Item C14
Revised 3/99
BOARD OF COUNTY COMMISSIONERS
AGENDA ITEM SUMMARY
Meeting Date: May 17. 2000
Division: Manaqement Services
Bulk Item: Yes [3J No 0
Department: Human Resources/
Group Insurance Office
AGENDA ITEM WORDING: Approval of the Hartford Life Insurance Policy Rider for FY
1999/2000 and the Group Life and Accidental Death & Dismemberment booklet-
certificate for our plan.
ITEM BACKGROUND: This is our first term with the Hartford Life Insurance Company.
PREVIOUS RELEVANT BOCC ACTION: soce approved proqram on September 8,
1999.
STAFF RECOMMENDATION: Approval.
TOTAL COST: Approx. $146,000
BUDGETED: Yes [3J No 0
COST TO COUNTY: $146,000
REVENUE PRODUCING: Yes 0 No [3J
AMOUNT PER MONTH N/A
YEAR N/A
APPROVED BY: COUNTY ATTY D OMS/PURCHASING D RISK MANAGEMENT D
DIVISION DIRECTOR APPROVAC'I'~~ -=z?~
DIVISION DIRECTOR NAME: James L. Roberts
DOCUMENTATION: INCLUDED: [gJ TO FOLLOW: D NOT REQUIRED: D
DISPOSITION: AGENDA ITEM #: ~
RIDER
This rider is attached to and made a part of Group Policy No. GVL-016007 issued by the HARTFORD LIFE AND
ACCIDENT INSURANCE COMPANY to the POLICYHOLDER,
TRUSTEE OF THE PUBLIC EMPLOYERS INDUSTRY GROUP VOLUNTARY LIFE AND DISABILITY
INSURANCE TRUST
It is understood and agreed that the policy is amended to include the following:
Participant:
-I
MONROE COUNTY BOARD OF COUNTY COMMISSIONERS
Account Number:
303613
Participation Requirements:
The Participant shall meet and maintain the following minimum participation requirements, in order to become a
Participant and remain a Participant under the policy:
I. 20 or more eligible employees;
2, 100 % minimum employee participation on a non-contributory basis; and
3. 75% minimum employee participation on a contributory basis.
The initial monthly premium rates are as follows:
Basic Life Insurance
Accidental Death, Dismemberment
And Loss of Sight Benefit
$ .39 for each $1,000 of Basic Life Insurance
$ .02 for each $1,000 of Principal Sum
RATE GUARANTEE PERIOD:
Basic Life Insurance
Basic Accidental Death, Dismemberment and Loss of Sight Benefit
Until October 1,2001
Until October I, 2001
PREMIUM DUE DATES:
Monthly on the first of each month.
Subject to the Rate Guarantee period shown above, Hartford Life has the right to change premium rates on any premium
due date if:
I. written notice is delivered to the Participant's last address on record; and
2. the change is effective at least 31 days after the date of notice.
The rate guarantee described above (the "Rate Guarantee") supersedes only those provisions appearing elsewhere in this
policy which give Hartford Life the right to change the premium rates, and then, only for the period of time stated for the
Rate Guarantee. However, Hartford Life may change the premium rates during the Rate Guarantee period if there is a
change in the policy, or if there is a 10% increase or decrease in the number ofInsured Persons, or if the Policyholder
adds or deletes a subsidiary or affiliated business entity, Hartford Life may also change the premium rates during the
Guarantee Period if there has been a material misstatement in the reported experience during the pre-sale process. The
Rate Guarantee in no way affects, amends or supersedes any other provision in this policy.
G race Period
Hartford Life will allow the Participant a 45 day grace period for the payment of all premiums after the first. During this
45 day period, the policy will stay in force. If the owed premium is not paid by the 45th day, participation in the policy
will automatically terminate. Premium is due for each day the policy is in force under the terms of this Grace Period. If
the Participant gives Hartford Life written advance notice of an earlier cancellation date, termination will occur on the
earlier date, Premium is due for each day the policy is in force for each Participant.
Calculation
Premiums may be calculated by multiplying the rate times the applicable numbers of units of coverage.
GR-11711(A) Rev. 7-'97
If any insurance is added, increased or becomes effective after a Participant's inclusion in the policy, premium charges
will begin on:
I. the day the coverage is effective, if it is also the first day of a month; or if not
2. the first day of the next month,
For insurance which is terminated, premium charges will stop as of the first day of the next month. Premiums may be
calculated by any other method which both Hartford Life and the Participant agree to in writing.
Experience Rating
Any credit amount due the Participant because of experience rating will be allowed him on the Participant Anniversary
Date and, at the Participant's request, will be: -I
I. paid to him in cash; or
2, used to reduce his premiums; or
3. used to provide additional insurance for covered persons.
Any credit amount shall be determined by the rating plan or plans used by Hartford Life.
Termination Date for Participants
Coverage for a Participant will terminate on the first to occur of:
I. if applicable to such Participant's insurance coverage(s), the day following the Grace Period if a premium is due but
unpaid;
2. the date a premium is due but unpaid;
3. the date such Participant withdraws from the Trust by giving written notice to Hartford Life;
4. the date such Participant elects to terminate coverage, by giving'written notice to Hartford Life;
5. the date such Participant fails to maintain the applicable participation requirements; or
6. the date Hartford Life terminates the policy in its entirety or with respect to any Participant in accordance with the
provisions of the policy.
Hartford Life may also terminate the Participant's coverage on any premium due date after such coverage has been in
force for 12 months by giving the Participant 31 days written notice.
Policy Termination
Hartford Life may terminate the policy on any premium due date after the policy has been in force for 12 months by
giving the Policyholder 31 days written notice.
Incorporation Provision
The Booklet-certificate(s) attached to this Rider and which is (are) listed below, is (are) hereby incorporated in and made
a part of the policy. The terms found in the Book1et-certificate(s) will control the benefit amounts and provisions; rules
of eligibility for individual employees and dependents; termination of insurance rules; exclusions; and other general
policy provisions pertaining to ERISA, claims and state insurance law requirements.
The following Booklet-certificate(s) is (are) attached to this Rider:
303613(GYL) I
Nothing herein contained shall be held to vary, waive, alter, or extend any of the terms, conditions or provisions of the
policy, other than as herein stated.
GR-11711(A) Rev. 7-'97
This Rider is signed by the HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY to take effect as of
October 1, 1999.
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY
Lynda Godkin, Secretary
.~p
~~
Lowndes A. Smith, President
Countersigned by
Registrar
GR-11711(A) Rev. 7-'97
RIDER
THIS RIDER IS A REPLACEMENT IN ITS ENTIRETY TO RIDER GR-11711(A) Rev., REVISED MARCH 30,
2000 EFFECTIVE OCTOBER I, 1999.
This rider is attached to and made a part of Group Policy No. GVL-016007 issued by the HARTFORD LIFE AND
ACCIDENT INSURANCE COMPANY to the POLICYHOLDER,
TRUSTEE OF THE PUBLIC El\IPLOYERS INDUSTRY GROUP VOLUNTARY LIFE AND DISABILITY
INSURANCE TRUST
It is understood and agreed that the policy is amended to include the following:
Participant:
MONROE COUNTY BOARD OF COUNTY COMMISSIONERS
Account Number:
303613
Participation Requirements:
The Participant shall meet and maintain the following minimum participation requirements, in order to become a
Participant and remain a Participant under the policy:
I. 20 or more eligible employees;
2. 100 % minimum employee participation on a non-contributory basis; and
3. 75% minimum employee participation on a contributory basis.
