applicant's Full legal Name (exactly as to be shown in Group Policy): City of Vernon 2. Main Office Address (physical location and group situs state): Street 4305 Santa Fe Avenue Zip 90058 Citv Vernon Phone# (323) 583-8811 FAX# (323) 826-1439 E-Mail Address (if available) B. REQUESTED COVERAGES State CA The following Group Insurance is applied for as specified in the sold case proposal(s). Complete the requested Effective Date for each coverage. Q Life & AD&D with Effective Date 1/1/09 ❑ Long Term Disability with Effective Date _ ❑ Short Term Disability with Effective Date _ n Dental with Effective Date C. BUSINESS INFORMATION ❑ Voluntary Life with Effective Date 0 Voluntary life & AD&D with Effective Date 1/1/09 ❑ Voluntary Long Term Disability with Effective Date ❑ Voluntary Dental with Effective Date 1. Nature of Business (Please specify): Municipality Years in Business 103 years Federal Tax ID# 95-6000808 2. Business is Organized As (select one): F] Corporation ❑ Non -Profit Organization ❑ Partnership ❑ Proprietorship Q Other Municipality 3. Financial Risk (If Yes to any part, please explain below.) Yes 0 No Has Applicant ever filed for bankruptcy? ❑ Yes n No Does Applicant anticipate ceasing or materially reducing active business operations? Yes n No Has Applicant opted out (or do they anticipate opting out) of Workers' Compensation? Explanation: 4. Binder payment submitted: Amount $ 804 47 (if applicable) D REPLACEMENT COVERAGE El Yes No Will all or part of this coverage replace any similar coverage? If Yes, provide details of the prior plan below and enclose a copy of each inforce contract to be replaced. Prior Plan Effective Date 3L2-APP.09102 CA E. FRAUD WARNING ' NOTICE: California law prohibits an HIV test from being requited or used by health insurance companies as a condition of obtaining health insurance coverage. NOTICE: A person may be committing insurance fraud if he or she submits an application containing a false or deceptive statement with the intent to defraud (or knowing that he or she is helping to defraud) an insurance company. F AGREEMENT. The Applicant hereby applies for group insurance. The information in this Application is true and correct to the best of the Applicant's knowledge and belief. It forms the basis for this request for group insurance. Omission or misstatement of known information on this Application could affect the validity of any insurance issued and cause the denial of an otherwise valid claim. The Applicant understands that the requested group insurance will: (a) be issued only if the requested insurance is acceptable to the Company and is legally permissible; (b) be issued under a group Policy or Policies in the language customarily used by the Company; (c) be subject to the Company's usual underwriting requirements (including Evidence of Insurability, if applicable); (d) be subject to all exclusions and limitations of the Policy; and (e) take effect on the date determined by the Company. The Applicant understands that no agent orbroker has the authority to guarantee the acceptability of the requested insurance. The effective date of insurance for which an employee is required to submit satisfactory Evidence of Insurability will be determined in accord with the Policy's terms, and will be subject to the Active Work requirement. The Applicant agrees not to: (a) collect or pay premiums (other than the Binder