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Approvall of 3 (three) year renlevwall with (Minnesota (Life for Group Term ILifef Acciidenital'
Death and Disnnemlbernnent (AD&D) and Supplemenitalll (Life effective October 3, 2012.01 -
September 301, 2023 with niol Increase in cost and no plain, dlesiglnl changes, and approval
for the IEmployee Services Director to sign all necessary documents.
I'nAn( rn"lat'ion
Department: Employee Services Sponsors:
Category: Renewal)
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Staff Recommendation
Approval.
Meeting History
hill 1 x ';202 1:ocl AM Video Board off County Regular Meeting Pd., Krafft
Commissioners
IRA: Sd JII...I[:: APPROVED[UNIA.NI.IR OUS]I
I101FICI. 'Sylvia Murphy,Commisslonei, District 5
t.„R i14:14G I Lincoln, Palayor Pro Tem/OoinmissionPl' Distilirt 2
A V11,S Headier C,ar�-Athers,I'llichelle Lincoln, Cil Cat..s,David Rice,Sylvia Ii
Group Term Life Insurance Policy
MINNESOTALIFE
Minnesota Life Insurance Company-A Securian Company
400 Robert Street North • St.Paul,Minnesota 55101-2098
Read Your Policy Carefully Right to Cancel
This policy was issued to the policyholder on the effective It is important to us that you are satisfied with this policy
date shown on the specifications page attached to this after it is issued. If you are not satisfied with this policy,
policy. We promise to pay the benefits provided by this you may cancel it by delivering or mailing a written notice
policy,subject to its conditions, limitations, and or sending a telegram to Minnesota Life Insurance
exceptions. We make this promise and issue this policy in Company(Minnesota Life),400 Robert Street North, St.
consideration of the application for this policy and the Paul, Minnesota 55101-2098 and returning the policy
payment of the premiums. before midnight of the 30th day after you received this
policy.
Minnesota Life Insurance Company is a subsidiary of
Minnesota Mutual Companies, Inc., a mutual insurance Notice given by mail and return of the policy by mail are
holding company. The policyholder is a member of effective on being postmarked,properly addressed, and
Minnesota Mutual Companies, Inc.,which holds its annual postage prepaid. If you return this policy,you will receive,
meetings on the first Tuesday in March of each year at 3 within 10 days of the date we receive a notice of
p.m. local time. The meetings are held at 400 Robert cancellation, a full refund of any premiums you paid.
Street North, St. Paul, Minnesota 55101-2098. Upon cancellation of this policy,it will be void as if it had
never been issued.
Signed for Minnesota Life Insurance Company at St. Paul,
Minnesota on the effective date.
Secretary President
Notice to Policyholders
If you have any questions regarding this group policy, or if you need assistance in resolving a complaint,you can contact
us at: Minnesota Life Insurance Company,400 Robert Street North, St. Paul, MN 55101-2098. Toll Free Telephone
Number: 1-866-293-6047.
TABLE OF CONTENTS
Definitions..........................................................................2 Termination........................................................................5
General Information ..........................................................2 Conversion Right...............................................................6
Premiums..........................................................................4 Additional Information........................................................6
DeathBenefit.....................................................................4
GROUP TERM LIFE INSURANCE POLICY • NONPARTICIPATING
MHC-96-13180.9 Minnesota Life 1
EdF81772 10-2014
GROUP POLICY SPECIFICATIONS PAGE
GENERAL INFORMATION
POLICYHOLDER: Monroe County Board of County Commissioners POLICY NO.: 34395-G
ASSOCIATED COMPANIES: All subsidiaries and affiliates reported to Minnesota Life by the policyholder for
inclusion in the policy.
POLICY SITUS: The policy was issued and delivered in the state of Florida.
POLICY EFFECTIVE DATE: Basic Coverage-October 1,2014
Supplemental Coverage for the Monroe County Sheriffs Dept—October 1,2014
Supplemental Coverage for all other employees except the Monroe County
Sheriffs Dept—January 1,2015
POLICY ANNIVERSARY DATE: October 1 of each year beginning October 1,2015.
PREMIUM DUE DATE(S): The first day of each month.
GROUP: The group is composed of all active full-time employees and retirees of the
policyholder and its associated companies working in the United States classified as
follows:
Class 1: All active,full-time employees
Class 2: Retired employees insured on October 1, 1987 or later who have worked
at Monroe County Board of County Commissioners for at least 10 years
Class 3: A closed class of retired employees insured prior to October 1, 1987
ENROLLMENT PERIOD: Not applicable for noncontributory insurance;31 days from the first day of eligibility
for contributory insurance.
WAITING PERIOD: Class 1: The period commencing with the employee's date of employment and ending
with the employee's completion of 60 days of continuous employment.
Classes 2 and 3: None
MINIMUM HOURS Class 1: 25 hours per week
PER WEEK REQUIRED: Classes 2 and 3: Not Applicable
PLAN OF INSURANCE
EMPLOYEE BENEFIT SCHEDULE
EMPLOYEE TERM LIFE INSURANCE:
Basic Life Insurance
Eligible Class Amount of Basic Life Insurance
Class 1 $20,000
Class 2 $20,000
Class 3 The lesser of 50%of the amount of life insurance in force prior to
October 1, 1987 or$5,000.
F.MHC-50062 A
Supplemental Life Insurance
Eligible Class Amount of Supplemental Life Insurance
Class 1 An amount elected by the employee in increments of$10,000,subject to a
maximum of the lesser of five times annual salary or$500,000.
Classes 2 and 3 None
EMPLOYEE ACCIDENTAL DEATH AND DISMEMBERMENT(AD&D)INSURANCE:
Basic and Supplemental Insurance
Eligible Class Amount of Basic and Supplemental AD&D Insurance
Class 1 An amount equal to the amount of basic and supplemental life insurance for
which the employee is insured under the group policy.
Classes 2 and 3 None
GENERAL PROVISIONS FOR EMPLOYEE INSURANCE
AGE REDUCTIONS FOR CLASS 1: The amount of basic life and basic AD&D insurance on an employee age 70 or
(applies to basic coverage only) older shall be a percentage of the amount otherwise provided by the plan of
insurance applicable to such employee in accordance with the following table:
Age of Employee Amount of Insurance will decrease by:
70-74 33%
75 and over 50%
Age reductions will apply on the insured employee's 70t'and 75t'birthdays.
The reduced amount of insurance will be rounded to the next higher multiple of
$1,000,if not a multiple thereof.
AGE REDUCTIONS FOR CLASS 2: The amount of basic life insurance on a retiree age 70 or older shall be reduced
(applies to basic life coverage only) to 50%of the amount otherwise provided by the plan of insurance applicable to
such retiree.
Age reductions will apply on the insured retiree's 70'birthday.
AGE REDUCTIONS FOR CLASS 3: None
CONTRIBUTORY/NONCONTRIBUTORY: Basic insurance is noncontributory insurance;supplemental insurance is
contributory insurance.
GUARANTEED ISSUE AMOUNT: Guaranteed issue is the maximum amount of insurance an employee can receive
without evidence of insurability when first eligible under the plan provided
enrollment is made within the enrollment period. The amounts are as follows:
For basic insurance:
All basic insurance is guaranteed issue.
For supplemental insurance:
For employees who first become eligible after the effective date of this
policy:
$150,000.
EVIDENCE OF INSURABILITY: Evidence of insurability is required as stated in the policy and for an amount of
insurance greater than the guaranteed issue amount.
F.MHC-50062 B
EFFECTIVE DATE OF INCREASES Increases and decreases due to a change in eligible class will become effective
AND DECREASES DUE TO CHANGE the date of the change in eligible class.
IN ELIGIBLE CLASS:
DEPENDENTS BENEFIT SCHEDULE
DEPENDENTS TERM LIFE INSURANCE:
Spouse/Domestic Partner Life Insurance
Eligible Class Amount of Spouse/Domestic Partner Life Insurance
Class 1 An amount elected by the employee,in increments of$5,000,subject to a
maximum of$250,000,not to exceed the employees amount of basic and
supplemental coverage combined.
