FY2001 05/14/2000
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\JPLOYERS INDUSTRY GROUP VOLUi\;TARY 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:
1. 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. Dismembem1ent
And Loss of Sie:ht Benefit
S .39 for each $ I ,000 of Basic Life Insurance
S .02 for each $ I ,000 of Principal Sum
RATE GUARANTEE PERIOD:
Basic Life Insurance
Basic Accidental Death. Dismemberment and Loss of Sie:ht Benefit
Until October 1,2001
Until October I, 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.
I f 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:
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 Pal1icipant 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) 1 Rev
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
~~~
#~
Lyrlda Godkin, SecretarjJ
Lowndes A. Smith, Presillf~nt
Countersigned by
J-;ChR--- CJfJD-h
Diane Zipoli, Registrar
GR-I1711(A) Rev. 7-'97
Name of Policyholder: TRUSTEB OF THE PUBLIC EKPLOYRRS GROUP VOLu1NTARY LIPS
AND DISABILITY INSURANCE TRUST
Policy Numbers:
GVL-016007
Effective Date:
1-1-94
Place of Delivery:
Rhode Island
BAltTPotw LIl"B INSURANCE c.<mPANY
Hartford Plaza, Hartford, Connecticut 061.15
(A stock insurance company, he~ein called The Hartford)
Agrees vith the Policyholder to insure certain persons vho a~e entitled to the
3.nsurance provided by thi s polf cy.
This policy is issued in consideration of the application of the Policyholder,
and of the payment by the Participant Employers of premium as provided herein.
A Participant Employer's first premium is du~ and payable on t.he effective date
of such employer'S inclusion under the Plan. Subject to the policy's gr.ace
period provision) all premiums aft~r toe first must be paid vhen or b~fore they
are due.
Signed for The Hartford:
~~
~~~
_._-#~
lhwn<k' A. ~ ~dtPLl
Countersigned
by............................,.. ,...... .................. ~..
Registrar
Table of Contents
Agreemen t to IIIsure ................................. _ . . . . . . . . . . . . .. 1
Defini tion ..................................... 2
ParHcipant Employers ..........................:::::::............. 3
Incorporation Provision..... -................ _....,... ~ ~::::: ~::::: 5
Premiums . - - . . . . . . . . . . . . . . . . . - . - . . . - - - . - . . . . . . . . . . . . . . . . . . 6
Policy Provisions ............................ _ . _ . . . . . . . . . : : : : : : . . .. B
GR-1l710(Ol)A
1
I)EFlNITIO~S
Trustee means Shawmut Bank located in Rhode Isl.:3nd.
Tru$t Agreemerlt means th~ trost agreement between Hartford Life Life and Accident Insurance Company
and Sl,awmut BMk for the purpose of implementing group ill.S1.l1"a1loe coverage for the benefit of employees
of employeni and sole ?roprietOrs partjci-pati.n~ in tile Trost
Tl"ust means the trust crc:eted under !Ju: f:cnns of the Trust Ayeemc.nt.
2
GR-1l710(06)A Rev_ 7-'97
PARTlCIPAI'ITS
In General
An entity may be iocluded as i\ Participant if"thc Policyholder and Hartford !,ife so agree. HaJ'1.ford I..ife
willl<.up a list of Clctept.ed Pllrticipants and rhc effective dates of coverage for eactt.
The Policyholder m.ay 3..Ct for Or On behalf of all Participants in all matters of !be policy. TIle (ollowing wjJl
be binding ern all Participants:
(J) all agreements between Hmford Life and r]le Policyholder;
(2) llU notices from Hartford Life to t'Je Policyholder; and
(3) :all notices (rom the Policyholder to HMtford Life.
AI) employ~e of B. Participant will be deemed to be an employee of !be Policyholder for insurance purposes.
A Particip:11l.t's premium is due and payable on the etrtctive date of his inclusion under the policy. Subject
to the Grace Period, if applicable to 5IJch Participant's insuram:e coverage(s), all Participant premium after
the first must be paid when or before they are d1Je.
for the purpose of this insurance, the term Participant shall mean:
(1) an employer who:
(a) has the required number of employees in his employ; and
(b) elec-..s to p.micipate in MO maJ<es required premium coDtributions, on behalfofhis
employees, to the Group Voluntary Life and. Disal)ilil)' IlJsura.ncc Trosr; or
(2) a sole prtlf'l"jet.or who elects tQ participate in ll1.ld mtkes req'Jired premium coctMbu.tions to tne
Group Voluntary Life and Disability Insurance Trust
In order to become 2 ParticipanT, ao entilY rT]1)st:
(1) make necessdry appfication for membership ;1) lhe Finance, II'lSUrallCe and Real Esut:e
Indu5t:ry Group Voluntary Life and Disability Insu~ncc TnJST.;
(2) be accepltd by Hanford Life for:;vch membership; and
(3) satisfy the 3pplicable Employee Participation Requirements.