Premium, if any) for such insurance, before receiving the Company's notice of approval; or (b) distribute material describing Policy coverage to persons to be insured, without the Company's prior written consent. If dental insurance is requested, the Applicant agrees to provide employees and dependents notice of any applicable continuation rights, required by federal COBRA law or any similar state continuation law. Premium rate quotes were based on data submitted to the Company. Final premium rates will be determined by the actual composition of the group. This application and the Binder payment, if any, constitutes the consideration for any Policy issued. After receipt of the Policy, payment of the premium is deemed acceptance of the Policy's terms. If this Application is approved, it will be made a part of any Policy issued. Writing Agent Or Broker's Signature Typed or Printed Name License Number State Signed by Applicant's Authorized Representative: Signature Typed or Printed Name wil Title Risk Manager State Signed CA . Yamaguchi Date 11/17/08 Must be signed prior to Effective Date jL2•APP.09102 CA PART/C/PA T/ON AGREEMENT The Lincoln National Life /nsurance Company (herein called the Company) Complete only if applying for coverage under The Lincoln National Life Insurance Company Voluntary /nsurance Trust. Note: Do not complete in AL. MN or MS. Application is hereby made to become a Participating Employer under The Lincoln National Life Insurance Company's Voluntary Insurance Trust, based on the following statements plus the attached application for group insurance coverage. The Group Employer named below (herein called the Employer) understands that if Voluntary Group Term Life and AD&D or Disability Income insurance is requested and approved, such Employer will become a Participating Employer under The Lincoln National Life Insurance Company Voluntary Insurance Trust, sitused in Kansas City, Missouri. The Employer agrees to the terms of the Trust Agreement, each group policy issued to the Trust under which the Employer's employees become insured, and any amendments to them. The Employer understands that group certificates will be supplied and agrees to distribute them to each employee enrolled in the program. After receipt of the group certificates, payment of premium is deemed acceptance of the policy's terms. The Employer agrees to be responsible for all premiums payable with respect to any of my employees who will be insured under the policy. The Employer agrees to honor and administer on a timely basis the written payroll deduction request of each participant, in the amount required to pay the necessary premium to keep coverage in•force. Payroll deductions will be remitted to the Company on a timely basis, in accord with the billing schedule agreed upon. The Employer agrees to promptly furnish the Company any information reasonably required to administer the coverage and claims under it. The Employer understands that participation in the program may be terminated at any time by giving prior written notice to the Company. The effective date of termination will be the date the notice is received by the Company's Group Insurance Service Office, or on any later date stated in the notice. The Employer understands that the Company may terminate the Employer's participation based on the following circumstances: a) at the end of the grace period