Classes 2 and 3 None
Spouse/Domestic Partner AD&D Insurance
Eligible Class Amount of Spouse/Domestic Partner AD&D Insurance
Class 1 An amount equal to the amount of supplemental life insurance for which the
spouse/domestic partner is insured under the group policy.
Classes 2 and 3 None
Child Life Insurance
Eligible Class Amount of Child Life Insurance
Children of class 1 $10,000
Classes 2 and 3 None
GENERAL PROVISIONS FOR DEPENDENTS INSURANCE
CONTRIBUTORY/NONCONTRIBUTORY: Dependents insurance is contributory insurance.
GUARANTEED ISSUE AMOUNT: Guaranteed issue is the maximum amount of insurance an eligible dependent
can receive without evidence of insurability when first eligible under the plan
provided enrollment is made within the enrollment period. The amounts are as
follows:
For employees who first become eligible for dependents insurance after the
effective date of this policy,the guaranteed issue amount is as follows:
For spouse/domestic partner insurance: $25,000
For child insurance: $10,000
EVIDENCE OF INSURABILITY: Evidence of insurability is required as stated in the policy and for an amount of
insurance greater than the guaranteed issue amount.
EFFECT OF EMPLOYEE'S RETIREMENT: All dependents insurance terminates upon the employee's retirement except as
provided under the portability provision.
F.MHC-50062 C
ADDITIONAL INFORMATION
SUICIDE EXCLUSION FOR LIFE Applies only to employee supplemental life and spouse/domestic partner life
INSURANCE: insurance under this policy. Exclusions for AD&D insurance,including a
suicide exclusion,are listed on the applicable policy rider
WAIVER OF PREMIUM APPLICATION: Applies to contributory and noncontributory employee insurance.
ACCELERATED DEATH BENEFIT RIDER: Notwithstanding anything in the policy to the contrary,the sections entitled
"How do we calculate the accelerated benefit?"and"How do we calculate the
accelerated benefit factor"do not apply under this policy.
PREMIUM PAYMENT GRACE PERIOD: Notwithstanding anything in the policy to the contrary,the premium payment
grace period is 60 days.
ONE TIME OPEN ENROLLMENT: The policyholder will hold a one-time open enrollment prior to January 1,2015.
During this enrollment,the following elections will not require evidence of
insurability:
• Employee supplemental life elections that do not exceed$150,000*
• Spouse/domestic partner life elections that do not exceed$25,000
• Any child life election
Coverage will be effective on January 1,2015,subject to the actively at work
requirement for employees and the hospitalization/confinement clause for
dependents.
*This one-time open enrollment does not apply to the Sheriffs of Class 1 who
were employed on or before October 1,2014.
ANNUAL ENROLLMENTS: During the policyholder's annual open enrollment,the following election
change can be made without providing evidence of insurability,provided the
insured receiving the increase has not previously been declined any insurance
amount under this policy due to failure to provide satisfactory evidence of
insurability:
• An employee may elect any child life amount
Coverage will be effective on January 1 following the annual enrollment,
subject to the actively at work requirement for employees and the
hospitalization/confinement clause for dependents.
QUALIFIED STATUS CHANGES: An employee who experiences one of the Qualified Status Changes listed below
may make the following election changes without providing evidence of
insurability,provided enrollment is made within 31 days of the status change
and the insured receiving the increase has not previously been declined any
insurance amount under this policy due to failure to provide satisfactory
evidence of insurability:
• An employee may enroll in spouse/domestic partner life insurance for
the first time provided the insurance amount does not exceed$25,000.
• An employee may elect any child life amount
Coverage will be effective on the date of the election,subject to the actively at
work requirement for employees and the hospitalization/confinement clause for
dependents.
F.MHC-50062 D
Qualified Status Change for this purpose means:
• Birth or adoption or otherwise acquiring a newly eligible child
• Marriage or creation of a domestic partnership
RIDER(S)TO THE GROUP POLICY
Accelerated Benefits Applies to all classes.
Accidental Death and Dismemberment Applies to class 1 only.
Dependents Term Life Applies to class 1 only.
Portability Applies to all classes.
Waiver of Premium Applies to class 1 only.
F.MHC-50062 E
Definitions Non-work day does not include time off for medical leave
of absence,temporary layoff,employer suspension of
age operations in total or in part,strike, and any time off due to
sickness or injury including sick days,short-term disability,
Attained age as of most recent birthday. or long-term disability.
associated company noncontributory insurance
Any company which is a subsidiary or affiliate of the Insurance for which an employee is not required to make
policyholder which is designated by the policyholder and premium contributions.
agreed to by us to participate under this policy.
policy anniversary
certificate effective date
The policy anniversary date shown on the specifications
The date the insured's coverage under this policy page attached to this policy.
becomes effective.
policy effective date
certificate holder
The date this policy was issued as shown on the
An employee who is eligible for and becomes insured specifications page attached to this policy.
according to the terms of this policy.
policyholder
contributory insurance
The owner of the group policy as shown on the
Insurance for which an employee is required to make specifications page attached to the group policy.
premium contributions.
specifications page
earnings
The outline which summarizes the policyholder's plan of
An employee's basic rate of compensation not including insurance.
commissions, overtime or premium pay, bonuses, or any
other additional compensation. waiting period
employee The period, if any,of continuous employment with the
employer required prior to becoming eligible for coverage
An individual who is employed by the policyholder or by an under this policy. The waiting period is shown on the
associated company. A sole proprietor will be considered specifications page attached to this policy.
the employee of the proprietorship. A partner in a
partnership will be considered an employee so long as the we,our,us
partner's principal work is the conduct of the partnership's
business. The term employee does not include temporary Minnesota Life Insurance Company.
employees nor corporate directors who are not otherwise
employees. you,your
employer The policyholder named on the specifications page
attached to this policy.
The policyholder or any designated associated
companies. General Information
evidence of insurability What is your agreement with us?
Evidence satisfactory to us of the good health of the This policy and your application contain the entire contract
prospective insured and any other underwriting between you and us. Any statements you make will, in
information we require. the absence of fraud, be considered representations and
not warranties. Also,any statement that you make will not
insured be used to void this policy, nor will it be used in our
defense if we refuse to pay a claim, unless the statement
A person who is eligible for and becomes insured is contained in your application.
according to the terms of this policy.
No change or waiver of any provisions of this policy, or
non-work day any certificate issued under it,will be valid unless made in
writing by us and signed by our president, a vice-
A day on which the employee is not regularly scheduled to president, our secretary, or an assistant secretary. No
work, including scheduled time off for vacations, personal agent or other person has the authority to change or waive
holidays,weekends and holidays,and approved leaves of
absence for non-medical reasons.
MHC-96-13180.9 Minnesota Life 2
EdF81772 10-2014
any provisions of this policy, or of any certificate issued increase in his or her amount of insurance would
under it. otherwise be effective, he or she will not be eligible for the
coverage or increase until he or she returns to active
Are employees of associated companies eligible for work. However, if the absence is on a non-work day,
insurance under this policy? coverage will not be delayed provided the employee was
actively at work on the work day immediately preceding
Yes. Employees of associated companies may be eligible the non-work day.
for insurance under this policy. Associated companies are
shown on the specifications page attached to this policy. Except as otherwise provided for in this policy, an
You represent any associated company in all transactions employee is eligible to continue to be insured only while
pertaining to this policy. Your acts or omissions and every he or she remains actively at work.
notice given by us to you shall be binding on every
associated company. When an associated company When will we require evidence of insurability?
ceases its participation under the policy,the policy shall
be considered to be terminated for all employees of the Evidence of insurability will be required if:
associated company. All provisions related to the policy
terminating will apply to such employees. (1) the specifications page attached to this policy
states that evidence of insurability is required; or
Can this policy be amended? (2) the insurance is contributory and the employee
does not enroll within the enrollment period shown
Yes. The insured's consent is not required to amend this on the specifications page attached to this policy;
policy or any certificates issued under it. Any amendment or
will be without prejudice to any claim for benefits incurred (3) the insurance for which the employee previously
prior to the effective date of the amendment. enrolled did not go into effect or was terminated
because the employee failed to make a required
Who is eligible for insurance? premium contribution; or
(4) during a previous period of eligibility,the
An employee is eligible if he or she: employee failed to submit required evidence of
insurability or that which was submitted was not
(1) is a member of the group and of an eligible class satisfactory to us; or
as shown on the specifications page attached to (5) the employee is insured by an individual policy
this policy;and issued under the terms of the conversion right
(2) works for the employer for at least the number of section.
