HomeMy WebLinkAboutContract 2011 2391 CNA
Policy Number: 10212TQ
Account Number: 0010039TQ
MASTER APPLICATION
FOR
LONG TERM CARE INSURANCE
The Applicant applies to the Continental Casualty Company ( "We ", "Our" or "Us ") for a Group Long Term Care Insurance
Policy ( "Master Policy ") based on the statements and representations below.
1. NAME AND ADDRESS OF APPLICANT
City of Columbia Heights
590 40th Avenue NE
Columbia Heights, MN 55421
2. MASTER POLICY EFFECTIVE DATE
July 1, 2011
3. INITIAL ENROLLMENT PERIOD
Begins: September 1, 2002
Ends: September 30, 2002
4. ELIGIBILITY CLASSES
No person may be an Insured under more than one Eligibility Class.
A. Class A — Employees
An Eligible Employee of City of Columbia Heights who is Actively at Work.
Eligible Employee means all Employees working 40 hours or more per week. Employees become Eligible on
their date of hire. Temporary and seasonal employees are not eligible.
Actively at Work means the Employee is physically at his or her usual place of business performing the
regular duties of his or her work.
B. Class B — Spouses of Eligible Employees
The Spouse of a member of Class A.
The Spouse must be the current, lawful spouse of the Eligible Employee.
C. Class C — Parents and Grandparents
The Parent and, if authorized by statute, the Parent -in -law, Grandparent, Grandparent -in -law, of a member of
Class A.
Parent means a natural parent; an adoptive parent; or any other person who is legally married to a natural
parent or adoptive parent. The spouse of the Parent or Parent -in -law must be the current, lawful spouse of
the Parent or Parent -in law.
Grandparent means a natural grandparent; an adoptive grandparent; or any person who is legally married to
a natural or adoptive grandparent. The spouse of the Grandparent or Grandparent -in -law must be the
current, lawful spouse of the Grandparent or Grandparent -in -law.
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D. Class D — Retirees
A Retiree of City of Columbia Heights
E. Class E — Spouses of Retirees
The Spouse must be the current, lawful spouse of the Retiree.
5. ENROLLMENT, UNDERWRITING CRITERIA & COVERAGE EFFECTIVE DATE
A. Class A — Employees
(1) An Eligible Employee may enroll /apply for coverage anytime during the year.
(2) The following underwriting criteria shall apply:
a. Coverage shall be granted without demonstrating evidence of insurability if the Eligible Employee
enrolls:
L During the Initial Enrollment Period, if he or she is Actively at Work;
ii. Within 30 days of his or her return to work, if he or she was not Actively at Work during the Initial
Enrollment Period for his or her location; or
iii. Within 30 days after becoming Eligible.
b. Coverage shall be granted subject to Our approval of evidence of insurability, if the Eligible Employee
applies for coverage at any other time or if the Eligible Employee selects the Lifetime Compound
Lifetime Automatic Benefit Increase inflation protection option greater than $120.
(3) The Eligible Employee must be Actively at Work on the Coverage Effective Date for coverage to take
effect. If the Eligible Employee is on a scheduled vacation, he or she will be deemed to be Actively at
Work on the Coverage Effective Date. If the Eligible Employee is on Sabbatical, Disability, Medical Leave,
or other Leave of Absence on the Coverage Effective Date, coverage will take effect on the first regular
scheduled day he or she returns to work.
a. If the Eligible Employee enrolls during the Initial Enrollment Period coverage shall be the Master
Policy Effective Date.
b. If the Eligible Employee enrolls or applies for coverage at any other time:
i. If We receive and process the enrollment form or approve and process the evidence of insurability
on or before the 15th day of the month, the insurance will be effective on the first day of the month
immediately following.
ii. If We receive and process the enrollment form or approve and process the evidence of insurability
after 15th day of the month, the insurance will be effective on the first day of the second month
following.
B. Class B — Spouses of Eligible Employees
(1) The Spouse of an Eligible Employee may elect to apply for coverage at anytime the Eligible Employee is
Actively at Work.
(2) Coverage shall be granted subject to our approval of evidence of insurability.
(3) Coverage shall take effect on the first pay period following the date we approve and process the evidence
of insurability.
C. Class C — Parents and Grandparents
(1) Parents, Parents -in -law, Grandparents, and Grandparents -in -law, may elect to apply for coverage at
anytime the Eligible Employee is Actively at Work.
(2) Coverage shall be granted subject to Our approval of evidence of insurability.
(3) Coverage shall take effect on the first day of the month that falls on or next following the date We approve
and process the evidence of insurability.
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D. Class D and E — Retirees and their Spouses
(1) Retirees and their Spouses my elect to apply for coverage at anytime.
(2) Coverage shall be granted subject to Our approval of evidence of insurability.
(3) Coverage shall take effect on the first day of the month that falls on or next following the date We approve
and process the evidence of insurability.
6. SCHEDULE OF BENEFITS
A. Long Term Care Benefit
(1) Long Term Care Benefit for Nursing Home Care
100% of the Eligible Expense per day of Nursing Home Care or Alternate Care Facility, not to exceed the
Daily Benefit, as determined by the option elected by the eligible person.
(2) Long Term Care Benefit for Assisted Living Care
100% of the Eligible Expense per day of Assisted Living Care, not to exceed 80% of the Daily Benefit for
Nursing Home Care, as elected by the eligible person.
(3) Long Term Care Benefit for Community Based Care
100% of the Eligible Expense per day of Community Based Care, not to exceed the corresponding monthly
limit as elected by the eligible person.
(4) Long Term Care Benefit for Hospice Care Facility
100% of the Eligible Expense per day not to exceed the Daily Benefit for Nursing Home Care, as elected by
the eligible person.
Corresponding Corresponding Corresponding
Daily Benefit Daily Benefit for Monthly Benefit for Daily Benefit for
for Nursing Assisted Living Community Based Hospice Care
Option Home Care Care Care Facility
1 $120.00 $96.00 $2,700 $120.00
2 $150.00 $120.00 $3,390 $150.00
3 $200.00 $160.00 $4,500 $200.00
4 $250.00 $200.00 $5,640 $250.00
B. Lifetime Maximum Benefit
730 times (2- years), 1250 times (3.4- years), or 1825 times (5- years) the Daily Benefit for Nursing Home Care, as
elected by the eligible person.
Daily Benefit Corresponding Corresponding Corresponding
for Nursing 2 -Year Lifetime 3.4 -Year Lifetime 5 -Year Lifetime
Option Home Care Maximum Benefit Maximum Benefit Maximum Benefit
1 $120.00 $ 87,600.00 $150,000.00 $219,000.00
2 $150.00 $109,500.00 $187,500.00 $273,750.00
3 $200.00 $146,000.00 $250,000.00 $365,000.00
4 $250.00 $182,500.00 $312,500.00 $456,250.00
C. Waiting Period
15 days of service for Community Based Care.
60 days of service for Nursing Home Care.
Once per lifetime.
D. Waiver of Premium
After completion of the Waiting Period.
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E. Caregiver Training Benefit
100% of the actual Expense per training, not to exceed the corresponding benefit, as elected by the eligible
person.
Corresponding Monthly Corresponding
Daily Benefit for Benefit for Community Benefit for
Option Nursing Home Care Based Care Caregiver Training
1 $120.00 $2,700 $270.00
2 $150.00 $3,390 $339.00
3 $200.00 $4,500 $450.00
4 $250.00 $5,640 $564.00
F. Temporary Bed Holding Benefit
100% of the Eligible Expense per day, not to exceed the Daily Benefit for Nursing Home Care, as elected by the
eligible person, with a maximum Annual Benefit of 21 calendar days.
Corresponding Daily Corresponding Annual
Daily Benefit for Temporary Bed Temporary Bed
Option Nursing Home Care Holding Benefit Holding Benefit
1 $120.00 $120.00 $2,520.00
2 $150.00 $150.00 $3,150.00
3 $200.00 $200.00 $4,200.00
4 $250.00 $250.00 $5,250.00
G. Emergency Alert Benefit
100% of the actual Expense per month for rental or lease of Emergency Alert equipment, not to exceed the
corresponding benefit as elected by the eligible person.
