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HomeMy WebLinkAboutC-1492 - Group health insuranceCITY OF NEWPORT BEACH 1 CALIFORNIA City Hall 3300 W. Newport Blvd. Area Code 714 673 -2110 DATE December 8 1972 TO: FINANCE DIRECTOR FROM: City Cleric SUBJECT: Contract No. 1;149 Description of Contract Health and Life Tnsunmoe (`(lp) Authorized by Resolution No. 7RB4 , adopted on DMpbeZ, 24, 1972 Effective date of Contract Nmmmher 1, 1 972 Contract with aetnn I a fe F (as tajV �,. TAMPOM43MG36 Amount of Contract City e < CITY OF NEWPORT BEACH MEMORANDUM: From To - Personnel Department 4y7 October 30 , ljz.... Per your request, enclosed is a certified copy of Resolution No. 7864, awarding a contract to the Aetna Life and Casualty Company providing group health and life it flaace benefftiffor City employees. 1 City Clerk Reply wanted Reply not necessary a N�,2D l RESOLUTION NO. 7 86 4 A RESOLUTION OF THE CITY COUNCIL OF THE CITY OF NEWPORT BEACH AWARDING A CONTRACT TO THE AETNA LIFE AND CASUALTY COMPANY PROVIDING GROUP HEALTH AND LIFE INSURANCE BENEFITS FOR CITY EMPLOYEES WHEREAS, the group life and health insurance program of the City has been reviewed, proposals for group life and health insurance and recommendations thereon have been re- ceived and considered, and the proposal of the Aetna Life and Casualty Company has been approved by the City Council; and WHEREAS, a policy contract for group life and health insurance has been presented to the City by the Aetna Life and Casualty Company and the City Council has reviewed the terms and conditions thereof and found them to be fair and equitable; NOW, THEREFORE, BE IT RESOLVED that the City Council of the City of Newport Beach finds that it would be in the best interest of the citizens of Newport Beach to award the contract to the Aetna Life and Casualty Company, providing group health and life insurance benefits for City employees at an annual premium rate of $336,6B1.00, said contract to be effective November 1, 1972 through June 30, 1973. ADOPTED this 24th day of October , 1972. Mayor ATTEST: City Clerk DON dm 10/24/72 C-] F, LIFE & CASUALTY YOUR GROUP POLICY is on a modern format to present now and in the future a clear description of the current provisions of the plan. The most important feature of this format is that the policy ordinarily will be amended by the addition, deletion or substitution of pages. The new pages will be accompanied by a rider face page and, after the rider has been executed, it will be necessary merely to substitute the new page for the old, attach the old pages to the • rider face page and file them behind the Historical tab for use when necessary to refer to provisions not currently effective. The date of the addition or substitution of pages after the issuance of the original policy will be shown at the bottom of the new page. The extent and effect of the vari- ous changes may be determined by reference to the riders and obsolete pages filed in the Historical Section. GR -23 -O •3-168 •`Trade Mark of Ana Life Insurance Company and its associated companies N O N N IS Group Control No. 333231 .z 3 M�Aefpj#-..' tswun 14* (Herein called the Insurance Company) Group Policy No.: GI-333231 y Policyholder: CITY OF NEWPORT MACH Policy Signed: November b, 1972 Policy Delivered In: California (State or other Jurisdiction) To Take Effect: November 1, 1972 This policy is a contract between the Policyholder and the Insurance Company and shall be construed in accordance with the law of the jurisdiction in which it is delivered. In consideration of the payment by the Policyholder of premiums in the amounts and at the times hereinafter provided, the Insurance Company hereby agrees with the Policyholder, sub- ject to the terms appearing on this and the following pages of this policy Gm;loding', if any, the riders, endorsements, and amendments, to this policy which are signed by the .lnsural;ce Company), to pay benefits in accordance with the terms of this policy. The obligations and the rights of all persons under this policy shall be determined in accordance with the terms of this policy. In witness whereof the Insurance Company has signed this policy at Hartford, Connecticut. Secretary Pres:denc. Registrar 00 a GROUP LIFE INSIURANCE POLICY 0 GR -22 Page 1 22025 INDEX Page Article I— GENERAL PROVISIONS . . . . . . . . . 3 Article II— BENEFITS . . . . . . . . . . . . . . 6 Article III — TERMINATION OF INSURANCE . . . . . . 7 Article IV— PP.EMIUMS . . . . . . . . . . . . . 8 Article V— DISCONTINUANCE OF POLICY . . . . . . 9 Article VI— MISCELLANEOUS PROVISIONS . . . . . . 10 COPY OF APPLICATION GR -22 Page 2 22099 4 `1 0) u GR -22 OPEN Ed. 5-'59 Page 33 22104 Article I— GENERAL PROVISIONS P O N N Section 1. General Definitions w As used in this policy: a O (a). The term "Employee Coverage" means only insurance as to an employee. (b) The term "date of issue" means the date this policy took effect as shown on Page 1 of this policy. (ep) Commencing February 1, 1973 "policy anniversaries" shall be deemed to occur on said date, and on the same day in each succeeding year. (d) The term "policy year" means a period commencing with the date of issue of this policy, or a policy anniversary, and terminating immediately prior to the next suc- ceeding policy anniversary. (e) A "policy month" shall commence on the date of issue. Each "policy month" thereafter shall be deemed to commence on the first day of the calendar month. (f) "Contributory insurance" means insurance for which an employee makes written re- quest to his Participant Employer and agrees to make the required contributions to his Participant Employer. "Non- contributory insurance" is insurance for which an employee does not make written request nor contribute toward the cost. This policy provides insurance on the non — contributory basis. 4 `1 0) u GR -22 OPEN Ed. 5-'59 Page 33 22104 f i n 9 U, Lj t. *J 4b Article I —GENERAL PROVISIONS (Continued) Section 2. List of Participant Employers An Employer shall be eligible to be included in this list as a Participant Employer if such inclusion is not contrary to any applicable insurance law of the state or other jurisdiction in which this policy is delivered. The Policyholder may act for and on behalf of any and all of the Employers included in this list in all matters pertaining to this policy, and every act done by the Policyholder, agreement made between the Insurance Company and the Policyholder, or notice given by the Insurance Company to the Policyholder or by the Folicyholder to the Insurance Com- pany, shall be binding on all such Employers. Any eligible Employer may be added to this list as a Participant Employer only upon written agreement between the Policyholder and the Insurance Company and upon terms mutually agreeable to them. An Employer shall be eliminated automatically from this list when this policy is discon- tinued with respect to employees of such Employer, as provided for elsewhere in this policy, but termination of an Employer's status as a Participant Employer shall not relieve such Employer from any obligations to the Insurance Company with respect to the time such Employer was a Participant Employer under this policy. Effective Date Name of Participant Employer Principal Location of Inclusion Policyholder 00 GR -22 Ed. 5259 Page 4 See Application Date of Issue 22142 Article I— GENERAL PROVISIONS (Continued) a N N Section 3. Employees to be Insured (I) Employee Coverage A. Employees Eligible: All employees of a Participant Employer shall be eligible for Employee Coverage ex- cept employees in the following classes: (a) temporary or substitute employees (i.e., employees who are not classified by such Employer as permanent employees) ; (b) employees who are actively working for such Employer on a part -time basis, but this exception shall not apply in the case of a regular, full -time, active em- ployee of such Employer if and while he is only temporarily working for such Employer on a part -time basis; (c) City Councilmen. C �J �i Each employee in an eligible class whose employment commenced on or be- fore the date of issue shall become eligible for Employee Coverage on the date of issue, and each other employee in an eligible class shall become eligible for Employee Coverage on the date he enters the service • of a Participant Employer. Anything to the contrary notwithstanding, if an individual is in the employ of or con - nected with two or more Participant Employers, he shall not be eligible for multiple coverage under this policy, but shall be treated the same as if he were in the employ of or connected with a single Participant Employer; the amount of insurance for which any such individual shall be eligible under this policy shall under no circumstances ex- ceed the amount which would apply if all of the Participant Employers with which he is employed or connected were a single Participant Employer and if the aggregate of the remuneration being paid to him by all such Participant Employers were being paid to him by a single Participant Employer. If any Participant Employer is a partnership, the natural - person partners thereof shall be considered to be employees within the meaning of this policy if and while they are actively engaged in and devoting their time on a substantially full -time basis to the conduct of the business of the partnership. If any Participant Employer is an indi- vidual proprietorship, the natural- person proprietor thereof shall be considered to be an employee within the meaning of this policy on the same terms as those applicable to partners of a partnership. GR -22 No Ed. 5259 Page 5 zzt9a U m N N N Article I— GENERAL PROVISIONS (Continued) Section 3. Employees to be Insured (Continued) (I) Employee Coverage (Continued) B. Effective Dates of Insurance: (1) As to contributory insurance, each employee who makes written request to his Participant Employer for Employee Coverage and agrees to make the required con- tributions therefor to his Participant Employer is to be insured for Employee Cov- erage on the date he becomes eligible for Employee Coverage or on the date he makes such request, whichever is later; provided, however, that (a) the Employee Coverage of any employee who makes such written request after thirty -one days from the date he becomes eligible, or who revokes any written request previously made, shall become effective only if and when the Insur- ance Company gives its written consent; and (b) any employee who is both disabled (i.e., ill or injured) and away from work on the date Employee Coverage is to become effective shall not be insured until he actually returns to work on a full -time basis. (2) As to non - contributory insurance, each employee is to be insured for Employee Cov- erage on the date he becomes eligible therefor; provided, however, that any em- ployee who is both disabled (i.e., ill or injured) and away from work on the date Employee Coverage is to become effective shall not be insured until he actually re- turns to work on a full -time basis. GR -22 Ed. 5-'59 Page 5 -A 22231 Article I— GENERAL PROVISIONS (Continued) Section 4. Changes in Amounts of Insurance The initial amount of insurance for an employee under any Title of this policy shall conform to that provided for his classification. As to contributory insurance, if, for any reason, the Schedule of Insurance under any Title of this policy warrants an amount of insurance for any employee greater or less than that for which he is then insured, the amount of his insurance shall be increased or reduced to that warranted by his new classification as follows: Any reduction in insurance shall become effec- tive on the date the employee makes a request therefor to his Participant Employer; any in- crease in insurance shall become effective only in conformity with the terms applicable with respect to the effecting of the initial insurance of employees as set forth in Section 3 of Article I of this policy. As to non- contributory insurance, if, for any reason, the Schedule of Insurance under any Title of this policy warrants an amount of insurance for any employee greater or less than that for which he is then insured, the amount of his insurance shall then be increased or reduced to that warranted by his new classification; provided, however, that in any instance in which an em- ployee is both disabled (i.e., ill or injured) and not working on the date his insurance would otherwise be increased, the effective date of the increase in insurance shall be deferred until he actually returns to active work on a full -time basis. A retroactive change in an employee's rate of earnings shall be deemed to be effective on the 4D date of the determination of the change in the rate of earnings. L2 ❑2 © GR -22 Ed. 10-'68 Page 5 -B 22282 Article II— BENEFITS N N OD TITLE ELIC — EMPLOYEES' LIFE INSURANCE COVERAGE Section 1. Life Insurance Benefit If an employee shall die while Employee Coverage is in force for the employee, the Insurance Company shall pay, upon receipt of due proof of the death of such employee —to the IZene- ficiary determined in accordance with the terms of this policy —the amount determined in accordance with the terms of this policy. Schedule of Insurance Classification_ All Employees Annual Rate of Basic Earnings $25,000 or more 22,500 but less than $25,000 20,000 but less than 22,500 17,500 but less than 20,000 15,000 but less than 17,500 12,500 but less than 15,000 10,000 but less than 12,500 7,500 but less than 10,000 Less than $7,500 Amount of Insurance $25,000 22,500 20,000 17,500 15,000 12,500 10,000 7,500 5,000 C R -2'L Ed. 5-'59 Page 6 —MC 22311 Article II— BENEFITS (Continued) TITLE ELIC — EMPLOYEES' LIFE INSURANCE COVERAGE (Continued) 410 Section 1 -A. Special Provisions Applicable To Title ELIC �Effect of Prior Coverage: An employee's insurance under this Title replaces and supersedes any prior coverage and shall be in exchange for all privileges and benefits under the prior coverage. However, if an employee oc or his beneficiary- becomes entitled to claim under such prior coverage, his insurance under this Title shall be cancelled, as of its effective date, and any premiums paid for his insurance under this Title shall be refunded to the Policyholder. "Prior Coverage" is any plan of group life insurance carried or sponsored by a Participant Em- ployer (or its predecessor) and underwritten by the Insurance Company or any other insurer 00 which has been replaced entirely or in part with respect to the class of employees of which the employee is a member, by insurance under this Title. If the prior coverage was underwritten by the Insurance Company, the latest election of an optional method of settlement and the latest designation of beneficiary of the employee under the OC prior coverage shall be effective under this Title until a change is made in accordance with the terms of this policy. i OC) r 04 •© O GR -22 Ed. 10 -'61 Page 6 –1 ELIC All Adjusted 22345 Article II— BENEFITS (Continued) ® TITLE ELIC — EMPLOYEES' LIFE INSURANCE COVERAGE (Continued) Section 2. Extended Insurance In Event of Permanent Total Disability Written notice of claim for extended insurance must be given to the Insurance Company at its Home Office within twelve months following the date the employee ceases active work. Upon receipt by the Insurance Company at its home Office, either before the discontinuance of pre- mium payments for an employee's insurance under this Title or within twelve months thereafter, of due proof, (i) that the employee, while insured under this Title, before attaining the age of sixty years, and before termination of employment with a Participant Employer, became totally and perma- nently disabled within the meaning of this section, namely, that, due to illness or injury, the employee is not engaged in his or any other gainful occupation and will continue to be un- able to engage in any gainful occupation for which he is, or may reasonably become, fitted by education, training or experience, and (ii) that the employee has been so disabled continuously for at least nine months, • then, provided timely written notice of claim for extended insurance has been given, and provided, further, that the Insurance Company is allowed the opportunity to examine the person of the em- ployee when and as often as it may reasonably require before approving the proof of total and permanent disability, the Insurance Company shall, as a permanent total disability benefit, extend insurance for the employee under this Title, in an amount determined from the terms of this section and without payment of further premiums, during the further continuance of such total and permanent disability, but not beyond the earliest to occur of the following dates: (a) the date any request of the Insurance Company for an examination of the person of the em- ployee or for due proof of the continuance of total and permanent disability is mailed or other- wise forwarded to the employee at the last address of the employee as shown on the records • of the Insurance Company, if the employee does not submit to such examination or does not furnish such proof, as the case may be, within thirty -one days after such date; and (b) the date the employee recovers sufficiently so as to be able to engage in any gainful occupa- tion for which he is, or may reasonably become, fitted by education, training, or experience; and ® (c) the date the employee starts to work in any gainful occupation. After any insurance of an employee has been extended under this section continuously for two full years following the approval by the Insurance Company of the proof of the total and permanent ® disability of the employee, the Insurance Company shall not request of the employee the examina- tions or proofs referred to in item (a) above more often than once per period of twelve consecutive months during the further continuance of the period of disability. The amount of insurance which may be extended under this section shall be the amount of in- surance to which this section applies for which the employee was insured under this Title in ac- cordance with the applicable terms of this policy on the date from which the employee has been continuously and totally disabled. If an employee is not eligible for life insurance under any group policy, whether issued by the In- surance Company- or by any other insurer, on the date on which the period of extension provided ® for in this section expires or within thirty -one days thereafter, the employee shall be entitled to the GR -22 PW .Ed. 6270 22388 Page 6- A -ELIC 0 Article II— BENEFITS (Continued) TITLE ELIC— ENIPLOYEES' LIFE INSURANCE COVERAGE (Continued) ® Section 2. Extended Insurance In Event of Permanent Total Disability (Continued) Conversion Privilege in Section 7, Article VI, to the same extent as though his employment had terminated on the date on which such period of extension expired, except that the amount of the individual policy shall not exceed the amount of insurance being extended for the employee under this section on the date on which such period of extension expired. t If (a) premium payments for an employee's insurance are discontinued while the employee is totally disabled by illness or injury and is thereby prevented from engaging in any gainful occupa- tion for which he is, or may reasonably become, fitted by education, training, or experience, and (b) the employee qualifies (or would have qualified if the disability had existed continuously for a period of at least nine months) for an extension of insurance under this section as above pro- vided in all other respects except that the proof required by the terms of this section has not yet been received (or if received has not yet been approved) by the Insurance Company, and (c) the employee dies during the uninterrupted continuance of such total disability and within twelve months following the discontinuance of premium payments for his insurance, and (d) due proof is furnished to the Insurance Company at its Home Office within twelve months after the date of death that all three of items (a), (b), and (c) of this paragraph apply to the employee, then a permanent total disability benefit in an amount equal to the amount of insurance in force on the life of the employee when the disability commenced will be paid to the beneficiary. When a claim for a permanent total disability benefit is approved by the Insurance Company, the permanent total disability benefit shall be in full settlement and satisfaction of every obligation of the Insurance Company to the employee or on account of the employee's insurance under this Title. Written notice of the death of an employee while covered under this section shall be given to the Insurance Company at its Home Office within twelve months after the date of death; if such notice is not duly given, the Insurance Company shall not be liable for any payment on account of such death. Notwithstanding any contrary provision in Article VI— Section 7, Conversion Privilege, if one or more individual policies have been issued to an employee pursuant thereto, the employee's rights un- der this section may nevertheless be restored to the same extent as though such individual policies had not been issued, provided the proofs required by this section are furnished to the Insurance Company within twelve months after cessation of premium payments for the insurance of the employee under this policy, and provided each such individual policy is surrendered without claim other than for the return of the premiums paid thereon. GR -22 PW Ed. 6 -70 22443 Page 6- B -ELIC (je Article III — TERMINATION OF INSURANCE Section 1. Employee Coverage All insurance of any employee under this policy shall terminate at the earliest time specified below: J� (1) Upon discontinuance of the policy. (2) Immediately when the employee's employment with a Participant Employer in the classes of employees eligible for insurance terminates. Cessation of active work by an employee shall be deemed to be termination of his employment, except that (a) in the case of an absence from active work because of sickness or injury, his employ- ment may, for the purposes of insurance under this policy, be deemed to continue un- til terminated by his Participant Employer, but in no case beyond twelve months from s_ the date such absence from active work started, or �! (b) in the case of absence of an employee from active work because of temporary lay -off or leave of absence, his employment may, for the purposes of insurance under this policy, be deemed to continue until terminated by his Participant Employer but in no case ® beyond the end of the policy month following the policy month in which such lay -off or leave of absence commenced. Q 2 �Vvj In the case of any of the exceptions in the foregoing paragraph, the insurance under this policy for such employee shall automatically cease on the date of such termination of his employment by his Participant Employer, as evidenced to the Insurance Company by the Policyholder, whether by notification or by cessation of premium payment on account of such employee's insurance hereunder. Any maximum period of continuation permitted by the foregoing paragraph may be extended by written mutual agreement between the Policyholder and the Insurance Company in each individual case. In no event may any insurance provided on a contributory basis be continued beyond the end of the period for which the employee has made to his Participant Employer the contributions required. Ed. 5 Ed. 5 -'59 Page 7 22507 Article IV- PREMIUMS Section 1. PREMIUM RATES EMPLOYEE COVERAGE TABLE OF PREMIUM RATES Age on Monthly Age on Monthly Age on Alonthly Age on Monthly Birthday Premium Birthday Premium Birthday Premium Birthday Premium Nearest Per Nearest Per Nearest Per Nearest Per Beginning $1,000 Beginning $1,000 Beginning $1,000 Beginning $1,000 of the of of the of of the of of the of Policy Year Insurance Policy Year Insurance Policy Year Insurance Policy Year lnsuraaee 15 $ .19 35 $ .32 55 $ 1.65 75 $ 8.56 16 .20 36 .34 56 1.80 76 9.24 17 .21 37 .36 57 1.97 77 10.00 18 .22 38 .38 58 2.14 78 10.86 19 .23 39 .41 59 2.32 79 11.81 20 .23 40 .45 60 2.51 80 12.83 21 .24 41 .49 61 2.72 81 13.93 22 .24 42 .53 62 2.96 82 15.07 23 .25 43 .58 63 3.21 83 16.26 24 .25 44 .63 25 .25 45 .68 64 3.48 65 3.78 84 85 17.50 18.80 26 .25 46 .74 66 4.11 86 20.16 27 .26 47 .81 67 4.48 87 21.60 28 .26 48 .89 68 4.89 88 23.13 29 .26 49 .97 69 5.34 89 24.79 30 .27 50 1.06 70 5.81 90 26.62 31 .27 51 1.16 71 6.32 91 28.68 32 .28 52 1.26 72 6.84 92 31.03 33 .29 53 1.38 73 7.38 93 33.75 34 .30 54 1.51 74 7.95 94 36.95 95 40.98 The above monthly premiums are applicable to male employees only. For female employee pre- miums, multiply the above monthly premiums by.60. For annual, semi- annual, or quarterly premiums multiply the monthly premiums determined from the above table by 11.83, 5.96 or 2.99 respectively. Policy Charge The premium calculated as above shall be increased by a policy charge of $.20 for each $1,000 of insurance in force hereunder at the beginning of the then current policy year for each policy month which occurs during the premium paying period, provided that the policy charge shall not exceed $8.00 in respect of any month. Advance Expense Adjustment For the first policy year the total premium, including the policy charge, shall be reduced by the applicable advance expense adjustment indicated below (for an- nual, semi - annual or quarterly premiums, divide the total premium, including the policy charge, by 12, 6, or 3, respectively, before entering this table) : Total Monthly Premium Advance Expense Total Monthly Premium Advance Expense Before Advance Expense Adjustment Adjustment Before Advance Expense Adjustment Adjustment Under $200 0% $ 1,700- 1,999 18% $ 200- 224 1 2,000- 2,499 19 225- 249 2 2,500- 2,999 20 250- 299 3 3,000- 3,499 21 300- 349 4 3,500- 3,999 22 350- 399 5 4,000- 4,999 23 400- 449 6 450- 499 7 5,000- 5,999 6,000- 7,499 24 25 500- 549 8 7,500- 9,499 26 550 - 599 9 9,500 - 11,999 27 600- 649 10 12,000- 14,999 28 650- 699 11 15,000 - 19,999 29 700- 799 12 20,000 - 26,999 30 800- 899 13 27,000 - 34,999 31 900- 999 14 35,000 - 44,999 32 1,000- 1,199 15 45,000 - 59,999 33 1,200- 1,399 16 60,000- 79,999 34 1,400- 1,699 17 80,000 and over 35 . GR -22 ED. 9271 Page 8 22577 ce Article IV— PREMIUMS (Continued) Section 2. Premium Calculations and Experience Rating �.! Portion Applicable to I :mployee Coverage Only: Premiums under this policy shall be calculated according to the table of premium rates in effect hereunder at the time the computation is made, on the basis of the amount of insurance then in force and the ages (nearest birthday) attained by the insured employees at the beginning of the then current policy year. PP Portion Having General Application: ' L� The premium due under this policy on any premium -due date shall be the sum of the premium charges for the insurance provided under the Titles then forming a part of this policy. If premiums are payable monthly, any insurance becoming effective shall, except as hereinafter provided, be charged for from the first day of the policy month coinciding with or next following the date the insurance takes effect, and premium charges for any insurance terminated shall cease as of the first day of the policy month coinciding with or next following the date the insurance terminates. If premiums are payable quarterly, semi - annually, or annually, premium charges or credits for a fraction of a premium- paying period required by the foregoing terms of this para- graph shall, except as hereinafter provided, be made on a pro -rata basis for the number of policy months between the date premium charges commence or cease and the end of the premium -pay- ing period. If this policy is amended to provide additional coverage, or any increase in coverage, and if the effective date of such amendment is other than the first day of a premium- paying period, a pro -rata premium in respect of such coverage shall become due and payable as of such date, to cover the period beginning on that date and ending immediately prior to the commencement of the next premium - paying period. 