hours per week shown as the minimum hours per
week requirement on the specifications page When does insurance become effective?
attached to this policy; and
(3) has satisfied the waiting period as shown on the Insurance becomes effective on the date that all of the
specifications page attached to this policy; and following conditions have been met:
(4) meets the actively at work requirement as shown
in the section entitled "What is the actively at work (1) an employee meets all eligibility requirements;
requirement?". and
(2) if required,the employee applies for the insurance
Are retired employees eligible for insurance? on forms which are approved by us; and
(3) we are satisfied with the employee's evidence of
If the policyholder's plan of insurance, as reflected in the insurability, if we require evidence; and
specifications page attached to this policy,does not (4) we receive the required premium.
specifically provide insurance for retired employees, a
retired employee shall not be eligible to become insured, Can an insured employee's coverage be continued
nor have his or her insurance continued. If the during sickness,injury,leave of absence or temporary
policyholder's plan of insurance specifically provides layoff?
insurance for retired employees,the minimum hours per
week and actively at work requirements will not apply to Yes. Insurance may be continued on an insured
such persons. employee who is not actively at work due to sickness,
injury, leave of absence or temporary layoff,subject to the
What is the actively at work requirement? employer's practices and procedures, including the
employer's limits on the length of continuation allowed for
To be eligible to become insured or to receive an increase the type of absence. Continuation is contingent upon
in the amount of insurance, an employee must be actively continued premium payment and is subject to the
at work fully performing his or her customary duties for his following maximum time frames:
or her regularly scheduled number of hours at the
employer's normal place of business, or at other places (1) for an employee on non-medical leave of absence
the employer's business requires him or her to travel. or temporary layoff,insurance cannot be
continued beyond 12 months from the last day the
If the employee is not actively at work on the date insured employee was actively at work.
coverage would otherwise begin,or on the date an
MHC-96-13180.9 Minnesota Life 3
EdF81772 10-2014
(2) for an employee on a medical leave of absence, may be paid during the 31-day period following the due
insurance cannot be continued beyond the later of date. The insurance under this policy will remain in effect
12 months from the last day the insured employee during the 31-day grace period.This grace period does
was actively at work or the date the employee not apply to the first premium payment.
attains age 65.
Can the premium be adjusted?
Continuation of insurance must be in accordance with
practices and procedures that preclude individual Yes. We will adjust the premium on each due date for
selection. insurance which was effective or terminated before the
most recent due date, but not reflected in prior premium
Coverage during a leave of absence and upon return from payments. We will charge you for any additional premium,
a leave of absence shall meet all state and federal and will refund any overpayment,excluding any
requirements. The above limits will be expanded if overpayment made more than 12 months before the
necessary in order to meet such requirements. adjustment.
Premiums Death Benefit
When and how often are premiums due? What is the amount of the death benefit?
Unless we have agreed to some other premium payment The amount of the death benefit is the amount of
procedure, premiums for this policy are remitted to us insurance shown on the specifications page attached to
monthly. Premiums are due on the premium due date as this group policy.
shown on the specifications page attached to this policy.
We apply premiums consecutively to keep the insurance Can an insured request a change in the amount of his
in force. or her contributory insurance?
You may pay premiums before they are due for any period An insured can request a change in his or her contributory
up to the next policy anniversary. Premiums paid in insurance amount only during an annual open enrollment
advance should be calculated at the rate of the monthly period, as determined by the employer, or within 31 days
premium currently due. of a Qualified Status Change. Qualified Status Change
shall be as determined by the employer.
Premium contributions for contributory insurance are to be
paid to you. The premium contributions by insureds for If an insured requests an increase in the amount of his or
contributory insurance should be remitted to us as due her contributory insurance,we will require evidence of
along with the premiums payable for noncontributory insurability, unless otherwise noted on the specifications
insurance. page.
How is the premium determined? When will changes in an insured's coverage amount
be effective?
The premium will be the premium rate multiplied by the
number of$1,000 units of insurance in force on the date Requested increases in the amount of an insured's
premiums are due. The premium may also be computed contributory insurance,if approved, are effective on the
by any other method on which you and we agree. date we approve the increase. Requested decreases in
the amount of an insured's contributory insurance are
We may change the premium rate: effective on the first day of the month following receipt of
the insured's request for a decrease, or if different,
(1) on any premium due date following the expiration according to the administrative practices of the employer.
of any rate guarantee period, or following the date
that the amount of insurance in force for any one Requests for a change made during a special enrollment
coverage changes by more than 15%from that period offered by the employer will not become effective
which was used to determine the current rates prior to the general effective date of elections made during
(active employee coverage and retiree coverage that enrollment.
are considered separate coverages, as are basic
life,supplemental life,spouse/domestic partner Increases and decreases in insurance amounts which
life, child life and AD&D);or result from a change in the insured's eligible class or
(2) anytime, if the policy terms are amended or the earnings will be effective as shown on the specifications
total amount of insurance in force changes by page attached to this policy.
15%from the volume that was used to determine
the current rates or more. All increases in the amount of insurance are subject to the
actively at work requirement.
Can a premium be paid after the date it is due? When will the death benefit be payable?
Yes. This policy has a 31-day grace period. If a premium We will pay the death benefit upon receipt at our home
is not paid on or before the date it is due,that premium office of written proof satisfactory to us that an individual
MHC-96-13180.9 Minnesota Life 4
EdF81772 10-2014
died while insured under this policy. All payments by us change will take effect as of the date it is signed, but will
are payable from our home office. not affect any payment we make or action we take before
receiving an insured's notice.
The death benefit will be paid in a single sum or by any
other method agreeable to us and the beneficiary. We will Termination
pay interest on the death benefit from the date of the
insured's death until the date of payment. Interest will be When does an insured's coverage terminate?
at an annual rate determined by us, but never less than
0.1%per year compounded annually, or the minimum The insured's coverage ends on the earliest of the
required by state law,whichever is greater. following:
Payment of the death benefit will extinguish our liability (1) the date this policy ends; or
under the certificate for which the death benefit has been (2) the date the employee no longer meets the
paid. eligibility requirements;or
(3) the date the policy is amended so the employee is
To whom will we pay the death benefit? no longer eligible; or
(4) 31 days(the grace period)after the due date of
We will pay the death benefit to the beneficiary or any premium contribution which is not paid; or
beneficiaries. A beneficiary is named by an insured to (5) the last day for which premium contributions have
receive the death benefit to be paid at the insured's death. been paid following an employee's written request
The insured may name one or more beneficiaries. The to cease participation under this policy.
insured cannot name you or an associated company as a
beneficiary. If an insured's coverage under this policy terminates due
The insured may also choose to name a beneficiary that to non-payment of premiums,his or her coverage may be
the insured cannot change without the beneficiary's reinstated if all premiums due are paid and received by us
consent. This is called an irrevocable beneficiary. within 31 days of the date of termination and during the
insured's lifetime.
If there is more than one beneficiary,each will receive an Can insurance on the life of an insured be reinstated
equal share, unless the insured has requested another after termination?
method in writing. To receive the death benefit, a
beneficiary must be living on the date of the insured's Yes. When an insured's coverage terminates because he
death. In the event a beneficiary is not living on the date or she is no longer eligible, and the insured becomes
of the insured's death,that beneficiary's portion of the eligible again within three months after the date his or her
death benefit shall be equally distributed to the remaining coverage terminated,the insured's coverage under this
surviving beneficiaries. In the event of the simultaneous policy may be reinstated.
deaths of the insured and a beneficiary,the death benefit
will be paid as if the insured survived the beneficiary. Provided the insured is not then covered by an individual
policy issued under the terms of the conversion right
If there is no eligible beneficiary, or if the insured does not section, his or her coverage under this group policy shall
name one,we will pay the death benefit to: be reinstated automatically,without evidence of
(1) the insured's lawful spouse(this does not apply to insurability or satisfaction of any waiting period. The
a domestic partner)if living, otherwise; amount of insurance will be that which applies to the
(2) the insured's natural or legally adopted child classification to which he or she then belongs, on the date
(children)in equal shares,if living, otherwise; he or she again becomes eligible. If the policyholder's
plan of insurance provides for contributory insurance
(3) the insured's parents in equal shares, if living, under this policy, an insured's amount of contributory
otherwise; insurance will be limited to that for which he or she was
(4) the personal representative of the insured's insured immediately prior to the loss of coverage.
estate.