Corresponding Monthly Corresponding Monthly
Daily Benefit for Benefit for Community Emergency Alert
Option Nursing Home Care Based Care Benefit
1 $120.00 $2,700.00 $ 90.00
2 $150.00 $3,390.00 $113.00
3 $200.00 $4,500.00 $150.00
4 $250.00 $5,640.00 $188.00
H. Care Assist Benefit
100% of the Eligible Expense per day, not to exceed the Daily Benefit for Nursing Home Care, as elected by the
eligible person, with a maximum Annual Benefit of 14 calendar days.
Corresponding Corresponding
Daily Benefit for Daily Care Assist Annual Care Assist
Option Nursing Home Care Benefit Benefit
1 $120.00 $120.00 $1,680.00
2 $150.00 $150.00 $2,100.00
3 $200.00 $200.00 $2,800.00
4 $250.00 $250.00 $3,500.00
I. Benefit Account (optional benefit)
If the Insured stops paying premiums after three (3) years of continuous coverage, Long Term Care coverage will
be continued. Daily Benefit levels remain the same; however, the Lifetime Maximum Benefit will be reduced to
the greater of the total premiums paid or 30 times the Daily Benefit for Nursing Home Care.
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J. Refund of Premium at Death
If the Insured dies on or before reaching age 65, We will return 100% of the premium paid, less any Benefits paid
or payable. After the Insured reaches age 65, the amount of premium returned, less any Benefits paid or
payable, will be as follows:
Premium Returned
Age at Death (less any Benefits paid)
65 and younger 100%
66 90%
67 80%
68 70%
69 60%
70 50%
71 40%
72 30%
73 20%
74 10%
75 and older 0
Coverage must be in effect at the time of death in order for any premium to be refunded.
K. World Wide Coverage Benefit
If the insured person becomes eligible to receive benefits under this plan while living or traveling outside the
United States, this benefit will provide a cash benefit equal to 75% of the insureds Daily Nursing Home Benefit.
This cash benefit is not based on actual charges incurred, is paid regardless of the provider of services, and is
paid in lieu of all benefit payment descriptions otherwise shown in the "Plans At A Glance." Expenses, however,
must occur outside the United States.
L. Inflation Protection (Insured selects one)
(1) Guaranteed Benefit Increase Option
Insureds will be offered opportunities to increase the Maximum Daily Benefit Levels and Lifetime Maximum on
the third anniversary of the Effective Date of the Master Policy, and no less than every three years thereafter.
The offered increase will be not less than a compounded annual five percent (5 %) rate. Insureds are not
obligated to purchase additional coverage in order for their policies to remain in effect.
(2) Lifetime Compound Automatic Benefit Increase
The Benefit Levels and Lifetime Maximum will be increased by five percent (5 %) of the prior year's amount
each year on the anniversary of the Insured's Certificate Effective Date.
7. PREMIUM PAYMENT MODES
A. For Actively at Work Employees and their Spouses, premiums are payable by deductions from a payroll
account.
B. For all other Insureds, including former Actively at Work Employees and Spouses on continuation policies,
premiums are payable on a quarterly, semi - annual, or annual direct - billed basis, or via monthly Electronic Funds
Transfer, unless We agree to another mode of payment.
8. PREMIUM DUE DATES
A. Initial Premium Due Date
(1) For Actively at Work Employees and their Spouses under payroll deduction, the initial Premium Due Date
is 50 days after the Master Policy Effective Date.
(2) For all other Insureds, the initial Premium Due Date is the Insured's Certificate Effective Date.
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B. Subsequent Premium Due Dates
(1) For Actively at Work Employees and their Spouses under payroll deduction, subsequent Premium Due
Dates will be monthly, as billed.
(2) For all other Insureds, including former Actively at Work Employees and Spouses on continuation policies,
subsequent Premium Due Dates will be monthly, quarterly, semi - annually, or annually, as billed, depending
upon the Premium Payment Mode selected by the Insured.
9. CHANGES AND CANCELLATIONS BY THE INSURED
A. Requests to increase the Benefits Level may be made at any time in writing to Us. Increases to the Benefits
Level shall be granted subject to Our approval of evidence of insurability.
B. Requests to reduce the Benefit Levels may be made at any time in writing to Us.
C. Requests to cancel coverage may be made at any time in writing to Us.
10. PREMIUM RATES
See Addenda 1 -12 attached to this Master Application.
11. CONTRACT TYPE
This contract is intended to be a Qualified Long Term Care contract as defined under section 7702B(b) of the Internal
Revenue Code of 1986.
12. MISCELLANEOUS
A. Initial Renewal Period: 36 months (3 Years)
B. Subsequent Renewal Periods: 12 months (1 Year)
C. Period of Notice for Non - Renewal 60 days
D. Initial Premium Rate Guarantee Period 36 months (3 Years)
E. Period of Notice of Premium Rate Changes 60 days
13. EFFECTIVE DATE
This Master Application is attached to and made a part of Group Long Term Care Policy Number 0010212TQ. The
Master Policy is Effective July 1, 2011. This Master Application cancels and replaces any prior Master Applications
attached to the Master Policy. The Effective Date of this Master Application is July 1, 2011.
Applicant: City o�f Columbia Heights /j
BY: UI/ ' f jli(,11 -fr's 17- S 1
j
(signature) (name printed)
(?,,t r ,, - 1-i t-1