The initial monthly premium rates are as follows:
Basic Life Insurance
Accidental Death. Dismemberment
And Loss of Sight Benefit
S .39 for each S I ,000 of Basic Life Insurance
S .02 for each $1,000 of Principal Sum
RATE GUARAl'ITEE PERIOD:
Basic Life Insurance
Basic Accidental Death. Dismemberment and Loss of Sight Benefit
Until October 1, 200 I
Until October 1,200 I
PREMIUM DUE DATES:
Monthly on the first of each month.
Subject to the Rate Guarantee period shown above, Hartford Life has the right to change premium rates on any premium
due date if:
I. written notice is delivered to the Participant's last address on record; and
2. the change is effective at least 31 days after the date of notice.
The rate guarantee described above (the "Rate Guarantee") supersedes only those provisions appearing elsewhere in this
policy which give Hartford Life the right to change the premium rates, and then, only for the period of time stated for the
Rate Guarantee. However, Hartford Life may change the premium rates during the Rate Guarantee period if there is a
change in the policy, or if there is a 10% increase or decrease in the number of Insured Persons, or if the Policyholder
adds or deletes a subsidiary or affiliated business entity. Hartford Life may also change the premium rates during the
Guarantee Period if there has been a material misstatement in the reported experience during the pre-sale process. The
Rate Guarantee in no way affects, amends or supersedes any other provision in this policy.
Grace Period
Hartford Life will allow the Participant a 45 day grace period for the payment of all premiums after the first. During this
45 day period, the policy will stay in force. If the owed premium is not paid by the 45th day, participation in the policy
will automatically terminate. Premium is due for each day the policy is in force under the terms of this Grace Period. If
the Participant gives Hartford Life written advance notice of an earlier cancellation date, termination will occur on the
earlier date. Premium is due for each day the policy is in force for each Participant.
GR-11711(A) Rev. 7-'97
Calculation
Premiums may be calculated by multiplying the rate times the applicable numbers of units of coverage.
If any insurance is added, increased or becomes effective after a Participant's inclusion in the policy, premium charges
will begin on:
I. the day the coverage is effective, if it is also the first day of a month; or if not
2. the first day of the next month.
For insurance which is terminated, premium charges will stop as of the first day of the next month. Premiums may be
calculated by any other method which both Hartford Life and the Participant agree to in writing.
Experience Rating
Any credit amount due the Participant because of experience rating will be allowed him on the Participant Anniversary
Date and, at the Participant's request, will be:
I. paid to him in cash; or
2. used to reduce his premiums; or
3. used to provide additional insurance for covered persons.
Any credit amount shall be determined by the rating plan or plans used by Hartford Life.
Termination Date for Participants
Coverage for a Participant will terminate on the first to occur of:
1. if applicable to such Participant's insurance coverage(s), the day following the Grace Period if a premium is due but
unpaid;
2. the date a premium is due but unpaid;
3. the date such Participant withdraws from the Trust by giving written notice to Hartford Life;
4. the date such Participant elects to terminate coverage, by giving written notice to Hartford Life;
5. the date such P3I1icipant fails to maintain the applicable participation requirements; or
6. the date Hartford Life terminates the policy in its entirety or with respect to any Participant in accordance with the
provisions of the policy.
Hartford Life may also terminate the Participant's coverage on any premium due date after such coverage has been in
force for 12 months by giving the Participant 31 days written notice.
Policy Termination
Hartford Life may terminate the policy on any premium due date after the policy has been in force for 12 months by
giving the Policyholder 31 days written notice.
Incorporation Provision
The Booklet-certificate(s) attached to this Rider and which is (are) listed below, is (are) hereby incorporated in and made
a part of the policy. The terms found in the Booklet-certificate(s) will control the benefit amounts and provisions; rules
of eligibility for individual employees and dependents; termination of insurance rules; exclusions; and other general
policy provisions pertaining to ERISA, claims and state insurance law requirements.
The following Booklet-certificate(s) is (are) attached to this Rider:
303613(GVL)IRev
Nothing herein contained shall be held to vary, waive, alter, or extend any of the terms, conditions or provisions of the
policy, other than as herein stated.
GR-11711(A) Rev. 7-'97
This Rider is signed by the HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY to take effect as of
October I, 1999.
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY
~~
##
Lynda Godkin, Secreta/!I
Lowndes A. Smith, P"esilif~lit
Countersigned by
10 ~ dfJo.M
Diane Zipoli, Registrar
GR-11711(A) Rev. 7-'97
Name of Policyholder: TRUSTEB OF THE PUBLIC EMPLOYERS GROUP VOLu~ARY LIPE
AND DISABILITY INSURANCE TRUST
Policy Numbers:
GVL-016007
Effective Date:
1-1-94
Place of Delivery:
Rhode Island
RAltTl'ORt> LIFE INSURANCE COMPANY
Hartford Plaza, Hartford, Connecticut 06115
(A stock insurance companYt he~ein called The Hartford)
Agrees vith the Policyholder to insure certain persons vho are entitled to the
3.nsurance provided by this policy.
This policy is issued in consideration of the application of the Policyholder,
and of the payment by the Pa.rticipant Employers of premium as provided herein.
A Participant Employer's first premium is du~ and payable on '-he effective date
of such employer'S inclusion under the Plan, Subject to the policy's gr.ace
period provision) all premiums aft~r tbe first must be paid vhen or b~fore they
are due.
Signed for The Hartford:
~~
L).Ma Go<<Idrt. ~
_.._-#~ "---.
t.own~. A SIn\lUI. Prr.wtkAl
Countersigned
by'............................,....... "'.... "'...... "'......
Registrar
Table of Contents
Agreemen t to IJJsure ................................................ 1
Defini tion ..................................... _ . . . . . . . . . . . . . . . . . .. 2
ParHcipant Employers .... - . . . .. . . . .. . .. . .. .. . . ...... ... . .. . . .. . . _ .. 3
Incorporation Provision..... -...................................... 5
Premi ums ............. - . . . . . . - - . . - . - . . - - . . . . . . . . . . . . . . . . . . . . . . . . . . .. 6
Policy PrQvisi ons ...................... _ . . . . . . _ . . . . . . . . . . . . . . . . . . .. 8
GR-1l710(Ol)A
1
DEFINITIO~S
Trustee means Shawmut Bank locate<! in Rhode Island.