2 Z 2 L] �j eGR -22 Page 8 -A 22628 Ed. 6270 TAB N Article IV— PREMIUMS (Continued) N b N N Section 2. Premium Calculations and Experience Rating (Continued) The premium charges for the insurance under any Title forming a part of this policy shall be calculated at the premium rates specified above, subject to such reductions or increases as the Insurance Company shall determine to be warranted by experience or by reason of any change in factors bearing on the risk assumed. Each reduction or increase in any premium rate shall be made by written notification to the Policyholder by the Insurance Company. No experience reduction or increase in premium rates shall become effective less than twelve months after the effective date of this policy. As of the end of any policy year the Insurance Company may declare an experience credit in such amount as the Insurance Company shall determine. The amount of each experience credit declared by the Insurance Company shall be refunded to the Policyholder, or upon request by the Policyholder, a part or all of the experience credit shall be applied against the payment of any premium or premiums. If at any time the aggregate of employee contributions theretofore made for group insurance shall exceed the aggregate of premiums theretofore paid for group insurance (after giving effect to any experience credits allowed the Policyholder), such excess shall be applied by the Policyholder for the sole benefit of employees, but the Insurance Company shall not be obliged to see to the application of any such excess. Instead of the method of calculation of premiums above provided, premiums may be calcu- lated by any method which produces approximately the same total amount of premiums and is mutually agreeable to the Insurance Company and the Policyholder. ® Section 3. Premiums, How Payable Premiums shall be payable by the Policyholder in advance at the Home Office of the Insurance Company or to its authorized agent. The first premium under this policy shall be due and payable as of the date of issue to cover the period beginning on that date and ending on the last day of the first policy month and thereafter premiums shall be due and payable on the first day of each policy month. The Policyholder may change the frequency of premium payments as of any premium -due date © with the written consent of the Insurance Company. Section 4. Grace Period EI V, A grace period of thirty -one days following the due -date shall be allowed the Policyholder for the payment of each premium. GR -22 Mo Ed. 5259 Page 8 -B .22652 0 Article V— DISCONTINUANCE OF POLICY D a The Policyholder may discontinue this policy with respect to all employees of any one or more Participant Employers, and any Participant Employer may discontinue this policy with respect to all employees of such Employer, by giving to the Insurance Company written notice stating when, after the date of such notice, such discontinuance shall become effective; but no such discontinuance shall become effective with respect to employees of any Participant Employer during any period for which a premium has been paid to the Insurance Company with respect to employees of such Em- ployer. The Insurance Company reserves the right to discontinue this policy, (a) with respect to all employees of any Participant Employer, at any time after the end of the grace period allowed for payment of a premium with respect to employees of such Em- ployer which has not been paid, by giving written notice to the Policyholder stating when such discontinuance shall become effective; (b) either in its entirety or with respect to all employees of any Participant Employer, at any time, by giving to the Policyholder written notice stating the date as of which such discon- tinuance shall become effective but such date shall not be one that occurs earlier than thirty - one days after the date of such notice unless mutually satisfactory to the Policyholder and the Insurance Company. If this policy discontinues with respect to any of the employees of a Participant Employer, the Policyholder and the Employer shall be jointly and severally liable to the Insurance Company for all unprid premiums for the period during which this policy was in force with respect to any of the employees of such Employer. GR -22 Ed. 1 -'72 Page 9 22683 Article VI— MISCELLANEOUS PROVISIONS Section I. Assignment No assignment of any present or future right or interest under this policy by the Policyholder or by any Participant Employer shall bind the Insurance Company without its written consent. Neither the employees nor their beneficiaries may assign any of the insurance or other benefits under this policy. Section I -A. Claims of Creditors Except so far as may be contrary to the laws of any state having jurisdiction in the premises, the insurance and other benefits under this policy shall be exempt from execution, attachment, garnishment, or other legal or equitable process, for the debts of the employees or their bene- ficiaries. Nothing in this section, however, shall be construed so as to prejudice the right of any person to receive payment pursuant to the beneficiary provisions of this policy. Section 2. Employees' Certificates The Insurance Company will issue to the Policyholder, for delivery to each insured employee, an individual certificate setting forth a summary of the essential features of the insurance cov- erage to which the employee is entitled and stating to whom the benefits are payable, together with a statement of the "Conversion Privilege" set forth in Section 7 of this Article. Section 3. Data Required — Clerical F, rror-3fissiatemen ts— Non-Discrimlllatlo?2 The Policyholder and each of the Participant Employers shall furnish to the Insurance Com- pany all information which the Hfsurance Company may reasonably require with regard to any matters pertaining to this policy. All documents, books, and records which may have a y bearing on the insurance or premiums shall be open for inspection by the Insurance Company at all reasonable times during the continuance of this policy and until the final determination of all rights and obligations under this policy. •Neither clerical error (whether by the Policyholder, by any of the Participant Employers, or by © the Insurance Company) in keeping any records pertaining to the insurance, nor delays in making entries thereon, shall invalidate insurance otherwise validly in force or continue insur- ance otherwise validly terminated, but upon discovery of such error or delay an equitable ad- justment of premiums shall be made. If any relevant facts pertaining to any individual to whom the insurance relates shall be found �© to have been misstated, an equitable adjustment of premiums shall be made, and if such mis- statement affects the existence or the amount of insurance, the true facts shall be used in de- termining whether insurance is in force under the terms of this policy and in what amount. No refund of any premium or portion thereof, whether paid in error or otherwise, shall be made . for any period commencing earlier than (a) three months prior to the date on which evidence that the particular refund should be made is received by the Insurance Company, or (b) the be- ginning of the policy year in which such evidence is received, whichever method (a) or (b) above would result in the greater refund. In connection with the administration of this policy, the Policyholder and the Participant Em- 0 ployers shall act so as not to discriminate unfairly between individuals in similar situations at the time of such action, but the Insurance Company shall be entitled to rely upon any action of the Policyholder or of any of the Participant Employers without being obliged to inquire into the circumstances thereof, • Q GR -22 Page 10 22716 Ed. 6 -'70 • Article VI— MISCELLANEOUS PROVISIONS (Continued) s Section 4. Entire Contract — Incontestability �• This policy, the application of the Policyholder, a copy of which is attached hereto, and the indi- vidual applications of the employees, if any, constitute the entire contract. All statements made by the Policyholder or by the insured employees shall, in the absence of fraud, be deemed repre- sentations and not warranties. No statement made by the Policyholder or by an insured employee (• shall be used in defense to a claim under the policy unless contained in a written application. V The validity of this policy shall not be contested, except for non - payment of premiums, after it has been in force for two years from its effective date. No statement made by any insured employee relating to his insurability shall be used by the Insurance Company in contesting the validity of 10 the insurance with respect to which such statement was made after such insurance has been in force prior to the contest for a period of two years during such employee's lifetime, nor unless such statement is contained in a written application. This policy is issued in the non - participating department of the Insurance Company. This policy i� may be changed at any tirne or times by written agreement between the Insurance Company and the Policyholder, without the consent of any employee or other person. All agreements made by the Insurance Company are signed by an executive officer of the Insurance Company. No other person can change or waive any of the terms of this policy or make any agreement which shall be binding upon the Insurance Company. Failure to insist upon compliance with any provision of this policy at any given time or times or under any given set or sets of circumstances shall not operate to waive or modify such provision, or in any manner whatsoever to render it unenforceable, as to any other time or times or as to any other occurrence or occurrences, whether the circumstances are, or are not, the same. Section 5. Contribution By Employee Contributory Insurance: The maximum amount that any employee shall be required or permitted to contribute toward the cost of his contributory insurance, if any, under Title ELIC shall be lip $.60 per month for each One Thousand Dollars of such insurance hereunder. Non - contributory Insurance: No insured employee shall be required or permitted to contribute toward the cost of his non - contributory insurance, if any hereunder. 10 L_f GR -22 Cal. Ed. 10269 Page 11 22744 A N m N N CJ 0 0 0 C Ll LJJ a Article VI—MISCELLANEOUS PROVISIONS (Continued) Section 6. Beneficiary and Mode of Settlement Beneficiary An employee, whether or not employment has terminated, may designate a beneficiary, and from time to time change his designation of beneficiary, by written request filed at the headquarters of the Policyholder or at the Home Office of the Insurance Company. Stich designation or change shall take effect as of the date of execution of such request, whether or not the employee be living at the time of such filing, but without prejudice to the Insurance Company on account of any payments made by it before receipt of such request at its Home Office. Any amount payable to a beneficiary shall be paid to the beneficiary or beneficiaries designated by the employee, except that, unless otherwise specifically provided by the employee in his beneficiary designation: (a) if more than one beneficiary is designated, the designated beneficiaries shall share equally; (b) if any designated beneficiary predeceases the employee, the share which such beneficiary would have received if surviving the employee shall be payable equally to the remaining designated beneficiary or beneficiaries, if any, who survive the employee; and (c) if no designated beneficiary survives the employee, or if no beneficiary has been designated, payment shall be made to the employee's widow or widower, if surviving the employee; if not surviving the employee, in equal shares to the employee's children who survive the employee; if none survives the employee, to the employee's parents, equally, or to the sur- vivor; if neither survives the employee, in equal shares to the employee's brothers and sisters who survive the employee; m', if none survives the employee, to the employee's executors or administrators. GR -22 Ed. 5-'59 Page 12 4BC 22782 _ Article VI— MISCELLANEOUS PROVISIONS (Continued) P W N N Section 6. Beneficiary and Mode of Settlement (Continued) Mode of Settlement The whole or any part of any amount payable under Article II shall be paid in accordance with that one of the following Methods (A) or (E) that shall be elected by the employee, or in accordance with such other method of settlement as shall be elected by the employee and agreed to by the Insurance Company. An employee may revoke any such election at any time before payments commence upon written notice filed at the Home Office of the Insurance Company. An employee may change any such election at any time but only with the consent of the Insurance Company. In any case where the amount of any death benefit is payable in one sum, the beneficiary may, after the death of the employee but before payment is made, elect that the whole or any part of any death benefit be payable in accordance with Method (E) below, or in accordance with such other method of settlement as shall be elected by the beneficiary and agreed to by the Insurance Company. A beneficiary may change or revoke any such election but only with the consent of the Insurance Company. METHOD (A) : Payment in one sum. This method shall be automatic if no other method is elected. A9 METHOD (B) : Payment in monthly instalments of any fixed amount specified in the election (which shall be not less than $5.00 per month per $1,000 so payable nor less than $10.00 per month regardless of the amount so payable), until the amount so pay- able with interest is exhausted. With respect to each such election of this method, P the rate of interest to be allowed on the unpaid balance shall be determined by the Insurance Company but shall in no case be less than the guaranteed rate of in- terest provided for with respect to optional methods of settlements under the individual policies of life insurance being issued by the Insurance Company on the date of such election. At the death of the payee to whom payment is being made under this method, the unpaid balance shall be paid in one sum to the executors or administrators of the payee, unless otherwise provided in the elec- tion. If any payee for any benefit payment under this policy is a minor or is, in the opinion of the Insurance Company, legally incapable of giving a valid receipt and discharge for such benefit payment, the Insurance Company shall have the option, unless claim has been made by a duly appointed guardian or committee of such payee, of paying such benefit in monthly instal- ments of not over $100 the first month and not over $50 a month thereafter to the person or persons who, in the opinion of the Insurance Company, are caring for and supporting such payee. Payment made in accordance with the terms of this paragraph shall be a complete discharge of the Insurance Company's obligations to the extent of such payment, and the In- surance Company shall not be obliged to see to the application of any payment so made. GR -22 Ed. 5 -'59 Page 13 22841 �rt Article VI— MISCELLANEOUS PROVISION'S (Continued) 0 N N Section 7. Conversion Privilege Employee Coverage If an employee's insurance under this policy, or any amount of such insurance, ceases because of termination of employ :ent, because of termination of membership in the class or classes of employees eligible for insurance under this policy, or because of age, pension, or retire- ment, the employee shall be entitled to have issued to him by the Insurance Company, without evidence of insurability, an individual policy of life insurance without disability or other sup- plementary benefits, provided written application for the individual policy shall be made, and the first premium thereon paid, to the Insurance Company within thirty -one days after such ® termination, and provided further that: (a) the individual policy shall be on any one of the forms, other than term insurance, that shall be selected by the employee from among the forms then customarily issued by the Insurance Company at the age and for the amount applied for; ® (b) the individual policy shall be in an amount equal to or, at the option of the employee, an amount less than the amount of the employee's life insurance which ceases under this policy because of such termination; (c) the premiums payable under the individual policy shall be at the Insurance Company's ® then customary rate applicable to the form and amount of the individual policy, to the class of risk to x hich the employee then belongs, and to his age (nearest birthday) attained on the effective date of the individual policy; and (d) any individual policy issued under the terms of this section shall take effect at the end of the thirty -one day period during which application for the individual policy may be made. Lif �' If this policy discontinues, whether b,: its terms or by agreement between the Insurance Com- pany and the Employer, and whether with respect to all employees or with respect to any class or classes of employees insured hereunder, any employee insured under this policy at the date of such discontinuance who has been continuously insured for group life insurance by the Insurance Company under this policy for at least five years prior to such discontinuance shall, if his insurance under this policy, or any portion of such insurance, ceases because of such discontinuance, be entitled to the conversion privilege as though his employment had ter- minated on the date of such discontinuance, except that the amount of the individual policy shall not exceed the smaller of (a) the amount of the employee's life insurance which ceases under this policy because of such discontinuance, less the amount of any life insurance for which he is or becomes eligible within thirty -one days after such discontinuance under any group policy, whether issued by the Insurance Company or by any other insurer, and (b) $2,000. If an employee dies during the thirty -one day period within which he is entitled to have an individual policy issued to him in accordance with this section and before any insurance under such individual policy has become effective, the amount of life insurance which the employee is entitled to have issued to him under such individual policy shall be payable as a claim under Title ELIC, whether or not application for the individual policy or the payment of the first premium therefor has been made. When any insurance becomes effective under an individual policy issued under the conver- sion privilege, it shall be in exchange for all privileges and benefits under the group policy. .GR -22 Ed. 5259 Page 14 22904 LIFE HISTORICAL A &H Group Control t .'o. jjj2jl Qy .co. (Herein called the Insurance Company) VERIFIED z,s 1 Group Policy No.: GC- 333231 Policy Delivered In: California (State or other Jurisdiction) Policyholder: CITY OF IcFt,.T-ORT RE ".CH 1 i Policy Signed: January 29, 1970 To Tale Effect: July 1, 1969 j r� This policy is a contract between the Policyholder and the 1nSUPa11ee Company and shall be construed in accordance with the law of the jurisdiction in which it is delivered. %c3 In consideration of the payment by the Policyholder of premiums in the amounts and at the times hereinaftcr provided. the Insurance Company hereby ag).-oes with the Policyholder, sub- ject to the terms appearing; on this and the following pages of this policy (including, if ana, the riders. endoisemcuts, and amendments, to this policy which are signed by the Insurance Company), to pity benefits in accordance with the terms of this policy. The obligations and the rights of all persons under this policy shall be determined in accordance with the terms of '. i this policy. In witness whereof the Insurance Company has signed this policy at Hartford, Connecticut. Secretary President. Registrar GROUP INSURANCE POLICY GR -23 Page 1 1121 INDEX Page Article I— GENERAL PROVISIONS . . . . . . .. . . 3 Article II— BENEFITS . . . . . . . . . . . . . . 6 Article III— TERAIINATION OF INSURANCE Article IV— PREMIUMS . . . .. .. . . . .. 7 8 Article V— DISCONTINUANCE OF POLICY . . .. . . 9 Article VI— DIISCELLANEOUS PROVISIONS .. 