Title (please print) Date
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ADDENDUM NO. 1
TABLE OF PREMIUM RATES
POLICYHOLDER: City of Columbia Heights LIFETIME
POLICY NUMBER: 10212TQ MAXIMUM: 730x (2 -Year)
Optional Benefits: Guaranteed Benefit Increase
AGE ON EFFECTIVE MONTHLY PREMIUM
DATE OF COVERAGE FOR DAILY BENEFIT SELECTED
Aug $120, $150 $200 $250
<25 6.79 8.49 11.31 14.14
25 7.53 9.42 12.56 15.70
26 7.59 9.49 12.66 15.82
27 7.71 9.64 12.85 16.06
28 7.91 9.89 13.18 16.48
29 8.07 10.09 13.45 16.82
30 8.26 10.32 13.76 17.20
31 8.48 10.60 14.13 17.67
32 8.79 10.99 14.66 18.32
33 9.19 11.49 15.32 19.15
34 9.69 12.12 16.16 20.19
35 10.24 12.80 17.07 21.34
36 10.85 13.56 18.08 22.60
37 11.49 14.36 19.15 23.94
38 12.13 15.16 20.22 25.27
39 12.83 16.04 21.38 26.73
40 13.53 16.91 22.55 28.19
41 14.31 17.89 23.85 29.82
42 15.13 18.91 25.21 31.52
43 15.97 19.96 26.61 33.27
44 16.81 21.01 28.01 35.02
45 17.71 22.13 29.51 36.89
46 18.69 23.36 31.14 38.93
47 19.83 24.79 33.05 41.31
48 21.02 26.27 35.03 43.79
49 22.23 27.79 37.05 46.32
50 23.61 29.51 39.35 49.18
51 25.21 31.51 42.01 52.51
52 27.19 33.99 45.32 56.64
53 29.56 36.95 49.26 61.58
54 32.17 40.21 53.62 67.02
55 35.09 43.86 58.48 73.09
56 38.25 47,81 63.74 79.68
57 41.68 52.09 69.46 86.82
58 45.42 56.77 75.70 94.62
59 49.48 61.85 82.46 103.08
60 53.75 67.19 89.58 111.97
61 58.08 72.59 96.79 120.99
62 62.32 77.90 103.87 129.83
63 66.15 82.68 110.24 137.81
64 69.70 87.13 116.17 145.22
65 73.30 91.62 122.16 152.70
66 77.65 97.06 129.41 161.77
67 83.11 103.88 138.51 173.14
68 89.33 111.67 148.89 186.11
69 95.98 119.98 159.97 199.96
70 103.55 129.44 172.59 215.74
71 112.66 140.83 187.77 234.71
72 124.00 155.00 206.67 258.33
73 137.55 171.94 229.26 286.57
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ADDENDUM NO. 1
TABLE OF PREMIUM RATES
POLICYHOLDER: City of Columbia Heights LIFETIME
POLICY NUMBER: 10212TQ MAXIMUM: 730x (2 -Year)
Optional Benefits: Guaranteed Benefit Increase
AGE ON EFFECTIVE MONTHLY PREMIUM
DATE OF COVERAGE FOR DAILY BENEFIT SELECTED
Age $120 $150 $200 $250
74 153.01 191.26 255.01 318.77
75 169.70 212.12 282.83 353.54
76 188.01 235.02 313.35 391.69
77 207.43 259.29 345.72 432.15
78 227.79 284.73 379.64 474.55
79 249.24 311.55 415.39 519.24
80 272.00 340.01 453.34 566.68
81 296.49 370.61 494.15 617.68
82 322.38 402.98 537.30 671.63
83 350.64 438.30 584.41 730.51
84 381.14 476.43 635.24 794.05
85 412.79 515.99 687.98 859.98
86 444.48 555.60 740.80 926.00
87 475.55 594.44 792.59 990.74
88 505.12 631.40 841.87 1,052.34
89 534.32 667.90 890.53 1,113.16
90 563.32 704.16 938.87 1,173.59
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ADDENDUM NO. 2
TABLE OF PREMIUM RATES
POLICYHOLDER: City of Columbia Heights LIFETIME
POLICY NUMBER: 10212TQ MAXIMUM: 1250x (3.4 -Year)
Optional Benefits: Guaranteed Benefit Increase
AGE ON EFFECTIVE MONTHLY PREMIUM
DATE OF COVERAGE FOR DAILY BENEFIT SELECTED
Age $120 $150 $200 $250
<25 8.07 10.10 13.47 16.83
25 9.19 11.48 15.31 19.13
26 9.34 11.67 15.56 19.45
27 9.59 12.00 16.00 20.00
28 9.90 12.38 16.51 20.63
29 10.21 12.77 17.03 21.28
30 10.51 13.15 17.53 21.92
31 10.92 13.65 18.20 22.75
32 11.39 14.25 19.00 23.75
33 12.01 15.02 20.03 25.03
34 12.74 15.92 21.23 26.53
35 13.58 16.97 22.63 28.28
36 14.48 18.10 24.13 30.17
37 15.44 19.30 25.73 32.17
38 16.43 20.55 27.40 34.25
39 17.46 21.83 29.11 36.38
40 18.54 23.18 30.91 38.63
41 19.72 24.65 32.87 41.08
42 20.94 26.17 34.89 43.62
43 22.18 27.73 36.97 46.22
44 23.46 29.32 39.09 48.87
45 24.80 31.00 41.33 51.67
46 26.29 32.88 43.84 54.80
47 27.98 34.97 46.63 58.28
48 29.75 37.20 49.60 62.00
49 31.60 39.50 52.67 65.83
50 33.62 42.02 56.03 70.03
51 36.04 45.05 60.07 75.08
52 38.93 48.67 64.89 81.12
53 42.37 52.97 70.63 88.28
54 46.16 57.70 76.93 96.17
55 50.34 62.93 83.91 104.88
56 54.95 68.70 91.60 114.50
57 59.93 74.93 99.91 124.88
58 65.51 81.90 109.20 136.50
59 71.55 89.45 119.27 149.08
60 77.94 97.43 129.91 162.38
61 84.41 105.53 140.71 175.88
62 90.71 113.40 151.20 189.00
63 96.33 120.43 160.57 200.72
64 101.50 126.87 169.16 211.45
65 106.75 133.45 177.93 222.42
66 113.18 141.47 188,63 235.78
67 121.34 151.68 202.24 252.80
68 130.73 163.40 217.87 272.33
69 140.82 176.02 234.69 293.37
70 152.33 190.42 253.89 317.37
71 166.10 207.62 276.83 346.03
72 183.11 228.90 305.20 381.50
73 203.43 254.30 339.07 423.83
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ADDENDUM 140.
TABLE OF PREMIUM RATES
POLICYHOLDER: City of Columbia Heights LIFETIME
POLICY NUMBER: 10212TQ MAXIMUM: 1250x (3.4 -Year)
Optional Benefits: Guaranteed Benefit Increase
AGE ON EFFECTIVE MONTHLY PREMIUM
DATE OF COVERAGE FOR DAILY BENEFIT SELECTED
Age $120 $150 $200 $250
74 226.55 283.20 377.60 472.00
75 251.48 314.35 419.13 523.92
76 278.81 348.53 464.71 580.88
77 307.77 384.70 512.93 641.17
78 338.07 422.60 563.47 704.33
79 369.98 462.47 616.63 770.78
80 403.82 504.77 673.03 841.28
81 440.19 550.25 733.67 917.08
82 478.65 598.33 797.77 997.22
83 520.66 650.83 867.77 1,084.72
84 565.97 707.47 943.29 1,179.12
85 612.95 766.20 1,021.60 1,277.00
86 659.96 824.95 1,099.93 1,374.92
87 705.95 882.45 1,176.60 1,470.75
88 749.60 937.00 1,249.33 1,561.67
89 792.60 990.75 1,321.00 1,651.25
90 835.21 1,044.03 1,392.04 1,740.05
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ADDENDUM NO. 3
TABLE OF PREMIUM RATES
POLICYHOLDER: City of Columbia Heights LIFETIME
POLICY NUMBER: 10212TQ MAXIMUM: 1825x (5 -Year)