Employee Partidpation Requ;rement;,
Each employer shall m.eet end maimain The minimum emplo)"ce .and dependent participatioo requiW'lleots,
if applfc~ble, in order TO become a ParticiPMt ~nd remain a ?cn1icipaflt under the policy. TIle participation
requirements are shown on Rider Form GR-1l71 I (A) Rcv_ 7-'97.
Errec:tJve Date for Purticip::U)t$
The effective cbtc of inclusion of a Participanr. under the policy is show:) 00 the Rider applicable to such
Participant.
3
GR-117 J O(OG)A Rev. 7-'97
PARTJCl.PANTS
(continued)
Tc:rminat;on Date for P3rtiCipllhts
Coverage for a Participimt will terminate on the first toO oecur of:
(1) if applicable to such Participant's inslJrance CQve."3ge(s), the day fQlIowjng tOe Grace Period jf
. a premium is due but unpajd;
(2) rbe date a premium is due but unpaid;
(3) the dare such Pmi.cip:int withdraws from rhe Trost by giving 'Written notice to HMtford Life;
(4) the dote sl,l<;b Panicjp.mt elects to terminate coverage, by giving wr.il,el'l Do/ice f.o HlUtfoTd
Life;
(5) the dat.e such Participant fails to mainrain the applicable p~rticipatjoJ] requi."e:neOt$; or
(6) (he date Hartford Life terminates the policy in its entirety or wj~ respect to :l.ny Participant in.
accordance with the provisions of the policy.
4.
GR-- 1111 O(06)A Rev. 7-'97
INCO~It-\TroN PROVISION
RookJe~Certific:ntc
The Booklet-emificate(s). and the endorsement formes) listed on Rider Form GR-Il'1 1 (A) Rev. 7.'97 are
hereby incorporated in, and mode a pm of, this pol;cy.
The terms found. in the Bool<let-cer.tificate(s) will control:
(I) lhe coverage provisions;
(2) the eligibi1i~ and effective date of in~mrance rules;
(3) the termination of insurance rules;
(4) exc!utiol.ls; and
(5) oilier gener~ policy provisions pertaining to state and federal in$IJC'3nce requirements.
Schedule of In5IlT!nc~
'file schedules of insu1'llJ1ce applicable to each Participant are shown in the Booklet-certificates. E~ch
schedule of insurance will contra! tile benefit <11Tlounts,
md.Ximum limics and lIny other amounts and limits which apply.
Monthly Premium Rates
The monthly premium rates to be charged 911d pro\ljsion~ applicable t,o premium$..rc shown O!I r))C 3rtsched
Rider Form GR-117] 1 (A) Rev. 7-"97, :tpplicable to each P3rticipnnt.
Premium Payments
Premium paymeot,,:
(1) are due and payable it] full to a place designated by Hzrtford Life; or
(2) with respoct c.o ljle initial premium payment, premium payment:! may be made to an
authorized agent of Hartford Life.
Payment ofpremilJms for a period before it is due will not guarantee the insurance for rllOlt period.
5'
GR-lJ710(06)A Rev. 7.'97
POLICY PROVISIONS
Entire Contnd
The contract between the parties COXlsists of:
(I) the polic)';
(2) the applic<Jtions, il3J1Y. of each Insured Person; ;.md
(3) the applfcation of cacb Participant.
All sr..nements made by the Policyholder, P."r~icipants, and. persons insured under the policy are If\le ~d
complete 1:0 the beSI of the knowledge and belie! of the p1m;on(s) mal{ing them. No statement will be used
in any contest unless it. is in writing and 2. copy of it is given to the person who made it, or to tJ.js
beneficiary.
Ineontesbbility
Except for non-payment of premium, the insurance providOO by the policy cannot be contested nfter such
insurance has been. in effect for 3 period or 2 years.