TnJ~t Agreemeflt means the trust agreement between Hartford Life Life and Accident Insurance Company
and Shawmut_Bank for the purpose of implementing group illSUTa1TOe cov~age for the beoefit of employees
of employers and sole proprietOrs partjci~tin~ in the Trust.
TruSt means the trust creeted under the terms of the Trust Agreement.
2
GR- J 171 O(06)A Rev. 7-'97
P ARTlCIPAf'lTS
In GeneTS'
An entity may be iocluded as It Participant if the Policyholder and Hartford J,ife so agtee. Hanford Life
willl<up a list of <1Ct:cpt.ed Pnrticipants and rhe effective dates of coverage for e.aclt.
The Policyholder may 3..Ct for Or On behalf of all ParticipantlO in all matters of the policy. TIle (ollowing will
be binding on all Participants:
(I) all agreements between Hanford life and r]le Policyholder;
(2) nl! notiees from Hanford Life to t'Je Policyholder; and
(3) ~t1 notices [Tom the Policyhord.er to Hartford Life.
An employee of a. Participant will be deemed to be an employee of the Policyholder for insurance purposes.
A Particip;mt's prcroium is due and payable on the etrtctive d~~ of his inclusion under the policy. Subject
to the Grace Period, if applicable to slJch Participnnt's insurance coverage(s), all Panicipant premium afT.er
the first must be paid wlleJl Or before they are dlJe,
for the purpose of this insurance. the term Participant shall mean:
(1) an employer who:
(a) has the required number ofempJoye>es in his employ; and
(b) elec-..s to participate JIJ Md maJ<es required premium c.on!l'ibutlons, on behalfofhis
employees, to the Group Voluntary Life and. Disal>iIil:y llJsuraoce Trost; or
(2) a sole pl'Ol7Tier.or who elects to participate in and m!:kes req'Jired premium cootribtltions to the
Group Voluntary Life and Disability Insurance Trust.
In order to become 2 Participanr, ao entilY mlJst:
(1) make necesso.ry applicalion (Qr membership ill Lhe Finance, llUiurallce and Real Esute
lndu~ Group Voluntary Ufe and Disability Insur.oncc TT'lJSf.;
(2) b~ accepted by Hanford Life for such membership; and
(3) satisfy the 3pplicablC! Employee Participation RequjrCTDents.
Employee PartielpatiorJ Requirements
Each emplo)'eT sha/J meet and maintain Tile minimum cmplo)"ee and dependent pamcipatiolJ requiwneots,
if applicable, in order '0 become a Fa:rticipSJ'lt ~nd remain a Ponticipallt under the policy. TIle participation
requirements are shown on Rider Farm GR.-l 171 I (A) Rev_ 7.'97.
Effective Date for l'Dl"tidp:mt$
The effective cbtc of inclusion of a Participant. under the policy is show:] oZl1he Rider applicQble to such
Participant.
3
GR-1171 O(06)A Rev. 7-'97
P ARTfCI.P ANTS
(continued)
Tc:rmination Date for hrticipllllts
Coverage fOr a Participimt will tcrminllte On the first f.o Occur of:
(1) . if applicable to such Participant's inS1Jrance CQve."3ge(s), the; day following tOe Grace Period if
a premium is due bur unpajd;
(2) the date a premium is due but unpaid;
(3) the dare such Participant withdraws from fhe mse by givjng writf.en notice to HWOtd Life;
(4) the dote sucb Partic:ii'-"111t elects to terminate Coverage, by gi"'ing wr.il,en Dorice 1:0 Hartford
Life;
(5) the dat.e such Participant fails to maintain the ~ppliCAbJe participation require:ne01S; or
(6) the dare Hartford Life terminates the policy in its entirety err wj~ respect to any Participant in.
accordance with the provisions of the policy.
4,
G&-1I710(06)^ Rev. 7-'97
INCOlU'ORATION PROVlSlON
Roolde~Cerijfj~l1tc
The Booklet-cmjficate(s), and tbe endorsement fom(s) listed on Rider Form GR-II i J I (A) Rev. 7.'97 are
hereby incorporated in, and made a pm of, this policy.
The terms found in the Bool<let-cer.ti(jcate(s) will control:
(I) I.he coverage provisions;
(2) the eli.gibilit}' and effective date of in:.urar!ce rules;
(3) the termination of insurance rules;
(4) exclutions; and
(:l) oilier gener~ policy provisions pertaining to state and feder3J insurance requircmeT1ts.
Schedule of In5l1r:lnc:c
"rne schedules of insurMce applicable to eaeh Participant are shown in the Booklet-cerrificates. Ench
schedule of insurance will control the benefit amounts,
m<n:imuTTl limits and any other amounts and limits which apply.
Monthly Premium Rates
ll1C monthly premium rares to be charged ll.l'ld provision:; appJic3.o!e '.0 premiums arc sJ,own O':l rJle atnched
Rider Form GR-1171 I (A) Rev. 7-'97, :!pplicable to eacb P3rticipant.
Premium Pftyments
Premium paym.enl"$:
(I) are due and payable in full to a pJa.c:e designated by Hartford Life; or
(2) witb respect to rJle initial premium payment, premium payment.5 may be made to an
authorized agent of Hartford Life.
Pa)'TTJeIlt of prerniQms for a paiod before it is due will not gllal"3J1.t.ee the insurance for rlun period.
s.
GR-l J 7JO(06)A Rev. 7-'97
POLICY PROVISIONS
Entire Contrut
The contract between the parties consists of:
(1) the policy;
(2) the applic;rtions, if any, of each Insu.rod Person; and
(3) the application of each Participant.
All sr~ementS made by ti,e Policyholder, Participants, and persoDs insured l.lT)der the policy are troe and
complete to tile besr of the knowledge a.nd belief of the pr:rsoI)(s) making Them. No s~l.ement wit! be used
in ar.y contest unle$S it is ;n writing and a copy of it is given to th.e person who made it, or to tis
beneficiary.
lneontesbbility
Excc;pt for non-payment of prem ium, the insurance ~ovidOO. by the policy Catl4lot be contested nfter such
insurance llas been in effel=t for 3 period or2 years.
Change In The Pol~y
No ch:mge may be mlde unless approved in writing by the Presid.eIlt; or a Vice Presic!enr.; or an Assistant
Vice President; or a Secretary; or an AssisWlt Soc.retary of Han!ord Life. No other person. may change or
waive any part of the policy, Any approved chemge shall be added 10 the policy wrir.ing.
It any cb;mge to state or federaJ lsw, including but not lim.ited to- the feder<Jl Socia.l Security Act. :affects
Hartford Life's liability undc:r the policy) Hanford life may chang.e the policy or rJ1e premiums, or both.
Such change:
(1) ....il11,e effective as oftile date of tIle ch~e to the stat.e or fcdem1law;
(2) will <lOC be made unT.jl Hanford. Life gives each Participant 31. days notice.