10 COPY OF APPLICATION GR -23 u 0 Article I— GENERAL PROVISIONS .O Section 1. General Definitions w As used in this policy: 0. (a) The term "Employee Coverage" means only insurance as to an employee. The term "Dependent Coverage" means insurance as to an employee's dependents. (b) The term "family member" means an employee or a dependent of the employee. A "de- pendent" means •GR -23 OPEN Ed. 9-'57 Page 3 .1309 (1) with respect to coverage under Title 11.13 only: (i) the employee's wife or husband or (ii) the employeels unmarried child under nineteen years of age (twenty -three years of aee with respect to an unmarried child who is attending, school regularly and depends solely upon the employee for support), (2) with respect to coverage under all other Titles: (i) the employee's wife or husband or (ii) the employee's unmarried child at least fourteen days of • age but under nineteen years of age (twenty -three years of age with restect to an unmarried child who is attending school regularly and depends solely upon the employee for support) but any person who is insured (or eligible for benefits by reason of having been insured) •% as an employee shall not be considered a dependent, and no person shall be considered as a dependent of more than one employee. The word "child" means, in addition to the employee's own or lawfully adopted child, • any step - child, foster child, or other child, who depends upon the employee for support and J lives with the employee in a regular parent - child. relationship. (c) For the purposes of any Title under Article II, the term "covered family member" means, as of any given time, and as to any employee, a family member with respect to whom in- surance is in force for the employee under such Title. (d) The term "non - occupational disease" means a disease which does not arise, and which is not caused or contributed to by, or as a consequence of, any disease which arises, out of or in the course of any employment. or occupation. for compensation or profit; however if evidence satisfactory to the Insurance Company is furnished that the individual con- cerned is covered as an employee under any workmen's compensation law, occupational disease law, or any other legislation of similar purpose, or under the maritime doctrine of maintenance, wages, and cure, but that the disease involved is one not covered under the applicable laws or doctrine, then such disease shall, for the purposes of this policy, be regarded as a "non - occupational disease ". (e) The term "non - occupational injury" means air accidental bodily injury which does not arise, and which is not caused or contributed to by, or as a consequence of, any injury which arises, out of or in the course of any employment or occupation for compensation or profit. , •GR -23 OPEN Ed. 9-'57 Page 3 .1309 (� Article T--GEN'ER! P :( Vi.° :vin's (Contiimed) -'j other employees, an the contributory basis as to covers_- under ` Seeiion 1. Geo :cral Dcpnitio ::s (Coniinvec`) Z (f) The term "hospital" means only an insUALi.,n which meets fully every one of the fol- d (p) lowing test;, naawly. (a) it is primarily euga re: in previding- -for coir.peus.cion from (q) its patienta auci on .':n inpa,,iect basis-- di^ffncstic and therapeutic facHRi•es for So surgical and medical dia nonA treatment, and care cf injured and sick persons by or Vunder time and place invoi7ed, the psrticn:ar ccntal procedure per`.,.ned 'ly U the supervision of a. srAf of physicians, and (b) it continuously provides twenty - him. '... � four hour a dad nursing service by registered graduaie nurses, and (c) it is nee, oth�n' than incidentally, a place for rest, a place for the aged, a place for drug addicts, a lost., EE-- hip, ?_ - GPEN place for alcoholics, or a nursing Paga 3 -A (i:c•,. 5 15 70 :_sa (g) The term "board and room" means not only the hospital's charges for board and room . but also charges, by whatever name called, whi;ar are made by the hospital at a :L-:illy or weekly rate for other hospital services and supplies, or which are regulariy r r,de w by the hospital as a condition of occupancy of the class of accommodation; occupied.. (h) An expense or charge shall be deemed to be incurred on the date on which the par- . ticular service or supply which gives rise to the expanse or charge is rendered or ob- tained. lu the absence of due proof to the contrary, when a single charge A node for a series of services each service shaii be deemed to bear a pro rata share of the charge. (i) The term "date of issue" means the date this policy took effect as shown on Pac I + of this policy. (j) Commencing February 1, 1�,70 "policy anniversaries" shall be deemed to occur on said date, and on the same day in each succeeding year. (k) The term "policy year" means a period commencing with the date of i�sue of `his policy, or a policy anniverary, and c immediately prior to the next. succccd- ing policy anniversary. (i) A "policy month" sha.`,i c0)nnni :aneq nn tf,e r.nt,e .., Each 'policy monxV thcr ._J ?' shell be deem :d to corm,_,._., ^' on the -... a Aday of the calendar month. (m) The term "physician" or "surgeon" means only a legally- qualified physician. (n) "Contributory insurance" means insurance for which an employee makes written re.- quest to his Participant Employer and agrees to make the required contr ^IuEors to : his Participant Employer. "icon- contributory insurance" is insurance for which at,, employee does not make written request nor contribute toward the cost. Tni:, policy J provides insurance on the ecntrit7t1tor;, and non— cortributcry 'cas_s as _ol�e•ss• (i) With respect to Employee Coverage and Dependent Cover gc for City Councilmen, cn the contributory basis; (iii) With respect to J „icvee Coverage and Dependent Cover_.go for all. other employees, an the contributory basis as to covers_- under ` Title 'r.nC and, on the non-- contritutory basis as to covere.-e urdet• all other Titles; (o) The term. "Flan A" ,.cans insurance with respect to one dependent. , (p) The tern "Plan 5" means insurance with respect to more than one derendcnt. (q) With re =react to Title SO, the term "dentist" manns only a legally oualified demist or rnvsician authorii.e. by license to perform, at the ,J time and place invoi7ed, the psrticn:ar ccntal procedure per`.,.ned 'ly U him. '... � GF 93 EE-- hip, ?_ - GPEN Ed. NA Paga 3 -A (i:c•,. 5 15 70 :_sa • Article I -- GENERAL PROVISIONS (Continued) • Section 1. General Definrtrons (Conthmed) 333231 (r ) The term "custodial care" means care comprised of services and supplies, including room and board and other institutional services, which are provided to an individual, whether disabled or not, primarily to assist him in the activities of daily living. Such services and supplies are custodial care without regard to the practitioner or provider by whom or by which they are prescribed, recommended or performed. Room and board and skilled nursing services, when provided to an individual in a hospital or other institution, for which coverage is specifically provided under a Title of Article 11, shall not be custodial care when such services must be combined with other necessary therapeutic services and supplies in accordance with generally accepted medical standards to establish a • program of medical treatment which can reasonably be expected to contribute substantially to the improvement of the individual's medical condition. P 0 i • 0 9 0 !* (0 GR -23 Ed. 6272 Page 3 -B 11 1 72 12 73 L. 40 *1 a) t T-) `J U Article I— GENERAL PROVISION'S (Continued) Section 2. List of Participant Employers An Employer shall be eligible to be included in this list as a Participant Employer if such inclusion is not contrary to any applicable insurance law of the state or other jurisdiction in which this policy is delivered. The Policyholder may act for and on behalf of any and all of the Employers included in this list in all matters pertaining to this policy, and every act done by the Policyholder, agreement made between the Insurance Company and the Policyholder, or notice given by the Insurance Company to the Policyholder or by the Policyholder to the Insurance Com- pany, shall be binding on all such Employers. Any eligible Employer may be added to this list as a Participant Employer only upon written agreement between the Policyholder and the Insurance Company and upon terms mutually agreeable to them. An Employer shall be eliminated automatically- from this list,when this policy is discon- tinued with respect to employees of such Employer, as provided for elsewhere in this policy, but termination of an Employer's status as a Participant Employer shall not relieve such Employer from any obligations to the Insurance Company with respect to the time such Employer was a Participant Employer under this policy. Name of Participant Employer GR -23 Ed. J-'b7 Policyholder Page 4 Principal Location SeE Application Effective Date of Inclusion Date of Issue 1413 • 333231 Article I— GENERAL PROVISIONS (Continued) N O N Section 3. Employees to be Insured o (I) Employee Coverage z • A. Employees Eligible: i All employees of a Participant Employer shall be eligible for Employee Coverage ex- cept employees in the following classes: (a) temporary or substitute employees (i.e., employees who are not classified by such • Employer as permanent employees) ; (b) employees who are actively working for such Employer on a part -time basis, but this exception shall not apply in the case of a regular, full -time, active em- ployee of such Employer if and while he is only temporarily working for such Employer on a part -time basis; (c) City Councilmen but only as to coverage under Titles ADDC & WBC. I(* (� Each employee in an eligible class whose employment commenced on or before the date of issue shall become eligible for Employee Coverage on the date of issue, and each other employee in an eligible class shall become eligible for Employee Coverage on the date he enters the service of a Participant Employer. r-1 LA Anything to the contrary notwithstanding, if an individual is in the employ of or con- nected with two or more Participant Employers, he shall not be eligible for multiple coverage under this policy, but shall be treated the same as if he were in the employ of or connected with a single Participant Employer; the amount of insurance for which any such individual shall be eligible under this policy shall under no circumstances ex- ceed the amount which would apply if all of the Participant Employers with which he is employed or connected were a single Participant Employer and if the aggregate of the remu-neration being paid to him by all such Participant Employers were being paid • to him by a single Participant Employer. If any Participant Employer is a partnership, the natural - person partners thereof shall be considered to be employees within the meaning of this policy if and while they are actively engaged in and devoting their time on a substantially full -time basis to the C • conduct of the business of the partnership. If any Participant Employer is an indi- vidual proprietorship, the natural - person proprietor thereof shall be considered to be an employee within the meaning of this policy on the same terms as those applicable to partners of a partnership. GR -23 No Ed. 9257 Page 5 11 1 72 1502 m� V z u 4: W, t I. LA Article I— GENERAL PROVISIONS (Continued) Section 3. Employees to be Insured (Continued) (I) Employee Coverage (Continued) B. Effective Dates of Insurance: (1) As to contributory insurance, each employee who makes written request to his Participant Employer for Employee Coverage and agrees to make the required con- tributions therefor to his Participant Employer is to be insured for Employee Cov- erage on the date he becomes eligible for Employee Coverage or on the date he makes such request, whichever is later; provided, however, that (a) the Employee Coverage of any employee who makes such written request after thirty -one days from the date he becomes eligible, or who revokes any written request previously made, shall become effective only if and when the Insur- ance Company gives its written consent; and (b) any employee who is both disabled (i.e., ill or injured) and away from work on the date Employee Coverage is to become effective shall not be insured until he actually returns to work on a full -time basis. (2) As to non - contributory insurance, each employee is to be insured for Employee Cov- erage on the date he becomes eligible therefor; provided, however, that any em- ployee who is both disabled (i.e., ill or injured) and away from work on the date Employee Coverage is to become effective shall not be insured until he actually re- turns to work on a full -time basis. GR -23 Ed. 9 -'57 Page 5- Continued C =NC .1$36 Article I— GENERAL PR0I7ISIONS (Continued) Section: 3. Employees to be Insured (Continued) �_. (II) Dependent Coverage A. Employees Eligible: (1) Each employee who has one or more dependents shall be eligible for Dependent Coverage on the date he becomes eligible for Employee Coverage, and (2) each employee without a dependent at the date he becomes eligible for Employee Coverage shall be eligible for Dependent Coverage on the date he acquires a de- pendent. GIL An employee who has only one dependent shall be eligible for Dependent Coverage - under Plan A. An employee who has more than one dependent shall be eligible L. for Dependent Coverage under Plan B. B. Effective Dates of Insurance: Each employee who makes written request for Dependent Coverage under the Plan for which he is eligible and agrees to make the required contributions therefor to his Par- ticipant Employer is to be insured for Dependent Coverage under that Plan from the date he becomes eligible under that Plan or on the date he makes such request, which- ever is later; provided, however, that � (a) no employee shall become insured for. Dependent Coverage at a time when he is not insured for Employee Coverage; (b) the Dependent Coverage of any employee who makes such written request after �\ thirty -one days from the date he becomes eligible for Dependent Coverage, or who revokes any written request previously made, shall become effective only if and when the Insurance Company gives its written consent; and (c) if an employee who is insured under one of the Plans makes written request for Dependent Coverage under another Plan after thirty -one days from the date the employee becomes eligible for Dependent Coverage thereunder, the Insurance Com- pany shall have the right to require evidence of insurability (without expense to the Insurance Company) of each of such employee's dependents not covered under this policy on the date of such written request; and insurance shall become effective with respect to a dependent of whom evidence of insurability is required only if ti and when the Insurance Company gives its written consent. GR -23 Page 5 -A AB Ed. 9257 (A & B) 1561 Article I— GENERAL PROVISIONS (Continued) r Section 3. Employees to be Insured (Continued) r If on the date an emploti-ec would othern-ise become insured with respect to a particular dependent, the effectiNe date of the Dependent Coverage under Title CAIEB, Title DIMEB or Title CDEB for that dependent would be deferred in accordance Nciih the • following paragraph, then insurance under such Title shall be deferred until such time as neither the terms of such paragraph nor the foregoing terms of this section require it to be deferred: 1. In any instance in which a dependent other than a child with respect to whoun the employee becomes insured under Title CMEB, Title :IVIED or Title CDEB within thirty -one days after the date of the child's birth —is confined, by reason of disease or injury, at home, in a hospital, or elsewhere, on the date the employee would otherwise become insured under Title CALEB, Title \HIES or Title CDEB with respect to such dependent, or in any instance in wMeh a dependent luas been 3 confined in a hospital at any time during the thirty -one day period iminediaiely preceding the date the employee would otherwise become insured under Title CMEB, Title JI\IEB or Title CDEB with respect to such dependent, the effective date of the employee's insurance under such Title with respect to any such do- pendent shall be deferred until the earlier to occur of (a) the end of a thirty -one day period during which there has been no confuic- ment of any hind, and -\� (b) the date the Insurance Company is furnished with evidence satisfactory to it + that the dependent has completely recovered from all such diseases and in- juries. �v •v 11�z. I\. GI: -2 Ed. 6-'GS Page 5 -E BIRTH 1573 Article !_ — l:iSl\TFR,".L PRZO v ISIO;'-tS (Condnucd', Section. 3. Employees to be insured (III) Special Ccnditions A. Employee Coverage: If a Title is added to this policy while Employee Coverage under this policy is ill force for an ernpioyee and if the employee is in a class of employees eligi le for Employee Coverage tinder such Title, the employee shall become eligible for E n- pAyee. Coverage trade: such Title on the date such Title is s.dded to the polio% any employee becoming eligible for P:mployee Coverage Linder such Title in ac.cor0ance with tai; preceding terms of this paragraph $flail become 1nsuzre.d for the beneilts pro- vided by shell Title only in accordance with the terms applicable to the eFczting of Employee Coverage as set forth in paragraph 1 -13 of this Section 3. B. Dependent Coverage: If a Title which provides D- ependent Coverage is added to this policy while Depen- dent Coverage under this policy is in force for an employee, and if the employee is in a class of employees eligible for Dependent Coverage under such Title, the Cl :_T:io.S'ee shall 'become eligible for Dependent Coverage under such Title on the data: tl,o Tick is added to the pokey but only with respect to each of his dependents fo-,- \',Lain De- pendent Coverage is then in force Milder this policy. Any stvlt employee becomi,n :' eligible for Dependent Coverage under such Tale in accordance with the preceding terms oL this parag)',apb shall become insured for tl;c heneilis provided b-` such Title only in - ..-cordL ce wli'n 4hn telm app _cabin to sae cffcccti g of .� ... co.�..r age as set forth in parIlbraph iI -B of tills Section 3. GR -23 Ed. 907 Page 5 —C 5 15 70 3 590 Article I— GENERAL PROVISIONS (Continued) Section 4. Changes in Amounts of Insurance 333231 The initial amount of insurance for an employee under any Title of this policy shall conform • to that provided in the Schedule of Insurance appearing in such Title. As to contributory insurance, if, for any reason, the Schedule of Insurance under any Title of this policy warrants an amount of insurance for any employee greater or less than that for which he is then insured, the amount of his insurance shall be increased or reduced to that warranted by his new classification as follows: Any reduction in insurance shall become effec- tive on the date the employee makes a request therefor to his Participant Employer. Any in- crease in insurance shall become effective only in conformity with the terms applicable with respect to the effecting of the initial insurance of employees as set forth in Section 3 of Article • I of this policy. As to non - contributory insurance, if, for any reason, the Schedule of Insurance under any Title of this policy warrants an amount of insurance for any employee greater or less than that for which he is then insured, the amount of his insurance shall be increased or reduced to the • applicable amount as specified in such schedule of insurance; provided, however, that in any instance in which an employee is both disabled (i.e., ill or injured) and not working on the date his insurance would otherwise be increased, the effective date of the increase in insurance shall be deferred until he actually returns to active work on a full -time basis. • A retroactive change in an employee's rate of earnings shall be deemed to have become effective on the date of the determination of the change in the rate of earnings. Anything to the contrary notwithstanding: • (1) The terms of the second and third paragraphs of this section shall not apply to Title CMEB, Title MMEB, or Title CDEB, if included in this policy. (2) As to any Title which provides both Employee Coverage and Dependent Coverage, if the effective date of any increase in an employee's Employee Coverage is deferred, • for any reason, the effective date of any increase in the employee's Dependent Cover- age under such Title shall be deferred until the increase in his Employee Coverage becomes effective. (3) The terms of this Section 4 shall not apply to changes in the amount of Principal Sum for an employee under Title ADDC because of the employee having attained a speci- fied age. Any provisions applying to a change in the amount of an employee's Prin- cipal Sum appear on Page 6 -ADDC. 0 9 10 10 GR -23 Ed. 11 268 Page 5 -AA 11 1 72 1612 Article II— BENEFITS m t;. TITLE NVBC—%N,EFKIY BENEFIT COVERAGE Section 1. Non- occapational Disability Benefit T i A disability absence is a period of time during all of which an insured employee is preve�rted from performing the duties of his occupation solely because of non - occupational injury- or co3i- occupational disease. If a disability absence of an employee commences while the employee is insured under tinis Title, the Insurance Companv hill, subject to the terms of this policy, pay a benef;t for t ;c period of such disability absence, less days excluded by the terms of this section, at the ,2e'd% rate applicable to the employee at the commencement of the period of clisabiiit;:, but for not more than twenty -six weeks during any ogle period of disability whether due to one or more causes and whether involving one or more disability absences. No benefit shall be payable under this section for (a) the first seven days of a period of disability; (b) any day for which the employee is entitled to receive pay under to sick leave plan of the Employer; (�) any day on which the employee is not wider the care of a physician or surgeon: no period of care shall be considered to haN•e started until the employee has been seen and treated personally by the physician or surgeon; (d) a!n> disability absence which is caused or contributed to by, or as a consequence Of. pregnancy or resulting childbirth, miscarriage, or abortion; (a ) any dad- ou which the employee is performing work of any kind, anywhere, fo com- pensation or profit. Ed. 12 -',57 Page G —WBC 2 1 72 0; EARN 3206 The amount of insurance (weekly benefit) for each employee shall be equal to the au_o:nt, if !) any, by which ,tern (1) below exceeds item (2) below: (1) 66 2/3r; of the employee's monthly rate of basic earnings, but in no event to exceed 2,000 per month; (2) the amount of disability or retirement benefit if any, the employee is entitled to receive under the Public Employee Retirement System (FIRS) or any plan spon- sored by any other Employer or 'provided for, by or through a Eoverniaent cr in- struinentality of a nation, state, province, county, municipality, or other sub- division of a grovern ant. In no case however, shall the amount of weekly benefit for any employee exceed 7% of his average weekly earnings, as hereinafter defined. T i A disability absence is a period of time during all of which an insured employee is preve�rted from performing the duties of his occupation solely because of non - occupational injury- or co3i- occupational disease. If a disability absence of an employee commences while the employee is insured under tinis Title, the Insurance Companv hill, subject to the terms of this policy, pay a benef;t for t ;c period of such disability absence, less days excluded by the terms of this section, at the ,2e'd% rate applicable to the employee at the commencement of the period of clisabiiit;:, but for not more than twenty -six weeks during any ogle period of disability whether due to one or more causes and whether involving one or more disability absences. No benefit shall be payable under this section for (a) the first seven days of a period of disability; (b) any day for which the employee is entitled to receive pay under to sick leave plan of the Employer; (�) any day on which the employee is not wider the care of a physician or surgeon: no period of care shall be considered to haN•e started until the employee has been seen and treated personally by the physician or surgeon; (d) a!n> disability absence which is caused or contributed to by, or as a consequence Of. pregnancy or resulting childbirth, miscarriage, or abortion; (a ) any dad- ou which the employee is performing work of any kind, anywhere, fo com- pensation or profit. Ed. 12 -',57 Page G —WBC 2 1 72 0; EARN 3206 i Article TITLE WPC— V1EEK!,Y• EHi+EHT CO-VORAGE • Secf;o ;: 1. Non- o«: :.:. xa! Disab :r,(y Bencp, ( ow;ni(ecr) All disability absences of an ennrloyee shall be i_; occurring during a sSn,,lc prsl.od of disability (whether: or not there has been any interruption in the ccntinzity of the em- ployee's insurance), exoent that: (a) successive disability absences separated by at least two consecutive weeks of sc- tive work on full time will not be considered as occurring during the same period of disability; (b) successive disability n bsences due to entirely different and unrelated causes a2x', sep- arated by a' least one clay of zctive work on full time Nvill not be considered :,s occur- ring during the sane period of disability provided no benefit has bcc3me payable under this section after the employee. last performed at. least tv:o consecutl,e <<rr_eks of active work on full time for a disability absence invoh•ing a cause which is the same as or related to any of the causes of the current absence. For the purposes or. this section.: (a) Average weekly, earnings ineaus the greater of (i) .,15 and (ii) the amount d .