Optional Benefits: Guaranteed Benefit Increase
AGE ON EFFECTIVE MONTHLY PREMIUM
DATE OF COVERAGE FOR DAILY BENEFIT SELECTED
Age $120 $150 $200 $250
<25 9.29 11.60 15.47 19.33
25 10.74 13.43 17.91 22.38
26 10.94 13.67 18.23 22.78
27 11.28 14.10 18.80 23.50
28 11.72 14.65 19.53 24.42
29 12.13 15.17 20.23 25.28
30 12.57 15.72 20.96 26.20
31 13.10 16.37 21.83 27.28
32 13.75 17.20 22.93 28.67
33 14.57 18.23 24.31 30.38
34 15.51 19.40 25.87 32.33
35 16.57 20.73 27.64 34.55
36 17.73 22.18 29.57 36.97
37 18.99 23.72 31.63 39.53
38 20.23 25.30 33.73 42.17
39 21.57 26.97 35.96 44.95
40 22.97 28,73 38.31 47.88
41 24.47 30.60 40.80 51.00
42 26.02 32.53 43.37 54.22
43 27.59 34.50 46.00 57.50
44 29.19 36.50 48.67 60.83
45 30.89 38.63 51.51 64.38
46 32.78 40.98 54.64 68.30
47 34.93 43.68 58.24 72.80
48 37.16 46.45 61.93 77.42
49 39.47 49.35 65.80 82.25
50 42.04 52.55 70.07 87.58
51 45.06 56.32 75.09 93.87
52 48.69 60.88 81.17 101.47
53 52.91 66.15 88.20 110.25
54 57.60 72.00 96.00 120.00
55 62.79 78.50 104.67 130.83
56 68.48 85.60 114.13 142.67
57 74.69 93.38 124.51 155.63
58 81.66 102.08 136.11 170.13
59 89.22 111.53 148.71 185.88
60 97.22 121.53 162.04 202.55
61 105.30 131.63 175.51 219.38
62 113.15 141.45 188.60 235.75
63 120.09 150.13 200.17 250.22
64 126.40 158.00 210.67 263.33
65 132.87 166.10 221.47 276.83
66 140.82 176.02 234.69 293.37
67 151.05 188.83 251.77 314.72
68 162.94 203.68 271.57 339.47
69 175.78 219.73 292.97 366.22
70 190.39 238.00 317.33 396.67
71 207.87 259.85 346.47 433.08
72 229.32 286.65 382.20 477.75
73 254.87 318.60 424.80 531.00
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ADDENDUM NO. 3
TABLE OF PREMIUM RATES
POLICYHOLDER: City of Columbia Heights LIFETIME
POLICY NUMBER: 10212TQ MAXIMUM: 1825x (5 -Year)
Optional Benefits: Guaranteed Benefit Increase
AGE ON EFFECTIVE MONTHLY PREMIUM
DATE OF COVERAGE FOR DAILY BENEFIT SELECTED
Age $120 $150 $200 $250
74 283.91 354.90 473.20 591.50
75 315.22 394.03 525.37 656.72
76 349.54 436.92 582.56 728.20
77 385.87 482.35 643.13 803.92
78 423.93 529.93 706.57 883.22
79 463.98 579.98 773.31 966.63
80 506.42 633.02 844.03 1,055.03
81 552.06 690.08 920.11 1,150.13
82 600.34 750.43 1,000.57 1,250.72
83 653.02 816.27 1,088.36 1,360.45
84 709.88 887.35 1,183.13 1,478.92
85 768.82 961.03 1,281.37 1,601.72
86 827.72 1,034.65 1,379.53 1,724.42
87 885.33 1,106.68 1,475.57 1,844.47
88 939.96 1,174.95 1,566.60 1,958.25
89 993.71 1,242.15 1,656.20 2,070.25
90 1,046.91 1,308.65 1,744.87 2,181.08
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ADDENDUM NO. 4
TABLE OF PREMIUM RATES
POLICYHOLDER: City of Columbia Heights LIFETIME
POLICY NUMBER: 10212TQ MAXIMUM: 730x (2 -Year)
Optional Benefits: Guaranteed Benefit Increase
Benefit Account
AGE ON EFFECTIVE MONTHLY PREMIUM
DATE OF COVERAGE FOR DAILY BENEFIT SELECTED
AAe, $12Q $150 $200 $250
<25 7.55 9.43 12.58 15.72
25 8.36 10.45 13.94 17.42
26 8.43 10.54 14.06 17.57
27 8.56 10.70 14.27 17.84
28 8.77 10.96 14.62 18.27
29 8.96 11.20 14.93 18.66
30 9.25 11.56 15.42 19.27
31 9.49 11.87 15.82 19.78
32 9.86 12.32 16.43 20.53
33 10.30 12.87 17.17 21.46
34 10.85 13.56 18.08 22.60
35 11.47 14.33 19.11 23.89
36 12.14 15.18 20.24 25.30
37 12.87 16.08 21.44 26.80
38 13.59 16.99 22.65 28.31
39 14.37 17.96 23.95 29.94
40 15.28 19.10 25.47 31.83
41 16.18 20.22 26.96 33.70
42 17.09 21.36 28.48 35.60
43 18.04 22.55 30.07 37.59
44 19.00 23.75 31.67 39.58
45 20.18 25.22 33.63 42.04
46 21.31 26.64 35.52 44.40
47 22.60 28.26 37.67 47.09
48 23.97 29.96 39.95 49.94
49 25.35 31.68 42.24 52.80
50 27.15 33.94 45.26 56.57
51 28.99 36.23 48.31 60.39
52 31.27 39.09 52.12 65.15
53 33.99 42.49 56.65 70.81
54 36.99 46.23 61.64 77.06
55 40.70 50.87 67.83 84.78
56 44.37 55.46 73.95 92.44
57 48.34 60.42 80.56 100.70
58 52.69 65.86 87.81 109.76
59 57.40 71.75 95.66 119.58
60 62.88 78.60 104.80 131.00
61 67.94 84.93 113.24 141.55
62 72.92 91.15 121.54 151.92
63 77.39 96.74 128.98 161.23
64 81.55 101.94 135.92 169.91
65 86.49 108.11 144.15 180.18
66 91.62 114.53 152.70 190.88
67 98.06 122.57 163.43 204.29
68 105.42 131.77 175.70 219.62
69 113.27 141.59 188.78 235.98
70 122.20 152.75 203.67 254.59
71 132.95 166.18 221.58 276.97
72 146.31 182.89 243.86 304.82
SPVIAA -13-
ADDENDUM NO. 4
TABLE OF PREMIUM RATES
POLICYHOLDER: City of Columbia Heights LIFETIME
POLICY NUMBER: 10212TQ MAXIMUM: 730x (2 -Year)
Optional Benefits: Guaranteed Benefit Increase
Benefit Account
AGE ON EFFECTIVE MONTHLY PREMIUM
DATE OF COVERAGE FOR DAILY BENEFIT SELECTED
Age $120 $150 $200 $250
73 162.32 202.90 270.53 338.16
74 180.56 225.70 300.93 376.16
75 200.24 250.29 333.73 417.16
76 221.86 277.33 369.77 462.21
77 244.77 305.96 407.95 509.94
78 268.79 335.98 447.98 559.97
79 291.61 364.51 486.02 607.52
80 318.24 397.80 530.40 663.00
81 343.93 429.91 573.21 716.51
82 373.96 467.45 623.27 779.08
83 406.75 508.43 677.91 847.39
84 442.12 552.65 736.87 921.09
85 474.71 593.39 791.19 988.99
86 511.15 638.94 851.92 1,064.90
87 546.88 683.60 911.46 1,139.33
88 575.84 719.80 959.73 1,199.67
89 603.77 754.72 1,006.29 1,257.87
90 636.56 795.70 1,060.94 1,326.17
SPV1AA -14-
ADDENDUM NO. 5
TABLE OF PREMIUM RATES
POLICYHOLDER: City of Columbia Heights LIFETIME
POLICY NUMBER: 10212TQ MAXIMUM: 1250x (3.4 -Year)
Optional Benefits: Guaranteed Benefit Increase
Benefit Account
AGE ON EFFECTIVE MONTHLY PREMIUM
DATE OF COVERAGE FOR DAILY BENEFIT SELECTED
Age $120 $150 $200 $250
<25 8.95 11.18 14.91 18.63
25 10.21 12.77 17.03 21.28