during which the required premium has not been paid; b) on any premium due date on which participation in the program falls below a minimum level of 10 employees; c) on any premium due date when the Employer has failed to perform any duties related to the policy in good faith; d) on any premium due date after the premium rate has been in effect for at least 12 months (or any longer Rate Guarantee period agreed upon by the Company). The Employer understands that the Company may change any premium rate: a) when there is a change in the terms of the policy, or in the factors bearing on the risk assumed; b) when the policy liability is changed as a result of a change in federal, state or local law; c) when a division, subsidiary or affiliate is added, removed, or relocated; d) when the number of insured employees has changed by 25% or more since the Rate Guarantee period began; e) on any premium due date after the expiration of the Rate Guarantee period agreed upon by the Company. SIGNATURE I have read and understand the agreement above and will comply with the agreement as stated. I have reviewed, understand and agree to the proposal, rate structure, and enrollment strategy presented to me by the Company representative. 1 understand that no agent, broker or field representative has any right to bind the requested coverage, alter the terms of the policies or enrollment materials, adjust any claim for benefits, or waive any of the Company's rights or requirements. Group Employer Name & ID City of Vernon Willard G. Yamaguchi' Printed Name of Authorized Company Officer Risk Manager Sigdature of Auth ' d Co pang ficer 11/17/08 Title Date PA2007 W' _' Ate Insurance Company on oil - ws APPLICATION FOR GROUP INSURANCE khwdrmadritW11MUNSAYI NA1WINSJAIMC01NPAlW'fib's nwanyi 1. APFUM.Ca Etdl Lapel Nano tataetry a to be aftowa 6 Brarp Po6htk City of Vernon 2. Main Office Adkm (phpsicd location end group situs state): Street 430E Santa Fe AVenua City Vernon state CA rp_!0059 WWneq (313) 503-60 FAXfI (393) B26-1439 E Address I of enaAdda) Tbo fdln*p Broup faatnaaee Is appW for to opedNed In the told ease proposalK Complete cola rot)ueatad Effective Oats for aadr oovangL 191110 & ADO whb Effective hate 1/1/09 ❑ vahmtary Life adth Effective Cote ❑ Lag Tana Dtaadffity with EffecFA Date f Votuntaryth A ARID witb EBaetive Date 1/1/09 ❑)dart Tana with Effective Date ❑ vdontery lane Tenn Doabidty wbh Eflscft DMq. -__,_� ❑ had tatb FJIvA rro 00 ❑ vstantary bald with Effective Doto 1. ffatumeleasinoaa(PleaasapaeN0 ttunicipality Yeah la Budass 103 years Fedard7aa to 95-6000009 L Buataass Is Orpaehad As ltelecf oast: �Copmdm ffotrProltt 01111w mien Pobw Bhwwmmp Qptpw2n!Elpality 3. Flatochl Ri1119 I Ya to any t�� pwM4 Yes No Ra Apoll" ever filed for h�ruptcyt Yes No foes Applteent aatlaipete sealap a malsritUy reducing active business operations? Yes Has App&aat opted out la do tbey antidpate opting out) of Workers' Compentatisn? Explanation: 4. BinderpapreantsuEtrdttad: Amsatt i 804.47 tit appitcowl) 0 fa ❑ e wo al) at pot d fhkt Camp "flood my ditcoverep ? 1f Yea, provide Matto of *o.Pdaf plan bdewand eaten' a cagy of each Inforae eoetnot b he roplacaL Coverope Type Prior Carder Nana Prior Plan ENsativa oeto Twzwtlon am Lite At AD&D mutual of Omaha 12/31/00 voluntary Lite swouaY of Omaha — A ADLD 1.249P.02 02 CA •� :r • :i trig i �r J' :' r � Y';f •�, K1 . e S', • � • . T � _ S!.!