Right to AmCJId
Notwlthscanding the above, ~ftcr the policy has been in. force for 12 month!, HaJ1ford Life may cbMge any
or all of rhe policy's provisions by noti fying Ule Poli.cyhojder. Hartford Life muSt give the Policyholder at
least 31 days ndV:llce writ:en notice of any change.
Termination ofPOJley
Hartford Life may rerminate this policy On any premium doe date after the policy has been in force for 12
months by giving the PolicyhOlder 31 days written nor.ice,
Crace Period
Hartford Life will allow the Policyholder a 3 I day grace period for th.e paym~t of aJl premiums after the
first. During this 31 day period, the policy will stay in force. If the owed premium is not paid by The 31st
day, p81ticipatlon in the policy will automatically terminate. Premium is due for each dDy the poHcy is in
foree under the terms of tllis Or~ Period, If the Policyholder- gives Hartford Life written advance notice
of an earlier cancellation date tem1in.a.tion wi /I OCCllr. on tbe e?rljer date. Premium is due for each day the
policy is in f<m:e for eacb Particip;:mt.
CertjfjCllte
H:lrtford. Ufe will h~ve a certificate of coverage prepared ror each Participant. The Bool(Jet-oertific:lte will.
explain the important features ofrhe poJic)',
. 6
GR-1l710(06)A Rev. 7.'97
POLley PROYISIO~S
(Continued)
Data To Be Furnished
The Policyholder and Participant will give Hartford Life all infoT17l3tion Hartford Life nocd~ regarding
mmcrs pcrtainillg r:o we insurance.
At any reasona.ble time:
(1) while the policy is in Coree; and
(2) for I year after tbat.
H31.1ford Life may insp<<t any of :he Policyholder's or Participar:t's documents, books or records whicb
roayaffect the insuraflte or premiums oftllis policy. Tfthe Policyholder or Participant gives Hartford Lire
any incorrect information, the relevant facts will be determ ined.1ll estl'lblish if il1SIJfl1l1CC is in effect and in
wbat. a:nount.
No person will:
(1) be deprived ofinsur:mce to which he is o:hcrwise entitled; or
(2) have insurance to which he is 0Ot. eo!irfcd,
be<:.\u$e of ar\)' misstatement of fact ~ the Policyholder Or Participant. Any required adjus::roent may be
ma.de in premiums or be'nefi~.
No R.ep\.aummt (or WorJ(ers' Compensation
The policy does Dot replace Workers' Comper.sation or affect aJJY requirement for Workers' Compeo~liol1
coverage.
Time Period
All periods begin and end at 12:01 A.M.., standard time, at dIe Policyholder'S ;1ddres5..
JuriJdiction
This policy is governed by the laws of the State where it is delivere<l.
7
GR-1I710(06)ARev.7.'9']
l\10NROE COUNTY BOARD OF
COUNTY COMMISSIONERS
Life and Accidental Death and
Dismemberment
TABLE OF CO:\TEf'iTS
Group Life InslIr:lnce Benefits
PAGE
CERTIFICATE OF INSURANCE .......................................................... 2
SCHEDULE OF I1\'SURANCE ....................,...................................,...... 3
Who is eligible for coverage? ....................,......................................... 3
. When \vill You become eligible? (Eligibility Waiting Period)............ 3
What is Evidence of Good Health? ..............,.......................................4
When will Evidence of Good Health be required? .............................. 4
What Life benefits are available to you?.................................,.......... 4
What Life Benefits are available to Retirees? ,................................,....4
What AD&D Benefits are available to You? .......................................5
What reductions in Your coverage will occur due to Your age? .........6
T\lust You contribute toward the cost of coverage?............................. 6
How do You request coverage for Yourself?...................................... 7
When does coverage start?..................................................................7
What is the Deferred Effective Date provision for Retirees?............... 8
What is the Deferred Effective Date provision for employees? ........... 8
When are changes effecti\.e?.........................................,......................9
BEN E FITS ..................................... ........... .......... ..... .......,.... .......... ... ..... 10
Life Insurance Benefit........................... ...,......................................... 10
Accelerated D.::ath Benefit ................................................................. 11
Accidental Death and Dismemberment (AD&D) Benefit ................. 12
TERlvllNA TION .................................................................................... 15
When does Your coverage terminate? ...............................................15
Under what conditions can Your insurance be continued under the
continuation provisions? . ............................ ....................................... 15
CONVERSION PRIVILEGE ................................................................18
G EN ERAL PROV I SION S........... ............ ... .... ...,....... .... ........... ........ ..... 20
DEFIl\' IT IONS.............. ........................... ........ ....... ...... .............. ........... 22
Z-TER"l (AOO)
12-'96
HARTFORD LIFE AND ACCIDENT INSURANCE COi\\PANY
Hartford, Connecticut
(Herein called Hartford Life)
CERTIFICATE OF INSURANCE
under !\laster Group Insurance Policy GVL-016007
Effective August 1, 1989
Issued by
Hartford Life
to
TRUSTEE OF
THE PUBLIC EMPLOYERS INDUSTRY GROUP VOLUNTARY
LIFE AND DISABILITY INSURANCE TRUST
(Herein called the Policyholder)
This is to certify that We have issued and delivered the above named Group
Insurance Policy (Policy) to The Policyholder. The Policy provides group
insurance benefits to the Participant Employer's employees who:
are eligible for the insurance;
beconle insured: and
continue to be insured,
according to the terms of the Policy.
The terms of the Policy \\hich affect an employee's insurance are contained
in the following pages. This Certificate of Insurance and the following
pages will become Your Booklet-certificate. This Booklet-certificate is a
part of the Policy. This Booklet-certificate replaces any other which We
may have issued to the Participant Employer to give to You under the Policy
specified herein.
oo~ J:Lr..dLU^-,
#P
L:"~,lh ,;, ..!k:r. Sd'",""ry
Lv",\"Ct!.> A ~lI~itl~. J',..-"j.!.-.,!
Z-TERi\I(COO)
12-'96
2
Some of the terms used within this Bookkt-certificate ar~ capitaliz~d and
hav:e special meanings. Please refer to the d~finitions at the end of this
Booklet-certificate when reading about Your benefits.
SCHEDULE OF Ii\'SURANCE
Final interpretation of all provisions and coverages will b~ govern~d by
tl1e- Group Insurance Policy on fil~ with Hartford Life at its home office,
Th~ Participant Employ~r:
MONROE COUNTY
BOARD OF COUNTY
COMMISSIONERS
Account 1'1 urn ber:
3036]3
Policy Effective Date:
October I. 1999
Anniversary Date:
October I of each year,
beginning in 2000.
Who is eligible for cOHrnge?
Eligible Class(es):
All Active Full-tim~
Employe~s
When ,viii You become eligible? (Eligibility Wniting Period)
If You are working for the Employer prior to the Policy Effective Date
and were covered under the Prior Plan, You are eligible for coverage on
the later of the Policy Effective Date or the date You ent~r an eligible
class.
If You start working for the Employer after the Policy Effective Date,
You are eligible for coverage on the date on ,vhich You complete a
waiting period of 60 days of continuous service.