Change In Tbe Polky
No change may be mtde unless approved in writing by the President; or a Vice ?resic:!en~; or an Assistant
Vice president; or a ~rc:ta.ry; or an AssisWlt Socretary of Hartf:ord Life. No other person. may eb3ll.ge or
waive lU1y part of the policy, Any approved chil11ge shaIl be added to the policy writing.
If any cb;mge to sute or federaJ lsw, including but not limited [i) the federal Social Security Act. :affects
Hartford Life's liability lJndc:r the policy, Hanford Life may chang.e the policy or tJ1e premiums, or both_
Such. change:
(1) ....ill be effcctive as oftile date oftne cll~e to the state or federal Jaw;
(2) will Dot be made until Hanford. Life gives each Pa.''tjcip~nt 3 I days notice.
Right to AmeJId
Notwithstanding the above, after the policy has been in. force fOT 12 months., HaJ1ford Life may cbMgc any
or all of r.b.1: policy's provisions by notifying Ihe Policy11oider. Hartford Life must give th.ePolicyholder at
tea.st 31 days adv:tTlce wrir::en notice of my change.
Termiutirm of Poliey
Hartford T-ife may terminate this policy on any premium due date 2ff.er the policy has been in force for 12
monw by ~iving the Policyholder 31 days written notlce.
Grace Period
H9ltford Life will allow the Policyholder a 3/ da.y grace period for th.e pa..ym::nt of aU premiums aftc' the
first. During this 31 day period, the policy will stay in force. If the owed premium is not paid by The 31st
day, participation in the policy will automatically terminate. Premium is due for each day the policy is in
force under the terms of this GrilCe Pmod. If the Policyholder gives li.artford Life writ1lm adVMce notice
of 313 earlier cancellation date termination will OCCIlr. on the ~rlier chlc. Premium is due for each day the
policy is in f<m;e for eacb Panicipitt:lt.
C erti {ka.le
Klrtford I~ife will h-'lve a certificate of coverage prepared ror each Participant. The BookJet-oertific:lte will.
explain the important feature$ ofd1.e policy.
. 6
GR.-1l710(OG)A R,cv. 7.'97
POLley PROVI$IOJ:liS
(Continued)
Data To Be Furnished
The PoJicyhold.cr and Partitip.mt will give Hartford Life all inforrn3tion Hartford Life nGed5 regarding,
m~crs pc:rtail)i'lg r.o the insurance.
At any reasonable time:
(1) while the policy is in force; and
(2) for 1 year after that.
H31tford Life roa.y inspect:my of :he Policyholeer.'s or Participant's documents, books or records whicb
may affect the insumce or premiums ofthis policy. fftlle Policyholder or Perticipant gives Hartford Lifu
any iocorrect information, the relevant facts will be determ ined. U) establish if il1Sl.lrllOCC is in effect a.nd in
what a.'nouDt.
No person will:
(1) be deprived ofinslJrance to which he is o~'erwise entitled; or
(2) have inS\lT311Ce to w~jch he is nOt eotitled,
b~\lse of any misstatement of fact by the Policyholder Or Participa:u. Any required adjus:ment may be
maDe in premiums or benefi~.
No R.ep\.aument for WOrJlcrs' Compensntion
The policy does oot replace Workers' Comper:sation or affect 2l1JY Wjuircrnent for Workers' Com!>Cl)~tion
coverage.
Time Period
All periods begin and end at 12:0 I A.M.., standard time, at tJle Policyholder's ~ddress.
JuriJdiction
This policy is governed by tlle laws of the State where it is delivere<J.