26 10.37 12.98 17.31 21.63
27 10.64 13.30 17.73 22.17
28 10.98 13.73 18.31 22.88
29 11.33 14.18 18.91 23.63
30 11.77 14.72 19.63 24.53
31 12.23 15.30 20.40 25.50
32 12.78 15.98 21.31 26.63
33 13.46 16.82 22.43 28.03
34 14.29 17.85 23.80 29.75
35 15.21 19.03 25.37 31.72
36 16.22 20.28 27.04 33.80
37 17.30 21.63 28.84 36.05
38 18.39 23.00 30.67 38.33
39 19.55 24.45 32.60 40.75
40 20.95 26.20 34.93 43.67
41 22.28 27.85 37.13 46.42
42 23.65 29.57 39.43 49.28
43 25.07 31.35 41.80 52.25
44 26.50 33.13 44.17 55.22
45 28.27 35.35 47.13 58.92
46 29.98 37.48 49.97 62.47
47 31.90 39.88 53.17 66.47
48 33.93 42.43 56.57 70.72
49 36.02 45.03 60.04 75.05
50 38.66 48.32 64.43 80.53
51 41.45 51.82 69.09 86.37
52 44.78 55.97 74.63 93.28
53 48.72 60.90 81.20 101.50
54 53.07 66.35 88.47 110.58
55 58.41 73.00 97.33 121.67
56 63.73 79.68 106.24 132.80
57 69.52 86.90 115.87 144.83
58 76.00 95.00 126.67 158.33
59 82.99 103.75 138.33 172.92
60 91.18 113.98 151.97 189.97
61 98.77 123.47 164.63 205.78
62 106.13 132.68 176.91 221.13
63 112.69 140.88 187.84 234.80
64 118.75 148.45 197.93 247.42
65 125.96 157.45 209.93 262.42
66 133.56 166.95 222.60 278.25
67 143.19 179.00 238.67 298.33
68 154.27 192.85 257.13 321.42
69 166.18 207.73 276.97 346.22
70 179.76 224.70 299.60 374.50
71 196.01 245.03 326.71 408.38
72 216.08 270.10 360.13 450.17
SPV1AA -15-
ADDENDUM NO. 5
TABLE OF PREMIUM RATES
POLICYHOLDER: City of Columbia Heights LIFETIME
POLICY NUMBER: 10212TQ MAXIMUM: 1250x (3.4 -Year)
Optional Benefits: Guaranteed Benefit Increase
Benefit Account
AGE ON EFFECTIVE MONTHLY PREMIUM
DATE OF COVERAGE FOR DAILY BENEFIT SELECTED
Age $120 $150 $200 $250
73 240.05 300.08 400.11 500.13
74 267.33 334.15 445.53 556.92
75 296.73 370.93 494.57 618.22
76 329.01 411.27 548.36 685.45
77 363.16 453.95 605.27 756.58
78 398.92 498.65 664.87 831.08
79 432.87 541.10 721.47 901.83
80 472.46 590.57 787.43 984.28
81 510.61 638.27 851.03 1,063.78
82 555.23 694.05 925.40 1,156.75
83 603.96 754.95 1,006.60 1,258.25
84 656.53 820.67 1,094.23 1,367.78
85 704.89 881.13 1,174.84 1,468.55
86 758.95 948.70 1,264.93 1,581.17
87 811.84 1,014.80 1,353.07 1,691.33
88 854.54 1,068.17 1,424.23 1,780.28
89 895.63 1,119.55 1,492.73 1,865.92
90 943.78 1,179,73 1,572.97 1,966.22
SPV1AA -16-
ADDENDUM NO. 6
TABLE OF PREMIUM RATES
POLICYHOLDER: City of Columbia Heights LIFETIME
POLICY NUMBER: 10212TQ MAXIMUM: 1825x (5 -Year)
Optional Benefits: Guaranteed Benefit Increase
Benefit Account
AGE ON EFFECTIVE MONTHLY PREMIUM
DATE OF COVERAGE FOR DAILY BENEFIT SELECTED
Age $120 $150 $200, $250
<25 10.31 12.90 17.20 21.50
25 11.91 14.90 19.87 24.83
26 12.15 15.20 20.27 25.33
27 12.52 15.65 20.87 26.08
28 13.00 16.25 21.67 27.08
29 13.46 16.82 22.43 28.03
30 14.09 17.62 23.49 29.37
31 14.68 18.35 24.47 30.58
32 15.41 19.28 25.71 32.13
33 16.31 20.38 27.17 33.97
34 17.37 21.73 28.97 36.22
35 18.54 23.18 30.91 38.63
36 19.85 24.82 33.09 41.37
37 21.27 26.60 35.47 44.33
38 22.65 28.32 37.76 47.20
39 24.16 30.20 40.27 50.33
40 25.95 32.45 43.27 54.08
41 27.66 34.58 46.11 57.63
42 29.41 36.77 49.03 61.28
43 31.19 39.00 52.00 65.00
44 32.99 41.25 55,00 68.75
45 35.22 44.03 58.71 73.38
46 37.37 46.70 62.27 77.83
47 39.81 49.78 66.37 82.97
48 42.37 52.97 70.63 88.28
49 45.00 56.25 75.00 93.75
50 48.35 60.45 80.60 100.75
51 51.82 64.77 86.36 107.95
52 55.99 70.00 93.33 116.67
53 60.85 76.08 101.44 126.80
54 66.24 82.80 110.40 138.00
55 72.84 91.05 121.40 151.75
56 79.43 99.30 132.40 165.50
57 86.65 108.32 144.43 180.53
58 94.74 118.42 157.89 197.37
59 103.50 129.38 172.51 215.63
60 113.75 142.20 189.60 237.00
61 123.21 154.03 205.37 256.72
62 132.39 165.47 220.63 275.78
63 140,50 175.63 234.17 292.72
64 147.90 184.88 246.51 308.13
65 156.78 195.98 261.31 326.63
66 166.17 207.73 276.97 346.22
67 178.23 222.80 297.07 371.33
68 192.26 240.33 320.44 400.55
69 207.41 259.27 345.69 432.12
70 224.67 280.85 374.47 468.08
71 245.27 306.60 408.80 511.00
72 270.59 338.23 450.97 563.72
SPVIAA -17-
ADDENDUM NO. 6
TABLE OF PREMIUM RATES
POLICYHOLDER: City of Columbia Heights LIFETIME
POLICY NUMBER: 10212TQ MAXIMUM: 1825x (5 -Year)
Optional Benefits: Guaranteed Benefit Increase
Benefit Account
AGE ON EFFECTIVE MONTHLY PREMIUM
DATE OF COVERAGE FOR DAILY BENEFIT SELECTED
Age $120 $150 $200 $250
73 300.75 375.95 501.27 626.58
74 335.03 418.80 558.40 698.00
75 371.96 464.95 619.93 774.92
76 412.47 515.60 687.47 859.33
77 455.33 569.18 758.91 948.63
78 500.23 625.30 833.73 1,042.17
79 542.85 678.57 904.76 1,130.95
80 592.52 740.65 987.53 1,234.42
81 640.40 800.50 1,067.33 1,334.17
82 696.38 870.47 1,160.63 1,450.78
83 757.49 946.87 1,262.49 1,578.12
84 823.47 1,029.35 1,372.47 1,715.58
85 884.14 1,105.17 1,473.56 1,841.95
86 951.89 1,189.87 1,586.49 1,983.12
87 1,018.14 1,272.67 1,696.89 2,121.12
88 1,071.57 1,339.45 1,785.93 2,232.42
89 1,122.90 1,403.62 1,871.49 2,339.37
90 1,183.01 1,478.77 1,971.69 2,464.62
SPV1AA - 18 -
ADDENDUM NO. 7
TABLE OF PREMIUM RATES
POLICYHOLDER: City of Columbia Heights LIFETIME
POLICY NUMBER: 10212TQ MAXIMUM: 730x (2 -Year)
Optional Benefits: Lifetime Compound Automatic Benefit Increase
AGE ON EFFECTIVE MONTHLY PREMIUM
DATE OF COVERAGE FOR DAILY BENEFIT SELECTED
Ape $120 $150 $200 $250
<25 20.38 25.47 33.96 42.45
25 22.62 28.27 37.69 47.12
26 22.79 28.49 37.99 47.48
27 23.13 28.91 38.55 48.19
28 23.67 29.58 39.44 49.30
29 24.10 30.12 40.16 50.20
30 24.56 30.71 40.94 51.18
31 25.12 31.41 41.87 52.34
32 25.95 32.44 43.25 54.07