-.hived • by Willing the employee's total earnings from his Participant limnloyer for the base weeks in the eight weekly payroll periods immediately preceding t'he tveeld;: payroll period in which the period of disability co2m22enceu, by the m:mber of such base weeks. (b) A base week is any ,veekly payroll period for which the employee receives total carn- has of not less that; All finni hi: Pnrr.irino»- Fln�nini•n :• (°) A retroncWT change in all en2" loyea's rate of Ball 0?d shai3 la iieClncci to h vc, ! ?e- come effective on the date of the determination of the change in th.e rate of (d) If an employee's payroll period is other than weekly, an appropriate adjustment shall be made in Me calculation of his earnings to give effect to the foregoing provision;. GR -23 \� 5 ?.y 7G MCI Ed. 12 -'5i Page G- A —VV130 F! V 10 Ij A R 0 .0 0 . 0 ErKLY BELNEFiT COVZRAG,'__� (Cont;nucd) TITIL VIBC­71 K Section I-A. Beliefit, shal' bo pa y' for a disability abs2l'lce v, itich from any iniur y or diqeasr! ;.i :s- ing ou' of and !n the ccn:-I'Se Of 0, Partic;parT on the sainw, vnn s would have applied if the disalbilLt-.- had been no,i-occup-tional in nature but in a V„,oh:%- benefit inIOU11' equal to the onl()LUIL' LI-r -xilich tlia non - occupational weekly blweritl exceecis hp weekly amount (v.-heth-i comm,ik.d or not and 7,11001P.1- coinprom!seci or not "S a red_mpJ.jil award or otherwise-) tlml. the eniploj-cc, by coinpl.vint- the provisions thereof, '1J0 entitled to receive for time lost from work tinder any applicabla v,-oi:kmen's compensation is occupationid disease law, or am other legislation of ,finflai, pin-pose, or under the m irji;,­e doctrine of inaintenarice, wa-ges, and cure (not co-rAing paylilel)tg SpeCifiC;z!I)7 zati­i, sm.rgical, or med`cai expenses and payments, or specific allowances for loss of or disfigurement). GP. -23 Ed. 12-'57 Page 6-AA--WBc 5 15 70 ' Article II— BENEFITS 0 m 0 TITLE ADDC— ACCIDENTA13 DEATH AND DISMEMBERMENT COVERAGE \ Section 1. Accidental Death and .Dismemberment Benefit Schedule of Insurance 0 Fi Classification All employees: Annual Hate of Basic Earnings $25,000 or more 22,500 but less than $25,000 20,000 but less than 22,500 17,500 but less than 20,000 15,000 but less than 17,500 12,500 but leas than 15,000 10,000 but less than 12,500 7,500 but less than 10,000 Less than $7,500 333231 Principal Sum $25,000 22,500 20,000 17,500 15,000 12,500 10,000 7,500 5,000 If an employee suffers a bodily injury caused by an accident and as a direct result of such in- jury and, to the exclusion of all other causes, sustains within not more than ninety days after the date of the accident which causes such injury any of the losses listed in the Table of Bene- fits in this section, then, provided: • (a) the injury occurs while insurance is in force for the employee under this Title; and (b) the loss resulting from the injury is not excluded from coverage in accordance with Section 2 of this Title; the Insurance Company shall, subject to the terms of this policy, pay a benefit in the amount provided for such loss in said Table of Benefits but in no case shall more than the Principal Sum be paid for all losses sustained by an employee through any one accident. Table of Benefits 1'q In the Event of Loss of The Benefit will be Life The Principal Sum • Hand One -Half The Principal Sum • Foot One -Half The Principal Sum An Eye One -Half The Principal Sum Loss means, with regard to a hand or foot, actual severance through or above the wrist or ankle joint; kith regard to an eye, the entire and irrecoverable loss of sight of such eye. (40 GR -23 Ed. 12 -'57 Page 6 —ADDC 11 1 72 3030 333231 Article II— BENEFITS (Continued) 0 m 0 m TITLE ADDC— ACCIDENTAL DEATH AND DISMEMBERMENT COVERAGE (Continued) ' • Section 2. Exclusions The insurance provided under this Title does not include, and no payment shall be made for, any loss resulting from any injury caused or contributed to by, or as a consequence of, any of the following excluded risks, even though the proximate or precipitating cause of loss is acci- dental bodily injury: (a) bodily or mental infirmity; or • (b) disease, ptomaines or bacterial infections, of any kind, except a pus- forming infection attributable solely to and occurring as the proximate result of an injury not excluded by this Title; or • (c) medical or surgical treatment, except a loss covered by this Title which results di- rectly from a surgical operation made necessary solely by an injury not excluded by this Title and performed within ninety days after the date of such injury; or (d) suicide or any attempt thereat (whether sane or insane), or intentionally self- inflicted injury; or (e) war or any act of war (whether war is declared or not). 0 0 0 0 \J 0 GR -23 Ed. 12 -'57 Page 6 -A —ADDC 11 1 72 .3080 333231 Article II— BENEFITS (Continued) T TITLE ADDC — ACCIDENTAL DEATH AND DISMEMBERMENT COVERAGE (Continued) Section 3. Beneficiary An employee, whether or not employment has terminated, may designate a beneficiary, and from time to time change his designation of beneficiary, by written request filed at the head- quarters of the Policyholder or at the Home Office of the Insurance Company. Such designa- tion or change shall take effect as of the date of execution of such request, whether or not the employee be living at the time of such filing, but without prejudice to the Insurance Company on account of any payments made by it before receipt of such request at its Home Office. Any amount payable to a beneficiary shall be paid to the beneficiary or beneficiaries designated by the employee, except that, unless otherwise specifically provided by the employee in his beneficiary designation. • (a) if more than one beneficiary is designated, the designated beneficiaries shall share equally; (b) if any designated beneficiary predeceases the employee, the share which such bene- ficiary would have received if surviving the employee shall be payable equally to the • remaining designated beneficiary or beneficiaries, if any, who survive the employee; and 0 G 0 C, 0 0 0 (c) if no designated beneficiary survives the employee, or if no beneficiary has been des- ignated, payment shall be made to the employee's widow or widower, if surviving the employee; if not surviving the employee, in equal shares to the employee's children who survive the employee; if none survives the employee, to the employee's parents, equally, or to the survivor; if neither survives the employee, in equal shares to the employee's brothers and sisters who survive the employee; or, if none survives the employee, to the employee's executors or administrators. 40 GR -23 46C IA. 12 -'57 Page 6- B—ADDC 11 1 72 3141 rJ m Y 1� *� �J •�7 Classification All employees Article II— BENEFITS TITLE HES— HOSPITAL EXPENSE BENEFTTS Schedule of Insurance Maximum Rate of Daily Benefit $40 Section 1. Hospital Expense Benefit Factor For Benefit Clause (a) 70 Factor For Benefit Clause (b F If, solely because of any non - occupational disease or non - occupational injury, a covered family member becomes confined in a hospital, the Insurance Company shall, subject to the terms of this policy, pay: (a) a benefit in an amount equal to the actual charges made by the hospital, in its own behalf, for board and room of the covered family member during such confinement, but in no event shall the aggregate benefit payable under this benefit clause (a) in connection with all hospital confinements commencing during any one continuo;-.s period of disability exceed the amount detem:ined by multiplying the applicable Maximum Rate of Daily Benefit by the lesser of (i) the number of days of confine- ment for which such charges are made_ and (ii) the applicable Factor for Benefit Clause (a); GR -23 Ed. V59 Page 6 — HEB ,4132 Article II— BENEFITS (� TITr.E HEB— HOSPITAL EXPENSE BE\EFITS (Continued) Section 1. Hospital Expense Benef t (Continued) (b) a benefit in an amount equal to tLe actual charges —other than those for board and room, for the services of any physician or intern, and for any private duty or special nursing services, regardless of whether the services are rendered under the direction of the hospital or otl:er.vise —made by the hospital, in its own behalf, for services and supplies required for and rendered to the covered family member in direct con- e nection with the treatn -ent of the ccvered family member; but in no event shall the aggregate benefit payable under this bcneiit cause (b) in connection with all hos- pital confinements conll ? :encing during any one continuous period of disability exceed the amount determined by multiplying the applicable .Maximum Rate of Daily Bene- fit by the applicable Factor for Benefit Clause (b) ; moreover, no benefit shall be payable under this benefit clause (b) with respect to any charges incurred during any period for which. a boa =d and room benefit is not payable under the foregoing benefit clause (a), except when the only hospital charge either is in connection with and for services rendered on the day of a surgical procedure or is for emergency 1 treatment required as a result of a non - occupational injury and rendered on the day of the injury or the day- next following. No benefit shall be payable under this section under any of the circumstances for which no ` insurance is afforded as stated in the provision of this Article entitled Exclusions, Limitations, And Provisions Applicable To All Titles Under Article II. All hospital confinements of a covered family member shall be considered as commencing dur- ing one continuous period of disability (whether or not there has been any interruption in the continuity of insurance as to such family member), except that if evidence satisfactory- to the Insurance Company- is furnished (a) that the cause or causes of the latest hospital confinement cannot be connected with the cause or causes of any of the Drior hospital confinements, or �- (b) that a connection with the cause or causes of any one' or more of the prior hospital confinements can be established but that between the date of the last of the orevious hospital confinements which are connected and the latest one the family member either has recovered completely from all of the causes of such prior hospital con- •' finements or, if he is the employee, has returned to active Nvork for at least one full V day or, if he is other than the employee, a period -of. at least ninety days free of hos- pital confinement has intervened, the latest hospital confinement will not be considered as having, commenced during the same �iperiod of disability. t? \ GR -23 Ed. 4259 Page 6 -A — HEB Article 11- BENEFITS N TITLE HEB-- HOSPITAL EXPENSE BENEFITS (Continued)' `Z Section 2. Pregnancy Expense Benefit J < Regardless of any subsequent termination of insurance, if a pregnancy of a female employee or the wife of a male employee commences while she is a covered family member, the Insur- es ante Company shall pay a benefit in an amount equal to the actual charges for hospital, sur- gical, and medical care with respect to such pregnancy; provided, however, that the aggre- gate benefit payable in connection with any one pregnancy shall not exceed that one of the following benefits which is applicable: (1) if the pregnancy terminates in childbirth, $ 100.00; (2) if the pregnancy terminates in an abdominal operation for extra- uterine pregnancy or caesarean section, $ 200. j0; (3) if the pregnancy- terminates in a miscarriage, $ j0.00. W Wk G t L' GR -23 EN/ -ALL INCL. �• Ed. 4259 Page 6 -AA - 1= 4231 Article II— BENEFITS a P, TITLE SEB– SURGICAL P'DENSE BENEFITS Y Schedule of Insurance • Schedule of Basic Maximum Classification Procedures Surgical Unit Benefit z o All employees K 22 $660 • 0 Section 1. Specific Definitions As used in this Title: (a) the term "operation" means the performance of one or more surgical procedures during a single operating period and shall, in any event, include all surgical pro- cedures performed during any one continuous period of anesthetization; (b) the term "surgical procedure" means any procedure specifically listed in the appli- cable Schedu'e of Procedures, and any other surgical procedure in the cac,.gones listed below: (1) the incision, excision, or electrocauterization of any organ or part of the body; (2) the manipulative reduction of a fracture or dislocation; �j (3) the suturing of a wound; (4) the removal by endoscopic means of a stone or other foreign object frcm the larynx, bronchus, trachea, esophagus, stomach, urinary bladder; or ureter. Section 2. Surgical Expense Benefit if, solely because of any non - occupational disease or non- occupational injury, a surgical pr ^- cedure is performed on a covered family member, the Insurance Company- shall, s :.,',Ct the terms of this policy, pay a benefit in an amount ecual to the total surgical fees charged by the operating physicians (but not including any fee. charged by a resident clan or intern of a hospital), for their professional services in performing such sur, : ,Ri oro- cedure but not exceeding the amount obtained by multiplying the applicable Basic S urgica: Unit by the factor determined for such procedure in accordance. with the applicable C= hedule of Procedures. No benefit shall be payable under this section (1) with respect to any medical treatment (whether involving injury or disease) other than the performance of surgical procedures, whether or not the alternative treat - �. ment is in lieu of or accomplishes the same result as the performance of the corres- ponding surgical procedures; or OPEN GR -23 K --Ed. 4-'59 Page 6 — SEB 46'13 Article II— BENEFITS r r TITLE SEB--- SURGICAL EXPENSE BENEFITS (Continued) be Section 2. Surgical Expense Benefit (Continued) (2) under any of the circumstances for which no insurance is afforded as stated in the provision of this Article entitled Exclusions, Limitations, And Provisions Applicable to All Titles Under Article II, or for dental work or oral surgery, except oral sur- gery for (a) excision of partially or completely unerupted impacted teeth, (b) ex- cision of tooth root without extraction of entire tooth, (c) closed or open reduction of fractures or dislocations of the jaw, and (d) other incision or excision procedures on the gums and tissues of the mouth when not performed in connection with the extraction of teeth —for the purposes of the oral surgery* recognized by the terms of this paragraph, the term "physician" shall be deemed to include a duly licensed dentist. Two or more surgical procedures performed during the course of a single operation either through the same incision, or through the same natural body- orifice, or in the same opera - tive field, shall, except to the extent, if any, that this provision is specifically contradicted by the provisions of the applicable Schedule of Procedures, be considered as one surgical proced- ure and the factor applicable shall be the greatest of the factors determined for such surgical procedures in accordance with the applicable Schedule of Procedures. Otherwise, payment will be made for each surgicai procedure as indicated in the preceding paragraph unless the •) applicable Schedule of Procedures specifies to the contrary. The aggregate benefit payable R-ith respect to all surgical procedures performed during one continuous period of disability shall not exceed the Maximum Benefit. All surgical procedures which are perforr•:ed on a covered family member shall be considered as having been performed during one continuous period of disability (whether or not there has been any interruption in the continuity of insurance as to such family member), except that if evIdence satisfactory to the Insurance Company is furnished. (a) that the cause or causes of the latest surgical procedure cannot be connected with the cause or causes of any of the prior surgical. procedures, or (b) that a connection with the cause or causes of any one or more of the prior surgical procedures can be established but that between the date of the last of the previous surgical procedures which are connected and the latest one the family- member either has recovered completely from all of the causes of such prior surgical procedures or, if he is the employee, has returned to active work for at least one full day or, if he is other than the employee, a period of at least ninety days free of surgery has in- tervened, the latest surgical procedure will not be considered as having been performed during the same period of disability. However, in any instance in which the applicable Schedule of Pro- cedures provides either (i) for a single factor to be applicable to a particular series of pro - cedures or to several stages of a procedure or (ii) for a lesser factor to be applicable to the second and subsequent procedures of a particular series of procedures than would apply to the first procedure in the series, then the provisions of the applicable Schedule of Procedures shall apply whether the procedures are performed during the same or different periods of disability. r�- `" Ed. 4359 Page 6 -A — SEB 4676 Article II — BENEII'CS ". TITLE SEB-- SURGICAL EXPENSE BENEFITS (Continued) Schedule of Procedutes Ii GENERAL Factor MUSCULOSKELETAL (Continued) Factor x Accidental lacerations of skin structures, Closed Open suture of Reduc- Reduc- Face, neck, genitalia and hands, all Dislocations tion tion lacerations combined 1 inch or less 1.5 Elbow . 4 10 More than I inch up to 2 inches 2 . . . . . . Shoulder 3.5 12.5 Other body areas, all lacerations Fractures, simple or combined compound 1 inch or less . 0.75 Ankle — llalleolus of More than 1 inch up to 2 inches 1 tibia or fibula . 5 10 Bronchoscopy — Diagnostic, with or . . . — Bimalleolar without biopsy 4.5 (Potts) . . . 6 15 •l — Operative removal of tumors foreign Clavicle . . . 3 10 or Elbow, distal end of bodies . . . . . . 7.5 hmnerus or proximal end Cystoscopy Diagnostic, with or without biopsy of radius or ulna, one or bones 6 15 Without ureteral catheterization 2.5 more Femur (except knee) 12 24 With ureteral catheterization 3.5 Fibula (except ankle) 4 8 Operative — Transurethral resection 'tumors Finger, thumb or toe of bladder neck or bladder or — One . 2 4 crushing of bladder stones . . . II' . - -Each additional 1 2 — Fulguration of bladder Humerus (except elbow) 7.5 15 �J tumors or removal of bladder stones, Knee, distal end of femur without crushing . . . . . . . 5 or proximal end of tibia, Cysts, excision of — Pilonidal cyst . . 9 one or both bones 7.5 15 — Sebaceous cyst. I.5 Radius, including Colles' Mammary glands (except elbow, 5 10 Excision of benign tumors or cysts Unilateral Radius and ulna !except — . . , _ , 5 elbow) . . . . . . 7 14 — Bilateral . 7,5 Ribs, one more 2 Mastectomy — Total . . . . . 10 Tibia (except t ankle and — Radical with axillary knee) 7.5 15 •� node dissection Skin abscess, superficial, incision and 20 Tibia and fibula drainage — One . . . . . 0.7-5 .except Ulna . . 10 Ulna (except elbow; 4 20 10 — Each additional — Maximum 0,40 ? 5 Closed reduction is correction of displace - Thyroid gland merit by manipulation without incision in- •� Thyroidectomy, total or subtotal I7.5 cluding. application of casts or traction and Thyroid lobectom }, including debridement at fracture sue. For _J hemithyroidectomy 15 closed reduction of a fracture with skeletal Excision of thyroid adenoma or cyst . 12,5 pinning and external fixation, the factor Tumors, benign, superficial amount is one and one-half times the factor Excision from face, neck, genitalia, hands, or feet — One . . . 2 for closed reduction. Open reduction is correction of displace- . . -Each additional. I merit by manipulation and incision with or Excision from other body areas without skeletal traction or metallic fixation. — One I Intervertebral disc, excision of — Each additional . . . 0.5 —Without spinal fusion 22.5 Electrocauterization or fulgu-ation. —With spinal fusion . 30 with or without curettage, per day Tendons — Excision of ganglion 4 of such treatment Suture of tendon laceration One tumor, except plantar wart 0.5 — One . . . . . 5 More than one tumor, or each — Each additional . . . 2.5 -� plantar wart . . . . . . 1 KYE' EAR, NOSE, AND THROAT MUSCULOSKELETAL Chalazion, excision or curettage ` Amputations — Single . . . . . . 1.5 Finger, thumb, or toe (one or more — Multiple . . . . . . 2.5 phalanges) --One . . . . . . 2.5 Extraction of lens for cataract . . . . 20 — Each additional - 1.5 Strabismus, operation for — One eye 13.5 \' Thigh, through femur 15 — Both eyes 17.5 GR -23 K v. . ,rn n -__ c n con Inns row' m� P � X Y 10 krtiele Il — BENEFITS TITLE SEB - SURGICAL EXPENSE BENEFITS (Continued) Sc•he(luly of Pro<•rvlures K (Coil fill ur(/) EYE, EAR, NOSE, AND THROAT (Continued) Each additional operation, one or both eyes Fenest . ion operation for otoMerosis Dlyringutomyortympanoeomv . Nasal polyps, removal of one or more one or more stages Unilateral . . . . . . . Bilateral . . Nasal septum, submucotu, resection of Tonsillectomv with or without adenoidectomv . . . . . . . . HEART AND BLOOD VESSELS Commissurotomv or valvotomy Saphenous vein, long, lization with or without retrograde injection or distal interruptions Without stripping -- Unilateral — Bilateral With strippiml- on same or sub- sequent days — Unilateral . — Bilateral CHEST Lobectomy — Total, subtotal or segmental . . — N� edge resection . . . Thoracotomy, for drainage of empyema . Without rib resection . . . . . With rib resection . . . . . . . ABDOMEN Appendectomy. with or without incision and drainage of append ircal abbsces Cholecysicc torn y. with or without ex- ploration of cocoon duct Colon resection — Partial, with or with- out colostomy . . . — Total . . . . . Gastrectomy, with or without vagotomy — Partial . . . . . . — Total . . Herniotomy, inguinal or femoral — Single . . . . . — Bilateral . . . . . . PROCTOLOGY AND UROLOGY Fistulectomy or fistulotomy — Single — Multiple Fistulectomy or fistulotomy !single or multiple), with incision and drainage of ischiorectal abscess . Hemorrhoidectomy. by excision. internal only or both internal and external — Without fistuiectomy — With fistulectom_v. . Hydrocele or varicocele, excision of — Unilateral . . . . . — Bilateral . . . . Ischiorectal abscess. incision and drainage . . . . . Nephrectomy or heminephrectomy- 30 7.5 11 10 15 30 22.5 5 10 11 17.5 25 30 25 30 11 15 6.5 9 9 8 10 . 7.5 10 3.5 22.5 GYNECOLOGY Conization of cervix . . . . . . . Cystoce!e, repair of . . . . . . . Rectoc•ele, repair of . . Cystocele and rectocele, repair of . . . Dilation of cervix and curettage of uterus, non - puerperal, with or without electrocauterizaLion. conizaiion or polypectomy . . . . Elect rocauterization of cervix, non - puerperal . Hysterectomy, with or without dilation and curettage Complete {pan - hysterectomy), with or without adnexa . . Subtotal or supracervical, with or without adnexa . . . . . . . Radical, for malignancy . . . . . Salpingectomy or oophorectomy, or both, unilateral or bilateral . Uterus, suspension of. any type. with or without dilation and curettage or sureery on tubes or ovaries . . . . NEUROSURGERY Craniotomy [other than trephination only; Decompression, unilateral or bilateral . . . . . Excision of brain cyst, neoplasm, or abscess . Lumbar sympathectomy — Unilateral . — Bilateral Trephination Drainage of subdural, epidural or brain abscess or hernatoma — Initial trephination — Subsequentneedling . Pneumoventriculography . . . . . Factor 30 25 20 3 10 7.5 14 4 1.5 18 15 25 12.5 12.5 17:5 30 15 22.5 15 3 10 The Insurance Company will determine a factor consistent with the factors listed, for a surgical pro - cedure not listed in the ','oreeoing Schedule - -such rieternunation_ in each case. to take into account the nature and complexity of the procedure involved and the exclusions and other restrictions applicable. ,t GR -23 K —X08 Ed. 4259 Page 6- C - -SEB 4803 PROCTOLOGY AND UROLOGY Factor (Con finned) Proctectomv, complete, combined 7.5 abdominal —perinea! procedure, one 30 or more stages . . . . . . . . 1.5 Prostatectomy -- Suprapubic, one or more stages . . . — Transuretln•al, one or 1.5 more stages including 2.5 control of postoper- 10 alive bleeding — Bilateral With strippiml- on same or sub- sequent days — Unilateral . — Bilateral CHEST Lobectomy — Total, subtotal or segmental . . — N� edge resection . . . Thoracotomy, for drainage of empyema . Without rib resection . . . . . With rib resection . . . . . . . ABDOMEN Appendectomy. with or without incision and drainage of append ircal abbsces Cholecysicc torn y. with or without ex- ploration of cocoon duct Colon resection — Partial, with or with- out colostomy . . . — Total . . . . . Gastrectomy, with or without vagotomy — Partial . . . . . . — Total . . Herniotomy, inguinal or femoral — Single . . . . . — Bilateral . . . . . . PROCTOLOGY AND UROLOGY Fistulectomy or fistulotomy — Single — Multiple Fistulectomy or fistulotomy !single or multiple), with incision and drainage of ischiorectal abscess . Hemorrhoidectomy. by excision. internal only or both internal and external — Without fistuiectomy — With fistulectom_v. . Hydrocele or varicocele, excision of — Unilateral . . . . . — Bilateral . . . . Ischiorectal abscess. incision and drainage . . . . . Nephrectomy or heminephrectomy- 30 7.5 11 10 15 30 22.5 5 10 11 17.5 25 30 25 30 11 15 6.5 9 9 8 10 . 