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NOTICD OF PROTÞCTION PROVIDED BYCALIFORNIA LIFE A¡ID HDALTH INSURANCE GUARA¡ITEE ASSOCIAÎION

This notice provides a brief summary regarding the protections provided to policyholders by theCalifornia Life and Health Insurance Guarantee Association ("the Association").

- f.hé purpo". óf th.

Association is to assure that policyholders will be protected, within certain limits, in the unlikely eventthat a member insurer of the Association becomes financially unable to meet its obligations.Insurance companies licensed in California to sell life insurance, health insurance, annuities andstructured settlement annuities are members of the Association. The protection provided by theAssociation is not unlimited and is not a substitute for consumers' care in selecting insurers. Thisprotection was created under California law, which determines who and what is covered and theamounts of coverage.

Below is a brief summary of the coverages, exclusions and limits provided by the Association. Thissummary does not cover all provisions of the law; nor does it in any way change anyone's rights orobligations or the rights or obligations of the Association.

COVERAGE

Persons Covered

Generally, an individual is covered by the Association if the insurer was a member of theAssociation and t}ee individual lives in California at the time the insurer is determined by a courtto be insolvent. Coverage is also provided to policy beneficiaries, payees or assignees, wñether ornot they live in California.

Amounts of Coverage

The basic coverage protections provided by the Association are as follows.

. Life Insurance. Annuities and Structured Settlement AnnuitiesFor life insurance policies, annuities and structured settlement annuities, the Association willprovide the following:

¡ Life Insurance

8Oo/o of death benefits but not to exceed $SOO,OOO8oo/o of cash surrender or withdrawal values but not to exceed $too,ooo

. Annuities and Structured Settlement Annuities

80o/o of the present value of annuity benefits, including net cash withdrawal and net cashsurrender values but not to exceed $250,O0O

The maximum amount of protection provided by the Association to an individual, for all lifeinsurance, annuities and structured settlement annuities is $3OO,0O0, regardless of thenumber of policies or contracts covering the individual.

¡ Health Insurance

The maximum amount of protection provided by the Association to an individual, as of April l,20 11, is #47o,I25. This amount will increase or decrease based upon changes in the healthcare cost component of the consumer price index to the date on which an insurer becomes aninsolvent insurer.

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d;'

COVERAGE LIMITAÎIONS A!{D EXCLUSIONS FROM COVERAGE

The Association may not provide coverage for this policy. Coverage by the Association generallyrequires residency in California. You should not rely on coverage by the Association in selectingan insurance company or in selecting an insurance policy.

The following policies and persons are arnong those that are excluded from Association coverage:

. A policy or contract issued by an insurer that was not authorized to do business inCalifornia when it issued the policy or contract

. A policy issued by a health care service plan (HMO), a hospital or medical serviceorganization, a charitable organization, a fraternal benefit society, a mandatory statepooling plan, a mutual assessment company, an insurance exchange, or a grants andannuities society

. If the person is provided coverage by the guaranty association of another state

. Unallocated annuity contracts; that is, contracts which are not issued to and owned by anindividual and which do not guarant¡r annuity benefits to an individual

. Ðmployer and association plans, to the extent they are self-funded or uninsured

. A policy or contract providing any health care benefits under Medicare Part C or Part D

¡ An annuity issued by an organization that is only licensed to issue charitable gift annuities

o Ariy policy or portion of a policy which is not guaranteed by the insurer or for which theindividual has assumed the risk, such as certain investment elements of a variable lifeinsurance policy or a variable annuity contract

. Any policy of reinsurance unless an assumption certificate was issued

o Interest rate yields (including implied yields) that exceed limits that are specified inInsurance Code Section 1607.02þX2XC).

NOTICES

Insurance companies or their agents are required by law to give or send you this notice.Policyholders with additional questions should first contact their insurer or agent. To learn moreabout coverages provided by the Association, please visit the Association's website atwww.califega.org, or contact either of the following:

California Department of InsuranceConsumer Communications Bureau30O South Spring StreetLos Angeles CA 90013(8OO) 927-4357

fnsurance companies and agents are not allowed by California law to use the existence ofthe Association or its coverage to solicit, induce or encourage you to purchase any form ofinsurance. lVhen selecting an insurance company, you should not rely on Associationcoverage. If there is any inconsistency between this notice and California law, thenCalifornia law will control.

The California Life and Health InsuranceGuarantee AssociationPO Box 16860Beverly Hills, CA 90209-33f 9(323) 782-Or82

CALIFORNIA NOTICE OF COMPI,AINT PROCEDURE

Should any dispute arise about your premium or about a claim that you have filed, write to thecompany that issued the group policy at:

Standard Insurance CompanyPO Box 711Portland, OR97207(97t132L-7OOO

If the problem ls not resolved, you may also write to the State of California at:

Department of InsuranceConsumer Senrices Division3OO S. Spring Street, l lth F.LLos Angeles, CA 9OO13r-aoo-gz7-HELP (4367)

This notice of complaint procedure is for information only and does not become a part orcondition of this group policy/certificate.

STANDARD INSURANCE COMPAI\IYA Stock Life Insurance Company

900 SW Fifth AvenuePortland, Oregon 97204-1282

(5O3) 321-7OOO

GROUP LIFE INSURATYCE POLICY

Policyholder:

Policy Number:

Effective Date:

County of Santa Clara

752598-A

July l, 2O16

The consideration for this Group Policy is the application of the Policyholder and the payment by thePolicyholder of premiums as provided herein.

Subject to the Policyholder Provisions and the Incontestability Provisions, this Group Policy (a) isissued for the Initial Rate Guarantee Period shown in the Coverage Features, and (b) may be renewedfor successive renewal periods by the payment of the premium set by us on each renewal date. Thelength of each renewal period will be set by us, but will not be less tlran 12 months.

For purposes of effective dates and ending dates under this Group Policy, all days begin and end atl2:OO midnight Standard Time at the Policyholder's address.

this policy includes an Accelerated Benefït. Death benefïts will be reduced if an AcceleratedBenefit is paid. the receipt of this benefìt may be taxable and may affect your eligibility forMedicaid or other government benefits or entitlements. However, if you meet the definition of"terminally ill individual" according to the Internal Revenue Code Section lOl, yourAccelerated Benefït may be non-taxable. You should consult your personal tax and/or legaladvisor before you apply for an Accelerated Benefìt.

All provisions on this and the following pages are part of this Group Policy. "You" and "your" mean theMember. "We", "us", and "our" mean Standard Insurance Company. Other defined terms appear withtheir initial letters capitalized. Section headings, and references to them, appear in boldface type.

STANDARD INSURANCB COMPANY

By

,,') /Cå3

/1 L/J{/ L,tCh¿¡irman. President and CEO

GPI90_LIFE/5399

l\pltrcr:ed as lo Forrn and l.eo ::l:i.i,

Corporate Secrclary

vt'to """-/ -rt -tþ

lable of Contents

COVERAGE FE.{TURÐSGENERAL POLICY INFORMATION ............BECOMING INSURÐDPREMIUM CONTRIBUTIONS.......SCHÐDULE OF INSURANCE.............RÐDUCTIONS IN INSURANCEOTHER BENEFITS.OTHER PROVISIONS...............PREMIUM RATES AND RENEWAI.S

LIFE INSURANCE ............A. Insuring Clause.......B. Amount Of Life Insurance..C. Changes In Life InsuranceD. Repatriation BenefitE. When Life Insurance Becomes Effective.....F. When Life Insurance EndsG. Reinstatement Of Life Insurance..............

ACCIDÐNTAL DEATH AND DISMEMBÐRMENT INSURANCE.A. Insuring Clause.......B. Definition Of Loss For AD&D InsuranceC. Amount PayableD. Changes In AD&D Insurance..E. AD&D Insurance Ðxclusions.F. Additional AD&D Benefits.....G. Becoming Insured For AD&D InsuranceH. \Mhen AD&D Insurance Ends .........

ACÏVE WORK PROVISIONS ...............CONTINUITY OF COVERAGE ...............PORTABILITY OF INSURANCE ............STRIKE CONTINUATION ............WAIVER OF PREMIUM..............ACCELÐRATED BENEFITRIGHT TO CONVERTCIAIMSASSIGNMENT ............BENEFIT PAYMENT AND BÐNEFICIARY PROVISIONS .. . . .. . . . . .TIME LIMITS ON LEGAL ACTIONSINCONTESTABILITY PROVISIONSCLERICAL ERROR AND MISST?\TEMENT........TERMINATION OR AMENDMENT OF THE GROUP POLICY ....DEFrNrTONS...............POLICYHOLDER PROVISIONS.................