7
GR..\I710(06)ARev.7-'97
l\10NROE COUNTY BOARD OF
COUNTY COMl\1ISSIONERS
Life and Accidental Death and
Dismemberment
TABLE OF CO~TEl'\TS
Group Life Insurance Benefits
PAGE
CERTIFICATE OF INSURANCE .......................................................... 2
SCHEDULE OF 11\'SURA1\'CE ...............................................................3
Who is eligible for coverage? .............................................................. 3
. When will '{ou become eligible':' (Eligibility Waiting Period)............ 3
What is E\'idence of Good Health? ......................................................4
When \vill 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 \\ill occur due to Your age? ......... 6
Must 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 effective?............................................................... 9
BENEFITS ........ .................. ............................................................. ...... 10
Life Insurance Benefit................................. .................................... ... 10
Accelerated Death Benefit ................................................................. 11
Accidental Death and Dismemberment (AD&D) Benefit ................. 12
TER1\110JA TIO:..' ................................................................................... 15
When does Your coverage terminate':' ...............................................15
Under what conditions can Your insurance be continued under the
continuation provisions? ............... .... ................................................. 15
CONVERSIOi'! PRIVILEGE ................................................................ 18
G EN ERA L PROV I SI ON S.. ......... .... ........ .... ... ...... ..... ......... ...... .......... ... 20
DEF Ii'! IT I O"0JS ........................................ .......... ..................................... 22
Z-TER\! (AOO)
12-'96
HARTFORD LIFE AND ACCIDEi'lT II'ISURAi'lCE COl\IPANY
Hartford, Connecticut
(Herein called Hal1ford Life)
CERTIFICATE OF II'ISURAl\'CE
under !\laster Group Insurance Policy GVL-016007
Effective August I, 1989
Issued by
Hartford Life
to
TRUSTEE OF
THE PUBLIC EMPLOYERS JI'IDUSTRY GROUP \'OLUl\'TARY
LIFE Al\D DISABILITY I:'\SURANCE 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;
become insured: and
continue to be insured,
according to the terms of the Policy"
The terms of the Policy \vhich affect an employee's insurance are contained
in the follo\ving pages. This Certificate of Insurance and the following
pages \\"ill 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}{r..oIU0
#P
1.:::.(!.1 i;,lII!'.;:r....:d.,.,r.'.!;
Ll,-.\'l,(lt'~ A ~ILilL l',.....t.!...!
Z-TERM(COO)
12-'96
:2
Some of the terms used within this Booklet-certiticate are capitalized and
ha-.:e special meanings. Please refer to the detinitions at the end of this
Booklet-certificate when reading about Your benetits.
SCHEDULE OF Ii'\SURANCE
Final interpretation of all provisions and coverages will be governed by
the' Group Insurance Policy on file with Hartford Life at its home office.
The Participant Employer:
MONROE COUNTY
BOARD OF COUNTY
COMMISSIONERS
Account Number:
303613
Policy Effective Date:
October I, 1999
Anniversary Date:
October I of each year,
beginning in 2000.
Who is eligible for coverage?
Eligible Class(es):
All Active Full-time
Employees
When ,viII )"ou become eligible? (Eligibility Waiting 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 enter an eligible
class.
] f You start working for the Employer after the Policy Effective Date,
You are eligible for coverage on the date on which You complete a
waiting period of 60 days of continuous service.
Retirees are eligible for coverage on the later of:
I. the date on which the indi vidual meets the detinition of a Retiree; or
2. the Policy Effective Date.
3
3036 \ 3(G\'L) 1 Re\
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 exams, 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.
YOllr Employer and'or Benefit Administrator will notify YOll of
approvals. We will notify YOll, in \\Titing, of any disapprovals.
When will Evidence of Good Health be required?
Evidence of Good Health is required if You elect no coverage for
Yourself when eligible to do so and later opt for coverage.
I f Evidence of Good Health is not approved in the situation(s) described
above, no coverage will become effective. Evidence of Good Health
must be provided at Your o\\"n expense.
AMOUj';T OF LIFE INSURANCE
Employee Only
What Life benefits are anilable to You?
Amount of Life Insurance:
An amount equal to S20,000.
AMOUj';T OF LIFE INSURANCE
Retiree Only
What Life benefits are available to Retirees?
Amount of Life Insurance:
Employees \\'ith 10 or more years of service, who retired on or after
October 1, 1987 have an amount of Life Insurance equal to S20,000,
which is reduced to S I 0,000 at age 70.
-I
Employees who retired, and elected Life Insurance benefits. prior to
October I, 1987 have an amount of Life I nsurance equal to the amount of
Employee Li fe Insurance in force on September I, 1987.
Employees who retired. and did not elect Life Insurance benefits. prior to
October I, ] 987 have an amount of Life 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. 55,000.
Your Amount of Li fe Insurance will be reduced by any Ii fe 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 convcrt, docs it affect the Amount of Life Insurance benefit
payable?
The Amount of Life Insurance under the Policy will be reduced by the
amount of the individual life insurance issued in accordance with the
Conversion Privilege for reasons other than reductions in coverage.
ACCIDENTAL DEATH, DISM El\lBERi\1 Et'."T
AND LOSS OF SIGHT BENEFIT (AD&D)
Employee Only
i\'OTE: i\'OT APPLICABLE TO RETIREES.