33 26.99 33.74 44.98 56.23
34 28.27 35.34 47.12 58.90
35 29.70 37.12 49.49 61.87
36 .31.20 39.00 52.00 65.00
37 32.75 40.94 54.59 68.23
38 34.16 42.71 56.94 71.17
39 35.60 44.50 59.33 74.16
40 36.94 46.17 61.57 76.96
41 38.48 48.10 64.13 80.17
42 40.08 50.10 66.80 83.49
43 41.78 52.23 69.63 87.04
44 43.47 54.34 72.45 90.57
45 45.28 56.60 75.47 94.33
46 47.26 59.08 78.77 98.46
47 49.57 61.97 82.62 103.28
48 51.94 64.93 86.57 108.21
49 54.30 67.87 90.49 113.12
50 57.00 71.25 95.00 118.75
51 60.07 75.09 100.12 125.15
52 63.90 79.87 106.49 133.12
53 68.33 85.41 113.88 142.35
54 73.05 91.31 121.75 152.19
55 78.20 97.74 130.33 162.91
56 83.70 104.63 139.50 174.38
57 89.59 111.99 149.32 186.65
58 96.19 120.24 160.32 200.40
59 103.36 129.19 172.26 215.32
60 110.77 138.47 184.62 230.78
61 118.00 147.51 196.67 245.84
62 124.65 155.82 207.76 259.69
63 129.77 162.22 216.29 270.36
64 133.76 167.20 222.94 278.67
65 137.43 171.78 229.04 286.30
66 142.41 178.01 237.34 296.68
67 149.59 186.99 249.32 311.65
68 158.49 198.11 264.15 330.19
69 168.26 210.33 280.44 350.55
70 179.67 224.59 299.45 374.32
71 193.55 241.94 322.59 403.23
72 210.79 263.49 351.32 439.15
73 231.09 288.86 385.15 481.43
SPV1AA -19-
ADDENDUM NO. 7
TABLE OF PREMIUM RATES
POLICYHOLDER: City of Columbia Heights LIFETIME
POLICY NUMBER: 10212TQ MAXIMUM: 730x (2 -Year)
Optional Benefits: Lifetime Compound Automatic Benefit Increase
AGE ON EFFECTIVE MONTHLY PREMIUM
DATE OF COVERAGE FOR DAILY BENEFIT SELECTED
Age $120 $150 $200 $250
74 254.00 317.49 423.33 529.16
75 278.30 347.88 463.84 579.80
76 304.58 380.73 507.64 634.55
77 331.89 414.86 553.15 691.43
78 359.89 449.87 599.82 749.78
79 388.81 486.01 648.01 810.02
80 418.88 523.60 698.13 872.66
81 450.66 563.33 751.10 938.88
82 483.57 604.46 805.94 1,007.43
83 518.95 648.69 864.92 1,081.16
84 556.47 695.58 927.44 1,159.30
85 594.42 743.03 990.70 1,238.38
86 631.16 788.95 1,051.94 1,314.92
87 665.77 832.21 1,109.62 1,387.02
88 697.06 871.33 1,161.77 1,452.22
89 726.67 908.33 1,211.11 1,513.89
90 754.86 943.57 1,258.10 1,572.62
SPV1AA _20_
ADDENDUM NO. 8
TABLE OF PREMIUM RATES
POLICYHOLDER: City of Columbia Heights LIFETIME
POLICY NUMBER: 10212TQ MAXIMUM: 1250x (3.4 -Year)
Optional Benefits: Lifetime Compound Automatic Benefit Increase
AGE ON EFFECTIVE MONTHLY PREMIUM
DATE OF COVERAGE FOR DAILY BENEFIT SELECTED
Age $120 $150 $200 $250
<25 24.20 30.25 40.33 50,42
25 27.58 34.48 45.97 57.47
26 28.02 35.03 46.71 58.38
27 28.75 35.94 47.92 59.90
28 29.64 37.05 49.40 61.75
29 30.47 38.09 50.79 63.48
30 31.29 39.11 52.15 65.18
31 32.37 40.46 53.95 67.43
32 33.63 42.04 56.05 70.07
33 35.27 44.09 58.79 73.48
34 37.21 46.51 62.01 77.52
35 39.38 49.23 65.64 82.05
36 41.68 52.10 69.47 86.83
37 44.01 55.01 73.35 91.68
38 46.25 57.81 77.08 96.35
39 48.44 60.55 80.73 100.92
40 50.63 63.29 84.39 105.48
41 53.01 66.26 88.35 110.43
42 55.47 69.34 92.45 115.57
43 58.05 72.56 96.75 120.93
44 60.65 75.81 101.08 126.35
45 63.43 79.29 105.72 132.15
46 66.48 83.10 110.80 138.50
47 69.97 87.46 116.61 145.77
48 73.53 91.91 122.55 153.18
49 77.16 96.45 128.60 160.75
50 81.16 101.45 13527 169.08
51 85.89 107.36 143.15 178.93
52 91.51 114.39 152.52 190.65
53 97.96 122.45 163.27 204.08
54 104.81 131.01 174.68 218.35
55 112.22 140.28 187.04 233.80
56 120.23 150.29 200.39 250.48
57 128.85 161.06 214.75 268.43
58 138.77 173.46 231.28 289.10
59 149.46 186.83 249.11 311.38
60 160.63 200.79 267.72 334.65
61 171.53 214.41 285.88 357.35
62 181.42 226.78 302.37 377.97
63 188.97 236.21 314.95 393.68
64 194.77 243.46 324.61 405.77
65 200.15 250.19 333.59 416.98
66 207.59 259.49 345.99 432.48
67 218.42 273.03 364.04 455.05
68 231.92 289.90 386.53 483.17
69 246.87 308.59 411.45 514.32
70 264.30 330.38 440.51 550.63
71 285.38 356.73 475.64 594.55
72 311.30 389.13 518.84 648.55
73 341.78 427.23 569.64 712.05
SPV1AA -21-
ADDENDUM NO. 8
TABLE OF PREMIUM RATES
POLICYHOLDER: City of Columbia Heights LIFETIME
POLICY NUMBER: 10212TQ MAXIMUM: 1250x (3.4 -Year)
Optional Benefits: Lifetime Compound Automatic Benefit Increase
AGE ON EFFECTIVE MONTHLY PREMIUM
DATE OF COVERAGE FOR DAILY BENEFIT SELECTED
Age $120 $150 $200 $250
74 376.07 470.09 626.79 783.48
75 412.42 515.53 687.37 859.22
76 451.69 564.61 752.81 941.02
77 492.42 615.53 820.71 1,025.88
78 534.16 667.70 890.27 1,112.83
79 577.16 721.45 961.93 1,202.42
80 621.87 777.34 1,036.45 1,295.57
81 669.08 836.35 1,115.13 1,393.92
82 717.97 897.46 1,196.61 1,495.77
83 770.57 963.21 1,284.28 1,605.35
84 826.33 1,032.91 1,377.21 1,721.52
85 882.65 1,103.31 1,471.08 1,838.85
86 937.15 1,171.44 1,561.92 1,952.40
87 988.33 1,235.41 1,647.21 2,059.02
88 1,034.45 1,293.06 1,724.08 2,155.10
89 1,077.94 1,347.43 1,796.57 2,245.72
90 1,119.18 1,398.98 1,865.31 2,331.63
SPVIAA _22_
ADDENDUM NO. 9
TABLE OF PREMIUM RATES
POLICYHOLDER: City of Columbia Heights LIFETIME
POLICY NUMBER: 10212TQ MAXIMUM: 1825x (5 -Year)
Optional Benefits: Lifetime Compound Automatic Benefit Increase
AGE ON EFFECTIVE MONTHLY PREMIUM
DATE OF COVERAGE FOR DAILY BENEFIT SELECTED
Age $120 $150 $200 $250
<25 27.85 34.81 46.41 58.02
25 32.19 40.24 53.65 67.07
26 32.83 41.04 54.72 68.40
27 33.84 42.30 56.40 70.50
28 35.09 43.86 58.48 73.10
29 36.21 45.26 60.35 75.43
30 37.43 46.79 62.39 77.98
31 38.82 48.53 64.71 80.88
32 40.58 50.73 67.64 84.55
33 42.75 53.44 71.25 89.07
34 45.25 56.56 75.41 94.27
35 48.03 60.04 80.05 100.07
36 51.01 63.76 85.01 106.27
37 54.10 67.63 90.17 112.72