Retirees are eligible for coverage on the later of:
]. the date on \vhich the individual meets the definition of a Retiree; or
2. the Policy Effective Date.
3
303613(G"L)IRe\
What is Evidence of Good Health?
Evidence of Good Health is information about a person's health from
which We can determine if coverage or increases in coverage will be
effective. Information may include questionnaires, physical e:\ams, or
written documentation as required by Us.
Inquiries as to the status of Your submission of Evidence of Good Health
should be addressed to Your Employer and/or Benefit Administrator.
'{our Employer and/or Benefit Administrator will notify You of
approvals. We will notify You, in writing, of any disapprovals.
When will Evidence of Good Health be required?
Evidence of Good Health is required if You elect no cowrage for
Yourselhvhen eligible to do so and later opt for coverage.
I f Evidence of Good Health is not approved in the situation(s) described
abo\"(', no coverage will become effective. Evidence of Good Health
must be provided at Your own e:\pense.
AMOUNT OF LIFE INSURANCE
Employee Only
What Life benefits are available to You?
Amount of Life Insurance:
An amount equal to 520,000.
AMOUi\'T OF LIFE INSURAi\'CE
Retiree Only
What Life benefits are available to Retirees?
Amount of Life Insurance:
Employees with 10 or more years of service, who retired on or after
October 1, 1987 have an amount of Life Insurance equal to 520,000,
which is reduced to 5] 0,000 at age 70.
-I
Employees who retired, and elected Life Insurance benefits, prior to
October I, 1987 have an amount of Life Insurance equal tL1 the amount of
Employ'ee Life Insurance in force on September I, 1987.
Employees who retired, and did not elect Life Insurance benefits, prior to
October I, 1987 have an amount of Li fe Insurance equal to lesser of;
I. 50% of the amount of Life Insurance in force on the day before the
date of retirement; or
2. _ S5,000.
Your Amount of Life Insurance will be reduced by any life benefit:
I. paid to You under an accelerated death benefit in the Prior Plan; and
2. in force for You under any disability extension provision of the
Prior Plan.
If You convert, does it affect the Amount of Life Insurance benefit
payable?
The Amount of Life Insurance under the Policy \\'ill be reduced by the
amount of the individual life insurance issued in accordance with the
Conversion Privilege for reasons other than reductions in coverage.
ACCIDEl'IT AL DEATH, DlSI\IEi\1 BERi\1El'IT
AND LOSS OF SIGHT BENEFIT (AD&D)
Employee Only
l'IOTE: l'IOT APPLICABLE TO RETIREES.
\Vhat AD&D Benefits are available to You?
Principal Sum:
An amount which equals the Amount of Life Insurance in force for You.
The Principal Sum will not exceed the Amount of Life Insurance for
which You are insured.
5
Reduced Amounts of Insurance
\\'hat reductions in Your coverage will occur due to Your age?
NOTE: NOT APPLICABLE TO RETIREES.
Your Amount of Life Insurance and Principal Sum will decrease on the
Anniversary Date \vhich occurs on or next follows the date '{ou attain
any of the ages specified in the following table. The Amount of Life
Insurance and Principal Sum in force immediately prior to that
Anniversary Date will be reduced by the percentage indicated in the
following table.
Additionally, if:
I. You become insured under the Policy: or
2. Your coverage increases,
on or after the date You attain age 70, We reduce the amount of coverage
for \\hich You would otherwise be eligible in the same manner.
Age When
Reduction Occurs
70
75
Percentage by
which current
amount of
coverage (after all
previous
reductions) will
be reduced
33~'o
50%
Reduced amounts of Life Insurance and Principal Sum will be rounded to
the next higher multiple of S I 000, if not already such a multiple.
Eligibility and Enrollment
I\lust You contribute toward the cost of coverage?
With respect to active Employee Life Insurance and AD&D coverage,
You do not contribute toward the cost.
6
With respect to Retiree Li fe Insurance co\'erage, you may hJW to
cOl}tribute towards the cost.
How do You request coverage for Yourself?
If You are not required to contribute toward the cost of coverage, You
are not required to request coverage. Enrollment \yill be automJtic.
However You will be required to complete a beneficiary election form.
If \' OU must contribute toward the cost of coverage. You are required to
enroll for coverage. To do so You must complete and sign a group
insllrJnce enrollment form acceptable to Us and deliver it to the
Employer.
'Vhen does coverage start?
If You are not required to contribute to\yard the cost of cow rage, You
will become insured on the date You become eligible for co\-erage.
If You mllst contribute to\\'ard the cost of coverage, You will become
insured on the first to occur of:
I. the date Y Oll are eligible, if You enroll on or before that date;
') the date YOll enroll, ifYOll enroll within 31 days after the date You
become eligible.
If You enroll more than 31 days after the date '{ou first become eligible
to do so, no coverage will be available without Evidence of Good
Health.
Coverage for which We require Evidence of Good Health will become
effective on the later of:
I. the date YOll become eligible; or
2. the date approved by Us.
All effecti\'e dates of coverage are subject to the Deferred Effective Date
provision.
7
\Vhat is the Deferred Effective Date provision for Retirees?
I f a Retiree is con fined at home, in a hospital or elsewhere because of a
physical or mental condition on the date an increase in coverage or a new
benefit added to the Policy would otherwise have become effective. the
effective date of any increase or additional benefit will be deferred until
the Retiree is discharged from the hospital or no longer confined and has
engaged in substantially all the normal activities ofa healthy person of
the same age for a period of at least 15 days in a row.
"Confined elsewhere" means the individual is unable to perform,
unaided, the normal functions of daily living, or leave home or other
place of residence without assistance.
\Vhat is the Deferred Effective Date provision for employees?
If You are absent from work due to a physical or mental condition on the
dale Your insurance. an increase in coverage or a new benefit added to
the Policy would otherwise have become effective, the effective date of
Your insurance. any increase in insurance or the additional benefit \\"ill
be deferred until the date You return to work as an Active Full-time
Employee.
Are there exceptions to the Deferred Effective Date provision?
i'o'OTE: i'o'OT APPLICABLE TO RETIREES
If You were insured under the Prior Plan on the day before the Policy
Effective Date and You would be eligible for coverage on the Policy
Effective Date except that You are not able to meet the requirements of
the Deferred Effective Date provision, then:
]. the Deferred Effective Date provision will not apply to the original
effective date of coverage; and
2. the coverage amount shown in the Schedule of Insurance will not
apply to You.
Instead, 'yO ou \vill be considered to be insured and your coverage amount
will be the lesser of:
I. the Amount of Life Insurance and Principal Sum under the Prior
Plan; or
2. the Amount of Life Insurance and Principal Sum shown in the
Schedule of Insurance.
s
reduced by:
I. any coverage amount in force or otherwise payable due to any
.disability benefit extension under the Prior Plan: or
2. any coverage amount that would have been in force due to any
disability benefit extension under the Prior Pbn had timely election
for the disabi I ity provision been made.