•',-' %T•'jd� }!t y{S•• , ofi( : ', .�,••.,• .=r. •.•' ;1. RI +, •f:•' ti i ., �, _I"• )) 4! ii' { i1 t}^ ,r lei,. .ry,rT: `'•• .• � ,' . t,'!p•.,',� T ,:.� �f r Xf 1hi (//y, jy a;. ;:�la'•. s''1:: •'!'• i •a'•t.. '•i ::i ,:3�•:- •' 1 .' li, d , - , ,y./'Ti . S• Y r!. ; i 1 1' . /':'•. 7! • '�' 1• ... . •.i'1 ' s ji. F" �X4iambit ap;i°ieiit,fr�leigikttitd jlf;tiiod tiy,kee�j�tq'ittraasti:gomyeai:t;itiszon�4iiddof agt�inta A6a�ih ' • NOiIL�Es=11 peratio: atay�he eolnnl>rtftngiisuianae'treud It: heror she submits an'appiloOl containing a `ieisa-or decepiWe statement with the intent tp delmud {or knowing teat he orsba,is beipbtp to delreud}aa insurente company. F. •ACREfME#r. 1ho Applicant.hareby.ppplies for praup fnsutetteo. 1ho Inlmntatian In this Application fs-truo and couect to -the but at Iho Applicant's ' ''•aW1pd �� Ij •li;l the t tT•tp9, fob ji4itilturdsice.• ftmJssian or ptbgll8i " I of futotvri infarmsdohbit this flppQaetlan eatiM alfl►et. qa, 1 a �,. ihslralfd!{�y o�t9 to i iue�:t ld. ai dtell ai�i �iii t nytN valid eitbn,' Yho Apb1i, efajendp tlip4 iljs#�i{uesied 9raup:fni�faiieQ + ' iaJ buissu®d oety if the requasted irre,'tca is aaptatila 9b the Company andis Wgatly permissible: lb) be issued under a group Peliey or Policies in the lartguapa csutnmadly usud by Use Cemasny; (cl be sub ct Id ilia Company's usual underwriting suquiraittanls lincluding Evidence of Insurability, it applicable): (? '; s toolludusim, nit rt tallons of the Policy; and. r•� ,�• dllijlit9dhY:tUeCdtt�tahy.• , . � a .::t• 'i: ,t i'' 4dg ` � Sti`l illii • r. �� to . bes'. lh 'tQ ggarantgti the:rtt , tYil. td and�d. niUde�e., ' .041f t o e,u rartc$ pits a' ,o 1. ; jll' tv, Mod,bf Intprabiiil�lw i� raid �;tlt:e�ti crd:i $ Pqq yb (qrp ,. l dbhJeotloi' r �!ItdirC i.?: AppG6aolsoApfip'�tb,<.•,:: :1:' c T ioj�,'�d��ecc��r;"p �'pi'• r., �aitu�•' iliu:6la�.t! =i',t��f',t3ieiiehb�uraaw.•tllilataii�eiv�tgltbaCompeity'��it'etiiti'blbp'piti"�1sor:. • ibi�•r:�atfil,G�las�datcwi�tl d�•'.'feovpta9otio��tt�lititnntred;wiitlpttttha�t�ttppny:'iN:(od It itealtJ Ufe App ygrees'lo pravldi• dygaispa;o[ man q*ad]*'COBRA:taiar a y eb»xdr�slsta.coiitGl<tiAtl6n 14i+i: •Pid<itfum•ieiert�uo((ai vtiFe bated dn:.di%rail nddCardpaa Ri praridian ret 'r ;be t b ,;y�t�e satnd `a''r`i of t 'e1.4� b ! T die %BSI t>lo�8iadeipeymett tl eny, lutes t i on.lar' ty Pa1lay issued. Auer . ?ljctt#, lL, p .I. ►hi! iY' �;1:C ihts A li Ike fs'e r6oeV�,%tr"s'uiitl tie a►cda a perf:of :aay'Pn>Eey i. • ' T iiryS114iT i::j: .:i;.ii.,.,;�;..i•.' , :•y : '� • i.L'• : ,•. . Ji',lt]i 1-� •. : i:': �S' ' w,.' ' I . • p ' . " ,. '• yy�4. �ra=aalW/rY. '. �; t = # ± `' `+'• Signed by A ' t A�AutKdihed� 'Or&�'�d6�jiiitetuiA,�: '•� ,� � .. '.' . K. LED ili`(�jmga�+:it;tl.1.-�"� 4. :8�aio' �• ' Typ.?d.ort'iinladl�apta w1.a • _ i'�::'•i $•':: ;'1 ' "i• . i:; .«.i ,!.: .rl i'i T•�ri: title 1Zi91C ,b1A�ts9�ic'.:� '' : -,• ~' '" SteteStgnal_i' . Dote Ii%17%Ott 1 Must hi igaeit pdor•tb Effitthie.0als ;.j':: i is :'1;�' •,! :: •-;.,�; •,y.. - •,.r,•:;,;�; � :. �.�••�,';l: , � s,r;�.�, :;:::.: .I �•t'�}pI�RTIL'IR.A•7Yi11�f;A1��6�'M�!{i]•',., . :••; . • • � �;, .' '. Ida �Itrcrrla Alatldri�ltl/e 1psuraaae CamFsA��briiln•ga/led tds•Com�$nr1.