38 56.97 71.21 94.95 118.68
39 59.86 74.83 99.77 124.72
40 62.70 78.38 104.51 130.63
41 65.77 82.21 109.61 137.02
42 68.95 86.19 114.92 143.65
43 72.22 90.28 120.37 150.47
44 75.51 94.39 125.85 157.32
45 79.01 98.76 131.68 164.60
46 82.90 103.63 138.17 172.72
47 87.31 109.14 145.52 181.90
48 91.81 114.76 153.01 191.27
49 96.40 120.50 160.67 200.83
50 101.50 126.88 169.17 211.47
51 107.37 134.21 178.95 223.68
52 114.40 143.00 190.67 238.33
53 122.33 152.91 203.88 254.85
54 130.80 163.50 218.00 272.50
55 139.96 174.95 233.27 291.58
56 149.84 187.30 249.73 312.17
57 160.62 200.78 267.71 334.63
58 172.96 216.20 288.27 360.33
59 186.38 232.98 310.64 388.30
60 200.36 250.45 333.93 417.42
61 213.98 267.48 356.64 445.80
62 226.29 282.86 377.15 471.43
63 235.60 294.50 392.67 490.83
64 242.58 303.23 404.31 505.38
65 249.13 311.41 415.21 519.02
66 258.26 322.83 430.44 538.05
67 271.88 339.85 453.13 566.42
68 289.04 361.30 481.73 602.17
69 308.12 385.15 513.53 641.92
70 330.34 412.93 550.57 688.22
71 357.10 446.38 595.17 743.97
72 389.84 487.30 649.73 812.17
73 428.18 535.23 713.64 892.05
SPV1AA -23-
ADDENDUM NO. 9
TABLE OF PREMIUM RATES
POLICYHOLDER: City of Columbia Heights LIFETIME
POLICY NUMBER: 10212TQ MAXIMUM: 1825x (5 -Year)
Optional Benefits: Lifetime Compound Automatic Benefit Increase
AGE ON EFFECTIVE MONTHLY PREMIUM
DATE OF COVERAGE FOR DAILY BENEFIT SELECTED
Age $120 $150 $200 $250
74 471.29 589.11 785.48 981.85
75 516.96 646.20 861.60 1,077.00
76 566.28 707.85 943.80 1,179.75
77 617.40 771.75 1,029.00 1,286.25
78 669.81 837.26 1,116.35 1,395.43
79 723.81 904.76 1,206.35 1,507.93
80 779.90 974.88 1,299.84 1,624.80
81 839.16 1,048.95 1,398.60 1,748.25
82 900.50 1,125.63 1,500.84 1,876.05
83 966.47 1,208.09 1,610.79 2,013.48
84 1,036.43 1,295.54 1,727.39 2,159.23
85 1,107.11 1,383.89 1,845.19 2,306.48
86 1,175.39 1,469.24 1,958.99 2,448.73
87 1,239.47 1,549.34 2,065.79 2,582.23
88 1,297.14 1,621.43 2,161.91 2,702.38
89 1,351.44 1,689.30 2,252.40 2,815.50
90 1,402.87 1,753.59 2,338.12 2,922.65
SPVIAA _24_
ADDENDUM NO. 10
TABLE OF PREMIUM RATES
P POLICYHOLDER: City of Columbia Heights LIFETIME
POLICY NUMBER: 10212TQ MAXIMUM: 730x (2 -Year)
Optional Benefits: Lifetime Compound Automatic Benefit Increase
Benefit Account
AGE ON EFFECTIVE MONTHLY PREMIUM
DATE OF COVERAGE FOR DAILY BENEFIT SELECTED
Age $120 $150 $200 $250
<25 22.63 28.29 37.71 47.14
25 25.10 31.38 41.83 52.29
26 25.30 31.62 42.17 52.71
27 25.67 32.09 42.79 53.48
28 26.27 32.83 43.78 54.72
29 26.76 33.45 44.60 55.74
30 27.52 34.39 45.86 57.32
31 28.13 35.17 46.89 58.61
32 29.07 36.33 48.44 60.56
33 30.22 37.78 50.37 62.96
34 31.67 39.58 52.78 65.97
35 33.25 41.57 55.42 69.28
36 34.93 43.67 58.22 72.78
37 36.68 45.85 61.14 76.42
38 38.27 47.84 63.78 79.73
39 39.87 49.83 66.45 83.06
40 41.75 52.18 69.58 86.97
41 43.48 54.35 72.47 90.59
42 45.29 56.61 75.49 94.36
43 47.22 59.02 78.69 98.37
44 49.12 61.40 81.86 102.33
45 51.61 64.52 86.02 107.53
46 53.88 67.35 89.79 112.24
47 56.51 70.64 94.19 117.73
48 59.22 74.02 98.70 123.37
49 61.90 77.38 103.17 128.96
50 65.55 81.94 109.25 136.57
51 69.07 86.34 115.12 143.90
52 73.48 91.85 122.47 153.09
53 78.57 98.21 130.95 163.68
54 84.00 105.00 140.01 175.01
55 90.71 113.39 151.18 188.98
56 97.09 121.36 161.82 202.27
57 103.93 129.91 173.21 216.51
58 111.59 139.49 185.98 232.48
59 119.89 149.87 199.82 249.78
60 129.61 162.01 216.02 270.02
61 138.07 172.58 230.11 287.64
62 145.85 182.31 243.08 303.85
63 151.83 189.79 253.05 316.31
64 156.50 195.62 260.83 326.03
65 162.15 202.69 270.25 337.82
66 168.04 210.05 280.07 350.09
67 176.51 220.64 294.19 367.73
68 187.01 233.76 311.68 389.60
69 198.56 248.20 330.93 413.66
70 212.02 265.02 353.36 441.70
71 228.39 285.49 380.66 475.82
72 248.73 310.92 414.56 518.20
SPV1AA -25-
ADDENDUM NO. 10
TABLE OF PREMIUM RATES
P POLICYHOLDER: City of Columbia Heights LIFETIME
POLICY NUMBER: 10212TQ MAXIMUM: 730x (2 -Year)
Optional Benefits: Lifetime Compound Automatic Benefit Increase
Benefit Account
AGE ON EFFECTIVE MONTHLY PREMIUM
DATE OF COVERAGE FOR DAILY BENEFIT SELECTED
?ge $120 $150 $200 $250
73 272.69 340.87 454.49 568.11
74 299.72 374.65 499.53 624.41
75 328.39 410.49 547.31 684.14
76 359.41 449.27 599.02 748.78
77 391.63 489.54 652/2 815.90
78 424.67 530.84 707.79 884.74
79 454.91 568.63 758.18 947.72
80 490.10 612.62 816.83 1,021.04
81 522.77 653.46 871.28 1,089.10
82 560.93 701.17 934.89 1,168.61
83 601.99 752.49 1,003.32 1,254.15
84 645.50 806.87 1,075.83 1,344.79
85 683.59 854.49 1,139.32 1,424.15
86 725.84 907.30 1,209.73 1,512.16
87 765.64 957.05 1,276.06 1,595.08
88 794.66 993.32 1,324.43 1,655.53
89 821.13 1,026.42 1,368.56 1,710.70
90 852.99 1,066.24 1,421.65 1,777.06
SPV1AA -26-
ADDENDUM NO. 11
TABLE OF PREMIUM RATES
POLICYHOLDER: City of Columbia Heights LIFETIME
POLICY NUMBER: 10212TQ MAXIMUM: 1250x (3.4 -Year)
Optional Benefits: Lifetime Compound Automatic Benefit Increase
Benefit Account
AGE ON EFFECTIVE MONTHLY PREMIUM
DATE OF COVERAGE FOR DAILY BENEFIT SELECTED
Age $120 $150 $200 $250
<25 26.87 33.59 44.79 55.98
25 30.62 38.28 51.04 63.80
26 31.09 38.86 51.81 64.77
27 31.91 39.89 53.19 66.48
28 32.90 41.13 54.84 68.55
29 33.81 42.26 56.35 70.43
30 35.02 43.78 58.37 72.97
31 36.26 45.33 60.44 75.55
32 37.66 47.08 62.77 78.47
33 39.51 49.39 65.85 82.32
34 41.68 52.10 69.47 86.83
35 44.10 55.13 73.51 91.88
36 46.67 58.34 77.79 97.23
37 49.29 61.61 82.15 102.68
38 51.80 64.75 86.33 107.92