.l,lI3.)566799I9I99

Index of Defined Terms

Accelerated Benefit, 17Active Work, Actively At Work, 14AD&D Insurance, 25Air Bag System, 12Annual Earnings, 25Automobile, 12

Berreficiary,22

child,26Class Definition, 2Conversion Period, 18

Disabled, 26Domestic Partner,27

Eligibility Waiting Period, 26Employer(s), 1

Evidence Of Insurability, 26

Grace Period, 7Group Policy, 26Group Policy Effective Date, IGroup Policy Number, I

Initial Rate Guarantee Period, 7Injury,26Insurance (for Accelerated Benefit), 18Insurance (for Right to Convert), 19Insurance (for V/aiver Of Premium), 16

Life Insurance,26Loss, 10

Member, IMinimum Participation, 7Minimum Participation Number, 7Minimum Participation Percentage(s), 7

Noncontributory, 26Notice of Rate Change, 7

Physician, 26Policyholder, IPregnancy, 26Premium Due Dates, 7Premium Rates, 7Prior Plan, 26ProofOfLoss,20

Quali$ring Event, 19Qualifring Medical Condition, 17

Recipient, 23Right To Convert, 18

Seat Belt System, 11Sickness, 27Spouse,27

Totally Disabled, L6, 27

Waiting Period (for Waiver Of Premium),16

Waiver Of Premium, 16War, I I

You, Your (for RightTo Convert), 19

CO\rERAGE FEAÎURES

This section contains many of the features of your group life insurance. Other provisions, includingexclusions and limitations, appear in other sections. Please refer to the text of each section for fuùdetails. The Table of Contents and the Index of Defined Terms help locate sections and definitions.

GENERAL POLICY INFORMATION

752598-AGroup Policy Number:

lrpe of Insurance Provided:Life Insurance:

Accidental Death And Dismemberment(AD&D) Insurance:

Policyholder:

Employer(s):

Group Policy Effective Date

Policy Issued in:

Yes

Yes

County of Santa Clara

County of Santa ClaraFairgrounds ManagementFirst 5 - Santa Clara CountyMidpeninsula Regional Open Space DistrictSanta Clara Valley Open Space AuthorityWest Valley Sanitation District

July l, 2016

California

BECOMING INSURED

To become insured for Life Insurance you must: (a) Be a Member; (b) Complete your Eligibility WaitingPeriod; and (c) Meet the requirements in Life Insurance and Active Work Provisions. The ActivéWork requirement does not apply to Members who are retired on the Group Policy Effective Date. Therequirements for becoming insured for coverages other than Life Insurance are set out in the text.

Definition of Member: You are a Member if you are:

1. An active employee of the Employer who:

a. is regularly working at least 4O hours each bi-weekly pay period; and

b. meets the requirements of one of the classdefinitions below; or

2. An executive management employee or dentist whoretired under the Employer's retirement program on orafterJuly f,2006.

You are not a Member if you are:

1. An extra help employee or a temporary or seasonalemployee.

2. A leased employee.

3. An independent contractor.

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4. A full time member of the armed forces of any country

Class Definition

Class l: Active Physicians as defined by the current Memorandumof Agreement between the County of Santa Clara andValley Physicians Group [VPG). Class I Members qualiffunder this class as well as under Class 1.

Active Executive Managers, Employees represented byUAPD and Dentists as defined by l) current ordinancerelating to the compensation of persons in leadershippositions of the County of Santa Clara unrepresented byrecognized employee organizations, 2) currentMemorandum of Agreement between the County of SantaClara and VPG, 3) current Memorandum of Agreementbetween the County of Santa Clara and Union of AmericanPhysicians and Dentists (UAPD).

Active employees represented by County EmployeesManagement Association (CEMA) and employeesdesignated as Confidential Administrative Employees.

All active non-management employees and employeesrepresented by the Committee of Interns and Residents(CIR)

Retired Ðxecutive Management Ðmployees or Dentists (asdescribed in Class 2)

Class 2:

Except for Class 1, a Member may not qualiff under more than one class definition.

Eligibility Waiting Period: You are eligible on the later of (A) the Group PolicyEffective Date, and (B) the first day following the first payperiod for which the Ðmployer makes a premiumcontribution for your insurance.

When Life Insurance Becomes Effective:

Subject to the Active \üork Provisions, your Life Insurance becomes effective on the date youbecome eligible.

When Changes In Life Insurance Become Effective:

Subject to the Active Work Provisions, a change in your Life Insurance becomes effective asfollows:

An increase in your Life Insurance becomes effective on the first day of the first day of the payperiod following the date of change in your classification.

A decrease in your Life Insurance because of a change in your classification or age becomeseffective on the first day of the pay period following the date of the change.

A decrease in your Life Insurance because of a change in your year of retirement becomeseffective on the anniversary of your retirement.

Class 3

Class 4:

Class 5

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Life Insurance:

AD&D Insurance

PREMIUM CONTRIBUTIONS

Noncontributory

Noncontributory

SCHEDULE OF LIFÐ INSURANCE

For you:

Life Insurance Benefit:

SCHEDULE OF INSURANCE

Class 1: determined by the percentage worked at ValleyMedical Center (VMC), as follows:

Working l00o/o of the time at VMC $3OO,000

Working 95olo but less than lOoo/o of the time at VMC$285,O00

WorkCng 9O% but less than 95o/o of the time at VMC#270,OOO

Working 85olo but less than gOo/o of the time at VMC$255,000

Working 80o/o but less than B5o/o of the time at VMC$240,O00

Working 75o/o bwt less than 8Oo/o of the time at VMC$225,O00

\A/orking 7oo/o bwt less than Z5o/o of the time at VMC$21O,0OO

Working 650lo but less than ZOo/o of the time at VMC$r95,ooo

Working 6oolo but less than 650/o of the time at VMC$rBo,ooo

Working 55% but less than 600/o of the time at VMC$t65,ooo

Working 5Oolo but less than 55o/o of the time at VMC$l50,ooo

Class 2: $200,000

Class 3: $50,000

Class 4: $25,000

Class 5: determined by year of retirement, as follows:lst year $2O0,OOO

2nd year $1SO,OOO3rd year $IGO,OOO4th year $t4o,O0o5th year $\2O,OOO6th year $IOO,OOOTthyear $8O,0OO

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8th year9th yearlOth year1 lth year

$6o,ooo$4o,ooo$20,000

$o

Repatriation Benefit

SCHEDULÐ OF AD&D INSURANCÐ

For you:

AD&D Insurance Benefit:

Seat Belt Benefit:

The expenses incurred to transport your body to amortuary near your primary place of residence, but not toexceed $5,0O0 or lOo/o of the Life Insurance Benefit,whichever is less.

Air Bag Benefit:

Classes I and 2:

The amount of your AD&D Insurance Benefit is equalto the amount of your Life Insurance Benefit.

The amount payable for certain Losses is less than10oo/o of the AD&D Insurance Benefit. See AD&DTable OfLosses.

Classes 3, 4, and 5: None

$25,ooo

$r2,5oo

If an AD&D Insurance Benefit is payable for Loss of your life as a result of an Automobile accidentand we cannot determine whether:

1. you were wearing and properly utilizing a Seat Belt System at the time of the accident; or

2. you were seated in a seating position intended to be protected by the Air Bag System or ifthe Air Bag System deployed;

we will increase the AD&D Insurance benefit by $1,OOO.

career Adjustmen Benerit: trålå'åäiffi.ffiïåå"il:ï:'.:t"ii""îïåiLiïå,:$i::?board and room, books, fees, supplies and other expenses,but not to exceed $5,OO0 per year, or the cumulative totalof $fO,00O or 25o/o of the AD&D Insurance Benefit,whichever is less.

Child Care Benefit: The total child care expense incurred by your Spousewithin 36 months after the date of your death for allChildren under age 13, but not to exceed $5,000 per year,

ff"*L""îi:'å:'ff ;iå:lJi:,::: or 250/o of the AD&D

Higher Education Benefit: The tuition expenses incurred per Child within 4 yearsafter the date of your death at an accredited institution ofhigher education, exclusive of board and room, books,fees, supplies and other expenses, but not to exceed$5,000 per year, or the cumulative total of $ZO,OOO or25o/o of the AD&D Insurance Benefit, whichever is less.

Occupational Assault Benefit: The lesser of (1) $25,0O0; or (2) 5Oo/o of the amount of theAD&D Insurance Benefit otherwise payable for the Loss.