You will remain insured under this provision until the first to occur of:
1. the date You return to work as an Active Full-time Employee;
2. the date Your insurance terminates for a reason stated under the
Termination provision;
3. the last day of a period of 12 consecutive months \vhich begins on
the Policy Effective Date; or
4. the last day You \vould have been covered under the Prior Plan, had
the Prior Plan not terminated.
\Yhen are changes effective?
The provisions, terms and conditions of the Schedule of Insurance or this
Booklet-certi ficate may be modi fied, amended or changed at any time;
consent from any covered individual is not required.
I fthere is any type of change in Your class, the Schedule of Insurance or
the Booklet-certificate which:
I. decreases an amount of coverage or deletes, limits or restricts the
availability of a benefit or provision. then that decrease, deletion,
limitation or restriction will b.:: effective on the date the chang.:: in
class, the Schedule of Insurance or the Booklet-certificate is
effective;
2. increases an amount of coverage or adds, improves or increases
availability of a benefit or provision, then that increase, addition or
improvement will be effective on the date the change in class, the
Schedule of Insurance or the Booklet-certificate is effective, subject
to application of the Deferred Effective Date provision and Our
approval ,vhere Evidence of Good Health is required.
9
BENEFITS
Life Insurance Benefit
To whom and how are benefits paid?
A completed claim form, a certified copy of the death certiticate and
Your enrollment form must be sent to the Employer or Us. When the
required claim papers are received and approved by Us. the Amount of
Life Insurance will be paid.
Your death benefit will be paid in a lump sum to the bendiciary(ies)
designated by You in writing and on file with the Employer.
Unless You have requested something different, payment \1 ill be made
as follows:
I. Ifmore than one beneficiary is named, each will be paid an equal
share.
2. Ifany named beneficiary dies before You, His share will be divided
equally among the named surviving beneficiaries.
I f no beneficiary is named, or if no named beneficiary survives You, We
may. at Our option, pay:
I. up to 5500 of Your Ii fe insurance to any party that We deem is
entitled because of the ir payment of burial expenses. We will be
released from further liability for any amount so paid: and/or
2. the executors or adm in istrators of Your estate; or
3. Your surviving relatives in the following order:
a) all to Your surviving spoLlse: or
b) if Your spouse does not survive You, in equal shares to Your
surviving children; or
c) ifno child survives YOLl, in equal shares to Your surviving
parents.
Ifa minor does not have a legal guardian, We may, until sllch a guardian
is appointed, pay the person We deem to be caring for and supporting
him. Such payment will be in monthly installments of not more than
5200.
10
I f a death benefit payable meets Our guidelines, then the benefit is
payable into a checking account. Your beneficiary owns the checking
account. A lump sum payment may be elected by writing a check for the
full amount in the checking account.
Accelerated Death Benefit
What is the benefit?
If'{ou are diagnosed as being Terminnlly III and proofofsuch dingnosis
is provided by an attending physician licensed to practice in the United
States, and You are:
J. less than age 60; and
2. insured for at least 5 I 0,000,
then You may request that a portion of Your Amount of Life Insurance
be paid to You prior to death.
The request cannot exceed 80';'0 of the in force Amount of Life Insurance,
and is subject to a minimum of 53,000 and a maximum of 5500,000.
You may exercise this option only once per person.
For example, if '{ ou have an Amount of Life Insurance equal to 520,000
and You are Terminally III, You can request any portion of the life
insurance bet\veen 53,000 to 516,000 to be paid to You now instead of to
Your beneficiary at Your death. However, if You decide to request only
53,000 now, You cannot request the additional 513,000 in the future.
What does Terminal Illness/Terminally III mean?
Terminally III or Terminal Illness means that an individual has a life
expectancy of 12 months or less.
RECEIPT OF AT'iY BET'iEFITS IN ACCORDANCE WITH THIS
PROVISION WILL REDUCE LIFE INSURANCE BENEFITS
PAYABLE UPO:\' DEATH.
Whnt if an individual is no longer Terminally Ill?
If diagnosed as no longer Terminally Ill, coverage mayor may not
remain in force. Coverage which remains in force will be reduced by any
amount of Accelerated Death Benefits received and premium is due for
this reduced amount. If coverage does not remain in force, then the
reduced amount of coverage may be converted.
II
What limitations apply to this benefit?
The; Accelerated Death Benefit provision will be subject to all applicable
terms and conditions of the Policy.
No Accelerated Death Benefit will be paid if You are required by law to
accelerate benefits to meet the claims of creditors. or if a government
agency requires You to apply for benefits to quali(\' for a government
benefit or entitlement.
What if You mnde nn nssignment under this plan?
If You have executed an assignment of rights and interest with respect to
Your Amount of Life Insurance, in order to pay benefits to You under
this provision, \Ve must receive a release from the individual to whom
the assignment was made before any benefits are payable.
Accidentnl Denth and Dismemberment (AD&D) Benefit
Employee Only
NOTE: NOT APPLICABLE TO RETIREES,
What conditions are necessary for benefits to become paynble?
We will pay a benefit if You suffer an accidental injury while insured
and:
1. a Loss results directly from such injury, independent of all other
causes; and
2. such Loss occurs within 90 days after the date of the accident
causing the injury.
When should \Ve be notified of a c1nim?
A claimant must give Us, or Our appropriate representative, \\Titten
notice ofa claim within 20 days after the loss happens or starts. Ifnotice
cannot be given within that time, it must be given as soon as possible
after that.
Such notice must include:
I. the claimant's name and address; and
2. the Policy or account number.
12
Are special forms required to file a claim?
\Vithin 15 days of receiving a notice of claim, We or Our appropriate
repr.esentative wi II send forms to the claimant for providing proof of loss.
If the forms are not provided within 15 days. the claimant may submit
any other written proof which fully describes the nature and extent of
claim.
When must Proof of Loss be giHn?
S,!tisfactory written proof of loss must be sent to Us or Our appropriate
representative, within 90 days after the date of such loss. However, all
claims must be submitted to Us within 90 days of the date any
individual's insurance terminates.
Ifproofis not given by the time it is due, it will not affect the claim if:
I. it was not possible to give proof within the required time; and
') proof is given as soon as possible, but no later than a year after it is
due unless the claimant is not legally competent.
\Yhcn and to ,yhom will Your claim be paid?
Benefits for Loss of life will be paid in accordance with Your life
insurance beneficiary designation. Unless otherwise specified, benefits
for all other Losses are payable to You.
Benefits for all other Losses will be paid as soon as due written proof is
received. Benefits for all other Losses will be paid not more than 60 days
after written proof is received.
Any payments, other than for Loss of/ife, which are owing at Your death
may be paid to Your estate. Ifany payment is owed to:
I. '{our estate;
2. a person who is a minor; or
3. a person who is not legally competent,
then \\' e may pay up to S 1 ,000 to Your relative who is entitled to it in
Our opinion. Any such payment shall fulfill Our responsibility for the
amount paid.