Can an insured add or change beneficiaries? When does this group policy terminate?
You may terminate this group policy by giving us 31 days
Yes. An insured can add or change beneficiaries if all of prior written notice. We reserve the right to terminate this
the following are true: policy on the earliest of the following to occur:
(1) the insured's coverage is in force; and (1) 31 days(the grace period)after the due date of
(2) we have written consent of all irrevocable any premiums which are not paid; or
beneficiaries; and (2) on any subsequent policy anniversary after the
(3) the insured has not assigned the ownership of his date the number of employees insured is less
or her insurance. than any minimum established by us or as
required by applicable state law; or
A request to add or change a beneficiary must be made in (3) 90 days after we provide you with notice of our
writing. All requests are subject to our approval. A intent to terminate this policy.
MHC-96-13180.9 Minnesota Life 5
EdF81772 10-2014
Can this policy be reinstated? How is the premium for the individual policy
determined?
No. We will not reinstate this policy after it terminates.
You must submit a new application for a new policy after We base the premium for the individual policy on the plan
this policy has terminated. of insurance,the insured's age, and the class of risk to
which the insured belongs on the date of the conversion.
Conversion Right
When is the individual policy effective?
What is the conversion right?
The individual policy takes effect 31 days after the group
An insured may be able to convert this insurance to a new insurance provided under this policy terminates.
individual life insurance policy if all or part of the insured's
life insurance under this policy terminates. What happens if the insured dies during the 31-day
period allowed for conversion?
The insured may convert up to the full amount of
terminated insurance if termination occurs because he or If the insured dies during the 31-day period allowed for
she moves from one existing eligible class to another, or conversion,we will pay a death benefit regardless of
he or she is no longer in an eligible class. whether or not an application for coverage under an
individual policy has been submitted. The death benefit
Limited conversion is available if, after the insured has will be the amount of insurance the insured would have
been insured for at least five years, insurance is been eligible to convert under the terms of the conversion
terminated because: right section.
(1) the policy is terminated;or We will return any premium the insured paid for an
(2) the policy is changed to reduce or terminate the individual policy to the insured's beneficiary named under
insurance for that individual. this group policy. In no event will we be liable under both
this group policy and the individual policy.
In such case,the insured may convert up to the full
amount of terminated insurance, but not more than the Additional Information
maximum. The maximum is the lesser of:
What if an insured's age has been misstated?
(a) $10,000;and
(b) the amount of life insurance which terminated If an insured's age has been misstated,the death benefit
minus any amount of group life insurance for payable will be that amount to which the insured is entitled
which the insured becomes eligible under any based on his or her correct age.
group policy issued or reinstated by us or any
other carrier within 31 days of the date the A premium adjustment will be made to the premium you
insurance terminated under this policy. pay for the insured's noncontributory insurance and to the
premium an insured pays for contributory insurance, if
Neither the conversion right nor the limited conversion any,so that the actual premium required at the insured's
right is available if the insured's coverage under this policy correct age is paid.
terminates due to failure to make,when due, required Is there a suicide exclusion?
premium contributions.
Under both the conversion right and the limited conversion The specifications page attached to this policy indicates
what insurance, if any, is subject to the suicide exclusion
right,the insured may convert his or her insurance to any outlined below.
type of individual policy of life insurance then customarily
issued by us for purposes of conversion,except term When applicable,this suicide exclusion limits our liability
insurance. The individual policy will not include any to an amount equal to the premiums paid for an insured, if
supplemental benefits,including, but not limited to,any that insured,whether sane or insane,dies by suicide
disability benefits,accidental death and dismemberment within two years of the effective date of his or her
benefits, or accelerated benefits. insurance.
How does an insured convert his or her insurance? If there has been an increase in the insured's amount of
insurance for which he or she was required to apply or for
An insured converts his or her insurance by applying for which we required evidence of insurability, and if the
an individual policy and paying the first premium within 31 insured dies by suicide within two years of the effective
days after the group insurance terminates. No evidence date of the increase, our liability with respect to that
of insurability will be required. increase will be limited to the premiums paid and
attributable to such increase.
MHC-96-13180.9 Minnesota Life 6
EdF81772 10-2014
When does an insured's insurance become Are you required to maintain records?
incontestable?
Yes. You are required to maintain adequate records of
Except for the non-payment of premiums, after the any information necessary for us to administer this policy.
insured's insurance has been in force during his or her We own the records relating to the insurance provided by
lifetime for two years from the effective date of his or her this policy, and can obtain them from you at any
coverage,we cannot contest the insured's coverage. reasonable time.
However, if there has been an increase in the amount of
insurance for which the insured was required to apply or If a clerical error is made in keeping records on the
for which we required evidence of insurability,then,to the insurance under this policy, it will not affect otherwise valid
extent of the increase,any loss which occurs within two insurance.A clerical error does not continue insurance
years of the effective date of the increase will be which is otherwise stopped. If an error causes a change in
contestable. premium payment,we will make a fair adjustment.
Any statements the insured makes in his or her application Will a certificate of insurance be provided for each
will, in the absence of fraud, be considered certificate holder?
representations and not warranties. Also,any statement
an insured makes will not be used to void his or her Yes. We will provide you with a certificate of insurance for
insurance, nor defend against a claim, unless the delivery to each certificate holder. The certificate will
statement is contained in the application and any evidence include information regarding the principal provisions of
of insurability application attached to the insured's his or her coverage.
certificate.
Will this policy receive experience credits?
Can an insured's insurance be assigned?
Each year we will determine if this policy will receive an
Yes. However,we will not be bound by an assignment of experience credit.
the certificate or of any interest in it unless it is made as a
written instrument,the insured files the original instrument Are you our agent?
or a certified copy with us at our home office, and we send
the insured an acknowledged copy. No. For all purposes of this policy, neither you, an
associated company, nor any administrator you appoint is
We are not responsible for the validity of any assignment. our agent. We will not be liable for any of your acts or
An insured is responsible for ensuring that the assignment omissions or those of an associated company or
is legal in his or her state and that it accomplishes his or administrator.
her intended goals. If a claim is based on an assignment,
we may require proof of interest of the claimant. A valid Will the provisions of this policy conform with state
assignment will take precedence over any claim of a law?
beneficiary. Yes. If any provision in this policy, or in the certificates
issued under this policy, is in conflict with the laws of the
state governing the policy or the certificates,the provision
will be deemed to be amended to conform to such laws.
MHC-96-13180.9 Minnesota Life 7
EdF81772 10-2014
Accelerated Benefits
Policy Rider
MINNESOTALIFE
Minnesota Life Insurance Company-A Securian Company
400 Robert Street North • St.Paul,Minnesota 55101-2098
Benefits received under this Accelerated Benefits Policy Terminal Condition
Rider may be taxable. Certificate holders should seek
assistance from a personal tax advisor prior to requesting What is a terminal condition?
an accelerated payment of death benefits.
A terminal condition is a condition caused by sickness or
General Information accident which directly results in a life expectancy of
twelve months or less.
This rider amends the group policy to which it is attached
and is subject to every term, condition,exclusion, What evidence do we require of the insured's terminal
limitation, and provision of the group policy unless condition?
otherwise expressly provided for herein.
We must be given evidence that satisfies us that the
What does this rider provide? insured's life expectancy,because of sickness or accident,
is twelve months or less. That evidence must include
This rider provides for the accelerated payment of either certification by a physician.
the full or a partial amount of an insured's death benefit
provided under the group policy. If the insured has a Do we have the right to obtain independent medical
terminal condition as defined in this rider, an accelerated verification?
payment of the death benefit may be requested.