What 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
What reductions in Your cOYCfage will OCCUf due to YOUf age?
NOTE: NOT APPLICABLE TO RETIREES.
Your Amount of Life Insurance and Principal Sum will decrease on the
Anniversary Date which occurs on or next follows the date You 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
cO\"erage (after all
pre\'lous
reductions) will
be reduced
33~'O
50%
Reduced amounts of Life Insurance and Principal Sum will be rounded to
the next higher multiple of5IOOO, ifnot already such a multiple.
Eligibility and Enrollment
!\Iust You contribute toward the cost of coycrage?
With respect to active Employee Life Insurance and AD&D coverage,
You do not contribute toward the cost.
6
With respect to Retiree Life Insurance coverage, you may have to
cOfJtribute towards the cost.
How do You request coverage for Yourself?
If You are not required to contribute toward the cost of co\-erage, You
are not required to request coverage. Enrollment \vill be automatic.
However You \\-ill be required to complete a bendiciary election form.
I f You must contribute toward the cost of coverage. You are required to
enroll for coverage. To do so You must complete and sign a group
insurance enrollment form acceptable to Us and deliver it to the
Employer.
'Vhen does coverage start?
1 f Yau are not required to contribute toward the cost of coverage, You
will become insured on the date You become eligible for co\erage.
If You must contribute to\\-ard the cost of coverage_ You will become
insured on the first to occur of:
I_ the date 'lOll are eligible, if You enroll on or before that date;
2 _ the date You enroll, if YOll enroll within 3] days after the date You
become eligible.
If You enrol! more than 3 I days after the date You first become el igible
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 'lOll become eligible; or
2. the date approved by Us.
All effective dates of coverage are subject to the Deferred Effective Date
prOVISIon.
7
What is the Deferred Effective Date provision for Retirees?
If a Retiree is confined at home, in a hospital or elsewhere because ofa
physical or mental condition on the date an increase in co\.erage 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 of a healthy person of
the same age for a period of at least] 5 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.
What is the Deferred Effective Date provision for employees?
If You are absent from work due to a physical or mental condition on the
date Your insurance. an increase in coverage or a new benefit added to
the Policy would othemise have become effective, the effective date of
'y' our insurance, any increase in insurance or the additional benefit will
be deferred until the date You return to work as an Active Full-time
Employee.
Are there exceptions to the Deferred Effective Date provision?
l'.'OTE: l'.'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:
1. the Deferred Effective Date provision will not apply to the original
effective date of coverage; and
2. the co\"erage amount shown in the Schedule of Insurance will not
apply to You.
Instead, You will 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.
8
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 Plan had timely election
for the disability provision been made.
You will remain insured under this provision until the first to occur of:
I. 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 which begins on
the Policy Effective Date; or
4. the last day You would have been covered under the Prior Plan, had
the Prior Plan not terminated.
When are changes effective?
The provisions, terms and conditions of the Schedule of Insurance or this
Booklet-certificate may be modified, amended or changed at any time;
consent from any covered individual is not required.
If there is any type of change in Your class, the Schedule of Insurance or
the Booklet-certificate which:
I. decreases an alllount of coverage or deletes, limits or restricts the
availability of a benefit or provision. then that decrease, deletion,
limitation or restriction will be effective on the date the change 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 where 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. \\'hen the
reqldred 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 beneficiary(ies)
designated by You in writing and on file with the Employer.
Unless You have requested something different, payment will be made
as follows:
1. 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,
Ifno beneficiary is named, or ifno named beneficiary sUr\'ives You, We
may. at Our option, pay:
1. up to 5500 of Your life insurance to any party that We deem is
entitled because of the ir payment of burial expenses. \\' e will be
released from further liability for any amount so paid; and/or
2, the executors or administrators of Your estate; or
3. Your sUr\'i\'ing relatives in the following order:
a) all to Your sur\'iving spouse; or
b) if '{our spouse does not survive You, in equal shares to Your
surviving children; or
c) ifno child survives You, in equal shares to Your surviving
parents,
Ifa minor does not have a legal guardian, We may, until such a guardian
is appointed, pay the person We deem to be caring for and supporting
him. Such payment \\ill be in monthly installments of not more than
5200.
10
I fa death benefit payable meets Our guidelines. then the benefit is
payable into a checking account. Your beneficiary o\\ns 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 Terminally III and proofofsuch diagnosis
is provided by an attending physician licensed to practice in the United
States, and You are:
I. 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 SO~O of the in force Amount of Life Insurance,
and is subject to a minimum of 53,000 and a maximum of5500,000.