13
What types of injuries are excluded from coverage?
No benefit will be pJid for a Loss caused or contributed to by:
I. . sickness;
2. disease;
3. any medical treatment for items (I) or (2);
4. any infection, e\cept a pus-forming infection of an accidental cut or
wound;
5. war or any act of war, whether war is declared or not:
6. any injury received while in any armed service ofa country which
is at war or engaged in armed conflict:
7. any intentionally self-inflicted injury, suicide, or suicide attempt,
vvhether sane or insane;
8. taking drugs, sedatives, narcotics, barbiturates, amphetamines or
hallucinogens unless prescribed for or administered by a licensed
physician; or
9. the injured person's into\ication.
Into\ication means that blood alcohol content or the results of other
means of testing blood alcohol level, meet or e\ceed the legal
presumption of into\ication under the law of the state where the accident
took place.
What is the benefit payable?
The benefit payable for any Loss is that which is shown opposite the
Loss in the following schedule. The Principal Sum is shown in the
Schedule of Insurance. No benefit is payable for any Loss which is not
shown in the schedule below.
DESCRIPTIO~ OF LOSS
Loss of life
Loss of a hand
Loss of a foot
Loss of an eye
More than one of the above
resulting from one accident
BENEFIT
Principal Sum
One-half the Principal Sum
One-half the Principal Sum
One-half the Principal Sum
Principal Sum or the sum of
the Benefits payable for each
Loss, whichever is lesser.
1.J
Loss means the following:
1. Loss of a hand or foot means that it is completely cut off at or above
. the wrist or ankle joint.
2. Loss of an eye means that sight in the eye is completely lost and
cannot be recovered or restored.
TERi\lI:\"A TION
Employee and Retiree Coverage
\\'hen docs Your coverage terminate?
Unless continued in accordance with the Exceptions to Termination
section, Your insurance will terminate on the first to occur of:
I. the date the Policy terminates;
2. the last day of the period for which You made any required
premium contribution, if You fail to make any further required
contribution;
3. the date You are no longer in a class eligible for cowrage;
4. the date Your Employer terminates Your employment;
5. the date You are absent from work as an Active Full-time
Employee; or
6. the date on which Your Employer ceases to be a Participant
Employer.
EXCEPTIO:"S TO TERI\IIi\;ATION
Under what conditions can Your insurance be continued under the
continuation provisions?
If You are absent from work as an Active Full-time Employee, Your
insurance may be continued up to the maximum period of time stated. In
each instance, such continuation shall be at the Employer's option, but
must be according to a plan which applies to all employees in the same
way. Continued coverage:
I. is subject to any reductions in the Policy;
2. is subject to payment of premium by the Employer; and
3. terminates when the Policy terminates or Your Employer ceases to
be a Participant Employer.
15
If You are on a documented leave of absence, other than Family or
r. kdical Leave, all of Your coverages, upon approval by the Employer,
may be continued for 6 consecutive month(s) following the month in
which the leave of absence commenced.
If You are granted a leave of absence according to the Family and
r. kdical Leave Act of 1993, all of Your coverages may be continued for
up to 12 weeks, or longer if required by state law. following the date
Your insurance would have terminated, subject to the following:
1. the leave authorization must be in writing:
.., the required premium for You must be paid:
.). 'Your benefit level wi II be that wh ich was in effect on the day before
said leave started, subject to any reductions included in the Policy;
4. the amount of Earnings upon wh ich Your benefit may be based, will
be that which was in effect on the day before said leave started; and
5. continued coverage will cease immediately if one of the following
events should occur:
a) the leave term inates prior to the agreed upon date;
b) the Policy terminates or Your Employer ceases to be a
Participant Employer;
c) You or the Policyholder fail to pay premium when due; or
d) the Policy no longer insures Your class.
In all other respects, the terms of Your insurance remain unchanged.
If You are absent from work due to sickness or injury, all of Your
coverages may be continued until the last day of a period of 12 month(s)
\\"hich begins on the date You \vere first absent from work as an Active
Full-time Employee. If You feel that Your condition may continue for
an extended period of time, You should request that Your Employer file a
waiver of premium claim.
What is \Vaiver of Premium?
Waiver of premium is a provision \vh ich allows for continued employee
life insurance, without payment of premium, while You are Disabled.
This provision does not apply to Retirees.
To what coverages docs the Waiver of Premium apply?
These provisions apply only to Your Life Insurance.
Waiver of Premium does not apply to any AD&D Insurance.
16
What conditions must be satisfied before You qualify for Waiver of
Premium?
I. You must be less than age 60, insured and Disabled; and
2. acceptable proof of Your condition must be furnished to Us within
one year of Your last day of work as an Active Full-time Employee.
What does Disabled mean?
Di?abled means that You have a condition that prevents You from doing
any work for which You are or could become qualified by education,
training or experience ancl it is expected that this condition will last for at
least six consecutive months from Your last day of work as an Active
Full-time Employee; or You have been diagnosed with a life expectancy
of ] 2 months or less.
\Vhen will \Ve waive premium?
We will waive premium after proof that You are Disabled is provided by
an attending physician licensed to practice in the United States and We
approve the proof. You will be notified by Us of the date We will begin
to waive premium.
Continued coverage will be subject to any age reductions provided by
any part of the Policy.
\Vhat if You die before You qualify for Waiver of Premium?
If:
1.
You should die within one year of Your last day of work as an
Active Full-time Employee but prior to qualifying for \vaiver of
premium; and
You were Disabled,
2.
We will pay the Amount of Life Insurance which is in force for You.
Can \Ve have You examined for proof that You continue to be
Disabled?
During the first two years following the date You qualify as Disabled,
We may have You examined at reasonable intervals. Thereafter, We will
only require an annual examination to confirm that You continue to be
Disabled. I f You fail to submit any required proof or refuse to be
examined as required by Us, then Your coverage will terminate.
17
'Vhat if You are 110 longer Disabled?
If, for any reason, You are no longer Disabled, Your premium will no
longer be waived. On that date, You mayor may not return to work.
If You return to work in an Eligible Class, then all of Your coverages
will be reinstated subject to the terms of the Policy in effect on the
reinstatement date.
If'{ou do not return to work within an Eligible Cbss, and You are not
eligible for any other group life insurance, then You are entitled to the
Conversion Privilege. You llIay conver1 the Amount of Life Insurance
that is in force for You on the date it is determined that You are no longer
Disabled.
On the date waiver of premium terminates, if You do not return to work,
You will be entitled to convet1 Your coverage. You may convert no
more than '{our Amount of Life Insurance that is in force 011 the date
waiver of premium terminates.
\Vhat if the Policy terminates before You qualify for waiver of
premium?
If the Policy terminates or an Employer ceases be a Participant
Employer, before You qualify for waiver of premium, You may be
eligible to convert. Additionally, You may later be approved for \\'aiver
of premium.
'\'hat if the Policy terminates after You qualify for waiver of
premium?