Yes. We retain the right to have the insured medically
Definitions examined at our own expense to verify the insured's
medical condition.We may do this as often as reasonably
accelerated benefit required while accelerated benefits are being considered
or paid.
The amount of the death benefit we will pay if the insured
is eligible under this rider. Payment of Accelerated Benefit
death benefit How do we calculate the accelerated benefit?
The amount of the insured's life insurance as shown on We will multiply the death benefit by the accelerated
the specifications page attached to the certificate holder's benefit factor to determine the accelerated benefit
certificate. available.
immediate family How do we calculate the accelerated benefit factor?
The certificate holder's spouse/domestic partner, children, The accelerated benefit factor will be stated as a
parents,grandparents,grandchildren,brothers and percentage of the insured's death benefit. When we
sisters, and their spouses. calculate this factor,we will consider the insured's age
and gender.
insured
We will also base our calculation on certain assumptions,
For purposes of this rider, an insured employee, an which we may change from time to time, including but not
insured spouse/domestic partner, or an insured dependent limited to assumptions about:
child.
(1) expected future premiums; and
physician (2) the insured's life expectancy.
An individual who is licensed to practice medicine or treat What are the conditions for the payment of an
illness in the state in which treatment is received. This accelerated benefit?
does not include the certificate holder, or a member of the
certificate holder's immediate family. We will consider the payment of an accelerated benefit,
MHC-96-13184.9 Minnesota Life 1
EdF81773 10-2014
subject to all of the following conditions: may ask for further satisfactory evidence that the insured
meets all requirements for the accelerated benefit.
(1) coverage must be in force and all premiums due
must be fully paid;and What is the effect on an insured's coverage of the
(2) application must be made in writing and in a form receipt of an accelerated benefit?
which is satisfactory to us. We will tell a certificate
holder what form is required;and If a certificate holder elects to accelerate the full amount of
(3) the certificate holder must be the sole owner of an insured's death benefit,the insured's coverage and all
the certificate; and other benefits under the certificate and any certificate
(4) the insured's insurance must not have an supplements which apply to that insured will end. If the
irrevocable beneficiary. insured is a certificate holder, any other individual insured
under his or her certificate will be allowed to convert any
Who may request an accelerated payment of the death such insurance to a policy of individual life insurance
benefit? according to the conversion right section of the group
policy to which this rider is attached.
A certificate holder may request an accelerated payment If a partial accelerated benefit is chosen, coverage will
of the insurance on his or her life or on the life of a remain in force and premiums will be reduced accordingly.
spouse/domestic partner or dependent child insured under The remaining amount of insurance under the certificate
his or her certificate. will be the full amount of insurance minus the amount of
Is the request for an accelerated benefit voluntary? insurance that was accelerated.
Yes. An accelerated benefit will be made available on a How will we pay the accelerated benefit?
voluntary basis only. An accelerated benefit under this We will pay the accelerated benefit in one lump sum or in
rider is not intended to cause an involuntary reduction of any other mutually agreeable manner.
the death benefit ultimately payable to the named
beneficiary. Therefore, payment of the death benefit To whom will we pay accelerated benefits?
cannot be accelerated under this rider if the insured:
(1) is required by law to use this option to meet the All accelerated benefits will be paid to the certificate
claims of creditors,whether in bankruptcy or holder who requested the accelerated payment unless the
otherwise; or certificate holder validly assigns them otherwise. If such
certificate holder dies before all payments have been
(2) is required by a government agency to use this made,we will pay the remainder to the insured's
option in order to apply for, obtain, or keep a beneficiary named under the certificate. Payment will be
government benefit or entitlement. made in one lump sum which will be the present value of
the payments that remain, using the interest rate we use
Is there a minimum or maximum death benefit eligible to determine the payments.
for an accelerated benefit?
Yes. The minimum death benefit to be eligible for an Termination
accelerated benefit under this rider is$10,000. The When does an insured's coverage under this rider
maximum death benefit to be eligible for an accelerated terminate?
benefit is$1,000,000.
Does a certificate holder have to take the entire An insured's coverage ends on the date the insured is no
accelerated benefit? longer covered for life insurance under the group policy.
No. The certificate holder may choose to receive a partial When does this rider terminate?
accelerated benefit. If he or she does so,the insured's This rider will terminate on the earlier of:
remaining coverage will stay in force.
If a certificate holder elects to receive only a partial (1) the date we receive a written request to cancel
accelerated benefit amount available under this rider,the this rider; or
remaining death benefit under the certificate must be at (2) the date the group policy is terminated.
least$25,000.
The certificate holder may reapply for the payment of the
remaining amount of insurance at any time. However,we
Secretary President
MHC-96-13184.9 Minnesota Life 2
EdF81773 10-2014
Accidental Death and Dismemberment
Policy Rider
MINNESOTALIFE
Minnesota Life Insurance Company,a Securian Financial Group affiliate
400 Robert Street North • St.Paul,Minnesota 55101-2098
Statement to Policyholders from, or where there is a contribution from,any of the
following:
If you have any questions regarding this policy rider, or if
you need assistance in resolving a complaint,you can (1) self-inflicted injury or self destruction,whether sane
contact us at: Minnesota Life Insurance Company,400 or insane; or
Robert Street North, St. Paul, MN 55101-2098. Toll-Free (2) suicide or attempted suicide,whether sane or
Telephone Number: 1-800-843-8358. insane-, or
(3) the insured's participation in or attempt to commit a
General Information crime, assault,felony, or any illegal activity,
regardless of any legal proceedings, or the
This rider is issued in consideration of the required absence of any legal proceedings,thereto; or
premium and amends the group policy to which it is (4) bodily or mental infirmity, illness or disease; or
attached. This rider is subject to every term, condition, (5) the use of alcohol,drugs, medications, poisons,
exclusion, limitation, and provision of the group policy gases,fumes or other substances taken, absorbed,
unless otherwise expressly provided for herein. inhaled, ingested or injected, unless taken upon
the advice of a licensed physician in the verifiable
What does this rider provide? prescribed manner and dosage;or
(6) motor vehicle collision or accident where the
This rider provides accidental death and dismemberment insured is the operator of the motor vehicle and this
coverage subject to all terms, conditions, and exclusions insured's blood alcohol level meets or exceeds the
herein. level at which intoxication is defined in the state
where the collision or accident occurred,
Who is eligible for insurance under this rider? regardless of any legal proceedings, or the
An employee or a spouse/domestic partner who is eligible absence of any legal proceedings,thereto; or
under the provisions applicable to life insurance coverage (7) infection, other than infection occurring
under the group policy is eligible for insurance under this simultaneously with, and as a direct result of,the
rider. accidental injury; or
(8) medical or surgical treatment or diagnostic
When does insurance under this rider become procedures or any resulting complications; or
effective? (9) travel in or descent from any aircraft,except as a
fare-paying passenger on a regularly scheduled
Insurance becomes effective on the date that the commercial flight on a licensed passenger aircraft;
employee or spouse/domestic partner becomes insured or
for life insurance under the group policy. (10) war or any act of war,whether declared or
undeclared; or
Accidental Death and Dismemberment (11) service in the military of any nation.
(AD&D) Benefit
What is the amount of the accidental death and
What does accidental death or dismemberment by dismemberment benefit?
accidental injury mean?
The amount of the benefit shall be a percentage of the
Accidental death or dismemberment by accidental injury amount of insurance shown on the specifications page
as used in this rider means that the insured's death or attached to the group policy. The percentage is
dismemberment results,directly and independently of all determined by the type of loss as shown in the following
other causes,from an accidental bodily injury which is table:
unintended, unexpected, and unforeseen. The bodily
injury must be evidenced by a visible contusion or wound, FOR LOSS OF AMOUNT OF BENEFIT
except in the case of accidental drowning. The bodily
injury must be the sole cause of death or dismemberment. Life....................................Full Amount of AD&D Insurance
Both Hands or Both Feet..Full Amount of AD&D Insurance
The injury must occur while the insured's coverage under Sight of Both Eyes............Full Amount of AD&D Insurance
this rider is in force. The insured's death or Speech and Hearing.........Full Amount of AD&D Insurance
dismemberment must occur within 180 days after the date One Hand and One Foot..Full Amount of AD&D Insurance
of the injury. One Foot and Sight
of One Eye........................Full Amount of AD&D Insurance
In no event will we pay the accidental death or One Hand and Sight
dismemberment benefit where the insured's death or of One Eye........................Full Amount of AD&D Insurance
dismemberment is caused directly or indirectly by, results Quadriplegia.....................Full Amount of AD&D Insurance
Paraplegia..................75% of Amount of AD&D Insurance
11-31358 Minnesota Life 1
EdF81774 10-2014
Sight of One Eye.........50%of Amount of AD&D Insurance to the person or persons entitled to receive a death benefit
Speech or Hearing......50%of Amount of AD&D Insurance under the terms of the group policy. The benefit for other
One Hand or losses sustained by a certificate holder will be paid to the
One Foot.....................50%of Amount of AD&D Insurance certificate holder, if living, otherwise to his or her estate.