7.5 10 3.5 22.5 GYNECOLOGY Conization of cervix . . . . . . . Cystoce!e, repair of . . . . . . . Rectoc•ele, repair of . . Cystocele and rectocele, repair of . . . Dilation of cervix and curettage of uterus, non - puerperal, with or without electrocauterizaLion. conizaiion or polypectomy . . . . Elect rocauterization of cervix, non - puerperal . Hysterectomy, with or without dilation and curettage Complete {pan - hysterectomy), with or without adnexa . . Subtotal or supracervical, with or without adnexa . . . . . . . Radical, for malignancy . . . . . Salpingectomy or oophorectomy, or both, unilateral or bilateral . Uterus, suspension of. any type. with or without dilation and curettage or sureery on tubes or ovaries . . . . NEUROSURGERY Craniotomy [other than trephination only; Decompression, unilateral or bilateral . . . . . Excision of brain cyst, neoplasm, or abscess . Lumbar sympathectomy — Unilateral . — Bilateral Trephination Drainage of subdural, epidural or brain abscess or hernatoma — Initial trephination — Subsequentneedling . Pneumoventriculography . . . . . Factor 30 25 20 3 10 7.5 14 4 1.5 18 15 25 12.5 12.5 17:5 30 15 22.5 15 3 10 The Insurance Company will determine a factor consistent with the factors listed, for a surgical pro - cedure not listed in the ','oreeoing Schedule - -such rieternunation_ in each case. to take into account the nature and complexity of the procedure involved and the exclusions and other restrictions applicable. ,t GR -23 K —X08 Ed. 4259 Page 6- C - -SEB 4803 FOR W 1) Article II- 131',NEFITS TITLE ANEB — ANESTHESIA EXPENSE BENEFITS Schedule of Insurance Classification Maximum Anesthesia Benefit All employees The greater of (i) 5`,'c of the applicable ;Maximum Benefit under Title SEB of Arti- cle II (ii) 20% of the total surgical allow- ance under Title SEB for all sur- gical procedures with respect to which anesthesia was adminis- tered If anesthesia, other than local infiltration anesthesia, is administered to a covered family member in connection with a surg_cal procedure for which Surgical Expense Benefits are payable under Title SEB and if the anesthesia, is administered and charged for by a physician who is not the operating surgeon or his assistant, then the Insurance Company shall; subject to the terms of this policy, pay a benefit in an amount equal to the actual charges made by the physician, but not exceeding the ap- plicable 'Maximum Anesthesia Benefit; provided, however, that the aggregate benefit payable with respect to any one continuous period of disability (as defined in Title SEB), whether such disabilitv be from one or more causes, shall be not more than 20% of the applicable Maximum Benefit under Title SEB. GR -23 rU 0 N j r N x N z 4 . L * C. Article 1I— BENEFITS TITLE LXF;B— LABORATORY AND X -RAY EXPENSE BENEFITS Classification All employees Section 1. Schedule of Insurance Maximum Benefit $50 If, solely for diagnosis of any non - occupational disease or non - occupational injury, a laboratory or x -ray examination of a covered family member is made, the Insurance Company shall, subject to the terms of this policy, par a benefit in an amount equal to the actual charges made with respect to such examination, but not exceeding the applicable Maximum Benefit. No benefit shall be payable under this Title (1) with respect to an examination received in or through a hospital except in connection with out - patient care for which no hospital expense benefit of any kind is payable under this policy on account of such examination; or (2) with respect to any dental x-ray except in connection with a non - occupational injury; or (3) under any of the circum?tances for which no insurance is afforded by this Title as stated in the provision of this Article entitled Exclusions, Limitations, And Provisions Applica- ble To All Titles Ender Article II. If two or more such examinations are involved, payment shall be made for each examination in accordance with the foregoing paraeraphs, but not more than the applicable Maximum Beneft shall tr be payable for all examinations made during any one calendar year, whether involving related or unrelated causes. �1 C • �J -L, �. GR -23. Ed. 4 -'59 Page 6 – LIEB YR -UNSCH S i 1 .5604 Article II— BENEFITS TITLE AL-B-- ACCIDENT EXPENSE BE\>;iTTS 0 0 JSchedrde of Insurance • Maximum Classification' Benefit All Employees $ 300 Section 1. If a covered family member sustains a 11011- occupational injury —and if, within ninety days after the date of the accident -,%hich caused such injury, any hospital, surgical, or medical serv- ices, or emergency professional ambulance service to transport the covered family member from the place where he is injured to the first hospital where treatment is given, or the serv- ices of a registered graduate nurse, are required by such family member for the treatment of such injury —and if the amount of expenses incurred for such services is in excess of the aggre- gate of the benefits p1'ovided under this policy (exclusive of this Title and Title AI]IEB, if in- cluded in thin police) it, connection with such expenses, the Insurance Company shall, subject to the terms of this policy, pay a benefit in an amount equal to such excess expenses, but not exceeding the applicable Slaximurr Benefit in connection with all injuries sustained by such family member through any one accident. No benefit shall be payable under this Title (1) with respect to any expenses other than those for such services as, in the opinion of a physician who is attending such family member, are required for the treatment of such injury; (2) for any services rendered more than ninety days after the date of the accident which caused such injury; and (3) under any of the circumstances for which no insurance is afforded by this Title as stated in the provision of this Article entitled Exclusions, Limitations, And Provisio:.s Applicable To All Titles Under article 11, or for surgical or medical services rendered other than by a physician or a duly licensed dentist. GF. -33 ALL 300 Ed. 8262 Page 6 —AEB 5756 0 ej qj 0.. v If an employee incurs, during a calendar year, "Covered Medical Expenses" for the treatment of a covered family member in excess of the sum of (a) the Deductible applicable to the mem- ber for that year and (b) the total of the benefits payable by reason of such expenses under this policy exclusive of this Title and exclusive of Titles ADDC and WBC, if included in this policy, the Insurance Company shall, subject to the terms of this policy, pay a benefit in an amount equal to 805'' of such excess Covered Medical Expenses incurred as to the mernher in that calendar year; but the aggregate of the benefits payable under this Title Nv th respect to a family member during his lifetime (whether or not there has been any interruption in the con- tinuity of his insurance) shall not exceed his "Maximum Benefit ". GR -23 Ed. 8 -'68 Page 6 -1IMEB 7016 Article II— BENUITS 0,1 TITLE MbicB —MAJOR MEDICAL EXPENSE BENEFITS Deductible Family Deductible 'Maximum Private Room Per Family Biember Limit Benefit Limit Classification $300 $20,000 The sum of (� All employees $ 100 (a) the hospital's average daily rate for board and room in semi - private accommodations and (b) $3. 0 ej qj 0.. v If an employee incurs, during a calendar year, "Covered Medical Expenses" for the treatment of a covered family member in excess of the sum of (a) the Deductible applicable to the mem- ber for that year and (b) the total of the benefits payable by reason of such expenses under this policy exclusive of this Title and exclusive of Titles ADDC and WBC, if included in this policy, the Insurance Company shall, subject to the terms of this policy, pay a benefit in an amount equal to 805'' of such excess Covered Medical Expenses incurred as to the mernher in that calendar year; but the aggregate of the benefits payable under this Title Nv th respect to a family member during his lifetime (whether or not there has been any interruption in the con- tinuity of his insurance) shall not exceed his "Maximum Benefit ". GR -23 Ed. 8 -'68 Page 6 -1IMEB 7016 Article II— BENEFITS (Continued) N M1 TITLE bIMEB —MAJOR MEDICAL EXPENSE BENEFITS (Continued) Covered Medical Expenses Covered Medical Expenses are the reasonable charges- which an employee is required to pay for the following services and supplies received by a covered family member for the necessary ireab ment of any non - occupational injury or non - occupational disease: HOSPITAL EXPESSEB: These are the charges made by a hospital, in its own behalf, for (a) Board and room. However, if private accommodations are used, any excess of daily board and room charges over the applicable Private Room Limit will be disregarded. (b) Necessary hospital services, other than board and room, furnished by the hospital. OTHER .MEDICAL EXPENSES: The following charges are considered "Other Medical Expenses ". provided that they have not been considered as "Hospital Expenses ": (1) The fees of a physician or surgeon; (2) The charges of a registered graduate nurse - -other than a nurse who ordinarily resides in the employee's home, or is a member of the family- of either the employee -or the em- ployee's Spouse; (3) The charges for the following medical services and supplies: (i) Drugs and medicines obtainable only upon a physician's prescription; (ii) Diagnostic x -ray and laboratory- examinations; • (iii) X -ray, radium, and radioactive isotopes therapy; (iv) Anesthesia and oxygen; (v) Rental of iron lung and other durable medical and surgical equipment; (vi) Artificial limbs and eyes —but not eye examinations, eye glasses, or hearing aids; (vii) Professional ambulance service when used to transport the individual from e �.' place where he is injured by an accident or stricken by a disease to the first hos- pital where treatment is given --but no other charges for transportation or trace:. �1 GR -2a Ed. 9-'57 Page 6- A —SIDIEB PVT ;.v. Article II —BENEI =ITS (Continued) o, r • TITLE NINIEB —MAJOR MEDICAL EXPENSE BENEFITS (Continued) ESPECIAL C.ONDITI0NS: i- -. Hospital Expenses ai_d Other Medical Expense; incurred in connection with cosmetic surgery necessary for the prompt repair of a non- occuna-,ional injury which occurs v hiie the indi- vidual concerned is a eo-rei ed laln:ily member are included as Covered lIedical Expenses. No other expense s for cosmetic surgery are included as Covered Medical Expenses. Hospital Expenses and Other lIedical Expenses, incurred in connection with dental %.work or oral surgery for the prop —mt repair of natural teeth or other body tissue, and required as a result of a non- occupatio :al injury- which occurs while the individual concerned is a covered family member, are inci! icd is Covered lIedical Expenses. Also. Hospital Expenses and Other - Medical Expenses remuired in connection ,citit the performance of the following oral sur- gical procedures are included as Covered Medical Expenses: (i) the excision of partially or completely unerupted teeth; (ii) the excision of a tooth root without the extraction of the entire tooth: or (r,i) other incision or excision procedures on the gums and tissues of the mouth when sot pericrn:ed in connection with extraction or repair of teeth. For the pur- poses of the dental ;corn or oral snrger:, covered by the terms of this paragraph, Other Medi- cal Expenses si:ali br: 6--E ,?d to include fees of a duly- licensed dentist. Ho other expenses for dental work or oral surgery are included as Covered .lIedical Expenses. Hospital Expenses and Other Jledical Expenses of a family' member incurred in connection with one of the following complications of a pru,,,nancy are included as Covered lIedical Ex- penses: (i) surgical operations for extra - uterine pregnancy- or for other complications requir- ing intra - abdominal surgery after termination of pregnarcy; (ii) pernicious vomiting of pregnancy (hyperemesis rav:aarum) ; or (itD toxemia with convulsions (eclampsia of preg- nancy). No other expenses in connection `nit^ pregnancy or resulting childbirth or miscar- riage are included as Covered - lIedical Expenses. Hospital 21Yrer.se5 and Cther :�ed_cal Rxpenses incurred dur_nE the first twelve months tnst insurance of a _ °2:i:l i;j ..ernc,er _a Ln _once under t' _is Title 'r;'.' -1 not be included as Co-rered .._.._cal Expenses if. they are in connection with a dis- ease or injur;; °or ch he received treatment or services, or took prescribed drugs or rned_cines, during the three month period prior to the effective date of such insurance. GR -23 Ed. 9-'07 Page 6- 13—M \IEB NO 50% MENT 7405 N(46 r 11 • • 4k t Article II— BENEFITS (Continued) TITLE MMEB —MAJOR MEDICAL EXPENSE BENEFITS (Continued) APPLICATION OF DEDUCTIBLE: Each Calendar year a Separate Deductible applies to each family member regardless of the number of his disabilities, but, when any part of a cale;i- dar year's Deductible is applied a- ainstt expenses arising during the last three months o£ that year, the following calendar year's Deductible will be reduced by the amount so applied. FAMILY LimIT ON DEDUCTIBLES: If, in a calendar year, the sum of the Covered Medical Ex- penses incurred by covered family members and applied against their Deductibles exceeds the Family Deductible Limit, an additional benefit in an amount equal to BC$ of such excess shall be payable. Any additional benefit payable by reason of this paragraph does not count against the ".Maximum Benefit" of any family member. C j GR•23 Ed. 9-'57 Page 6- C- 111i<TEB FAMILY LMT .7472 Article Ii— BENEFITS (Continued) .P r TITLE bib1EB —MAJOR MEDICAL EXPENSE BENEFITS (Continued) Maximum Benefit a The Maxirlum Benefit of each family member applies to all Covered Medical Expenses com- bined during his lifetime. When Major _Medical Expense Benefits have been paid as to a cov- ered family member in an amount equal to his Maximum Benefit, in one year or over a period of years, no further benefits shall be payable as to him; subject, however, to the terms of the following two paragraphs. Reinstatement —The Insurance Company will consent to the ignoring of benefits paid for pre- vious expenses in applying the _Maximum Benefit provisions to benefits payable for Covered Medical Expenses incurred with respect to a covered family member after the effective date of such cogent, but only if such family member while benefits of at least $1,000 remain charged against his Maximum Benefit submits, at no expense to the Insurance Company, evidence of his insurability satisfactory to the Insurance Company. Restoration—On each January 1, while the employee is insured under this Title with respect to a family member, the used portion of the covered family member's Maximum Benefit shall be automatically restored, for Covered Medical Expenses incurred with respect to a covered family member after the effective date of such restoration, by an amount equal to the lesser of (i) $1,000 and (ii) the amount of benefits, if any, remaining charged against the family member's Maximum Benefit. The foregoing terms of this paragraph shall apply regardless of whether �% the terms of the preceding paragraph are, or are not, utilized, but shall not operate so as to increase tire Maximum Benefit of any covered family member, as of any given time, to an amount in excess of the Maximum Benefit specified for such individual on Page 6 of this Title. �l t eti GR -23 Ed. 9257 Page 6- D —MMEB AUTO 7595 �� Article 11-070123 (Continuod) ........ US; LIMITATIMS, AID PEOVIS1027 APPLICA31,1-� 10 TITLE 1,2= No insurance is afforded under this Title TOM P'' (1) as to charges in connection uith a disease other than a non-occulational disease or an injury attar than a non-ocen3ational injury; under any of the circ---stances for uhich no insurance is afforded as stated in the provision of this Article entitled Exclusicne, Limitations, And Provisions Applicable To All Titles Under Article 11. I GR-23 Pa; e 6- -!S`%3 (2) as to charges incurred with ressect to any individual while he is not a covered (7111 member; (3) as to char-es in connection with any nervous or mental condition; but this exclusion (3) shall not apply as to expenses incurred vith respect to a covered (All family mefler while W nwcer is necessarily confined in a hospital or similar Institution as an inpatient; under any of the circ---stances for uhich no insurance is afforded as stated in the provision of this Article entitled Exclusicne, Limitations, And Provisions Applicable To All Titles Under Article 11. I GR-23 Pa; e 6- -!S`%3 Article II— BENEFITS N •, � TITLE CDEII— COUPREI- iENS1VB DENTAL EXPENSE BENEPI'iS Cash Deductible Family Calendar Year Maxinuun Classification Pe_ r Familly Member Deductible Limit Maximum Benefit All employees $100 $300 $500 $20,000 w i) W `1 W) If an employee incurs, during a calendar year, "Covered Dental Expenses" for the treatment of a covered family member in excess of the Cash Deductible applicable to the member for that Fear, the Insurance Company shall, subject to the terms of this policy, pay a benefit in an amount equal to 805 OV0 as to inlay's, gold fallings, crowns, including precision attachments for dentures. and fixed bridgework) of such excess Covered Dental Expenses incurred as to the member in that calendar year; but the aggregate of the benefits payable under this Title (whether or not there has been any interruption in the continuity of insurance) as to all such expenses incurred V ith respec. to any family member in any calendar year shall not exceed his "Calendar Year Maximum" nor shall the aggregate of the benefits payable under this Title with respect to any family member during his lifetime (whether or not there has been any interruption in the continuity of insurance) exceed his "Maximum Benefit". •1 GR -23 •�1 Ed. 7-'64 Page 6 —CDEB sozs Article II— BENEFITS (Continued) o� TITLE CDEB — COMPREHENSIVE DENTAL EXPENSE BENEFITS (Cominucd) • Covered Dental Expenses Covered Dental Expenses are the reasonable charges which an employee is required to pay for the following services and supplies received by a covered family member for the necessary treatment of any non - occupational injury or non - occupational disease: The charges of a dentist, but only for the following: (1) Oral examinations, including scalim —and cleaning of teeth, but not more than one ex- amination in any period of six consecutive months; (2) Topical application of sodium or stannous fluoride, but only if.the covered family mem- ber has not yet attained the age of fifteen years; (3) Dental x -rays; (4) Extractions: (5) Oral surgery, includinn, excision of impacted teeth; (6) Fillings; (7) Anesthetics administered in connection with oral surgery or other covered dental ser- vices; (8) Inlays, gold fillings, crowns (including precision attachments for dentures), and initial installation of Tixed bridgework (including inlays and crowns to form abutments) to re- place one or more natural teeth extracted while the family member is covered unuer this Title; (9) Treatment of periodontal and other diseases of the gums and tissues of the mouth; •; (10) Endodontic treatment, including root canal therapy; (11) Initial installation (including adjustments for the six month period following installa- tion) of partial or frill rertovable dentures to replace one or more natural teeth extracted while the family member is covered under this Title; �j �j GR -23 Ed. V64 Page 6 -A —CDEB 5030 Article II— BENEFITS •o 4T r ' TTTLE CDE13— COLMPKEFIENSIVE DENTAL EXPENSE BENEFITS (Continued) Covered Dental Expenses (Continued) (12) Replacement of an existing partial or full removable denture or fixed bridge•,rork by a new denture or new bridgework, or the addition of teeth to an existing partial rcmov- able denture or to bridgework to replace extracted natural teeth, but only if evidence satisfactory to the Insurance Company is presented that (i) the replacement or addition of teeth is required to replace one or more additional natural teeth extracted after the existing denture or bridgework was installed and j while the family- member is covered under this Title; or (ii) the existing denture or bridgework was installed at least five years prior to its re- placement and that the existing denture or bridgework cannot be made serviceable; or (iii) the existing denture is an immediate temporary denture and replacement by a per- manent denture is required, and takes place within twelve months from the date of installation of the immediate denture. (13) Space maintainers; (14) Repair or recementing of crowns, inlays, bridgework, or dentures; or relining of dentures; (15) Injections of antibiotic drugs by the attending dentist. 0) 0, ) tl GR -23 Ed. W64 Page 6- A —CDEB (Continued) 5033 Article II— BENEFITS (Continued) L1 . O r TITLE CDEB— COMPREHENSIVE DENTAL EXPENSE BENEFITS (Continued) • Special Conditions: APPLICATION; OF DEDUCTIBLE: Each calendar year a separate Deductible applies to each f.nmily member, but when any part of a calendar year's Deductible is applied against expenses incurred • during the last three months of that year, the following calendar year's Deductible will be reduced by the amount so applied. The Deductibles provided for under this Title and Title A MEB are not separate and only a sir.g!e deductible kill be applied to the combined amount of Covered Dental Expenses under this Title and Covered Medical Expenses under Title MMEB which are subject to the application of a deductible in the determination of benefits payable. .) FAMILY LIMIT Oh DEDUCTIBLES: If, in a calendar year, the sum of the Dental Expenses incurred by covered family members and applied against their Deductibles exceeds the Family Deductible Limit applicable to this Title, an additional benefit in an amount equal to 80�* of such excess shall be payable. Any additional benefit payable by reason of this paragraph does not count agains_ the "Maximum Benefit" or the "Calendar Year _Maximum" of any family member. The Family Limits on Deductibles provided for under this Title and Title MMEB are not separate and a single family limit on deductibles will be applied to the combined amount of Covered Mecccal Expenses and Covered Dental Expenses applied against the deductibles under this Title and under Title MAIEB. •J i �I • MMES GR -23 INTEG. Ed. 7-'64 Page 6 -B —CDEB 5051 Article II— BENEFITS (Continued) „ TITLE CDEB- rCOMPREHENSIVE DENTAL EXPENSE BENEFITS (Continued) MAXIMUM BENEFIT; The Maximum Benefits provided for under this Title and under Title MMEB are not separate and only a single Maximum benefit will apply to all of the combined Covered Medical and Dental Expenses of a covered family member during his lifetime. APPLICATION OF BENEFITS PAYABLE: Any benefits payable under this Title shall be charged against the Maximum Benefit under Title MMEB of the covered family member concerned. For the purposes of any provisions of Title .II.IIEB relating to the Maximum Benefit, benefits for Cov- ered Dental Expenses charged against the Maximum Benefit will be treated as though they were Mbenefits for Covered Medical Expenses under Title MMEB. EXTENSION of BENEFITS: If insurance with respect to a family member terminates while he is totally disabled and before benefits aggregating his Maximum Benefit become payable with respect to him, any benefits provided under this Title for that family member, but for no other family member, will continue to be available as to expenses incurred during the uninterrupted continu- ance of such total disability but not beyond the period of twelve months immediately following such termination of insurance and in no event beyond the date the family member becomes insured under any other group policy, whether issued by the Insurance Company or any other insurer, for benefits of a type similar to that provided for in this Title. The words "totally disabled" and "total disability" mean that the family member, if an employee, is prevented, solely because of a non - occupational injury or non - occupational disease from engaging in his regular or customary- occu- pation and is performing no work of any kind for compensation or profit, or if a dependent, is pre- vented, solely because of a non- occupational injury or non - occupational disease from engaging in substantially all of the normal activities of a person of like age and sex in good health. "( GR -23 Ed. W64 Page 6- C—CDEB MIMES INTEG. 