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Public Transportation Benefit: The lesser of (l) $2OO,OOO; or (2) LOOo/o of the amount ofthe AD&D Insurance Benefit otherwise payable for theLoss of your life.

AD&D TABLE OF LOSSES

The amount payable is a percentage of the AD&D Insurance Benefit in effect on the date of theaccident and is determined by the Loss suffered as shown in the following table:

Loss: Percentage payable:

a. Life LOOo/o

b. One hand or one foot 5Oo/o

c. Sight in one eye, speech, orhearing in both ears

d. TWo or more of the t osses listedin b. and c. above

Thumb and index finger of thesame hand

e

5Oo/o

lOOo/o

25o/o *

looo/o**

5oo/o *+

7E;o/o **

f. Quadriplegia

g. Hemiplegia

h. Paraplegia

i. Coma Lo/o per month of the remainder of the AD&DInsurance Benefit payable for Loss of life afterreduction by any AD&D Insurance Benefit paid forany other Loss as a result of the same accident.PaSrments for coma will not exceed a maximum of 12months.

No more than looo/o of your AD&D Insurance will be paid for all Losses resulting from oneaccident.* No AD&D Insurance Benefit will be paid for Loss of thumb and index finger of the samehand if an AD&D Insurance Benefit is payable for the Loss of that entire hand.r* No AD&D rnsurance Benefit will be paid for loss of a hand or foot if an AD&D InsuranceBenefÏt is payable for Quadriplegia, Hemiptegia, or Paraplegia involving that same hand orfoot.

REDUCTIONS IN INSURANCE

Class 1: If you reach an age sho',m below, the amount of insurance will be the amount determinedfrom the schedule of Insurance, multiplied by the appropriate percentage below:

Life Insurance:Age Of Member70 or over

AD&D Insurance:Age Of Member70 through 79

Percentage5Oo/o

Percentage5Oo/o

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8O or over 25o/o

All other Classes: Your insurance will not be reduced because of your age unless your insurance issubject to termination under the Waiver of Premium provision.

\Ir/'aiver Of Premium

OTHER BENEFITS

Classes I, 2, 3,4: Yes

Class 5: No

Classes l, 2, 3,4: Yes

Class 5: No

Accelerated Benefit:

Other Continuation Periods:

Strike Continuation:

Insurance Eligible For Portability:

For you:

Life Insurance

Minimum amount:

Maximum amount:

AD&D Insurance

Minimum amount:

Maximum amount:

Annual Earnings based on:

OTHER PROVISIONS

During a scheduled leave of absence approved by yourEmployer in advance and in writing; and

During a temporary layoff.

See Life Insurance for more information.

Yes. The Strike Continuation premium percentage is l2Oo/oof the Premium Rate.

Yes

$to,ooo

$3oo,ooo

Yes

$lo,ooo

$3oo,ooo

Earnings in effect on your last full day of Active Work.

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Premium Rates:

Life Insurance:

AD&D Insurance

Premium Due Dates:

Grace Period:

Notice of Rate Change:

Minimum Participation:

Life Insurance:

Number:

Percentage:

PREMIUM RATES AND RENEWALS

$0.09 monthly per $ t ,OOO of Life Insurance

$O.otz monthly per $l,OOO of AD&D Insurance

July l, 2O16 and the first day of each calendar monththereafter.

60 days

180 days

10 insured Members

IOOo/o of eligible Members

Initial Rate Guarantee Period

Contingent Rate Guarantee

July l, 2O16 to July r, 2Or9

The Contingent Rate Guarantee will apply for one year if, on November I, 2Olg, both the IncurredLoss Ratio and Current Loss Ratio for Life Insurance under the Group policy are gOo/o or less.

The Contingent Rate Guarantee will apply for a second year if, on November l, ZOlg, both theIncurred Loss Ratio and Current Loss Ratio for Life Insurance under the Group policy are g0olo or less.The premium rates during the Contingent Rate Guarantee will equal the premium rates in effect at theend of the Initial Rate Guarantee period.

Calculating Loss Ratios

The Incurred Loss Ratio is the result of the following calculation:

Incurred Loss Ratio = Incurred claims divided by Earned premium

Each element is calculated from the Group policy Effective Date.

The Current Loss Ratio is the result of the following calculation:

current Loss Ratio = Incurred claims divided by Earned premium

With respect to the first year, each element is calculated from the beginning to the end of the12 month period ending on the day before November l, 20lg.With respect to the-second year, each element is calculated from the beginning to the end ofthe L2 month period ending on the day before November l,2olg.

Definitions

Earned Premium = a + b - c, where:

a = Paid premiums.

76/7 /2016 752598-A

= Change in uncollected premium.

= Change in advance premium.

Incurred Claims = a + b + c + d, where:

a = Claims paid, including benefits paid and costs incurred under any provision of the GroupPolicy.

b = Legal fees, expenses, settlements and judgments paid in connection with lawsuits relating toclaims.

if c = Conversion charges for converting to an individual life insurance policy under the Right ToConvert provision (if applicable).

d = Change in claims reserves, including Incurred But Not Reported (IBNR), pending, active andoutstanding claims reserves.

i

b

c

6/7 /2016 -8- 752598-A

LIFE INSURANCE

A. Insuring Clause

If you die while insured for Life Insurance, we will pay benefits according to the terms of the GroupPolicy after we receive Proof Of Loss satisfactory to us.

B. Amount Of Life Insurance

See the Coverage Features for the Life Insurance schedule.

C. Changes In Life Insurance

See the Coverage Features for When Changes In Life Insurance Become Effective.

D. Repatriation Benefit

The amount of the Repatriation Benefit is shown in the Coverage Features.

V/e will pay a Repatriation Benefit if all of the following requirements are met.

l. A Life Insurance Benefit is payable because of your death.

2. You die more than 2OO miles from your primary place of residence.

3. Expenses are incurred to transport your body to a mortuary near your primary place ofresidence.

E. When Life Insurance Becomes Effective

see the coverage Features for when Life Insurance Becomes Effective.

Takeover Provision:

If you were insured under the Prior Plan on the day before the effective date of your Employer'scoverage under the Group Policy, your Eligibility \Maiting Period is waived on the effective dale ofyour Employer's coverage under the Group Policy.

F. When Life Insurance Ends

Life Insurance ends automatically on the earliest of:

1. The date the last period ends for which a premium was paid for your Life Insurance;

2. The date the Group Policy terminates;

3. The last day of the pay period in which your emplo¡rment terminates, unless you are covered asa retired Member; and

4. The last day of the pay period in which you cease to be a Member. However, if you cease to bea Member because you are working less than the required minimum number of hours, yourLife Insurance will be continued \¡/ith premium pa¡rment during the following periods, unless itends under I through 3 above.

a. While your Employer is paylng you at least the same Annual Earnings paid to youimmediately before you ceased to be a Member.

b. While your ability to work is limited because of Sickness, Injury, or Pregnancy.

c. During a leave of absence if continuation of your insurance under the Group policy isrequired by a state-mandated family or medical leave act or law.

d. During the other continuation periods shown in the Coverage Features.

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G. Reinstatement Of Life Insurance

If your Life Insurance ends, you may become insured again as a new Member. However, I through3 below will apply.

1. If your Life Insurance ends because you cease to Lre a Member, and if you become a Memberagain within 9O days, the Eligibility Waiting Period will be waived.

2. If you exercised your Right To Convert, you must provide Evidence Of Insurability to becomeinsured again.

3. If your Life Insurance ends because you are on a federal or state-mandated family or medicalleave of absence, and you become a Member again immediately following the period allowed,your insurance will be reinstated pursuant to the federal or state-mandated family or medicalleave act or law.

(REPAT) Lr.LF.CÀ3

ACCIDENTAL DEAÎH AND DISMEMBDRMENT INSURANCD

A. Insuring Clause

If you have an accident, including accidental exposure to adverse weather conditions, whileinsured for AD&D Insurance, and the accident results in a Loss, we will pay benefits according tothe terms of the Group Policy after we receive Proof Of Loss satisfactory to us.

B. Definition Of Loss For AD&D Insurance

Loss means loss of life, hand, foot, sight, speech, hearing in both ears, thumb and index finger ofthe same hand, coma, and Quadriplegia, Hemiplegia or Paraplegia which meets all of the followingrequirements:

1. Is caused solely and directly by an accident.

2. Occurs independently of all other causes.

3. Occurs within 365 days after the accident.

4. With respect to Loss of life, is evidenced by a certified copy of the death certificate.

5. With respect to all other Losses, is certified by a Physician in the appropriate specialty asdetermined by us.

With respect to Loss of life, death will be presumed if you disappear and the disappearance:

l. Is caused solely and directly by an accident that reasonably could have caused l¡ss of life;

2. Occurs independently of all other causes; and

3. Continues for a period of 365 days after the date of the accident, despite reasonable searchefforts.

With respect to a hand or foot, [,oss means actual and permanent severance from the body at orabove the wrist or ankle joint, whether or not surgically reattached.