You may exercise this option only once per person.
For example, if You have an Amount of Life Insurance equal to 520,000
and You are Terminally Ill, You can request any portion of the life
insurance between 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 on Iy
53,000 now, You cannot request the additional 513,000 in the future.
What docs 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 Ar"Y BEr"EFITS IN ACCORDANCE WITH THIS
PROVISION WILL REDUCE LIFE INSURAr"CE BENEFITS
PAYABLE UPO:"\ DEATH.
What 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 bcncfit?
Th~ 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 qualify for a government
benefit or entitlement.
What if You made an assignment under this plan?
If You have executed an assignment ofrights and interest with respect to
Your Amount of Life Insurance, in order to pay benefits to You under
this provision, We must receive a release from the individual to whom
the assignment was made before any benefits are payable.
Accidental Death and Dismemberment (AD&D) Benefit
Employce Only
NOTE: NOT APPLICABLE TO RETIREES.
What conditions are necessary for benefits to bccome payable?
We will pay a benefit if You suffer an accidental injury \,.hile insured
and:
I. 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 We be notified of a claim?
A claimant must give Us, or Our appropriate representative, written
notice of a claim within 20 days after the loss happens or starts. If notice
cannot be given within that time, it must be given as soon as possible
after that.
Such notice must include:
1. the claimant's name and address; and
2. the Policy or account number.
12
Are special forms required to file a claim?
Within 15 days of receiving a notice of claim, We or Our appropriate
representative will 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 given?
Satisfactory 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 \vas not possible to give proof within the required time; and
:2. proof is given as soon as possible, but no later than a year after it is
due unless the claimant is not legally competent.
\Yhell and to \vhom 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 \\Titten proof is received.
Any payments, other than for Loss of life, which are owing at Your death
may be paid to Your estate. !fany payment is owed to:
1. Your estate;
:2. a person who is a minor; or
3. a person who is not legally competent,
then We may pay up to S] ,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 covcrnge?
No benefit will be paid for a Loss caused or contributed to by:
I. . sickness;
2. disease;
_'. nny medical treatment for items (I) or (2):
4. any infection, except a pus-forming infection of an accidental cut or
wound;
5. war or any act of war, whether \var is declared or not:
6. any injury recei\'ed 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.
\vhether 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 intoxication.
Intoxication means that blood alcohol content or the results of other
means of testing blood alcohol level, meet or exceed the legal
presumption of intoxication under the law of the state where the accident
took place.
\Vhnt 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.
DESCRIPTI00: 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 SUlll
One-half the Principal Sum
Principal Sum or the sum of
the Benefits payable for each
Loss, whichever is lesser.
1.+
Loss means the following:
I. 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 1'10:'\
Employee nnd Retiree Coverage
\Vhen does 'Your coverage terminnte?
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, i f You fail to make any further required
contribution:
3. the date You are no longer in a class eligible for coverage;
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.
EXCEPTIONS TO TERI\lIi'1ATIO:'\
Under \\'hnt conditions can 'four insurnnce be continued under the
continuntion 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:
1. 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
1 f You are on a documented leave of absence, other than Family or
Medical 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
l\ledical Leave Act of 1993, all of Your coverages may be continued for
up to 1:2 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:
2, the required premium for You must be paid;
3. 'Your benefit level will be that which was in effect on the day before
said leave started, subject to any reductions included in the Policy;
4. the amount of Earnings upon which 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 ifone of the following
events should occur:
a) the leave terminates 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
cl) 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 ofa period of 12 month(s)
\\'hich begins on the date You were first absent from \\ork as an Active
full-time Employee. If You feel that Your condition may continue for
an extended period of time, You should request that '{our Employer file a
waiver of premium claim.
\Vhnt is \Vaiver of Premium?
Waiver of premium is a provision \vhich allows for continued employee
life insurance, without pay'ment of premium, while You are Disabled.
This provision does not apply to Retirees.
To what covernges does the \Vnivcr of Premium apply?
These provisions apply only to Your Life Insurance.
Waiver of Premium does not apply to any AD&D Insurance,
16
Whnt conditions must be sntisfied before You qualify for Waivcr of
Premium?
1. 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 bst day of\\'ork as an Active Full-time Employee.
What does Disabled mean?