Termination of the Policy, or an Employer ceasing to be a Participant
Employer, wi II not affect Your coverage under the terms of this
provision.
CO:'iVERSION PRIVILEGE
The following does not apply to any AD&D Benefits.
'\'hen can an individual convert?
If insurance, or any portion thereof, terminates, then any individual
covered under the Policy may convert his life insurance to a conversion
policy without providing Evidence of Good Health.
IS
I f the qual ifying event is policy termination, termination of coverage for
a class, or Your Employer is no longer a Participant Employer then the
individual must have been insured for at least 5 years under the Policy in
order to be eligible for this conversion pri\'ilege.
What is the conversion policy?
The conversion policy will:
1. .be on one of the life insurance policy forms. except term insurance,
then customarily issued by Us for conversion purposes:
') contain no disability, supplementary or AD&D benefits: and
3. be effective on the 32nd day after group life insurance terminates.
How much can be converted?
If the qualifying event is policy termination, termination of coverage for
a class, or Your Employer is no longer a Participant Employer then the
amount which may be converted is limited to the lesser of:
I. the amount of group coverage in force prior to the qualifying event,
reduced by the amount of any other group coverage for \vhich the
individual becomes covered within 31 days of termination of group
coverage; or
2. 52,000.
I f conversion is due to retirement or any other qualifying event, the full
amount of coverage lost may be converted.
How does an individual convert coverage?
To convert life insurance, the individual must, \vithin 31 days of the date
group coverage terminates. make \vrilten application to Us and pay the
premium required for his age and class of risk.
\Yhat if death occurs during the conversion election period?
If the individual should die within the 31 day conversion election period,
\V e will, upon receipt of acceptable proof of H is death, pay the Amount
of Life Insurance He was' entitled to convert.
19
GEj\;ERAL PROYISIOr-;S
Whcn can this plan bc contestcd?
Except for non-payment of premium, the Policy cannot be contested after
two years from the Policy Effective Date.
No statement relating to insurability will be used to contest the insurance
for \\'hich the statement was made after the insurance has been in force
for two years during the individual's lifetime. In order to be used, the
statement must be in writing and signed by the affected individual.
Who interprets policy terms and conditions?
We have full discretion and authority to determine eligibility for benefits
and to construe and interpret all terms and provisions of the Policy.
Are there any rights of assignment?
Except for the dismemberment benefits under the AD&D Benefit, )'ou
ha\e the right to absolutely assign all of Your rights and interest under
the Policy including. but not limited to, the following:
I. the right to make any contributions required to keep the insurance in
force;
2. the privilege of converting; and
3. the right to name and change a beneficiary.
No absolute assignment of rights and interest shall be binding on Us until
and unless:
I. the original of the form documenting the absolute assignment: or
2. a true copy of it,
is received and acknowledged by Us at our home office.
We have no responsibility:
I. for the val idity or effect of any assignment; or
2. to provide any assignee with notices which We may be obligated to
provide to You.
How do You designate or change Your beneficiary?
You may designate or change a beneficiary by doing so in writing on a
form satisfactory to Us and filing the form with the Employer. Only
satisfactory forms sent to Us prior to Your death will be accepted.
20
Designations will become effective as of the date You signed and dated
the form, even if You have since died. We will not be liable for any
amounts paid before receiving notice of a beneficiary change from the
Employer.
In no event may a beneficiary be changed by a Power of Attorney.
Can :We hnve a c1nirnnnt examined or request an autopsy?
We reserve the right to have a claimant examined and to have an autopsy
performed, ifnot forbidden by law. Any such examinations will be as
reasonably required by Us and at Our expense.
\Vhnt notification ,viII You receive if Your claim is denied?
If a claim for benefits is wholly or partly denied, the claimant will be
furnished with m'itten notification of the decision. This written decision
will:
I. give the specific reason(s) for the denial;
2. make specific reference to the provisions upon which the denial is
based; and
3. provide an explanation of the review procedure.
\Vhnt recourse do 'You hnvc if Your c1nim is denied?
On any denied claim, the claimant or His representative may appeal to Us
for a full and fair review,
The claimant may:
I. request a review upon written application within 60 days of receipt
of claim denial;
2. review pertinent documents; and
3. submit issues and comments in writing.
A request for an appeal will not be denied ifnot submitted within 60 days
if it is not reasonably possible to make such request within 60 days. In
this case, the request must be submitted as soon as reasonably possible
thereafter.
A decision \vill be made by Us no more than 60 days after the receipt of
the request, except in special circumstances (such as the need to hold a
hearing), but in no event more than 120 days after the request for review
is received.
21
Whcn can legal action bc takcn?
Legal action cannot be taken against Us:
I. sooner than 60 days after proof of loss has been furnished; or
2. 3 or more years after the time proof of loss is required to be
furnished according to the terms of the Policy.
How does this plan affect \Vorkers' Compensation coverage?
T~e Policy does not replace Workers' Compensation or affect any
requirement for Workers' Compensation coverage.
Physician-paticnt Relationship
You may choose any licensed physician. We shall not in any way disturb
the physician-patient relationship.
DEFJNITIOXS
Actiyc Full-time Employee - An employee who works for the
Employer on a regular basis in the usual course of the Employer's
business, An employee must work at least the number of hours in the
Employer's normal work week. This must be at least 25 hours. You will
be considered actively at work \vith Your Employer on a day which is
one of Your Employer's scheduled work days if You are performing. in
the usual way, all of the regular duties of Your job on a full-time basis
on that day. You \\ill also be considered actively at work on a paid
vacation day or a day which is not one of Your Employer's scheduled
work days only if You were actively at work on the preceding scheduled
work day.
Anniversary Date - The date occurring in each calendar year which is
an anniversary of the Policy Effective Date.
Employer - The Participant Employer named in the Schedule of
Insurance.
He/His - He or she. His or her.
22
Participant Employcr - An Employer who agrees to participate in the
Trust, pays the required contribution for His employees and is a
Participant in accordance with the provisions of the Policy.
Policy Effectiyc Date - The effective date of the Participant Employer's
plan of insurance shown in the Schedule of Insurance.
Prior Plan - A plan of group term life insurance sponsored by the
Employer which was in force on the day before the Policy Effective
Date.
Retiree - A former Active Full-time Employee of the Employer who:
. has completed at least 10 years of active full-time service with the
Employer; and
. is participating in an Employer-sponsored plan.
Or
. has completed a total of 10 years of active full-time service with
Florida Government Agencies: and
. is eligible for immediate benefits under the Florida State Retirement
System.
Trust - The Public Employers Industry Group Voluntary Life and
Disability Insurance Trust.
WelUs/Our - The Hartford Life and Accident lnsurance Company.
You/Your - The employee to \vhom this Booklet-certificate is issued.
')'
,
The Plan Described in this Booklet
is "Insured by the
Hartford Life and Accident Insurance Company
Hartford. Connecticllt
Member of The Hartford Insurance Group
Form 303613(GVL) 1 Rev
Printed in U.S.A. 3-'00