With respect to coma, Loss means a profound state of mental unconsciousness with no evidence ofappropriate responses to stimulation, lasting for at least 2l consecutive days.

With respect to sight, Loss means entire, uncorrectable, and irrecoverable loss of sight.

With respect to speech, Loss means entire, uncorrectable, and irrecoverable loss of audible speech.

With respect to hearing, Loss means entire, uncorrectable, and irrecoverable loss of hearing inboth ears.

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With respect to thumb and index finger of the same hand, Loss means actual and permanentseverance from the body at or above the metacarpophalangeal joints.With respect to Quadriplegia, Hemiplegia, and Paraplegia, Loss must be permanent, complete, andirreversible.

Quadriplegia means total paralysis of both upper and lower limbs. Hemiplegia means totalparalysis of the upper and lower limbs on the iame side of the body. paraplegia means totalparaþis of both lower limbs.

C. Amount Payable

See Covera$e Features for the AD&D Insurance schedule. The amount payable is a percentage ofthe AD&D Insurance Benefit in effect on the date of the accident and ii ãetermined by the losssuffered. See AD&D Table Of Losses in the Coverage Features.

D. Changes In AD&D Insurance

Changes in your AD&D Insurance will become effective on the date your Life Insurance changes.E. AD&D Insurance Ðxclusions

No AD&D Insurance benefit is payable if the accident or Loss is caused or contributed to by any ofthe following:

I' War or act of War. War means declared or undeclared war, whether civil or international, andany substantial armed conflict between organized forces of a military nature.

2. Suicide or other intentionally self-inflicted Injury, while sane or insane.

3' Committing or attempting to commit an assault or felony, or actively participating in a violentdisorder or riot.

- Actively participating does not include being at the scene of a vio-Íent disorder

or riot while performing your official duties.

4. The voluntary use or consumption of any poison, chemical compound, or drug, unless used orconsumed according to the directions of a physician.

5. Sickness or Pregnancy existing at the time of the accident.

6. Heart attack or stroke.

7. Roarding, leaving, or being in or on any kind of aircraft. However, this exclusion will not applyif the person who suffers the Loss is a fare paylng passenger on a commercial aircraft.

8. Medical or surgical treatment for any of the above.

F. Additional AD&D Benefits

Seat Belt Benefit

The amount of the Seat Belt Benefit is shown in the Coverage Features.We will pay a Seat Belt Benefit if all of the following requirements are met:1. You die as a result of an Automobile accident for which an AD&D Insurance Benefit is

payable for Loss ofyour Life; and

2. You are wearing and properly utilizing a Seat Belt System at the time of the accident, asevidenced by a police accident report.

Seat Belt Sys.tem means a properly installed combination lap and shoulder restraint systemthat meets the Federal Vehicle Safety Standards of the Ñational Highway Traffic SafetyAdministration. Seat Belt System will include a lap belt alone, but only if th. Rrto*obile didnot have a combination lap and shoulder restraint system when mânufactured. Seat BeltSystem does not include a shoulder restraint alone.

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Automobile means a motor vehicle licensed for use on public highways.

Air Bag Benefit

The amount of the Air Bag Benefit is shown in the Coverage Features.

We will pay an Air Bag Benefit if all of the following requirements are met:

l You die as a result of an Automobile accident for which a Seat Belt Benefit is payable forLoss of your life.

2. The Automobile is equipped with an Air Bag System that was installed as originalequipment by the Automobile manufacturer and has received regular maintenance orscheduled replacement as recommended by the Automobile or Air Bag manufacturer.

3. You are seated in the driver's or a passenger's seating position intended to be protected bythe Air Bag System and the Air Bag System deploys, as evidenced by a police accidentreport.

Air Bag System means an automatically inflatable passive restraint system that is designed toprovide automatic crash protection in front or side impact Automobile accidents and meets theFederal Vehicle Safety Standards of the National Highway Traffic Safety Administration.

Automobile means a motor vehicle licensed for use on public highways.

Career Adjustment Benefit

The amount of the Career Adjustment Benefit is shown in the Coverage Features.

We will pay a Career Adjustment Benefit to your Spouse if all of the following requirements aremet:

l. You are insured for AD&D Insurance under the Group Policy.

2. You die as a result of an accident for which an AD&D Insurance Benefit is payable for Lossof your life.

3. Your Spouse is, within 36 months after the date of your death, registered and in attendanceat an accredited institution of higher education or trades training program for the purposeof obtaining employment or increasing earnings.

No Career Adjustment Benefit will be paid if you have no surviving Spouse.

Child Care Benefit

The amount of the Child Care Benefit is shown in the Coverage Features.

We will pay a Child Care Benefit to your Spouse if all of the following requirements are met:

1. You are insured for AD&D Insurance under the Group Policy.

2. You die as a result of an accident for which an AD&D Insurance Benefit is payable for Lossof your life.

3. Your Spouse pays a licensed child care provider who is not a member of your family forchild care provided to your Child(ren) under age 13 within 36 months of your death.

4. The child care is necessary in order for your Spouse to work or to obtain training for workor to increase earnings.

No Child Care Benefit will be paid if you have no surviving Spouse.

Higher Education Benefit

The amount of the Higher Education Benefit is shown in the Coverage Features.

We will pay a Higher Education Benefit to your Child if all of the following requirements are

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met:

You are insured for AD&D Insurance under the Group policy.

You die as a result of an accident for which an AD&D Insurance Benefit is payable for Lossof your life.

Your Child is, within 12 months after the date of your death, registered and in full-timeattendance at an accredited institution of higher education beyond iigh school.

The Higher Education Benefit will be paid to each Child who meets the requirements of item 3above, for a maximum of 4 consecutive years beginning on the date of your death. No HigherÐducation Benefit will be paid if there is no Child ètigintã to receive it.

Occupational Assault Benefit

The amount of the Occupational Assault Benefit is shown in the Coverage Features.We will pay an Occupational Assault Benefit if all of the following requirements are met:1. While Actively At Work you suffer a Loss for which an AD&D Insurance Benefit is payable.2. The Loss is the result of an act of physical violence against you that is punishable by law

and is evidenced by a police report.

Public Transportation Benefit

The amount of the Public Transportation Benefit is shown in the Coverage Features.We will pay a Public Transportation Benefit if all of the following requirements are met:I ' You die as a result of an accident for which an AD&D Insurance Benefit is payable for Loss

of your life.

2. The accident occurs while you are riding as a fare-paying passenger on publicTransportation.

Public Transportation means a public passenger conveyance operated by a licensed commoncarrier for the transportation of- the gen-eral public for a fâre and óperating on regularpassenger routes with a definite schedule of departures and arrivals.

G. Becoming Insured For AD&D Insurance

l. Eligibility

You become eligible for AD&D Insurance on the date your Life Insurance is effective.2. Effective Date

Subject to the Active Work Provisions, AD&D Insurance becomes effective on the date youbecome eligible.

H. When AD&D Insurance Ends

AD&D Insurance ends automatically on the earlier of:

l. The date your Life Insurance ends.

2. The date your Waiver Of premium begins.

3. The date AD&D Insurance terminates under the Group policy.

4. The date the last period ends for which a premium was paid for your AD&D Insurance.(FB NO DDP REgD-FULL XP BDN PKG-.A¡RCRFT EXCI:SEAT AIR COMBO) LI,AD.OÎ.5

I

2

J

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ACTTVE WORK PROVISIONS

If you are incapable of Active Work because of Sickness, Injury or Pregnancy on the day before thescheduled effective date of your insurance or an increase in your insurance, your insurance orincrease will not become effective until the day after you complete one full day of Active Work as aneligible Member.

Active Work and Actively At Work mean performing the material duties of your own occupation at yourEmployer's usual place of business. You will also meet the Active Work requirement if:

J. You were absent from Active \Mork because of a regularly scheduled day off, holiday, or vacationday;

2. You were Actively At Work on your last scheduled work day before the date of your absence; and

3. You were capable of Active Work on the day before the scheduled effective date of your insuranceor increase in your insurance.