Disabled 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 and 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,
\Yhen will We waive premium?
\Ve 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 \\'ill be subject to any age reductions provided by
any part of the Policy.
Whnt if"You die before You qunlify for Wniver 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 waiver of
premium; and
You were Disabled,
:2,
We \vill pay the Amount of Life Insurance which is in force for You.
Can We have You exnmined for proof thnt You continue to be
Disabled?
During the first two years follo\ving 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. If You fail to submit any required proofor refuse to be
examined as required by Us, then Your coverage will terminate.
17
What if You are no 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.
I f 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 You do not return to work \vithin an Eligible Class, and You are not
eligible for any other group life insurance, then You are entitled to the
Conversion Privilege, You may convert 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 conveI1 Your coverage. You may convert no
more than Your Amount of Life Insurance that is in force on the date
waiver of premium terminates,
\Vhat if the Policy terminates before You qunlify 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 appro\ed for waiver
of premium.
What if the Policy terminates after You qualify for waiHr of
premium?
Termination of the Policy, or an Employer ceasing to be a Participant
Employer, will not affect Your coverage under the terms of this
provision,
CO:\'VERSION PRIVILEGE
The follo\ving does not apply to any AD&D Benefits,
\\'hen cnn nn 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 term ination, 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.
Whnt is the conversion policy?
The conversion policy will:
I. 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 convcrted?
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 \\"hich the
individual becomes covered within 31 days of termination of group
coverage; or
2. S2,000.
] f conversion is due to retirement or any other qualifying event, the full
amount of coverage lost may be converted.
How does nn individual convert covernge?
To convert life insurance, the individual must, within 31 days of the date
group coverage terminates, make written application to Us and pay the
premium required for his age and class of risk.
\Yhnt if denth 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 His death, pay the Amount
of Life Insurance He was entitled to convert.
19
GEf'lERAL PROVISIONS
When cnn this plan be contested?
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 which the statement was made after the insurance has been in force
fort\\o 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 oflhe Policy.
Are there nn)' rights of assignment?
Except for the dismemberment benefits under the AD&D Benefit, You
haw the right to absolutely assign all of Your rights and interest under
the Policy including, but not limited to, the following:
1. 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:
1. 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:
1. for the val idity or effect of any assignment; or
:2. to provide any assignee with notices \vhich We may be obligated to
provide to l' ou.
Ho\\ do You designnte 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
D~signations will become effective as of the dat~ 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.
Cnn \Ve hnvc a claimant exnmined or request an autopsy?
We reserve the right to have a claimant examined and to have an autopsy
performed, if not forbidden by law. Any such examinations will be as
r~asonably required by Us and at Our expense.
What notification \vill You receivc if Your c1nim is denied?
Ifa claim for benefits is wholly or partly denied, the claimant will be
furnished with \\Titten notification of the decision. This written decision
will:
I. give the specific reason(s) for the d~nial;
2. make specific reference to the provisions upon which the denial is
based; and
3. provide an explanation of the review procedure.
\Vhat recourse do 'You have if Your c1nim is denied?
On any deni~d claim, the claimant or His representative may appeal to Us
for a full and fair review.
The claimant may:
]. request a revie\\ upon \vritten application within 60 days ofreceipt
of claim denial;
:2. review pertinent documents; and
3. submit issues and comments in writing.
A request for an appeal will not be denied if not submitted \vithin 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 will 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
When can legnl action be tnken?
Legal action cannot be taken against Us:
1. 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 \Yorkers' Compensation coverage?
The Pol icy does not replace Workers' Compensation or affect any
requirement for Workers' Compensation coverage.
Physician-patient Relationship
You may choose any licensed physician, We shall not in any way disturb
the physician-patient relationship.
DEFJNITIO~S
Acti\'e 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 \vork week. This must be at least 25 hours. You will
be considered actively at work with 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 will 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 active ly at \\wk on the preceding scheduled
work day.
AnniYersnry Dnte - 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
] nsurance.
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 Effective 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 \vith
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.
We/Us/Our - The Hartford Life and Accident lnsurance Company.
Y ou/)' ou r - The employee to \vhom this Booklet-certificate is issued.
-"
,
The Plan Described in this Booklet
is"Insured by the
Hartford Life ancl Accident Insurance Company
I Ia rlfon!, Connecticut
Member of The Hartford Insurnncr Group
Form 303613(G\'L)1 Rcy
Printed in U.S.A, 3-'00