5043 Article 11-- BUNEFITS (Continued) EXCLUSIONS, LISIITATIONS, AND PROVISIONS APPLICABLE TO TITLE CDEP. No insurance is afforded udder this Title CDEB (1) as to charges incurred with respect to any individual while he is not a covered family mem- ber; (2) as to charges for any denial services and supplies which are included as covered medical ex- penses under Title `�i11ER or C,;iEB, if included in this policy, or under any comprehensive medical or major medial exrnr ^se benefits plan carried or sponsored by the Participant Ern - plover, or as to any dental services and supplies to the extent benefits are payanle therefor under any other T itie included in this policy, or under any other medical expense plan carried or sponsored by the Participant Employer, (3) as to charges made by other than a dentist, or as to charges for treatment by other than a dentist, except that cleaning or settling of teeth may be performed by a licensed dental hy- gienist, if such u-satini.mt is rendered under the supervision and direction of the dentist; (4) as to charges for the initial installation of dentures and bridgework (including crowns and inlays forming the abutments), when such charges are incurred for replacement of corgeni- tally missing teeth, or for replacement of natural teeth ail of which .vote lost while the indi- vidual was not a covered family member; (5) as to charges for services and supplies that are partially or wholly cosmetic in nature, includ. ing charges for persona!iz atior. or characterization of dentures; (6) as to charges for prosthetic devices (including bridges and crovmsi and the fitting thereof which were ordered while the individual was not a covered family member, or which were ordered while the individual was a covered family member but are finally installed or deliv- ered to such individual more than thirty days after termination of coverage; (7) as to charges for the replacement of a lost or stolen prosthetic device; (8) as to charges for any services or supplies which are for orthodontic treatment (including cor- rection of malocclusion): (9) under any of the circumstances for which no insurance is afforded as stated in the provision of this Article entitled "Exclusions, Limitations, And Provisions Applicable to All Titles Under Article II." •j, W. -�J • t . GR -23 ED. 7-'64 Page 6- D —CDEB 505r 333231 0 Article II— BEl\EFITS EXCLUSIONS, LIDIITATIONS, AND PROVISIONS APPLICABLE TO • ALI. TITLES UNDER ARTICLI: II Extension of P>enefitm If insurance with respect to a family member tinder one or more of the Titles under Article II (except Titles ADDC, WIT!, AMER CDI,P,. PE13, and AEP. if included in this policy-) terminates while he in totally disabled, any benefit provided under such 'Titles for that family member, but for no other fa.nil- member, will continue to be available as to expenses incurred dur- ing the uninterrupted continuance of such total disability but lot beyond a period of three months following the date surh termination of insurance occurs. Expenses in respect of which henelits are payable tinder 'Title III ?P,, if included in this jaHey-, will be deemed to be incurred within such three months period if the hospital confinement commenced within such period. The words "lotaliv dis- abled" and "total disability" mean, for the purposes of this paragraph, that the family member. if an employee, is prevented, solely because of injury- or disease. from engaging in his regular or cus- tomary occupation and is peforming no work of any- kind for compensation, or if it dependent, is prevented, solely- because of iujtn-y- nr disease, from engaging in substantially all of the normal ac- tivities of a person of like age and sex in „rood health. No insurance is afforded under any Title of Article II as to charges (1) that would not have been made if no insurance existed or that no individual with respect to whom insurance under such Title relates is legally obliged to pay; or (2) for services or supplies which are furnished or braid for, or with respect to which benefits are provided, under any law of a government (national or otherwise) by reason of the past or present service of any person in the armed forces of a gowninient; or (3) for services or supplies, other than those referred to in item (2) above- which are paid for, or with respect to which benefits are provided, under any law of it govenment budh wl or otherwise) except where such payments are minute or such benefits are provided under it plan specifically established by a goverment for its own civilian employees and their dependents; or 0 0 0 0 r ( 0 (4) in connection with any hospital confinement or any surgical, medical, or other treatment, services, or supplies which are not ieconnnexled and approved by a physician who is at- tending the covered family member; or (a) for care, treatment, services or supplies which are not necessary for the treatment of the injury or disease concerned not- to the extent that any charges for care, treatment, services or supplies are unreasonable; or (6) caused or contributed to by. or as a consequence of, progmmcy or resulting childbirth, nnis- carriage or abortion; except to the extent, if any, that benefits are specifically provided therefor under the provisions of any title of Article H of this policy; and before determining benefits under or,y Title, the anwnnt of any such char *es shall be deducted from e the family mnhe& expenses which are covered under such Title nlWfrom his Allowable Expenses (as hereinafter dethned). If any NO' of the jurisdiction in which this policy is delivered prohibits or restricts the application of item (2) or (3) above as to a facility owned or operated by such ,jurisdiction or by any of its political subdivisions, said items (2) and (3) shall be applicable only to the extent permitted by such law. No benefits are payable under this policy to the extent that the provision of such benefits is pro- hibited by any applicable law of the jurisdiction in which the individual resides at the time the claim is incurred. (• GR -23 9 M0. MAT. —A.D. Ed. 11269 Page 6—ELP 11 1 72 5898 r L L 11 0 n 0 J lJ 0 0 F- L-1 333231 Article II— BENEFITS (Continued) EXCLUSIONS, LIMITATIONS AND PROVISIONS APPLICABLE TO ALL TITLES UNDER ARTICLE 11 (Continued) No insurance is afforded under any Title of Article II as to charges for custodial care; and before determining benefits under any Title, the amount of any such charges shall be deducted from the family member's expenses which are covered under such Title and from his Allowable Expenses (as hereinafter defined). GR -23 Ed. 6-72 Page 6 -ELP (Continued) 11 1 72 5957 Article II— BENEFITS (Continued) EXCLUSIONS, LIMITATIONS, AND PROVISIONS APPLICABLE TO ALL TITLES UNDER ARTICLE II (Continued) Provision For Co- ordination Of Benefits under This Policy With Other Benefits A. Benefits Subject To This Provision: • All of the benefits provided under this Article II (except those provided under Titles ADDC and 1VBC, if included) are subject to this provision. B. Definitions (1) "Plan" means any plan providing benefits or services for or by reason of medical or dental care or treatment, which benefits or services are provided by group insurance or any other arrangement of coverage for individuals in a group whether on an insured or uninsured basis. W LJJ (1) This provision shall apply in determining the benefits as to a person covered under this Plan for any Claim Determination Period if, for the Allowable Expenses incurred as to such person during such Claim Determination Period, the sum of (a) the benefits that would be payable underthis Plan in the absence of this provision, and (b) the benefits that would be payable under all other Plans in the absence therein of provisions of similar purpose to this provision would exceed such Allowable Expenses. GR -23 Ed. 12262 Page 6- I —ELP 5838 The term "Plan" shall be construed separately with respect to each policy, contract, or other arrangement for benefits or services and separately with respect to that portion of any such policy, contract, or other arrangement which reserves the rightto take the benefits or services of other Plans into consideration in determining its benefits and that does portion which not. (2) "This Plan" means those portions of this policy which provide the benefits that are sub- ject to this provision. (3) "Allowable Expense" means any necessary, reasonable, and customary item of expense at least a portion of which is covered under at least one. of the Plans covering the person for whore claim is made. When a Plan provides benefits in the form of services rather than cash paymems, the value be deemed to be boor an Ailo%v- reasonable cash of each service rendered shall able Expense and a benefit paid. (4) "Claim Determination Period" means calendar year, but if a person is not eligible for bene- fits under this Plan during all of a calendar year, then the Claim Determination Period for such person as to ti:at year shall be the total period thereof during which he was eligible for benefits. C. Effect on Benefits W LJJ (1) This provision shall apply in determining the benefits as to a person covered under this Plan for any Claim Determination Period if, for the Allowable Expenses incurred as to such person during such Claim Determination Period, the sum of (a) the benefits that would be payable underthis Plan in the absence of this provision, and (b) the benefits that would be payable under all other Plans in the absence therein of provisions of similar purpose to this provision would exceed such Allowable Expenses. GR -23 Ed. 12262 Page 6- I —ELP 5838 Article II— BENEFITS (Continued) r EXCLUSION, LIMITATIONS, AND PROVISIONS APPLICABLE TO (� ALL TITLES UNDER ARTICLE II (Continued) Provision For Co- ordination Of Benefits Under This Policy With Other Benefits (Continued) C. Effect on Benefits (Continued) (2) As to any Claim Determination Period with respect to which this provision is appli- cable, the benefits that would be parable under this Plan in the absence of this provision for the Allowable Expenses incurred as to such person during such Claim Decermina- tion Period shall be reduced to the extent necessary so that the sum of such reduced benefits and all the benefits payable for such Allowable Expenses under all other Plans, except as provided in item (3) of this section C, shall not exceed the total of such Allow- able Expenses. Benefits payable under another Plan include the benefits that would have been payable had claim been duly made therefor. (3) If (a) another Plan which is involved in item (2) of this section C and which contains a provision co- ordinating its benefits with those of this Plan would, according to its rules, determine its benefits after the benefits of this Plan have been determined, and (b) the rules set forth in item (4) of this section C would require this Plan to determine its benefits before such other Plan, then the benefits of such other Plan will be ignored for the purposes of determining the benefits under this Plan. (4) For the purposes of item (3) of this section C, the rules establishing the order of benefit determination are: (a) The benefits of a Plan which covers the person on whose expenses claim is based other than as a dependent shall be determined before the benefits of a Plan which •� covers such person as a dependent; J (b) The benefits of a Plan which covers the person on whose expenses claim is based as a dependent of a male person shall be determined 'before the benefits of a Plan which covers such person as a dependent of a female. person; �j (c) When rules (a) and (b) do not establish an order of benefit determination, the bene- fits of a Plan which has covered the person on whose expenses claim is based for the longer period of time shall be determined before the.benefits of a.Plan which has cov- ered such person the shorter period of time, (5) When this provision operates to reduce the total amount of- benefits otherwise payable as to a person covered under this Plan during ary Claim Determination Period, each bene- fit that would be pava':Jie in the absence of this provision shall be reduced proportionately, and such reduced amount shall be charged against any applicable benefit limit of this Plan. t) lam`, T's GR -23 Ed. 12 -'62 Page 6- 2 —ELP 5817 t4b Article II— BENEFITS (Continued) I m.. m 11 EXCLUSIONS, LIMITATIONS, AND PROVISIONS APPLICABLE TO ALL TITLES UNDER ARTICLE II (Continued) Provision For Co-ordination Of Benefits Under This Policy With Other Benefits (Continued) 1, D. Right to Receive and Release Necessary Information For the purposes of determining the applicability of and implementing the terms of this pro- vision of this Plan or any provision of similar purpose of any other Plan, the Insurance �. Company may, without the consent of or notice to any person, release to or obtain from any other insurance company or other organization or person any information, with respect to any person, which the Insurance Company deems to be necessary for such purposes. Any person claiming benefits under this Plan shall furnish to the Insurance Company- such information as may be necessary to implement this provision, E. Facility of Payment Whenever payments which should have been made under this Plan in accordance with this provision have been made under any other Plans, the Insurance Company shall have the right, exercisable alone and in its sole discretion, to pay over to any organizations making such other payments any amounts it shall determine to be warranted in order to satisfy- the intent of this provision, and amounts so paid shall be deemed to be benefits paid under this Plan and, 49 to the extent of such payments, the Insurance Company shall be fully discharged from liabil- ity under this Plan. -_ F. Right of Recovery Whenever payments have been made by the Insurance Company with respect to Allowable Expenses in a total amount which is, at any time, in excess of the maximum amount of pay- ment necessary at that time to satisfy the intent of this provision, the Insurance Company �1 shall have the right to recover such payments, to the extent of such excess, from among one or more of the following, as the Insurance Company shall determine: any persons to or for or with respect to whom such payments were made, any other insurance companies, any other organizations. t t GR -23 Ed. 12 -'62 Page 6 -3 —ELP .5818 Article II— BENEFTTS EXCLUSIONS, LIMITATIONS AND PROVISIONS APPLICABLE TO ALL TITLES UNDER ARTICLE II Effect of Coverage under the Prior Policy: An employee's insurance under this policy replaces and supersedes the employee's insurance, if any, under the Insurance Company's Group Policy (ies) \o. (s) GG -46443 (each of which may herein be referred to as the prior policy), and shall be in exchange for all privileges and benefits under any prior policy. Any benefit paid under the prior policy for a given event shall be taken into account in deter- mining the amount of any corresponding benefit payable under this policy. As to Title ADDC, if included in this policy, the latest designation of the beneficiary of the employee under the prior policy shall be effective under this policy until a change is made in accordance with the terms of this policy. As to Title MMEB or CMEB: (a) if any part (or all) of a covered family member's Deductible under any section of the prior policy providing Major Medical Expense Benefits or Comprehensive _Medi- cal Expense Benefits is applied under said section against covered expenses incurred thereunder by the employee with respect to such member (i) during the calendar year in which Title MAIEB or CMEB of this policy becomes effective, or (ii) during the last three months of the calendar year preceding the calendar year in which said Title becomes effective, the member's Deductible under said Title for the calendar year in which said Title becomes effective shall be reduced by the amount so applied to the same extent as though such Deductible under the prior policy had been applied under said Title, (b) if any benefits have been paid or accrued as to a covered family member under any section of the prior policy providing Major Medical Expense Benefits or Comprehen- sive Medical Expense Banents, the "Maximum Benefit" of such member shall be the applicable "Maximum Benefit" shown on Page 6 of Title 141IEB or CMEB of this policy, reduced by the aggregate amount of benefits remaining charged a .-ainst such member's "Maximum Benefit" as of the day before said Title becomes effective. GR -23 MMES or CMEB Ed. 10261 Page 6 .4 —ELP 5912 �l 0-) t_1. Article III — TERMINATION OF INSURANCE Section 1. Employee and Dependent Coverage All insurance of any employee under this policy shall terminate at the earliest time specified below: (1) Upon discontinuance of the policy, (2) Immediately when the employee's employment with a Participant Employer in the classes of employees eligible for insurance terminates. Cessation of active work by an employee shall be deemed to be termination of his employment, except that (a) in the case of an absence from active work because of sickness or injury, his employ - ment may, for the purposes of insurance under this policy, be deemed to continue until terminated by his Participant Employer but in no case beyond twelve months from the date such absence from active work started, or (b) in the case of absence of an employee from active work because of temporary lay -off or leave of absence, his employment may, for the purposes of insurance under this policy, be deemed to continue untii terminated by his Participant Employer but in no case be- yond the end of the policy month follovaing the policy month in which such lay -off or leave of absence commenced. In the case of any of the exceptions in the foregoing paragraph, the insurance under this policy for such employee shall autornatic .b'y cease on the date of such termination of his em- ployment by his Participant Employer, as evidenced to the Insurance Company by the Policy- holder, whether by notification or by cessation of premium payment on account of such em- ployee's insurance hereunder. Any maximum period of continuation permitted by the foregoing paragraph may be eetended by written mutual agreement between the Policy- holder and the Insurance Company in each individual case. In no event may any insurance provided on a contributory basis be continued beyond the end of the period for which the employee has made to his Participant Employer. the contributions required. GR -23 Ed. 9 -'57 Page 7 8713 m .. r m. c Article III — TERMINATION OF INSURANCE (Continued) Section 2. Dependent- Coverage Only I. All Dependent Coverage of an employee shall terminate, notivithsLanding any continuation of his Employee Coverage, at the earlier of the times specified below: (a) Upon the discontinuance of all Dependent Coverage under this policy. (b) Immediately when the employee shall cease to be included in the classes of employees eligible for Dependent Coverage. .' I1. When Individual Dependents Cease To Be Covered: Any dependent of an employee insured for Dependent Coverage shall cease to be covered under this policy prior to the termination of all of the employee's Dependent Coverage at the earlier of the times specified below: (a) When such dependent becomes insured for Employee Coverage under this policy. 0) wi k, 1 r t �i (b) When such person ceases to be a dependent of. the insured employee. GR -23 Ed. 9-'57 Page 7 -A AUTO .87ea 'b Article Ill — TERMINATION OF INSURANCE (Continued) oo oo Section 2 -A Continuation of Dependent Coverage For Certain Incapacitaled Children An unmarried child who is covered as a dependent under this policy and who is incapable of self- sustaining employment by reason of mental retardation or physical handicap, and who is chiefly dependent upon the employee for support and maintenance on the date such child would cease to be covered as a dependent under this policy because of the attainment of the limiting age for De- pendent Coverage of children shall continue to be covered as a dependent under the policy, pro- vided: (a) he became so incapacitated prior to attainment of the limiting age for Dependent Cover- age of children under this policy; (b) he has not been issued an individual policy of medical expense insurance under any con- version privilege otherwise available to him because he ceased to be covered as a depen- dent under this policy; and (c) due proof of such incapacity is furnished the Insurance Company at its Horne Office not later than thirty -one days after the date upon which he would otherwise cease to be cov- ered as a dependent under this policy. The Insurance Company reserves the right to require subsequent due proof of the uninterrupted continuance of such incapacity and shall have the right and opportunity, at its own expense, to examine the person of such child when and as often as it may reasonably require during the con- tinuation of such incapacity, but in no event shall such an examination be required more often than once each year after a period of two years has elapsed from the child's attainment of the limiting age for Dependent Coverage of children under this policy. Any continuance of Dependent Coverage for a child under the above provisions shall automati- cally terminate on the earliest to occur of (i) cessation of such incapacity; (ii) failure to furnish any required proof of the uninterrupted continuance of such incapacity or to submit to any required examination; or O(iii) termination of Dependent Coverage, for reason other than attainment of the limiting age, as provided in this policy. `j l !i GR -23 Ed. V69 Page 7 -Al 8770 P" Section 2. Premium Calcula. ions and cxpe.ience Rating The premium due wader this policy on any premiurl -due date shall be the sum. of dhe premis;m charges fo_ the insurance prodded under the Titles then forming a pert 3f this poiic'. The premium chages for the insurance under any such Title shall be. calcu],v'ced at the 'ini'�ial Premium dates specified above, subject to such reductions or increases as the Insurancc Com- pany shall determine 'ao be warranted by experien ^_e or by reason of army change in facxcrs bearing on the risk assumed. teach reduction or incre ::se in any premium rate shall be made by written notification to the Policyholder by the Lisurance Company. No premium -rate may be increased except either by ticritten notification from the Insurance Company to the PoRe hoider at Ieast thirty-ore days hefore the effective date of suci, increase µJior by mutual agreement between the Policyholder and the Insurance Company. No experience reduction or increase in premium rates shall become effective less than twelve months after the effecti-.c date of this policy. As of the end of any policy year the insurance Company may declare an experience credit in such amount as the insurance Company shall determine. The amount of each e:;nerience credit declared by the insurance Company mall be refunded to the Policyholder, or upon re- quest by the Policyholder, a part cr al] of the cxperience credit shall be applied zgainsi. t):e �. payment of any premium or p_emiums. • GR 23 CA Ed. 9267 Page 8 5 15 70 s, z 'cl TAI r +` : —`: r1F R (a, jSection 1. Prerr, :rsrr. Lwfes . The initial premium rate; are as follows- The premium rates sho ;w are for a period of cne non h. Title ;iBG-Mm..ium 1--_ 110.0 of ,ieekly Bneiit: S.29 Qarr ni.ly su^_ ct to a .,, reduction) E....r,love Coyeray__ Rev , ent Cove raw Plan A Fla L Title HEB $7.88 18.73 $15.65 Title SEE 1.74 2.29 4.N Title °K H .22 .31 .64 Title LKIED .64 .58 1.03 Title AE5 .26 .21 .66 Title 2. W" 3.22 4.76 Title GDW; 1.46 1.63 2.23 P" Section 2. Premium Calcula. ions and cxpe.ience Rating The premium due wader this policy on any premiurl -due date shall be the sum. of dhe premis;m charges fo_ the insurance prodded under the Titles then forming a pert 3f this poiic'. The premium chages for the insurance under any such Title shall be. calcu],v'ced at the 'ini'�ial Premium dates specified above, subject to such reductions or increases as the Insurancc Com- pany shall determine 'ao be warranted by experien ^_e or by reason of army change in facxcrs bearing on the risk assumed. teach reduction or incre ::se in any premium rate shall be made by written notification to the Policyholder by the Lisurance Company. No premium -rate may be increased except either by ticritten notification from the Insurance Company to the PoRe hoider at Ieast thirty-ore days hefore the effective date of suci, increase µJior by mutual agreement between the Policyholder and the Insurance Company. No experience reduction or increase in premium rates shall become effective less than twelve months after the effecti-.c date of this policy. As of the end of any policy year the insurance Company may declare an experience credit in such amount as the insurance Company shall determine. The amount of each e:;nerience credit declared by the insurance Company mall be refunded to the Policyholder, or upon re- quest by the Policyholder, a part cr al] of the cxperience credit shall be applied zgainsi. t):e �. payment of any premium or p_emiums. • GR 23 CA Ed. 9267 Page 8 5 15 70 s, z '0 333231 Article IV— PREMIUMS (Continued) Section 2. Premium Calculations and Experience Rating (Continued) If at any time the aggregate of employee contributions theretofore made for group insurance shall exceed the aggregate of prennii;ms theretofore paid for group insurance (after giving ef- fect to any experience credits allo%ved the I'olicvholder), such excess shall be applied by the. Policyholder for the sole benefit of employees, but the Insurance Company shall not be obliged to see to the application of any such excess. If premiums are payable monthly, any insurance becoming effective shall, except as hereinafter provided, be charged for from the first day of the policy month coinciding with or next following the date the insurance takes effect, and premium charges for any insurance terminated shall cease as of the first day of the policy month coinciding with or next following the date the insurance ter- minates. If premiums are payable quarterly, semi - annually, or annually, premium charges or credits for a fraction of a premium - paying period required by the foregoing terms of this para- graph shall, except as hereinafter provided, he made on a pro -rata basis for the number of policy months between the date premium charges commence or cease and the end of the premium - paying period. If this policy is amender] to provide additional insurance, or any increase in insurance, and if the effective date of such amendment is other than the first clay of a premium - paying period, a pro -rata premium in respect of such insurance shall become clue and payable as of such date, to cover the period beginning on that date and ending immediately prior to the commencement of the next premium - paying period. Instead of the method of calculation of premiums above provided, premiums may be calcu- lated by any method which produces approximately the same total amount of premiums and is mutually agreeable to the Insurance Company and the Policyholder. Section 3. Premiums, How Payable Premiums shall be payable by the Policyholder in advance at the Home Office of the insurance • Company or to its authorized agent. The first premium under this policy shall be due and payable as of the date of issue to cover the period beginning on that (late and ending on the last clay of the first policy month and thereafter rniums shall be clue and payable on the first day of each policy month. Section Q. Grace Period A grace period of thirty -one days following the due -date shall be allowed the Policyholder for 40 the payment of each premium. 