Hemiplegia..................50%of Amount of AD&D Insurance
Thumb and Index Additional Benefits
Finger of One Hand.....25%of Amount of AD&D Insurance
Unless stated otherwise, additional benefits are payable to
Loss of hands or feet means complete severance at or the same person or persons who receive the AD&D
above the wrist or ankle joints. Loss of sight,speech, or benefits. Additional benefits are paid in addition to any
hearing means the entire and irrecoverable loss of sight, AD&D benefits described in the Accidental Death and
speech, or hearing which cannot be corrected by medical Dismemberment section, unless otherwise stated. All
or surgical treatment or by artificial means. Loss of thumb provisions of this rider, including but not limited to the
or finger means complete severance at or above the exclusions listed under the"What does accidental death or
metacarpophalangeal joints(the joints closest to the palm dismemberment by accidental injury mean?"section,shall
of the hand). apply to these additional benefits.
Quadriplegia means total and permanent paralysis of both Air Bag Benefit
upper limbs(from the shoulder down including total
paralysis of both hands)and both lower limbs(from the What is the air bag benefit?
waist down including total paralysis of both feet).
Paraplegia means total and permanent paralysis of both If an insured dies as a result of a covered accident which
lower limbs(from the waist down including total paralysis occurs while he or she is driving or riding in a private
of both feet). Hemiplegia means total and permanent passenger car,we will pay an additional AD&D benefit
paralysis of both the upper limb(from the shoulder down equal to the lesser of:
including total paralysis of the hand)and lower limb(from
the waist down including total paralysis of the foot)on one (1) $10,000; or
side of the body. (2) 10%of the insured's amount of AD&D insurance.
A benefit is not payable for both loss of one hand and the In order to be eligible for this benefit,the following must
loss of thumb and index finger of one hand for injury to the apply:
same hand as a result of any one accident. Under no
circumstance will more than one payment be made for the (1) the seat in which the insured was seated was
loss or paralysis of the same limb,eye,finger,thumb, equipped with a properly installed airbag at the
hand,foot,sight,speech, or hearing if one payment has time of the accident; and
already been made for that loss. (2) the private passenger car is equipped with
seatbelts; and
Benefits may be paid for more than one accidental loss (3) a seatbelt was in proper use by the insured at the
but the total amount of AD&D insurance payable under time of the accident as certified in the official
this rider for all of an insured's losses due to any one accident report or by the investigating officer;and
accident, not including any amount paid according to the (4) at the time of the accident,the driver of the private
terms of the Additional Benefits section of this rider,will passenger car was a licensed driver and was not
never exceed the full amount of AD&D insurance shown intoxicated, impaired, or under the influence of
on the specifications page attached to the group policy. alcohol or drugs.
When will the accidental death and dismemberment Airbag means a passive restraint device in a vehicle which
benefit be payable? inflates upon collision to protect an individual from injury or
We will pay the AD&D benefit upon receipt at our home death.
office of written proof satisfactory to us that the insured Seatbelt means a properly installed seatbelt(or child
died or suffered dismemberment as a result of an restraint if the insured is a child), lap and shoulder restraint,
accidental injury. All payments by us are payable from our or other restraint approved by the National Highway Traffic
home office. Safety Administration or any successor governmental
The benefit will be paid in a single sum. We will pay agency. A private passenger car means a validly
interest on the benefit from the date of the insured's death registered four-wheeled private passenger car or
or dismemberment until the date of payment. Interest will policyholder-owned car,jeep, pickup truck or van, including
be at an annual rate determined by us, but never less than a sport utility vehicle(SUV),that is not licensed
0.1%per year compounded annually or the minimum commercially or being used for racing, or acrobatic or stunt
required by state law,whichever is greater. driving.
To whom do we pay the benefit?
A certificate holder's accidental death benefit will be paid
11-31358 Minnesota Life 2
EdF81774 10-2014
Seatbelt Benefit When does this rider terminate?
What is the seatbelt benefit? This rider will terminate on the earlier of:
If an insured dies as a result of a covered accident which (1) the date we receive a written request from the
occurs while he or she is driving or riding in a private policyholder to cancel this rider; or
passenger car,we will pay an additional AD&D benefit (2) the date the group policy is terminated.
equal to the lesser of:
(1) $20,000;or Additional Information
(2) 20%of the insured's amount of AD&D insurance. Do we have the right to obtain independent medical
verification?
In order to be eligible for this benefit,the following must
apply: Yes. We retain the right to have an insured medically
examined at our expense whenever a claim is pending and,
(1) the private passenger car was equipped with where not forbidden by law,we reserve the right to have an
seatbelts; and autopsy performed in case of death.
(2) a seatbelt was in proper use by the insured at the
time of the accident as certified in the official Can insurance under this rider be converted to a policy
accident report or by the investigating officer;and of individual insurance upon termination?
(3) at the time of the accident,the driver of the private
passenger car was a licensed driver and was not No. Coverage under this rider will not be included in any
intoxicated, impaired, or under the influence of insurance issued under the conversion right section of the
alcohol or drugs. group policy.
Termination 407�,.
When does an insured's coverage under this rider
terminate? Secretary President
An insured's coverage ends on the earlier of:
(1) the date the certificate holder is no longer covered
for life insurance under the group policy; or
(2) for an insured dependent spouse/domestic
partner,the date the dependent spouse/domestic
partner no longer meets the eligibility
requirements; or
(3) for an insured dependent spouse/domestic
partner,the date the dependent is no longer
covered for life insurance under the group policy;
or
(4) 31 days(the grace period)after the due date of
any premium contribution which is not paid.
11-31358 Minnesota Life 3
EdF81774 10-2014
Dependents Term Life Insurance
Policy Rider
MINNESOTALIFE
Minnesota Life Insurance Company-A Securian Company
400 Robert Street North • St.Paul,Minnesota 55101-2098
General Information dependent on the employee for more than one-
half of their support and maintenance.
This rider is issued in consideration of the required
premium and amends the group policy to which it is If both parents of a child qualify as eligible employees
attached. The rider is subject to every term, condition, under the group policy,the child shall be considered a
exclusion, limitation, and provision of the group policy dependent of only one parent for purposes of this rider. If
unless otherwise expressly provided for herein. any child qualifies as an eligible employee under the
group policy, he or she is not eligible to be insured as a
What does this rider provide? dependent child.
This rider provides insurance on the lives of the insured Any dependent child who,subsequent to the effective date
employee's eligible dependents. of the insured employee's child life insurance, meets the
requirements of this provision will become insured on the
What members of the insured employee's family are date he or she so qualifies.
eligible for insurance under this rider?
When will we require evidence of insurability?
The following members of the insured employee's family
are eligible for insurance under this rider: Evidence of insurability will be required if:
(1) the insured employee's lawful spouse who is not (1) the specifications page attached to the group
legally separated from the insured and who is not policy states that evidence of insurability is
eligible for insurance as an employee under the required; or
policy to which this rider is attached; and (2) the insurance is contributory and the employee
(2) the insured employee's domestic partner who is does not enroll for coverage under this rider within
not eligible for insurance as an employee under the enrollment period shown on the specifications
the policy to which this rider is attached. page attached to the group policy; or
Domestic partners are two adults who have (3) dependents insurance for which the employee
chosen to share one another's lives in a previously enrolled did not go into effect or was
committed family relationship of mutual caring. terminated because the employee failed to make
Two individuals are considered to be domestic a required premium contribution; or
partners if: (4) during a previous period of eligibility,the
(a) they consider themselves to be members of employee failed to submit evidence of insurability
each other's immediate family; and that was required for a dependent or that which
(b) they agree to be jointly responsible for each was submitted was not satisfactory to us; or
other's basic living expenses; and (5) the dependent is insured by an individual policy
(c) neither of them is married or a member of issued under the terms of the conversion right of
another domestic partnership; and this rider.