LI,AW'OT.I

CONTINUITY OF COVERAGE

A. Waiver Of Active Work Requirement

If you were insured under the Prior Plan on the day before the effective date of your Employer'scoverage under the Group Policy, you can become insured on the effective date of your Ðmployer'scoverage without meeting the Active Work requirement. See Active Work Provisions.

B. Payrnent Of Benefit

The benefits payable before you meet the Active Work requirement will be:

1. The benefìts which would have been payable under the terms of the Prior Plan if it had remainedin force; reduced by

2. Any benefits payable under the Prior Plan.

LI.CC.OI

PORÎABILIÎY OF INSURANCE

A. Portability Of Insurance

If your insurance under the Group Policy ends because your employment with your Ðmployerterminates, you may be eligible to buy portable group insurance coverage as shown in theCoverage Features for yourself without submitting Evidence Of Insurability. To be eligible youmust satisflr the following requirements:

i. On the date your employment terminates, you must be able to perform with reasonablecontinuity the material duties of at least one gainful occupation for which you arereasonably fitted by education, training and experience.

(If you are unable to meet this requirement, see the Right To Convert and Waiver OfPremium provisions for other options that may be available to you under the Group Policy.)

2. On the date your employment terminates, you are under age 65.

3. On the date your employment terminates, you must have been continuously insured underthe Group Policy for at least t2 consecutive months. In computing the 12 consecutivemonth period, we will include time insured under the Prior Plan.

4. You must apply in wfiting and pay the first premium directly to us at our Home Officewithin 60 days after the date your employment terminates. You must purchase portable

6/7 /2016 -t4- 752598-A

group life insurance coverage for yourself in order to purchase any other insurance eligiblefor portability.

This portable group insurance will be provided under a master Group Life portability InsurancePolicy we have issued to the Standard Insurance Company Group Inùrance Trust. if approved,the certificate you will receive will be governed under the terms of the Group Life pôrìabilityInsurance Policy and will contain provisions that differ from your Employer's coverage under theGroup Policy.

B. Amount Of Portable Insurance

The minimum and maximum amounts that you are eligible to buy under the Group Life portabilityInsurance Policy are shown in the Coverage Featurõs. You may buy less than the maximumamounts in increments of $1,0O0.

The combined amounts of insurance purchased under this Portability of Insurance provisionand the Right To Convert provision cannot exceed the amount in effect under the Group Þolicy onthe day trefore your employment terminates.

C. When Portable Insurance Becomes Effective

Portable group insurance will become effective the day after your emplo¡rment with your Employerterminates, if you apply within 6O days after the date your employment têrminates.If death occurs within 60 days after the date insurance ends under the Group policy, life insurancebenefits, if any, will be paid according to the terms of the Group policy in Ëffect oï tn. date youremployment terminates and not the tenls of the Group Life portability Insurance policy. eóAobenefits, if any, will be paid according to the terms of thè Gro-up Policy or the Group Life ÉortabilityInsurance Policy, but not both. In no event will the benefitã paid exceed the ámount in effeciunder the Group Policy on the day before your emplo¡rment terminates.

(WTTH ADAD REF) LI.TP.OT.I

STRIKE CONTINUATION

Insurance may be continued for up to 6 months while you are absent from Active Work because of astrike, lockout or other general work stoppage caused by a labor dispute. Rules I through 4 below willapply.

l. when your compensation is suspended or terminated because of a work stoppage, your Employerwill immediately notifr you in writing of your rights under this provision. your Èmptoy.. will mailthe notice to you at your last address on record with the Employer.2' You must pay the entire premium for your insurance, including the Ðmployer's share, if any, toyour Employer on or before each premium Due Date.

3' The premiums for your insurance during the work stoppage will equal a percentage of thepremium rate in effect on the date the work stoppage began lsee coveiage Features). \Me maychange premium rates during the work stoppage åócoiainglo the terms of tlhe Group policy.

4. Insurance continued under this provision will end on the earliest of:

a' Any Premium Due Date if you fail to make the required premium contribution to yourEmployer on or before that date.

b. The date you have been absent from Active \Mork for 6 months.

c. on the date you begin full-time emplo¡rment with another employer.

d. At our option, on any Premium Due Date if less tlrran 75o/o of the Members eligitrle to continueinsurance under this provision make the required premium payment to the Omployer.

LLSK.OI.r

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WATVER OF PREMIUM

A. \Ã/'aiver Of Premium Benefit

Insurance will be continued without payment of premiums while you are Totally Disabled ill. You become Totally Disabled while insured under the Group Policy and under age 6O;

2. You complete your Waiting Period; and

3. You give us satisfactory Proof Of Loss.

\Me may have you examined at our expense at reasonable intervals. Any such examination will beconducted by specialists of our choice.

B. Definitions For Waiver Of Premium

l. lnsurance means all your insurance under the Group Policy, except AD&D Insurance.

2. Totally Disabled means that, as a result of Sickness, accidental Injury, or Pregnancy, you areunable to perform with reasonable continuity the material duties of any gainful occupation forwhich you are reasonably fitted by education, training and experience.

3. V/aiting Period means the 180 consecutive day period beginning on the date you becomeTotally Disabled. Waiver Of Premium begins when you complete the Waiting Period.

C. Premium Payment

Premium payment must continue until the later of:

I. The date you complete your Waiting Period; and

2. The date we approve your claim for Waiver Of Premium.

D. Refund Of Premiums

We will refund up to 12 months of the premiums that were paid for Insurance after the date youbecome Totally Disabled.

E. Amount Of Insurance

The amount of Insurance eligible for Waiver Of Premium is the amount in effect on the day beforeyou become Totally Disabled. However, the following will apply:

1. Insurance will be reduced or terminated according to the Group Policy provisions in effect onthe day before you become Totally Disabled.

2. If you become insured under a group life insurance plan that replaces the Group Policy whileyou are eligible for Waiver Of Premium, any death benefit payable under the Group Policy willbe reduced by the amount payable under the replacement group life insurance plan.

3. If you receive an Accelerated Benefit, Insurance will be reduced according to the AcceleratedBenefìt provision.

F. Effect Of Death During The V/aiting Period

If you die during the Waiting Period and are otherwise eligible for Waiver Of Premium, the WaitingPeriod will be waived.

G. Termination Or Amendment Of The Group Policy

Insurance will not be affected by termination or amendment of the Group Policy after you becomeTotally Disabled.

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H. When Waiver Of Premium Ðnds

Waiver Of Premium ends on the earliest of:

I. The date you cease to be Totally Disabled;

2. 90 days after the date we mail you a request for additional Proof Of Loss, if it is not given;3. The date you fail to attend an examination or cooperate with the examiner;4' \Mith respect to the amount of Insurance which an insured has converted, the effective date of

the individual life insurance policy issued to the insured; and

5. The date you reach age ZO.

LI.WP.OT.2

ACCELER.ATED BENEFIT

A. Accelerated Benefit

If you give us satisfactory proof of having a QualiSring Medical Condition while you are insuredunder the Group Policy, you may have the right to reðeive during your lifetime a portion of yourInsurance as an Accelerated Benefit. You must have at least $lO,ooO of Insurance in effect t-o beeligible.

If your Insurance is scheduled to end within 24 months following the date you apply for theAccelerated Benefit, you will not be eligible for the Accelerated Benefii.

Qualiflring Medical Condition means you are_terminally ill as a result of an illness or physicalcondition which is reasonably expected to result in death within 12 months.

Y. T"y have you examined at our expense in connection with your claim for an AcceleratedBenefit. Any such examination will be conducted by one or more Physicians of our choice.

B. Application For Accelerated Benefit

You must apply for an Accelerated Benefit. To apply you must give us satisfactory proof Of Losson our forms. Proof Of Loss must include a statemènt from a phlisician that you hãve a eualiSringMedical Condition.

C. Amount Of Accelerated Benefit

You may receive an Accelerated Benefit ,of up to 75o/o of your Insurance. The maximumAccelerated Benefit is $50O,O00. The minimum Accelerated Benefit is $5,000 or IOo/o of yourInsurance, whichever is greater.

If the amount of your Insurance is scheduled to reduce within 24 months following the date youapply for the Accelerated Benefit, your Accelerated Benefit will be based on the reduced amount.The Accelerated Benefit will be paid to you once in your lifetime in a lump sum. If you recoverfrom yo-ur Qualifying Medical Condition after receiving an Accelerated geneiit, we will iot ask youfor a refund.

D. Effect On Insurance And Other Benefits

For any purpose other than premium payment, the amount of your Insurance after pa¡rment of theAccelerated Benefit-will be the greater of the amounts in (l) añd (2) below; howevei, iryor assignyour rights under the Group Policy, the amount of your Insurance will be the amount in lZ¡ Ueto,,ri.