0 (* CR -23 Page 8 -A 11 1 72 Ed. 9 -'57 MO 8859 0 Article V—DI SCONTI NUANCE OF POLICY 333231 the Policyholder mac discont.mue this policy with respect to all employees of any one o more Participant Employers, and any Participant Employer may discontinue this police with respect to all employees of such Hmployer, by giving- to the Insurance Company written notice stat- ing when, after the date of such notice, such discontinuance shall become effective; but no such discontinuance shall become effective with respect to employees of anv Participant Employer during any period for which a premium has been paid to the Insurance Company with respect to employees of such Emplo3 ev. The Insurance Company reserves the right to discontinue this policy, (a) with respect to all employees of any Participant Imployer, at any time after the end of the grace period allowed for payment of it premium with respect to employees of such i Employer which has not been paid, by giving written notice to the Policyholder stating . when such discontinuance small 'become efl'ective; (b) either in its entirety or with respect to all employees of any Participant Employer, at any time, by giving 'to the Policyholder written notice stating that the date as of which such discontinuance shall become effective but such date shall not be one that occurs earlier than thirty -one days after the date of such notice unless mutually satisfactory to the Policyholder anc the Insurance Company. If this policy discontinues with respect, to any of the employees of a Participant Employer, the Policyholder and the Employer shall be jointly and severally liable to the Insurance Com- pany for all unpaid premiums for the period during which this policy was in force with re- spect to any of the employees of such Employer. 0 1* lu 9 lie (• I(* (• GR -23 I I 1 72 Ed. I '72 Page 9 8905 • Article VI— MISCELLANEOUS PROVISIONS 333231 Section 1. Assignment No assignment of any present or future right, interest, or benefit under this policy shall bind the Insurance Company, except that upon written consent of the employee with respect to a partic- ular claim, the Insurance Company shall pay benefits under this policy for expenses incurred on account of hospitalization or medical or surgical care to the person or persons furnishing such care. Section 2. Employees' Certi jcates The Insurance Company will issue to the Policyholder, for delivery to each insured employee, an individual certificate setting forth a summary of the essential features of the insurance cov- erage to which the employee is entitled and stating to whom the benefits are payable. Section 3. Data Required— Clerical Error — Misstatements — Nor- Discrimination The Policyholder and each of the Participant Employers shall furnish to the Insurance Com- pany all information which the Insurance Company may reasonably require with regard to any matters pertaining to this policy. All documents, books, and records which may have a bearing on the insurance or premiums shall be open for inspection by the Insurance Company at all rea- sonable times during the continuance of this policy and until the final determination of all rights and obligations under this policy. Neither clerical error (whether by the Policyholder, by any of the Participant Employers, or by the Insurance Company) in ]seeping any records pertaining to the insurance, nor delays in making entries thereon, shall invalidate insurance otherwise validly in force or continue insuranice other- wise validly terminated, but upon discovery of such error or delay an equitable adjustment of pre- miums shall be made. If any relevant facts pertaining to any individual to whom the insurance relates shall be found to have been misstated, an equitable adjustment of premiums shall be made, and if such mis- statement affects the existence or the amount of insurance, the true facts shall be used in deter- mining whether insurance is in force under the terms of this policy and in what amount. No refund of any premium or portion thereof, whether paid in error or otherwise, shall be made for any period commencing earlier than twelve months prior to the date on which evidence that the particular refund should be made is received by the Insurance Company. In connection with the administration of this policy, the Policyholder and the Participant Employers shall act so as not to discriminate unfairly between individuals in similar situations at the time of such action, but the Insurance Company shall be entitled to rely upon any action of the Policy- holder or of any of the Participant Employers without being obliged to inquire into the circum- • stances thereof Section 4. Entire Contract: Changes This policy, the application of the Policyholder, and the individual applications of the employees, if any, constitute the entire contract between the parties, and any statement made by the Policy - holder or by any employee shall, in the absence of fraud, be deemed a representation and not a warranty. No such statement shall avoid the insurance or reduce the benefits under this policy or be used in defense to a claim unless it is contained in a written application, nor shall any such statement of the Policyholder, except a fraudulent misstatement, be used to void this policy after it has been in force for two years from the date of its issue, nor shall any such statement of any • employee eligible for coverage under the policy, except a fraudulent misstatement, be used in defense to a claim for loss incurred or commencing after the insurance coverage with respect to which claim is made has been in effect for two years. This policy is issued in the non - participating department of the Insurance Company. This policy may be changed at any time or times by written agreement between the Insurance Company and the Policyholder, without the consent, of any employee or other person. No chanty -e in this policy shall be valid unless approved by an executive officer of the Insurance Company and unless such approval be endorsed hereon. or attached hereto. No agent has authority to change this policy or to waive any of its provisions. Failure to insist upon compliance with any provision of this policy at any given time or times or under any given set or sets of circumstances shall not operate to waive or modify such provision, or in any manner whatsoever to render it unenforceable, as to any other time or times or as to any other occurrence or occurrences, whether the circumstances are, or are not, the saune. GR -23 Cal. Ed. 10269 Page 10 11 1 72 9049 D 333231 Article VI— MISCELLANEOUS PROVISIONS (Continued) Notice o f C( aim-- -Claims Forms Section 5. Time Limit on Certain .Defenses— round that a disease or name or specific description claim ff iis oil adclic date of to which claim is made shall he reduced or denied on the �' No claim for lossicurred or conunei sing aftexetvo years from the effective date of the insurance crage Nvith respec physical condition, not excluded from covera6 y loss, had existed prior to the effective date of the coverage with respect to " of s soon thereafter as is the policy, at its st be W notice of clxin, title, ss )1, period of disability cove red by within , Insu al Con>lhanV..cu itlttlIn- """ell , furnished to or r`ucenlent of iven by or on behalf of the claimant to the. insurance span, .Y reasonably possible. notice 6 Home Office in Hartford, Connecticut, or to any authorized aSent of the nsl formation sufficient to identify the, insured employee, shall be deemed notice to the Insurance Gomp�171Y• The Insurance Company, neon receipt of a written 11 bee deemisitel furly ithl thenregi Lure - L si are usually all', Up" by it for lilulg proofs of loss. I£ such forms are not furnished ti +ithin c forms within the time fixed in the policy' for filling days after the giving of suchh oof'of loss upon submitting ments of this poliov as to proof the occurrence, tlxe character, and the extent of the loss for which proofs of loss, Written proof covering claim is made. I Pi 0 Section 6. Proofs of Loss xcithin 90 days if included in thiiul inycase of claim for `ecti en proof covering the occurrence, the character, and the extent of Joss must be furnished toile n- suranae C onipativ, in case of claim for loss under Title 11 five proof within possible to 6 after the termination of, he period for �clxich the Insurance Company is fish e, except in the any other loss, within Stir days of +;er the date of such loss. hailure. to siblesandi ixxi of event, excel) the time after the expiration of three years hater than one year from the time Proof is otherx i c required. sugchiti ncsll lovidcdtsuch Proof l& fu�.n lie cli as soon 3aslreas'e., f 0111 t le reasonably P sh ill be brought to recover oil this policy absencr. of letcal capacity of the enip,oyae. No action at law or in cquitg >ifter the time 'el'itten Proof of loss is required to be furnished. U 0 Section 7. Payment of Claims Benefits payable under this policy for any loss � +gill be Paid immediately upon receipt of clue writ en proof of loss. able ill accordance with to the e iisfursdyen p10 Yee. The benefit, if any, for loss of life kill be payable or the provision respecting such P",yment• All other benefits are pay< the insurance shall be Payable to the estate of s If any benefit under any Title lid rele' employee, "1.,000 to any relative by blood or con - of this policy icy to an insured emPlnYCe who is a minor or otherwise not exceeding ethe h surance Company to be equitabh' Company may pay such benefit up to an loiV eeiWhotis deemed b,' section by marriage of the insured emP+ the Insurance Gonlpany in flood iI pursuant to flits Provi Company to the extent of. such payment, all or entitled theretoats barge the Insura�tcc Come ti` medical, or sur- sion shall fully ee in a request for insurance i" otherwise, Subject to any 'ritYcn direction of the insured emPlo•'. ee requests other a portion of the benefits if. any Pi'ocided by this Policy on account le hospital, nursm6, hoof of loss is filed, be paid directly toatpartcular hospiit, or a Po service may, at the Insurance Gonxpanv,s optloml, and unless the fiord d O t oy "vise in writing not later than the time T. ' . ortunity to examine the person renderinS such services, Uut It is not required that the service be rendered y Person. at its tin's expense shall have the right and opp The Insurance Company • tx• sickness is the basis of claim ,'hen and as often as It may reasons Y of any, individual whose injury require during the Pendency of a claim hereunder. 4 Not a Substitute For Workmen's Compensation Section 7 -A• Policy This policy is not in lieu of and does not affect i,'orkmen's compensation insurance. page 11 Ed. 9-'63 11 1 72 9064 333231 Article VI— MISCELLANEOUS PROVISIONS (Continued) Section 8. Conversion Privilege Note; This section does not continue group insurance, but provides for the obtaining of an individual policy under certain conditions. As used in this section, the expre,sion "said Titles" shall mean all Titles included in this policy with the exception of Titles ADDC, WDC, DEB and CDEB, if included in this policy. In the event that (a) all of an employee's insurance under said Titles of this policy (including insurance, if any, with respect to dependents) terminates because of termination for any reason whatsoever of the employment of the employee or because of termination of membership in the class of employees then still eligible for such insurance, or (b) the employee's Employee Coverage under said Titles continues but the employee's Dependent Coverage under said Titles for an individual terminates because such individual ceases to be eligible for inclusion under Dependent. Coverage, then the employee in case (a), or the dependent in case (b) or in the event the employee's employ- ment terminates by reason of his death, shall have the privilege of obtaining from the Insurance Company, without any requirement of medical evidence of insurability, an individual policy of in- surance of a kind then being issued by the Insurance Company for group conversion purposes (such policy bein,. hereinafter referred to as the "converted policy ") which includes thercin a right of refusal by the Insurance Company to renew the converted policy, provided written appli- cation for the converted policy shall be made. and the initial quarterly (or at option of the appli- cant, semi - annual or annual) p:.emhun therefor paid, to the Insurance Company within thirty -one days after the date of such termination of insurance; provided, further, that (1) except as otherwise specifically stated, the form of the converted policy, the insurance provid- ed thereunder, and all of the other terms of the converted policy, shall be such as are then cus- tomarily being offered by the Insurance Company for conversions of group insurance of the kind or kinds provided by. said Title; of this policy at the time the application for the convert- ed policy is made to the Insurance Company, but in no case shall the converted policy at date of issue provide benefits less than those specified in any applicable law or regulation or be con- trary in any other respect to the terms of any applicable law or regulation —the Insurance Company or the Policyhob:ler, upon request, will furnish the details of the converted policy then available; and (2) the converted policy may provide that any benefits payable under the converted policy with respect to any individual covered thereunder will be reduced by the amount of any like bene- fits payable under said Titles of this policy with respect to such individual after the termina- tion of his insurance hereunder; and (3) the Insurance Company shall not be required io issue a converted policy covering any indi- vidual if it is indicated that such individual shall at the date of conversion be covered by an- other policy of hospital or surgical expense insurance or hospital service or mrdical expense indemnity corporation subscriber contract providing,, similar benefits or is covered by or eligible to be covered by a group contract or policy providing similar benefits or is provided with similar benefits required by any statute or provided by any welfare plan or program, which to�xether with the converted policy would result in overinsurance or duplication of benefits according to the Insurance Company's applicable standards relatimt to converted policies last made effective by the insurance Company with respect to the jurisdiction in which the converted policy would otherwise be delivered; and GR -23 Ed. 2 -'G9 Page 12 11 72 CAL 9206 ® Article VI— MISCELLANEOUS PROVISIONS (Continued) 0 N 0 Section S. Conversion Privilege (Continued) C- �i GR -23 Ed. 7 -'S9 Page 12 -A CAL 9200 (4) the Insurance Company may decline to issue the converted policy V � (i) if application therefor is not made in the jurisdiction in which this group police is delivered or in some other jurisdiction in ,vhich the Insurance Colupany is author- - ized to issue or deliver the converted policy; or (ii) if termination of insurance under said Titles of this policy .takes place prior to the date the employee concerned has been insured thereunder for at least three months; and (5) the Insurance Company may decline (i) to cover an individual who it is desired be included in the converted policy, if the insurance under said Titles of this policy- terininated because such individual had ex- hausted the maximum benefit available to him under said Titles; and (ii) to cover an individual who it is desired be included in the converted policy for any one or more of the benefits included in the converted policy. if the provision of such benefit or benefits, as the case may be, is prohibited by any applicable law of the jurisdiction in which the individual resides at the time application for such policy is made; and (6) the premium payable under the converted policy on its effective date shall be at the In- surance Company's then customary rate applicable to the class of risk to which the in- sured individual under the converted policy belongs, to the age of such insured individual _ and to the form and amount of insurance under the converted policy; and (7) any converted policy issued under the terms of this section shall take effect as of the date of termination of insurance under said Titles of this policy. Any converted policy issued pursuant to this section shall be in exchange for all privileges and benefits under said Titles with respect to a person named in the converted policy, without pre- judice, however, to an event insured against by this policy which occurred while insurance was in force for such person. C- �i GR -23 Ed. 7 -'S9 Page 12 -A CAL 9200 W PROVISIONS RELATING TO MEDICARE m. (1) ";Medicare" means the "Health Insurance For The Aged" portion of the Social Security Act • of the United States, as presently constituted or as hereafter amended. (2) Unless otherwise -specifically provided herein, the following sections are applicable only to "basic benefits ". 'Basic benctits" means the medical expense benefits provided under this policy, excluding* any major medical expense benefits or comprehensive medical expense bene- fits which may be provided. (3) The benefits payable as to an individual under the medical expense coverages included in this policy shall be equal to the excess of Item (a) below over Item (b) below, a separate determi- nation of such excess to be made to the extent indicated below, and if there is no such excess, then no benefits shalt be payable under such coverages: Item (a) the benefits which would be payable under each basic benefit coverage, determined separately, if none of the charges to which such coverage applies were covered under Medicare; Item (b) the benefits to which the individual is entitled under lledicare with respect to the charges to which the coverages pertain, a separate determination of ,Medicare benefits by coverage to be made as in Item (a). The determination of the benefits payable will be made as provided above with resnect to each claim for benefits to which the foregoing terms of this Section (3) apply. No recalculation of benefits will be made with respect to charges included in a prior claim for, or computation of, such benefits. The benefits payable as determined in accordance with this section and the benefits referred to in Item (a) above shall be those determined before any provision of this policy which oper- ates to take into account the benefits or services of other plans in the determination of bene- fits under this poiicy. The foregoing terms of this Section (3) and the terms of the following Section (4) will oper- ate in lieu of any governmental benefit exclusion, as it affects _lIedicare. �J (4), In addition to the provisions of the major medical expense benefits coverage which provide for the deduction of basic benefits from Covered Medical Expenses, Covered ,Medical Expenses shall also be reduced by the benefits to which the individual is entitled under Medicare with re- spect to the charges to which both Medicare and major medical expense benefits coverage 40) - pertain. (5) In determining the benefits provided for under Medicare, the amount of any deductible which applies jointly to charges made by various providers of care will be applied against the charges to which the coverages of this policy pertain, in the order in which the charges are received. If a claim for benefits includes two or more such charges. the amount of any remaining de- ductible under Medicare will be applied to the charges presented by the various providers of services starting with the largest charge first, then the next largest charge, etc. If the amount of benefits provided for under Medicare for any charge to which the coverages of this policy pertain cannot be determined in accordance with the foregoing rules of this Sec- tion (5), then reasonable estimates, computed on a basis designed to avoid unfair discrimina- tion, of the dollar amount of such benefits will be made and used to determine the benefits under this policy. (6) The applicable premium rate for medical expense coverages under the policy or policies to which this rider is attached for each individual (employee or dependent), in respect of whom benefits would be adjusted based upon the terms of Section (3) or Section (4) above due to eligibility under Medicare, shall be that set forth below. $3.99 per month per individual Series 53 -54 Basic G MM— Enrolled 10335 i i APPLICATION FOR GROUP INSURANCE � % - - Application i <hirt. v made a _-i':C \_A LII'tIi lN l 12_ASC1? C )JI[.�N1-, of Hartford, Connecticut for group insurance 'providing the kinds of insurance specified helots. ✓t Applicant _. ... Address ..... ...... i'..... ..................... _ .............. The purpose of the application is to request 2 issuance of nett coverage. b. i__ change in eluting coverages. C. extension of existitt, coverages to additional groups of employees. This applicaI ion includes the folIotsing associated employers (any entry in conflict « it It applicable laic cannot be included): 3............................... ................................................... . ----------- located at ................_- .._.... ......................... .... -- ..........._.... .... -- ..._..........__.. - -...... -- .........._.. ..._ ........................ located at --- ----- -- - - ----- -- ............................... . � - ......... ........__....._...._......._.. ......._......._........._... ..........- ............._...... located at ....... ............ _. ................. e-,, "1 U All of the regular, full -time, active employees of any employer mentioned above shall be eligible to participate as to the insurance herelh applied for, except the following (State here the class or classes excluded). Retired employees are F-11 are not n to be eligible. For For 5 i:mpl0)'Ce5 Dependents Bind of Insurance Maximum Scheduled amount *Dependents coverage available only 1 ❑ * Term Life where not contrary to late. S Not Available Paid -up & Term Life S n f7 Accidental Death S Dismemberment S / Not _. Available Disability Income S r7 Comprehensive Medical Fxpense $ ' ID 11lajor Medical Expense S ^ l r l � ( Other Medical Fxpense _2sic X Y X x Y l Other (Specify) rr-i X X Y t Y _l' Agent(s) of Record....._ '' .,, - 7 -->> u:=r.....`1i .. 6 ...... ........................_...... ..- --- --- --------------..._.... ---------------...--------.._------------ ---------- --- --- --------- - - - - -- ......................... Note: If counteri,niattire laws require commission sharing tyith a duly Licensed Resident Agent in another jurisdiction the above desi.„nation trill be modified to the extent required hy' the lass. It is requested that the policy or policies be issued on the 0 contributory, E non - contributory- basis The applicant agrees that at no time shrill any employee be permitted or required to contribute for non - contributor.: 67 insurance; or, unless the change is approved in writing by the In.suraticc Company at its Home Office, to m;:kr co ; :- tributions for contributor' insurance at a rate hig n her than the initial contribution rate applicable for the empb��ec- then current insurance. It is agrcod that no insurance shall become effective as to any person if he is not then a bona fide, full time employee, reguiarh performing the duties of his occupation, unless otherwise specifically provided in (� the Group Policy. C':' csi ^. CITY C'�' `P03^_ E-11-11 Signed at........: "......_ _..__4_. Applicant �... ............._........_... - -- y .... 1 -- Date r / Witness Official Title GR -23 -3 (Rev. 4/64) 1 9953 Gr. Pol. or Cont. No. APPLICATION FOR GROUP COVERAGE 333,231 -10 Application is hereby made to ETNA LIFE INSURANCE COMPANY, of Hartford, Connecticut for the kinds ' of group coverage specified below. Applicant.... _Ci.ty_of. Newport Beach, ... ..._.. ..... Address...__ 3300 Newport Blvd.., Newport Beach, California -92660 - ................. The purpose of the application is to request 2 a. C1 issuance of new coverage. ". b. ❑ change in existing coverages. c. ❑ extension of existing coverages to additional groups of employees. In 0 Im IN M N 4) 12 IV This application includes the following associated employers (Any entry in conflict with applicable law cannot be 3 Nincluded) None '.. one located at .. .. .... .... located at ..... ., .... ... ..... ......... located at .... All of the regular, full -time. active employees of any employer mentioned above shall be eligible to participate as to the coverage hereby applied for, except the following (State here the class or classes excluded). 4 City Councilmen Retired employees are ❑ are not I to be eligible. For 5 Employees For Dependents Kind of Coverage Maximum Scheduled Amount ❑* I Dependents coverage available only 'Perm Life where not contrary to law. $ 2$,000 ❑ Not Available Paid -up & Term Life $ ❑ Not Available Survivor Income X X X X X X Is ❑ Accidental Dc..ath & Dismemberment $ 2$,000 ❑ Not Available Disability Im:ome $ ❑ ❑ Comprehensive Medical Expense $ Cl ❑ Major Medical Expense $ ❑ ❑ Other Medical Expense XXXXX X ❑ ❑ Other (Specify) X X X X X X Agent(s) of Record .... None„ 6 Note: If countersignature laws require commission sharing with a duly Licensed Resident Agent in anotherjuris- diction the above designation will be modified to the extent required by the law. It is requested that the policy(ies) or contract(s) be issued on the ❑ contributory, Qt non - contributory basis. The Applicant agrees that at no time shall any employee be permitted or required to contribute for non - contributory coverage; or, unless the change is approved in writing by the Insurance Company at its Home Office, to make con- tributions for contributory coverage at a rate higher than the initial contribution rate applicable for the employee's 7 then current coverage. It is agreed that no coverage shall become effective as to any person if he is not then a bona fide, full time employee, regularly performing the duties of his occupation, unless otherwise specifically provided in the Group Policy or Contract. Signed at...New.por.t. Beach, California.__... IK -l" Date tie- Witness GR -23 -4 City_of..Newpor.t. Beach. - Applicant by i tityna {ir ..._ ....... a i Official Title CAT. 201642 A &H HISTORICAL Group Control No. 333231 • RIDER ATTACKED To AND MADE A. PART oio GROUP POLICY No. GC- 333231 • A CONTRACT BETWEEN A TNA LIFE INSURANCE COMPANY AND TFIE POLICYHOLDER, CITY OF NE74PUAT BEACH • It is understood and agreed as follows: (1) The policy is changed by the addition or deletion of the pages listed below. Page Numbers Of Pages Added Page Numbers Of Pages Deleted • All Bearing 11 1 72 Date 3 -B -- 5 5 5 15 70 5-,AA 5—AA • 6—ADDC -_ 6 —A —ADDC 6—B ADDC - -- 6 —ELP 6—ELP • 6—E11' (Continued) -- 8—A 8 —A 9 9 10 10 11 11 • 12 12 (2) The Premium Hates for the coverage provided by the Title added to the group policy by this rider are shown below._ These rates are for each month and are subject to change in accordance with the terms of the group policy. Title ADDC: $.06 per $1,000 of Principal Sum. Nothing contained in this rider shall be held to alter or affect any of the terms of the policy other than as herein specifically stated. IN WITNESS WIIEREOF the ,ETNA LIFE INSURANCE COMPANY has signed this rider at HARTFORD, CONNECTICUT, to become effective November 1, 1972. Signed by the Insurance Co mpany November 14, 1972. • Registrar Secretary i . Signed by the Policyholder_.... February ...2.0. ..... 19.23....... 1 • Assistant to City Manager ...__...__.. .. .__.. ............ .. _..........._.... .. Signature O%jicial Title • GR -23 -R1 Ed. 9257 9980 k ' (Coil tillucd) '3_11AI Article. Section 3. Employees it-. lie fmqttrcd (I) Employce Coverage z A. Employees Eligitic-: All employees of a P&rticipant Eniploycr shall be eligible f,-.i- Ell'.p;oyce Coverage cept elnployecs ill the follovilll_; classes: (a) temporary orFubstiuto cnlj)10yc.e'j (i.e., enipjoyees whr ire not classiied by such Employer as pen'nancn, cniployees) (b) cnlplclyee:, who are for such Employer on a part -time basis, but this c'�ception Shall not -IV il a of a rogul, full-time, active am- p -') -i the cas H -01 kiln -11 y 1. H and while he is only tclnl)orarJY \k iOl Su- ployee of such Emplo, Employer 0111 a part -tinge basis; (c) City Councilmen but only as tc coverage under Title WEC. t • Each employee in an eligible class Nvho-5c employment commenced oil or before the date of issue shall become eligible for Employee Covanse on the date of issue, and each other employee A an eligible class shall becolln eligible for Einployec COVCIT.C'e on the date he enters the service of a Pai'ticiPaut EMPIOYev. Anything to the contrary notwithstanding, if an individual is in the employ of or con - nected &A two or rinve Participant he shall not be eligible for mulirile coverage under this pehu, brat slial! be trem the same as if he -xere in C:Ill"Aoy of or connected with a single Participant;. od mployer; lnie amount of insurance v,-Hch any such indhidunl shall be cli,_Jble tinder this policy AN under no circumsmnecs ex- ceed the amount which would apply if all of the Participant Einloyars with which he is employed or connected were a sing!-, Faiticipant Eraptoyev nnd if the of the remuneiation be-n„ paid to him by A! such Participant Employers vore being paid to him by a single Participant Employer. If any Participant Employer is i,, partnersnip, the nazural-p-'_,rSon partrlol's thfn-enif shall be considered to be enipioyees whilin the meaning of this policy if and while My arc - - -L',l 'in( - ` actively engaged in and Anottv thek Me an a subkanti.My ft Al -, to lae conduct of the lousiness c.,* the par'.nr rship. if nny I articipant E. u. p 1 o;:: L- Ls a i i i i Adual Inopriotorship, :ho natunkposon propinzor thereof rhall be consWe" to Q an empliryce within Lilo 1renninj; of this policy A the samE tarns as tWNQ :DP pit to partners of a parInarship. GR-28 a Ed. 9 -Vi Page 5 NO 5 15 70 A502 Article I— GENERAL PROVISIONS (Continued) J Section 4. Changes in Amounts of Insurance The initial amount of insurance for an employee under any Title of this policy shall conform to that provided in the Schedule of Insurance appearing in such Title. As to contributory insurance, if, for any reason, the Schedule of Insurance under any Title of this policy warrants an amount of insurance for any employee greater or less than that for which lie is then insured, the amount of his insurance shall be increased or reduced to that warranted by his new classification as follows: Any reduction in insurance shall become ef]'ee- tive on the date the employee makes a request therefor to his Participant Employer. Any in- crease in insurance shall become effective only in conformity with the terms applicable kith respect to the effecting of the initial insurance of employees asset forth in Section 3 of Article I of this policy. As to non - contributory insurance, if, for any reason, the Schedule of Insurance under any Title of this policy warrants an amount of insurance for any employee greater or less than that for which he is then insured, the amount of his insurance shall be increased or reduced to the applicable amount as specified in such schedule of insurance; provided, however, that in any instance in which an employee is both disabled (i.e., ill or injured) and not working on the date his insurance would othenviw be increased, the effective date of the increase in insurance shall be deferred until he actually returns to active wort: on a full -time basis. A retroactive change in an employee's rate of earnings shall be deemed to have become effective on the date of the determination of the change in the rate of earnings. Anything to the contrary notwithstanding: (1) The terms cf the second and third paragraphs of this section shall rot apply to Title C:? , Title :�2=, or Title CDE3, if included in this policy. (2) As to any Title which provides both Employee Coverage and Dependent Coverage, if the effective date of any increase in an employee's F- cloyee Ccverace �C is deferred, for any reason, the effective date of any increase in t,ne employee's Decendent Coverage under such Title shall be deferred until the increase in his E-nplcyee Coverage becomes effective.. ' GR -23 Ed. 11 -'68 Page 5 -AA 1611 Article IV— PRaJIUMS (Continued) m Section 2. Premium .Calculations and Experience Rating (Continued) If at any time the aggregate of employee contributions theretofore made for group insurance shall exceed the aggregate of premiums theretofore paid for group insurance (after gi•.;ng ef- fect to any experience credits allowed the Policyholder), such excess shall be applied by the Policyholder for the sole benefit of employees, but the Insurance Company shall not be obliged to see to the application of any such excess. Any insurance becoming effective shall be charged for from the first day of the policy month coinciding with or next following the date the insurance takes effect. Premium charges for any insurance terminated shall cease as of the first day of the policy month coinciding with or next following the date the insurance terminates. If premiums are payable quarterly, semi annually, or annually, premium charges or credits for a fraction of a premium - paying period shall be made on a pro -rata basis for the number of policy months between the date premium charges commence or cease and the end of the premium- paying period. Instead of the method of calculation of premiums above provided, premiums may be calcu- lated by any method which produces approximately the same total amount of premiums and is mutually agreeable to the Insurance Company and the Policyholder. Section 3. Premiums, How Payable �j Premiums shall be payable by the Policyholder in advance at the Home Office of the Insur- ance Company or to its authorized agent. The first premium under this policy shall be due and payable as of the date of issue to cover _ the period beginning on that date and ending on the last day of the first policy month and t:nere- �/ after premiums shall be due and payable on the first day of each policy month. Section 4. Grace Period A grace period of thirty -one days following the due -date shall be allowed the Policyholder for the payment of each premium. WO 0 GR -23 Ed. 9-'57 Page 8 -A S5 (� Article VI— MISCELLANEOUS PROVISIONS Section 1. Assignment No assignment of any present or future right, interest, Insurance Company, except that upon written consen t cular claim, the Insurance Company shall pay benelii s on account of hospitalization or medical or surgical such care. Section 2. Employees' Certificates or benefit under this policy shall bind the of the employee Nvith respect to a paiti- under this policy for expenses incurred care to the person or persons furuishina, The Insurance Company will issue to the Policyholder, for delivery to each insured employee, an individual certificate setting forth a summary of the essential features of the insurance cov- erage to which the employee is entitled and stating to whom the benefits are payable. Section 3. Data Required— Clerical Error — Misstatements —Noti- Discrimination The Policyholder and each -of the Participant Employers shall furnish to the Insurance Com- /� pany all information which the Insurance Company may reasonably require with regard to any matters pertaining to this policy. 11 documents, books. and records which may have a hearing on the insurance or premiums shall be open for inspection by the Insurance Company at all reasonable times during the continuance of this policy and until the final determination of all rights and obligations under this policy. Neither clerical error (whether by the Policyholder, by any of the Participant Employers, or by the Insurance Company) in keeping any records pertaining to the insurance, nor delays in making entries thereon, shall invalidate insurance otherwise Validly in force or continue jnsur- ance otherwise validly terminated, but upon discovery of such error or delay au equitable ad- justment of premiums shall be made. If any relevant facts pertaining to any individual to whom the insurance relates shall be found to have been misstated, an equitable adjustment of premiums shall be made, and if such mis- statement affects the existence or the amount of insurance, the true facts shall be used in de- termining whether insurance is in force under the terms of this policy and in what amount. No refund of any premium or portion thereof, whether paid in error or other ise, shall be made for any period commencing earlier than twelve months prior to the date on which eNi- dence that the particular refund should be made is received by the Insurance Company. In connection with the administration of this policy, the Policyholder and the Participant Em- ployers shall act so as not to discriminate unfairly betwQen individuals in similar situations at �) the time of such action, but the Insm•ance Company shall be entitled to rely upon any action of the Policyholder or of any of the Participant Eanployers without being, obliged to inquire into the circumstances thereof. `CJ t • 1 Section 4. Entire Contract: Changes This policy constitutes the entire contract between the parties; and no statement made by the Policyholder or by ant, employee whose elizzibility has been accepted by the Insurance Com- pany shall avoid the insurance or .educe the benefits under this policy or be used in defense to a claim hereunder. This policy is issued in the non - participating department of the Insurance Company. This policy may be changed at any time or times by Nsritten agreement between the Insurance Company and the Policyholder. without the consent of any employee or other person. No change in this policy shall be valid unless approved by an executive officer of the Insurance Company and unless such approval be endorsed hereon or attached hereto.. No agent has authority to change this policy or to waive any of its provisions. Failure to insist upon compliance with any provision of this policy at any given time or times or under any given set or sets of circumstances shall not operate to waive or modify such pro- vision, or in am manner whatsoever to render it unenforceable, as to any other time or times or as to any other occurrence or occurrences, whether the circumstances are, or are not, the same. GP. -23 Ed. 4 -'ti3 Page 10 Cal. 9039E Article VI— MISCELLANEOUS PROVISIONS (Continued) Section 5. Time Limit on Certain Defenses Notice of Clains— Claims Fornns No claim for loss incurred or commencing after two years from the effective date of the insurance cov- erage with respect to which claim is made shall be reduced or denied on the ground thai a disease or physical condition, not excluded from coverage by name or specific description effective on the date of loss, had existed prior to the effective date of the coverage with respect to which claim is made. Written notice of claim must be furnished to the Insurance Company within 20 days after the occurrence ®or commencement of any loss or period of disability covered by the policy, or as soon thereafter as is reasonably possible. Notice given by or on behalf of the claimant to the Insurance Company at its Home Office in Hartford, Connecticut, or to any authorized agent of the Insurance Company, with in- formation sufficient to identify the insured employee, shall be deemed notice to the Insurance Company. The Insurance Company, upon receipt of a written notice of claim, will furnish to the claimant such i' forms as are usually furnished by it for filing proofs of loss. If such forms are not furnished within lit days after the giving of such notice, the claimant shall be deemed to have complied with the require- ments of this policy as to proof of loss upon submitting within the time fixed in the policy for filing proofs of loss, written proof covering the occurrence, the character, and the extent of the loss for which claim is made. Section 6. Proofs of Loss Written proof covering the occurrence, the character, and the extent of loss must be furnished to the In- surance Company, in case of claim for loss under Title WBC, if included in this policy, within 90 days after the termination of the period for which the Insurance Company is liable, and in case of claim for any other loss, within 90 days after the date of such loss. Failure to furnish such proof within the time required shall not invalidate nor reduce any claim if it was not reasonably possible to give proof within such time, provided such proof is furnished as soon as reasonably possible and in no event, except in the absence of legal capacity of the employee, later than one year from the time proof is otherwise required. • No action at law or in equity shall be brought to recover on this policy after the expiration of three years after the time written proof of loss is required to be furnished. Section 7. Payment of Claims Benefits payable under this policy for any loss will be paid immediately upon receipt of due written proof of loss. The benefit, if any, for loss of life will be payable in accordance with the beneficiary designation and the provisions respecting such payment. All other benefits are payable to the insured employee. If any benefit under any Title of this policy shall be payable to the estate of the insured employee, or to an insured employee who is a minor or otherwise not competent to give a valid release, the Insurance Company may pay such benefit up to an amount not exceeding $1,000 to any relative by blood or con- nection by marriage of the insured employee who is deemed by the Insurance Company to be equitably entitled thereto. Any payment made by the Insurance Company in good faith pursuant to this provi- sion shall fully discharge the Insurance Company to the extent of such payment. Subject to any written direction of the insured employee in a request for insurance or otherwise, all or a portion of the benefits, if any, provided by this policy on account of hospital, nursing, medical, or sur- gical service may, at the Insurance Company's option, and unless the insured employee requests other- wise in writing not later than the time proof of loss is filed, be paid directly to the hospital or person rendering such services, but it is not required that the service be rendered by a particular hospital or person. The Insurance Company at its own expense shall have the right and opportunity to examine the person of any individual whose injury or sickness is the basis of claim when and as often as it may reasonably require during the pendency of a claim hereunder. Section 7 -A. Policy Not a Substitute For Workmen's Compensation This policy is not in lieu of and does not affect workmen's compensation insurance. 1!p GP. -23 I Ed. 4268 Page 11 9039R Article \71-- 1IISCELLANEOUS PROVISIONS (Continued) Section 8. Conversion Privilege Note: This section does not continue group insurance, but provides for the obtaining of an individual policy under certain conditions. As used in this section, the expression ''said Titles" shall mean all Titles included in this policy with Ah the exception of Titles 1'Lr?DC, >inC and CDEH if included in this policy. In the event that (a) all of an employee's insurance under said Titles of this policy (including insurance, if any, with respect to dependents) terminates because of termination for any reason whatsoever of the em- ployment of the employee or because of termination of membership in the class of employees then still eligible for such insurance. or (b) the employee's Employee Coverage under said Titles continues but the employee's Dependent Coverage under said Titles for an individual terminates because such individual ceases to be eligible for inclusion under Dependent Coverage, then the employee in case (a). or the dependent in case (b) or in the event the employee's employment terminates by reason of his death, shall have the priviiege of obtaining from the Insurance Company. without any requirement of evidence of insurability. an individual policy of insurance of a kind then being issued by the Insurance Company for group conversion purposes (such policy being heminaiter referred to as the "concerted policy") which includes therein a right of refusal by the Insurance Com- pany to renew the converted policy, provided written application for the converted policy shall be made, and the initial quarterly (or at option of the applicant, semi- annual or annual) premium there- for paid, to the Insurance Company. within thirty -one days after the date of such termination of insurance; provided, further, that (1) except as otherwise specifically stated, the form of the converted policy, the insurance provided thereunder, and all of the other terms of the converted policy, shall be such as are then custom- arily being offered by the Insurance Company for conversions of group insurance of the kind or kinds provided by said Titles of this policy at the time the application for the converted colic% a made to the Insurance Company. but in no case shall the converted policy at dace of i ste pro- vide benefits less than those specified in any applicable law or regulation or be contrary: in an_: other respect to the terms of any applicable law or regulation —the Insurance Company or tha Policyholder, upon request, v611 furnish the details of the converted policy then available; and (2) the converted policy may provide that any benefits payable under the converted policy with respect to any individual covered thereunder will he reduced by the amount of any line benefit' payable under said Titles of this policy with respect to such individual after the termination o_ his insurance hereunder; and (3) the Insurance Company shall not be required to issue a converted policy covering any individua: if it is indicated that such individual shall at the date of conversion be covered by another polic': !: of hospital or surgical expense insurance or hospital service or medical expense indemnity corpor- ation subscriber contract providing similar benefits or is covered by or eligible to be cc,.-,-red b% group contract or policy providing similar benefits required by any statute or provided by any welfare plan or program, which together with the converted policy would result in over- ir.surac.= or duplication of benefits according to the Insurance Company's applicable standards r=_ nting t converted policies last made effective by the Insurance Company with respect to the jurisdiction �j in which the converted policy would otherwise be delivered; and t GR -23 cat_ Ed. 5269 Page 12 9204