• . /aea WOW. aeoGr'A/el elUl9iaaraaae.0007wV titayl�sarni►nThat; Nina: Co.nofe8m lole.i"i Ndr.MB: Applicaltao is hereby made In 110Cem0 a Penicipa ft Enrployar undar Thu lincok Notional ltio Insurance Company's Voluntary Insurance Trust, based an the fa1lowGtg statemanl: pha rile atlachad appGcallan tor. group insurance cavaraga. The Gaup EnWayer nanmd•betow (herein called the Employed undarstends ihe�lfp' !troop 7e1 �lte aatfAtlili'pr Olsiibgity �neotitd iMtirtittcais regitbstad'badiprbiladr:audifirloYet•WUI6netimB e:Paitteip0tiiip'Ertiptayu iutder 1Zie Ac61n Neifooel a (niiii CBrtlpatty'Vorututirlj tmiiiranca Ttuil, ad In Kiln'tbs;City,.Mtaaai�: •rAe•swaydi'Igraei'io'•Ihe teriiif pt•iCte 7cast AQreernent, sash group peticy Issued to rho Trust urtdu which the Employer's ampleyou become insured, and any am wmants to diem. The Employer undorstends lhal group cerlilicafa triA Lo sup{died and egrens to dishibula them to each employee amoilad in the pragrant. Alter receipt of Ibe.graup . eorlilieatas, payment of premium is deemed acceptance of trio policy's rani:. agnas td'bi.tiospdnsibCe (ac ap prontlapeyeble tvtth teapeot to lay of mlf tbupldyads tdlto:told ho Mtursd.Iatda dtB:ptt*."f bo ftplat 'pa0:ldmloter on i'ttninttj bask', Coll,pbljidp itedtldtiah ter It o{ lihe andegit;iequired carp Ih�'i# ry ptetrit&t ` ooyiraps'tii�falto. Pegrclt drt'ibtetini �tid i nilie'd'io lA� CdptFan�hBlf A• eta; tit oid itrilli l{ter6y11itd tcheibAe'tigreed µpoii dlia t=mptoyglrti+iq prorggy rnndsh ttre�WamRanf f rirGit¢tr�aiian'igotbtteidyid tb dt;f he cor�fa04,led:etar�indar,Ji: ail 7h0 BfrB .. Y ley ql etslead ,lha4 Putteip tiq!ltn;the p< ¢ran �ieY by l�tn�noted el.Bgy dm* OA►fr►a Pd �v!l 4lan notice•to_:.f G.¢}'APlap Y;: itve ! 81B ol:temQabt(bfl ii(tielhe.tddKtatheaott 'iaeA ,,,; mP 3 P M r p ' tad thB;Aa iedmu tiuur cB8BrvmOlgQco orani Car'da tedtiiihatriithe tliii.fnr�loyer intdauaiids3hat thR CompnAy nteY tdnn�ratte'tho Emplapsr!s pariidtpelion Wad on the laltawirtg'elreumsteaeea: . �' aj •pt 4ha edd dr tl�,grats pBt(adidinlap.wbitil Iheit3gidred plendlotlbpseet,pa�� . • ... �; �• '�mjj pi iirn ate dine on-ti fi Raltttdp6lilhiatha progttRt (ale lidaid e' Wral el 10 all ofift qy : o iy'ptt dui<;ddi4ti-Titptdyt faNtid isii(Brin'eny'dutisi iiid t8 Ifiti'p , a'nooir litllE� j ; Y pr dtte`tldtd il(er i(ro'pieadmniale`lipi•blMi effect (oral- ot-fdoit'1Z'aiaaifis (if e�,y Aat�.Qil ipnne ported=a sad ipaa bythb tin nY1 ?; ibnF. aye tiadpr++�g$�,Zbe��Q mPOOMOM!?�oB'dQV'pt�•m�umnisi,:`: a)', --whin there Iva 460-ln dig temts bl ttiel'pbley, Otto l hotoatfleti{(hp`al tbattsl!eptaned; lil the ►.pa68ity b tdoOd'as tirtt dt'at.a ebeape Cn tedaita;:trite bi (aces law; dlvbtop;'ilrbsfrgary'or4fli6ateEt; et�ad4 tQtno6td�.dt1bc01iEQ;.'' 1"WAM'.Imp i :!re d iiy2644 �riaoid 11aoB ttro fhr�e 6defahteb;( igd begdnr ;: ; ' . e1•.. on y;pratlMm tine oat Rua{aoiea peitgd ajmid by;the coiapatijj: {:: 4v4,jtesiltand anderat id tflB'a roUment B dke;tapd, jiftodt AV.-W1t611i aBrepmontovoketed..lieve rav)evoed;'utidamtepd:an$ pgrea,to;tha peopds>fifttrte.eirueture; apd enn (inalit pt[eteAy:�reeaMad to ni :by lbd;�itidpany ile<itdtantBttep: 1 wtddretdh'd { bt.ho npeat broWK0hold tepresent>ldtiie.itae ady itght to brad Ihe'teouidd dAvilie, ulter'Welairr4 of the Rollotes or anrlllmeat tilaleiisid,.bdJuet any,claim toy rsbtie0ta. :' b'i.v+raJdb•igyofthe Coi>llpany'e tla�itt.�bfto.,qult�atolit� '; • . , ° Qr4dP boyar NAafBlD'City. of � Vernon . :,Hillard fi. Yanlri5u4bi... ' .j: .� Prtitled Narite'or AuthoritadCariiperiyalrtelt • SfB alure of Milt " am ft -Risk mmutger 11/17/0B DolB. i,-17 NPA2007