(1) 10olo of the amount of your Insurance as if no Accelerated Benefit had been paid; or

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(2) The amount of your Insurance as if no Accelerated Benefit had been paid; minus

The amount of the Accelerated Benefit; minus

An interest charge calculated as follows:

A times B times C divided by 365 = interest charge.

A = The amount of the Accelerated Benefit.

B = The monthly average of our variable policy loan interest rate.

C = The number of days from payment of the Accelerated Benefit to the earlier of (I) the dateyou die, and (2) the date you have a Right To Convert.

The amount of your AD&D Insurance, if any, is not affected by payment of the Accelerated Benefit.AD&D is not continued under Waiver Of Premium.

Note: If you assign your rights under the Group Policy, the amount of your Insurance afterpayment of the Accelerated Benefit will be the amount in (2) above.

Ð. Exclusions

No Accelerated Benefit will be paid if:

l All or part of your Insurance must be paid to your Child(ren), or your Spouse or former Spouseas part of a court approved divorce decree, separate maintenance agreement, or propertysettlement agreement.

2. You are married and live in a community property state unless you give us a signed writtenconsent from your Spouse.

3. You have made an assignment of all or part of your Insurance unless you give us a signedwritten consent from the assignee.

4. You have filed for bankruptcy, unless you give us written approval from the Bankruptcy Courtfor pa¡rment of the Accelerated Benefit.

5. You are required by a government agency to use the Accelerated Benefit to apply for, receive, orcontinue a government benefit or entitlement.

6. You have previously received an Accelerated Benefìt under the Group Policy.

F. Definitions For Accelerated Benefit

Insurance means your Life Insurance Benefit under the Group Policy.

LI.AB.OT.5

RIGHT TO COIVIrERT

A. Right To Convert

You may buy an individual policy of life insurance without Evidence Of Insurability if:

l. Your Insurance ends or is reduced due to a Qualifring Event; and

2. You apply in writing and pay us the first premium during the Conversion Period.

The maximum amount you have a Right To Convert is the amount of your Insurance which ended.

B. Definitions For Right To Convert

1. Conversion Period means the 6O-day period after the date of any Quali$ring Event.

2. Insurance means all your insurance under the Group Policy, including insurance continuedunder Waiver Of Premium, but excluding AD&D Insurance.

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3. Qualifying Event means termination or reduction of your Insurance for any reason except:a. The Member's failure to make a required premium contribution.b. Payment of an Accelerated Benefit.

4. You and your mean any person insured under the Group policy.

C. Limits On Right To Convert

If your Insurance ends or is reduced because of termination or amendment of the Group policy,the maximum amount you have a Right To Convert is the amount of your Insurance which ended,minus any other group life insurance for which you become eligible dúring the Conversion period.

D. The Individual Policy

You may select any form of individual life insurance policy we issue to persons of your age, except:1. A term insurance policy;

2. A universal life policy;

3. A policy with disability, accidental death, or other additional benefïts; or4. A policy in an amount less than the minimum amount we issue for the form of life insurance

you select.

The individual policy of life insurance will become effective on the day after the end of theConversion Period. We will use our published rates for standard risks to determine the premium.

Ð. Death During The Conversion period

If yoy die during the Conversion Period, we will pay a death benefit equal to the maximum amountyou had a Right To Convert, whether or not you applied for an individual policy. The benefit willbe paid according to the Benefït payment ena nenéficiary provisions.

LI.RC.CA.l

CLAIMS

A. FilingA Claim

Claims should be filed on our forms. If we do not provide our forms within 15 days after they arerequested, the claim may be submitted in a letter to us.

B. Time Limits On Filing Proof Of Loss

Proof Of Loss must be provided within 90 days after the date of the loss. If that is not possible, itmust be provided as soon as reasonably possible, but not later than one year after that 90-jayperiod.

Proof of Loss for Waiver of Premium must be provided within 12 months after the end of theWaiting Period. \üe will require further Proof Of Loss at reasonable intervals, but not more oftenthan once a year after you have been continuously Totally Disabled for two years.

If Proof of Loss is filed outside these time limits, the claim will be denied.apply while the Member or Beneficiary lacks legal capacity.

These limits will not

With respect to coma, we will require Proof Of Loss of the comatose condition at reasonableintervals' If proof is not given within 90 days, benefits payable for coma will end.

C. Proof Of Loss

Proof Of Loss means written proof that a loss occurred:

l. For which the Group policy provides benefits;

6/7 /2016 -19- 752598-A

2. Which is not subject to any exclusions; and

3. Which meets all other conditions for benefits.

Proof Of Loss includes any other information we may reasonably require in support of a claim.Proof Of Loss must be in writing and must be provided at the expense of the claimant. No benefitswill be provided until we receive Proof Of Loss satisfactory to us.

D. Investigation Of Claim

We may have you examined at our expense at reasonable intervals. Any such examination will beconducted by specialists of our choice.

We may have an autopsy performed at our expense, except where prohibited by law.

E. Time Of Payment

We will pay benefits within 60 days after Proof Of Loss is satisfied.

F. Notice Of Decision On Claim

We will evaluate a claim for benefits promptly after we receive it. With respect to all claims exceptWaiver Of Premium claims (or other benefits based on disability), within 90 days after we receivethe claim we will send the claimant: (a) a written decision on the claim; or (b) a notice that we areextending the period to decide the claim for an additional 90 days.

With respect to Waiver Of Premium claims (or other benefits based on disability), within 45 daysafter we receive the claim we will send the claimant: (a) a written decision on the claim; or (Lr) anotice that we are extending the period to decide the claim for 30 days. Before the end of thisextension period we will send the claimant: (a) a written decision on the Waiver Of Premium claim(or other benefits based on disability); or (b) a notice that we are extending the period to decide theclaim for an additional 30 days. If an extension is due to the claimant's failure to provideinformation necessary to decide the Waiver Of Premium claim (or other benefits based ondisability), the extended time period for deciding the claim will not begin until the claimantprovides the information or otherwise responds.

If we extend the period to decide the claim, we will notiff the claimant of the following: (a) thereasons for the extension; (b) when we expect to decide the claim; (c) an explanation of thestandards on which entitlement to benefits is based; (d) the unresolved issues preventing adecision; and (e) any additional information we need to resolve those issues.

If we request additional information, the claimant will have 45 days to provide the information. Ifthe claimant does not provide the requested information within 45 days, we may decide the claimbased on the information we have received.

If we deny any part of the claim, we w'ill send the claimant a written notice of denial containing:

l. The reasons for our decision.

2. Reference to the parts of the Group Policy on which our decision is based.

3. A description of any additional information needed to support the claim.

4. Information concerning the claimant's right to a review of our decision.

G. Review Procedure

If all or part of a claim is denied, the claimant may request a review. The claimant must request areview in writing:

l. \Mithin lSOdaysafterreceivingnoticeof thedenialof aclaimfor'W'aiverOf Premium(orotherbenefits based on disability);

2. V/ithin 60 days after receiving notice of the denial of any other claim.

6/7 /2016 -20- 75259A-A

The claimant may send us written comments or other items to support the claim. The claimantmay review and receive copies of any non-privileged information thal is relevant to the request forreview. There will be no charge for such copies. Our review will include any written comments orother items the claimant submits to support the claim.

\Me will review the claim promptly after we receive the request. With respect to all claims exceptWaiver Of Premium claims (or other benefits based on disäbility), within^OO a.y" after we receiiethe request for review we will send the claimant: (a) a written decision on review; or (b) a noticethat we are etending the review period for 60 days.

With respect to Waiver Of Premium claims (or other benefits based on disability), within 45 daysafter we receive the request for review we will send the claimant: (a) a written decision on review; är(b) a notice that we are extending the review period for 45 days.

If an extension is due to the claimant's failure to provide information riecessary to decide the claimon review, the extended time period for review of the claim will not begin until the claimantprovides the information or otherwise responds.

If we extend the review period, we will notiff the claimant of the following: (a) the reasons for theextension; (b) when we expect to decide the claim on review; and (c) .try.ãditional information weneed to decide the claim.

If we request additional information, the claimant will have 45 days to provide the information. Ifthe claimant does not provide the requested information within +S 0"y", we may conclude ourreview of the claim based on the information we have received.