(d) they are not blood related in a way that would
prevent them from being married to each When does insurance on a dependent become
other under the laws of Florida;and effective?
(e) each is at least of the legal age and
competency required by Florida law to enter Insurance on a dependent becomes effective on the date
into a marriage or other binding contract; and when all of the following conditions have been met:
(f) they must each sign a Declaration of
Domestic Partnership as provided for in (1) the dependent meets all eligibility requirements;
Section 14.03; and and
(g) they both reside at the same residence; and (2) if required,the insured employee applies for
(3) the insured employee's and domestic partner's dependents coverage on forms which are
children,stepchildren and legally adopted approved us; and
children. Children are eligible from live birth (3) we are satisfied'with the dependent's evidence of
(stillborn and unborn children are not eligible)to insurability, if we require evidence; and
the attainment of age 26. Children age 26 or (4) we receive the required premium.
older are also eligible if they are physically or
mentally incapable of self-support,were incapable If a dependent is hospitalized or confined because of
of self-support prior to age 26 and are financially illness or disease on the date his or her insurance would
otherwise become effective, his or her effective date shall
MHC-96-13186 Minnesota Life 1
EdF81775 10-2014
be delayed until he or she is released from such Additional Information
hospitalization or confinement. This does not apply to a
newborn child. However,in no event will insurance on a What is the conversion right under this rider?
dependent be effective before the insured employee's
insurance under the group policy is effective. If an insured dependent's coverage under this rider
terminates because he or she is no longer eligible, or
Death Benefit because of the death of the insured employee, or because
of termination or amendment of this rider,the insurance
What is the amount of life insurance on each insured may be converted to a policy of individual insurance with
dependent? Minnesota Life.
The amount of life insurance on each insured dependent Conversion may be requested by the insured employee,
is shown on the specifications page attached to the group an insured dependent of legal capacity, or the insured
policy. dependent's guardian, if applicable. All other conditions
and provisions of the conversion right section of the group
To whom will we pay the death benefit? policy to which this rider is attached will apply.
The death benefit payable under this rider will be paid to Does the Waiver of Premium rider to the group policy
the insured employee if living, otherwise to his or her apply to insured dependents?
estate.
The Waiver of Premium rider to the group policy will not
Termination apply to disabilities for dependents covered under this
rider.
When does an insured dependent's coverage under
this rider terminate? However, if,due to the insured employee's disability, his
or her insurance is continued in force without further
An insured dependent's coverage ends on the earliest of payment of premiums due to the Waiver of Premium rider
the following: to the group policy, any dependents insurance provided by
this rider shall also continue in force without further
(1) the date the dependent no longer meets the payment of premiums until the dependent's eligibility
eligibility requirements;or terminates or until the insured employee's insurance is no
(2) 31 days(the grace period)after the due date of longer continued in force due to the Waiver of Premium
any premium contribution which is not paid; or rider to the group policy.
(3) the last day for which premium contributions have
been made following an employee's written This provision is not applicable if the dependent's
request that insurance on his or her eligible insurance has been converted under the conversion right
dependents be terminated; or section of this rider, unless the converted policy is
(4) the date the employee is no longer covered under surrendered without claim except for refund of premiums.
the group policy.
The employee must notify us or the employer when a
dependent is no longer eligible for coverage under this f/
rider so that premiums may be discontinued. All Secretary President
premiums paid for dependents who are no longer eligible
for coverage under this rider will be refunded without any
payment of claim.
When does this rider terminate?
This rider will terminate on the earlier of:
(1) the date we receive a written request to cancel
this rider; or
(2) the date the group policy is terminated.
MHC-96-13186 Minnesota Life 2
EdF81775 10-2014
Term Life Insurance Portability
Policy Rider
MINNESOTALIFE
Minnesota Life Insurance Company-A Securian Company
400 Robert Street North • St.Paul,Minnesota 55101-2098
General Information What insurance can be continued under this rider?
This rider is issued in consideration of the required Contributory life and AD&D insurance and noncontributory
premium and amends the group policy to which it is life and AD&D insurance may be continued under this
attached. This rider is subject to every term, condition, rider. If the certificate holder elects to continue his or her
exclusion, limitation and provision of the group policy own coverage according to the provisions of this rider, he
unless otherwise expressly provided for herein. or she may also elect to continue contributory insurance
for any other individual insured under his or her certificate.
What does this rider provide? The certificate holder may also continue coverage under
all supplements to such certificate which apply to
This rider provides for continuation of group life insurance contributory insurance and by which he or she was
for insureds who no longer meet the eligibility insured immediately preceding his or her portability date,
requirements of the group policy except as provided for except the Waiver of Premium Certificate Supplement,
herein. which shall terminate upon porting.
To continue coverage under the provisions of this rider, an The amount of insurance continued under this rider for
eligible insured must make a written request and make the any individual will be subject to any applicable state law or
first premium contribution within 31 days after insurance regulation relating to allowable amounts of insurance.
provided by the group policy would otherwise terminate.
Evidence of insurability will not be required. Coverage What is the minimum amount of insurance that can be
provided by this rider will then be deemed effective continued under this rider?
retroactive to the beginning of the 31-day period. This
date is considered to be the insured's portability date and The minimum amount of insurance that can be continued
the insured is then considered to have portability status. on the life of an insured under this rider is$10,000 for an
employee and $1,000 for each of his or her insured
Who is eligible to continue insurance under this rider? dependents.
A certificate holder is eligible to continue insurance under What is the maximum amount of insurance that can
this rider if he or she,except as provided by this rider, no be continued under this rider?
longer meets the eligibility requirements of the group
policy due to any of the following: The maximum amount of insurance that can be continued
under this rider is the amount of insurance that was in
(1) the employee terminates employment, including force on the insured's portability date, but not more than
retirement; or $1,000,000 for an employee or$150,000 for a
(2) the employee is no longer in a class eligible for spouse/domestic partner. However,for an insured who is
insurance or is on a leave or layoff; or age 65 or older on his or her portability date,the amount
(3) a class or group of employees insured under the will not be more than 65%of the amount in force on the
policy is no longer considered eligible and there is insured's portability date,to a maximum of$650,000 for
no successor plan for that class or group. an employee or$97,500 for a spouse/domestic partner.
Successor plan means an insurance policy or The amount of ported AD&D insurance cannot exceed the
policies provided by us or another insurer that amount of ported life insurance.
replaces insurance provided under this policy.
Will the amount of insurance continued under this
The certificate holder will not be eligible to request rider change?
coverage under this rider if he or she:
Yes. On the first day of the month following the date an
(1) has attained the age of 70;or insured attains age 65,the amount of insurance on his or
(2) has converted his or her insurance to an individual her life continued under this rider will reduce to 65%of the
life policy under the terms of the group policy's amount of insurance in force on the day prior to his or her
conversion right section; or attainment of age 65. Insurance terminates at age 70.
(3) was not actively at work due to sickness or injury
on the day immediately preceding his or her Can a certificate holder request a change in his or her
portability date; or amount of insurance continued under this rider?
(4) loses eligibility due to termination of the group
policy. Yes. The certificate holder may elect to reduce the
amount of insurance provided under his or her certificate.
MHC-96-13214 Minnesota Life 1
EdF81776 10-2014
The remaining amount of insurance on the life of a What happens to insurance provided under this rider
certificate holder must be at least$10,000. when the group policy terminates?
The amount of insurance continued under this rider will Anything in the group policy notwithstanding,termination
never increase. of the group policy by the policyholder or us will not
terminate life insurance then in force for any person under
How will premium contributions be paid? the terms of this rider. The group policy will be deemed to
remain in force solely for the purpose of continuing such
Premium contributions will be paid directly to us on a insurance, but without further obligation of the
monthly,quarterly,semi-annual, or annual basis and will policyholder.
be subject to an administrative charge per billing period.