With respect to Waiver Of Premium claims (or other benefits based on disability), the personconducting the review will be someone other than the person who denied the claim ánd willïot Lresubordinate to th-at person. The person conducting thè review will not give deference to the initialdenial decision. If the denial was based on a mediõal judgment, the peison conducting the reviewwill consult with a qualified health care professional. This health care professional will be someoneother than the person who made the original medical judgment and wilt not be subordinate to thatperson. The claimant may request the names of medical õr vocational experts who provided adviceto us about a claim for Waiver Of Premium (or other benefits based on disability). ^

If we deny any part of the claim on review, the claimant will receive a wdtten notice of denialcontaining:

1. The reasons for our decision.

2. Reference to the parts of the Group Policy on which our decision is based.

3. Information concerning the claimant's right to receive, free of charge, copies of non-privilegeddocuments and records relevant to the claim.

(2ND REV pUB q¡RDG_r\rEW WOp V¡RDG) LI.CL.OT.5

ASSIGNMDNT

The rights and benefits under the Group policy cannot be assigned.

LI.AS.OT.I

BENDFIT PAYMENT AND BENEFICIARY PROVISIONS

A. Pa¡rment Of Benefits

I. Except as provided in item 4 below, benefits payable because of your death or coma will bepaid to the Beneficiary you name. Benefits for coma will cease aiter the comatose conditionhas ceased, whether by death, recovery, or any other change in condition. See B through Ð ofthis section.

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2. AD&D Insurance benefits payable for Losses other than Loss of Life or coma will be paid to theperson who suffers the Loss for which benefits are payable. Any such Lrenefits remainingunpaid at that person's death will be paid according to the provisions for payment of a deathbenefit.

3. Accelerated Benefits will be paid to you if you are living.

4. Additional Benefits will be paid as follows:

The Child Care Benefit will be paid to your surviving Spouse. No Child Care Benefit will be paidifyou have no Spouse.

The Career Adjustment Benefit will be paid to your Spouse, No Career Adjustment Benefit willLre paid if you have no Spouse.

The Higher Education Benefit will be paid to each eligible Child. No Higher Education Benefitwill be paid if there is no Child eligible to receive it.

The Repatriation Benefit will be paid to the person who incurs the transportation expenses.

B. Naming A Beneficiar¡r

Beneficiary means a person you narne to receive death benefits. You may narne one or moreBeneficiaries.

If you name two or more Beneficiaries in a class:

J. TWo or more surviving Beneficiaries will share equally, unless you provide for unequal shares.

2. If you provide for unequal shares in a class, and two or more Beneficiaries in that classsurvive, we will pay each surviving Beneficiary his or her designated share. Unless you provideotherwise, we will then pay the share(s) otherwise due to any deceased Beneficiary(ies) to thesurviving Beneficiaries pro rata based on the relationship that the designated percentage orfractional share of each surviving Beneficiar5r bears to the total shares of all survivingBeneficiaries.

3. If only one Beneficiary in a class survives, we will pay the total death benefits to thatBeneficiary.

You may name or change Beneficiaries at any time without the consent of a Beneficiary.

Your Beneficiary designation must be the same for Life Insurance and AD&D Insurance deathbenefits.

You may name or change Beneficiaries in writing. Writing includes a form signed by you; or averification from us, or our designated agent, the Policyholder, the Policyholder's designated agent,the Ðmployer, or the Employer's designated agent of an electronic or telephonic designation madeby you.

Your designation:

1. Must be dated;

2. Must be delivered to us, our designated agent, the Policyholder, the Policyholder's designatedagent, the Employer, or the Employer's designated agent; during your lifetime.

3. Must relate to the insurance provided under the Group Policy; and

4. Will take effect on the date it is delivered or, if a telephonic or electronic designation, verified byus, our designated agent, the Policyholder, the Policyholder's designated agent, the Employer,or the Employer's designated agent.

If we approve it, a designation, which meets the requirements of a Prior Plan, will be accepted asyour Beneficiary designation under the Group Policy.

6/7 /2016 -22- 752598-A

C. Simultaneous Death Provision

If a Beneficiary or a person in one of the classes listed in item D. No Surviving Beneficiary dies onthe same day you die, or within l5 days thereafter, benefits will be paid as iÍ tn.t eeneiiciary árperson had died before you, unless Proof of Loss with respect to ¡rour death is delivered tó usbefore the date of the Beneficiary's death.

D. No Surviving Beneficiary

If you do not narne a Beneficiary, or if you are not survived by one, benefits wilt be paid in equalshares to the first surviving class of the classes below.

l. Your Spouse. (See Definitions)

2. Your children.

3. Your parents.

4. Your brothers and sisters.

5. Your estate.

Ð. Methods Of Payment

Recipient means a person who is entitled to benefits under this Benefït payment and BeneficiarSrProvisions section.

1. Lump Sum

If the amount payable to a Recipient is less than $25,OO0, we will pay it in a lump sum.2. Standard Secure Access CheckingAccount

If the amount payable to a Recipient is $25,000, or more, we will deposit it into a StandardSecure Access checking account which:

a. Bears interest at a rate equal to the l3-week Treasury Bill (T-Bill) auction rate, but not toexceed 5olo;

b. Is owned by the Recipient;

c' Is subject to the terms and conditions of a confirmation certificate which will be given to theRecipient; and

d. Is fully guaranteed by us.

3. Installments

Pa¡rment to a Recipient may be made in installments if:

a. The amount payable is $25,O0O or more;

b. The Recipient chooses; and

c. We agree.

To the extent permitted by law, the amount payable to the Recipient will not be subject to any legalprocess or to the claims of any creditor or creditor's representative.(NO FB-RÐPA1-ELECT/TEL DESIG-WITH DEF SP-WrrH REV SSA_SPOUSD DEF TERM_IHrRD pARI.y DESrc) Lr.BB.OT.6

6/7 /2Ot6 qo752598-A

ÎIME LIMITS ON LEGAL ACTIONS

No action at law or in equity may be brought until 6O days after we have been given Proof Of Loss. Nosuch action may be brought more than three years after the earlier of:

]. The date we receive Proof Of Loss; and

2. The time within which Proof Of Loss is required to be given.

LI,IL.OT.I

INCONTESÎABILITY PROVISIONS

A. Incontestability Of Insurance

Any statement made to obtain or to increase insurance is a representation and not a warranty.

No misrepresentation will be used to reduce or deny a claim unless:

1. The insurance would not have been approved if we had known the truth; and

2. We have given you or any other person claiming benefits a copy of the signed writteninstrument which contains the misrepresentation.

We will not use a misrepresentation to reduce or deny a claim after the insured's insurance hasbeen in effect for two years during the lifetime of the insured.

B. Incontestability Of Group Poliry

Any statement made by the Policyholder or Employer to obtain the Group Policy is a representationand not a warranty.

No misrepresentation by the Policyholder or Employer will be used to deny a claim or to deny thevalidity of the Group Policy unless:

l. The Group Policy would not have been issued if we had known the truth; and

2. V/e have given the Policyholder or Employer a copy of a written instrument signed by thePolicyholder or Employer which contains the misrepresentation.

The validity of the Group Policy will not be contested after it has been in force for two years, exceptfor nonpayment of premiums.

LI.IN.OT.2

CLERICAL ERROR AND MISSÎATEMENÎ

A. Clerical Ðrror

Clerical error by the Policyholder, your Employer, or their respective employees or representativeswill not:

1. Cause a person to become insured;

2. Invalidate insurance under the Group Policy otherwise validly in force; or

3. Continue insurance under the Group Policy otherwise validly terminated.

B. The Policyholder and your Employer act on their own behalf as your agent, and not as our agent.

C. Misstatement Of Age

If a person's age has been misstated, we will make an equitable adjustment of premiums, benefits,or both. The adjustment will be based on:

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i. The amount of insurance based on the correct age; and

2' The difference between the premiums paid and the premiums which would have been paid ifthe age had been correctly stated.

LI.CE.OT.2

ÎERMINATION OR AIVIENDMENT OF lHE GROUP POLICY

The Group Policy may be terminated by us or the Policyholder according to its terms. It will terminateautomatically for nonpayrnent of premium. The Policyholder may terminate the Group policy in whole,and may terminate insurance for any class or group of Members, at any time by giving us writtennotice.

Benefits under the Group Policy are limited to its terms, including any valid amendment. No changeor amendment will be valid unless it is approved in writing by one of our executive officers and given Tothe Policyholder for attachment to the Group Policy. If the terms of the Certificate differ fñm theGroup Policy, the terms stated in the Group Policy will govern. The Policyholder, your Employer, andtheir respective employees or representatives have no right or authority to change ó. am.nd the GroupPolicy or to waive any of its terms or provisions without our signed written apprõval.

We may change the Group Policy in whole or in part when any change or clarification in law orgoverïrmental regulation affects our obligations under the Group Policy, or with the policyholder'sconsent.

Any such change or amendment of the Group Policy may apply to current or future Members or to anyseparate classes or groups thereof.

LI.TAOT.l

DEFINITIONS

AD&D Insurance means accidental death and dismemberment insurance, if any, under the GroupPolicy.

Annual Earnings means your annual rate of earnings from your Ðmployer. Your Annual Earnings willbe based on your earnings in effect on your last full day of Active Work unless a different date Sphes(see the Coverage Features). Annual Ðarnings includes:

l. Contributions you make through a salary reduction agreement with your Ðmployer to:

a' An Internal Revenue Code (IRC) Section 401(k), 4O3(b), 40S(k), or 45T deferredcompensation arrangement; or

b. An execr.rtive nonqualified deferred compensation arrangement.

2. Amounts contributed to your fringe benefits according to a salary reduction agreement underan IRC Section 125 plan.

Annual Earnings does not include:

l Bonuses.

2. Commissions.

3. Overtime pay.

4. Shift differential pay.

5. Stock options or stock bonuses.

6. Your Employer's contributions on your behalf to any deferred compensation arrangement orpension plan.

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7. Any other extra compensation.

Child means:

l. Your child from live birth through age 20 (through age 24 if a registered student in full timeattendance at an accredited educational institution); or

2. Your child who meets either of the following requirements:

a. The child is insured under the Group Policy and, on and after the date on which insurancewould otherwise end because of the Child's age, is continuously Disabled.

b. The child was insured under the Prior Plan on the day before the effective date of yourEmployer's coverage under the Group Policy and was Disabled on that day, and iscontinuously Disabled thereafter.

Child includes any of the following, if they otherwise meet the definition of Child:

i. Your adopted child; or

ii. Your stepchild and the child of your Spouse, if living in your home.

Your child is Disabled if your child is:

1. Continuously incapable of self-sustaining employment because of mental retardation orphysical handicap; and

2. Chiefly dependent upon you for support and maintenance, or institutionalized because ofmental retardation or physical handicap.

Eligibility Waiting Period means the period you must be a Member before you become eligible forinsurance. See Coverage Features.

Evidence Of Insurability means an applicant must:

l. Complete and sign our medical history statement;

2. Sign our form authorizing us to obtain information about the applicant's health;

3. Undergo a physical examination, if required by us, which may include blood testing; and

4. Provide any additional information about the applicant's insurability that we may reasonablyrequire.

Group Policy means the group life insurance policy issued by us to the Policyholder and identified bythe Group Policy Number.

Injury means an injury to your body.

Life Insurance means life insurance under the Group Policy.

Noncontributory means the Policyholder or Employer pays the entire premium for insurance.

Physician means a licensed M.D. or D.O., acting \Mithin the scope of the license. Physician does notinclude you or your Spouse, or the brother, sister, parent or child of either you or your Spouse.

Pregnancy means your pregnancy, childbirth, or related medical conditions, including complications ofpregnancy.

Prior Plan means your Employer's group life insurance plan in effect on the day before the effectivedate of your Employer's coverage under the Group Policy and which is replaced by the Group Policy.

Sickness means your sickness, illness, or disease.

Spouse means:

l. A person to whom you are legally married; or

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2. Your Domestic PartnerCalifornia state law.

Your Domestic Partner means an individual recognized as such under

For purposes of insurance under the Group Policy, Spouse does not include a person who is a full-time member of the armed forces of any country or a person from whom you are divorced or fromwhom you have terminated a Domestic Partner relationship.

Totally Disabled means that, as a result of Sickness, accidental Injury, or Pregnancy, you are unableto perform with reasonable continuity the material duties of any gainful occupation for which you arereasonably fitted by education, training and experience.

(BASD-NO STOCK_DOM STAT) rJ.DF.CA,5

POLICYHOLDER PROVISIONS

A. Premiums

The premium due on each Premium Due Date is the sum of the premiums for all persons theninsured. Premium Rates are shown in the Coverage Features.

B. Contributions From Members

The Policyholder determines the amount, if any, of each Member's contribution toward the cost ofinsurance under the Group Policy.

C. Changes In Premium Rates

We may change Premium Rates when:

1. A change or clarification in law or governmental regulation affects the amount payable underthe Group Policy. Any such change in Premium Rates will reflect only the change in ourobligations; or

2. Factors material to underwriting the risk we assumed under the Group Policy, including, butnot limited to, number of persons insured, age, Annual Earnings, gender and occupalionalclassification, change by 25o/o or more; or

3. We and the Policyholder mutually agree to change Premium Rates.

Except as provided above, Premium Rates will not be changed during the Initial Rate GuaranteePeriod shown in the Coverage Features. Thereafter, except as provided above, we may changePremium Rates upon advance written notice to the Policyholder. The minimum advance notice ìsshown in the Coverage Features as Notice of Rate Change. Any such change in Premium Ratesmay be made effective on any Premium Due Date, but no such change will be made more thanonce in any contract year. Contract years are successive 12 month periods computed from the endof the Initial Rate Guarantee Period.

D. Payment Of Premiums

All premiums are due on the Premium Due Dates shown in the Coverage Features.

Each premium is payable on or before its Premium Due Date directly to us at our home office. Thepayment of each premium as it becomes due will maintain the Group Policy in force until the nextPremium Due Date.

E. Grace Period And Termination For Nonpayment

If a premium is not paid on or before its Premium Due Date, it may be paid during the followingGrace Period. The length of the Grace Period is shown in the Coverage Features. The GroupPolicy will remain in force during the Grace Period.

If the premium is not paid during the Grace Period, the Group Policy will terminate automaticallyat the end of the Grace Period.

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The Policyholder is liable for premium for insurance under the Group Policy during the GracePeriod. We may charge interest at the legal rate for any premium which is not paid during theGrace Period, beginning with the first day after the Grace Period.

F. Termination For Other Reasons

The Policyholder may terminate the Group Policy by giving us written notice. The effective date oftermination will be the later of:

1. The date stated in the notice; and

2. The date we receive the notice.

V/e may terminate the Group Policy as follows:

1. On any Premium Due Date if the number of persons insured is less than the MinimumParticipation shown in the Coverage Features.

2. On any Premium Due Date if we determine that the Policyholder has failed to promptly furnishany necessary information requested by us, or has failed to perform any other obligationsrelating to the Group Policy.

The minimum advance notice of such termination by us is 60 days.

G. Premium Adjustments

Premium adjustments involving a return of unearned premiums to the Policyholder will be limitedto the 12 months just before the date we receive a request for premium adjustment.

H. Certificates

We will issue certificates to the Policyholder showing the coverage under the Group Policy. ThePolicyholder will distribute a certificate to each insured Member. If the terms of the Certificatediffer from the Group Policy, the terms stated in the Group Policy will govern.

I. Records And Reports

The Policyholder or Employer will furnish on our forms all information reasonably necessary toadminister the Group Policy. We have the right at all reasonable times to inspect the payroll andother records of the Policyholder or Employer which relate to insurance under the Group Policy.

J. Agency And Release

Individuals selected by the Policyholder or by any Ðmployer to secure coverage under the GroupPolicy or to perform their administrative function under it, represent and act on behalf of theperson selecting them, and do not represent or act on behalf of Standard Insurance Company. ThePolicyholder, Employer and such individuals have no authority to alter, expand or extend ourliability or to waive, modif,i or compromise any defense or right we may have under the GroupPolicy. The Policyholder and each Employer hereby release, hold harmless and indemni[zStandard Insurance Company from any liability arising from or related to any negligence, error,omission, misrepresentation or dishonesty of any of them or their representatives, agents oremployees.

K. Notice Of Suit

The Policyholder or Employer shall promptly give us written notice of any lawsuit or other legalproceedings arising under the Group Policy.

L. Entire Contract, Changes

The Group Policy and the application of the Policyholder constitute the entire contract between theparties. A copy of the Policyholder's application is attached to the Group Policy when issued.

The Group Policy may be changed in whole or in part. No change in the Group Policy will be validunless it is approved in writing by one of our executive officers and given to the Policyholder for

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attachment to the Group Policyany of its provisions.

No agent has authority to change the Group policy or to waive

M. Effect On \Ã/orkers' Compensation, State Disability Insurance

The coverage provided under the Group Policy is not a substitute for coverage under a workers,compensation or state disabilit¡r income benefit law and does not relieve the Employer of anyobligation to provide such coverage.

(NO DIV) Lr,PH.OT.4

ALI99

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