We may adjust the amount of the charge, but not more Any insurance continued under the terms of this rider will
often than once per year. remain in force until terminated by the provisions of the
section entitled "When will insurance continued under this
Can the premium rate change? rider terminate?".
Yes. The premium rate may increase on the portability No individual may elect coverage under this rider on or
date. The premium rate may also increase in the future after the date of termination of the group policy.
but will not change more often than once per year.
When will insurance continued under this rider
Can insurance continued under this rider be terminate?
converted to a policy of individual insurance?
Insurance continued under this rider will terminate on the
Yes. At any time after insurance has been continued earliest of the following:
under the provisions of this rider, it may be converted to a
policy of individual insurance with Minnesota Life. All (1) the insured's 70th birthday; or
other conditions and provisions of the conversion right (2) the date the certificate holder again meets the
section of the group policy to which this rider is attached eligibility requirements of the group policy, not
will apply. including the terms of this rider;or
What happens if a certificate holder again becomes (3) in the case of a dependent child or a
spouse/domestic partner who is insured by a rider
eligible under the group policy? to the certificate holder's coverage,the date the
If a certificate holder who is continuing coverage under the certificate holder's coverage is no longer being
provisions of this rider again meets the eligibility continued under this rider,or the date the
requirements of the group policy, not including the terms certificate holder's spouse/domestic partner or
of this rider, he or she shall no longer be considered to child ceases to be eligible as defined under the
have portability status. Insurance for that certificate holder terms of the group policy;or
may be provided only under the terms of the group policy, (4) 31 days after the due date of any premium
not including this rider, unless and until he or she no contribution which is not made.
longer meets the eligibility requirements of the group
policy and again returns to portability status as provided
for herein. 1Q7/ � �►+�
Secretary President
MHC-96-13214 Minnesota Life 2
EdF81776 10-2014
Term Life Waiver of Premium
Policy Rider
MINNESOTALIFE
Minnesota Life Insurance Company-A Securian Company
400 Robert Street North • St.Paul,Minnesota 55101-2098
General Information Do premiums have to be paid for a certificate holder
after he or she becomes disabled?
This rider is issued in consideration of the required
premium and amends the group policy to which it is Yes. Premiums have to be paid after a certificate holder
attached.The specifications page attached to the group becomes disabled, but only until we approve his or her
policy indicates whether this rider applies to contributory total and permanent disability claim. Continued payment
insurance or noncontributory insurance. This rider is prevents the possible loss of the certificate holder's
subject to every term, condition,exclusion, limitation,and coverage and eligibility if the claim is not approved.
provision of the group policy unless otherwise expressly What if a certificate holder converts his or her group
provided for herein.Coverage under this rider will not be
included in any insurance issued under the conversion life insurance to a policy of individual insurance prior
right section of the group policy. to the approval of his or her disability claim?
What does this rider provide? If a certificate holder's coverage has been converted in
accordance with the conversion right section of the group
This rider provides for waiver of premium for certificate policy, benefits under this rider will apply only if the
holders who become totally and permanently disabled, as converted policy is surrendered without claim,except for
defined herein,while under age 60. Upon approval of refund of premiums.
proof of such disability, a certificate holder's insurance, What will be considered due proof of total and
including all riders applicable to such certificate holder
which were in force on the date of the onset of the permanent disability?
certificate holder's disability,will be continued in force A certificate holder must furnish evidence satisfactory to
without payment of premiums during the uninterrupted us that his or her disability:
continuance of the total and permanent disability.
What is total disability? (1) commenced while his or her insurance under the
group policy was in force;and
Total disability is a disability which occurs while a (2) meets the definition of total disability; and
certificate holder's insurance and the coverage under this (3) commenced before his or her 60th birthday; and
rider is in force and which results from an accidental injury (4) was continuous for six months or more.
or an illness that continuously prevents the certificate We will,from time to time, also require additional proof
holder from engaging in any occupation for which he or satisfactory to us that the certificate holder continues to be
she is reasonably suited by education,training, or totally and permanently disabled. We may also require
experience. The certificate holder must be under the care that the certificate holder submit to one or more medical
of a licensed physician. The licensed physician cannot be examinations at our expense.
the certificate holder or a member of the certificate
holder's immediate family. For purposes of this rider,the If a certificate holder dies within one year of the date of
certificate holder's immediate family consists of his or her onset of his or her disability,the certificate holder's
spouse/domestic partner, children, parents,grandparents, beneficiary may claim benefits under this rider even if the
grandchildren, brothers and sisters and their spouses. certificate holder's premium payments were discontinued
and he or she had not submitted due proof satisfactory to
What is permanent disability? us of his or her total disability or was continuously
Permanent disability is a total disability which has existed disabled for less than six months. The certificate holder's
continuously for at least six months. beneficiary must submit due proof satisfactory to us that
the certificate holder's total disability,which began before
Are there any limitations? the certificate holder's premium payments were
discontinued and before his or her 60th birthday,
Yes. Insurance will not be continued if a certificate continued without interruption until his or her death.
holder's disability results from intentionally self-inflicted When must we be notified of a certificate holder's
injury, participation in or any attempt to commit a felony, or disability or death?
war or any act of war,whether declared or undeclared.
We must receive written notice at our home office of a
certificate holder's total disability within one year of the
MHC-96-13208 Minnesota Life 1
EdF81777 10-2014
date of onset of such disability. However,failure to give What happens to a certificate holder's insurance when
notice within the time provided will not invalidate the claim the waiver of premium benefit ends?
if it is shown that notice was given as soon as reasonably
possible. When the benefits under this rider end according to the
provisions of the section entitled "How long will insurance
We must receive written notice at our home office within be continued without payment of premium?,"the following
one year of death that a certificate holder died during a will apply:
period of continuance provided by this rider. Proof must
be furnished that he or she continued to be totally disabled (1) If the certificate holder is then eligible for coverage
during the entire period of continuance until death. If such under the group policy, his or her insurance may
notice and proof are not provided within the required time be continued under the group policy provided that
frame,there shall be no liability for any payment under this premiums are paid. The first such premium
rider. payment must be made within 31 days of the date
the waiver of premium benefit ends.
What is the amount of insurance to be continued (2) If the certificate holder is no longer eligible for
without payment of premium under this rider? coverage under the group policy, he or she may
p y p convert coverage to an individual policy, as
provided for under the conversion right section of
The amount of insurance continued without payment of the group policy.
premium shall be the amount of insurance that was in
force on the date of onset of total disability. Insurance will end for a certificate holder unless,within 31
days of the date benefits under this rider end, premium
If the group policy provides for reductions in amounts of payment is resumed or the insured applies to convert his
insurance based on age or retirement,such reductions or her coverage.
shall apply to the insurance of the disabled certificate
holder. When does this rider terminate?
How long will insurance be continued without This rider will terminate on the earlier of:
payment of premium?
(1) the date we receive a written request to terminate
If a certificate holder becomes totally and permanently this rider; or
disabled, insurance will be continued,without payment of (2) the date the group policy is terminated.
premium, until the earliest of:
Insurance being continued without further payment of
(1) the date the certificate holder recovers so that he premiums in accordance with the provisions of this rider
or she is no longer totally and permanently will not end due solely to the termination of this rider or of
disabled; or the group policy.
(2) the date the certificate holder fails to furnish proof
of continued disability when requested or refuses
to submit to a required medical examination.
However, if the group policy provides for termination of
insurance at retirement, insurance provided under this Secretary President
rider will terminate when the insured employee retires,
including normal or early retirement. The retirement date
for an employee whose insurance is being continued by
the terms of this rider shall be the earlier of:
(1) the date he or she actually retires; or
(2) his or her presumed normal retirement date as
established by the employer's applicable
retirement plan. If no such date has been
established,the insured employee's presumed
retirement date shall be age 65.
MHC-96-13208 Minnesota Life 2
EdF81777 10-2014
MINNEsoTALIFE
400 Robert Street North • St. Paul, Minnesota 55101-2098
GROUP TERM LIFE INSURANCE POLICY • NONPARTICIPATING