39 54.26 67.83 90.44 113.05
40 57.21 71.51 95.35 119.18
41 59.90 74.88 99.84 124.80
42 62.69 78.36 104.48 130.60
43 65.60 82.00 109.33 136.67
44 68.54 85.68 114.24 142.80
45 72.32 90.40 120.53 150.67
46 75.79 94.74 126.32 157.90
47 79.76 99.70 132.93 166.17
48 83.83 104.79 139.72 174.65
49 87.96 109.95 146.60 183.25
50 93.32 116.65 155.53 194.42
51 98.79 123.49 164.65 205.82
52 105.24 131.55 175.40 219.25
53 112.65 140.81 187.75 234.68
54 120.54 150.68 200.91 251.13
55 130.18 162.73 216.97 271.22
56 139.45 174.31 232.41 290.52
57 149.47 186.84 249.12 311.40
58 160.97 201.21 268.28 335.35
59 173.37 216.71 288.95 361.18
60 187.93 234.91 313.21 391.52
61 200.69 250.86 334.48 418.10
62 212.26 265.33 353.77 442.22
63 221.10 276.38 368.51 460.63
64 227.88 284.85 379.80 474.75
65 236.17 295.21 393.61 492.02
66 244.95 306.19 408.25 510.32
67 257.74 322.18 429.57 536.97
68 273.66 342.08 456.11 570.13
69 291.30 364.13 485.51 606.88
70 311.86 389.83 519.77 649.72
71 336.75 420.94 561.25 701.57
72 367.33 459.16 612.21 765.27
SPV1AA _27_
ADDENDUM NO. 11
TABLE OF PREMIUM RATES
POLICYHOLDER: City of Columbia Heights LIFETIME
POLICY NUMBER: 10212TQ MAXIMUM: 1250x (3.4 -Year)
Optional Benefits: Lifetime Compound Automatic Benefit Increase
Benefit Account
AGE ON EFFECTIVE MONTHLY PREMIUM
DATE OF COVERAGE FOR DAILY BENEFIT SELECTED
Age $120 $150 $200 $250
73 40329 504.11 672.15 840.18
74 443.76 554.70 739.60 924.50
75 486.65 608.31 811.08 1,013.85
76 532.99 666.24 888.32 1,110.40
77 581.05 726.31 968.41 1,210.52
78 630.30 787.88 1,050.51 1,313.13
79 675.28 844.10 1,125.47 1,406.83
80 727.59 909.49 1,212.65 1,515.82
81 776.13 970.16 1,293.55 1,616.93
82 832.85 1,041.06 1,388.08 1,735.10
83 893.86 1,117.33 1,489.77 1,862.22
84 958.53 1,198.16 1,597.55 1,996.93
85 1,015.05 1,268.81 1,691.75 2,114.68
86 1,077.71 1,347.14 1,796.19 2,245.23
87 1,136.57 1,420.71 1,894.28 2,367.85
88 1,179.26 1,474.08 1,965.44 2,456.80
89 1,218.07 1,522.59 2,030.12 2,537.65
90 1,264.67 1,580.84 2,107.79 2,634.73
SPVIAA -28-
ADDENDUM NO. 12
TABLE OF PREMIUM RATES
POLICYHOLDER: City of Columbia Heights LIFETIME
POLICY NUMBER: 10212TQ MAXIMUM: 1825x (5 -Year)
Optional Benefits: Lifetime Compound Automatic Benefit Increase
Benefit Account
AGE ON EFFECTIVE MONTHLY PREMIUM
DATE OF COVERAGE FOR DAILY BENEFIT SELECTED
Aye $120 $150 $200 $250
<25 30.92 38.65 51.53 64.42
25 35.74 44.68 59.57 74.47
26 36.45 45.56 60.75 75.93
27 37.56 46.95 62.60 78.25
28 38.94 48.68 64.91 81.13
29 40.21 50.26 67.01 83.77
30 41.94 52.43 69.91 87.38
31 43.48 54.35 72.47 90.58
32 45.45 56.81 75.75 94.68
33 47.87 59.84 79.79 99.73
34 50.70 63.38 84.51 105.63
35 53.79 67.24 89.65 112.07
36 57.13 71.41 95.21 119.02
37 60.60 75.75 101.00 126.25
38 63.81 79.76 106.35 132.93
39 67.05 83.81 111.75 139.68
40 70.86 88.58 118.11 147.63
41 74.33 92.91 123.88 154.85
42 77.90 97.38 129.84 162.30
43 81.62 102.03 136.04 170.05
44 85.33 106.66 142.21 177.77
45 90.08 112.60 150.13 187.67
46 94.50 118.13 157.51 196.88
47 99.53 124.41 165.88 207.35
48 104.66 130.83 174.44 218.05
49 109.90 137.38 183.17 228.97
50 116.73 145.91 194.55 243.18
51 123.49 154.36 205.81 257.27
52 131.57 164.46 219.28 274.10
53 140.68 175.85 234.47 293.08
54 150.42 188.03 250.71 313.38
55 162.36 202.95 270.60 338.25
56 173.80 217.25 289.67 362.08
57 186.31 232.89 310.52 388.15
58 200.64 250.80 334.40 418.00
59 216.19 270.24 360.32 450.40
60 234.42 293.03 390.71 488.38
61 250.35 312.94 417.25 521.57
62 264.76 330.95 441.27 551.58
63 275.66 344.58 459.44 574.30
64 283.81 354.76 473.01 591.27
65 293.98 367.48 489.97 612.47
66 304.75 380.94 507.92 634.90
67 320.81 401.01 534.68 668.35
68 341.06 426.33 568.44 710.55
69 363.60 454.50 606.00 757.50
70 389.80 487.25 649.67 812.08
71 421.38 526.73 702.31 877.88
72 460.00 575.00 766.67 958.33
SPV1AA -29-
ADDENDUM NO. 12
TABLE OF PREMIUM RATES
POLICYHOLDER: City of Columbia Heights LIFETIME
POLICY NUMBER: 10212TQ MAXIMUM: 1825x (5 -Year)
Optional Benefits: Lifetime Compound Automatic Benefit Increase
Benefit Account
AGE ON EFFECTIVE MONTHLY PREMIUM
DATE OF COVERAGE FOR DAILY BENEFIT SELECTED
Age $120 $150 $200 $250
73 505.25 631.56 842.08 1,052.60
74 556.12 695.15 926.87 1,158.58
75 610.02 762.53 1,016.71 1,270.88
76 668.20 835.25 1,113.67 1,392.08
77 728.52 910.65 1,214.20 1,517.75
78 790.37 987.96 1,317.28 1,646.60
79 846.85 1,058.56 1,411.41 1,764.27
80 912.48 1,140.60 1,520.80 1,901.00
81 973.41 1,216.76 1,622.35 2,027.93
82 1,044.58 1,305.73 1,740.97 2,176.22
83 1,121.09 1,401.36 1,868.48 2,335.60
84 1,202.26 1,502.83 2,003.77 2,504.72
85 1,273.17 1,591.46 2,121.95 2,652.43
86 1,351.68 1,689.60 2,252.80 2,816.00
87 1,425.38 1,781.73 2,375.64 2,969.55
88 1,478.75 1,848.44 2,464.59 3,080.73
89 1,527.13 1,908.91 2,545.21 3,181.52
90 1,565.23 1,981.54 2,642.05 3,302.57
SPV1AA -30-
Continental Casualty Company
333 S. Wabash Ave. A Stock Company
Chicago, Illinois 60604
A
POLICY AMENDMENT
Holder: City of Columbia Heights
Policy Number: 10212TQ
Effective Date: July 1, 2011
IT IS HEREBY AGREED that, effective on and after the Effective Date indicated, the Policy to which this Amendment is
attached is amended as follows
1. Item 6. of the Provision entitled "Exclusions" which reads "Long Term Care received outside the United States
and its possessions" is hereby deleted.
2. The Rider entitled "WORLD WIDE COVERAGE RIDER" containing the identifying form number of GLTC- 3 -R12-
XX-01 is added to said Policy.
IN ALL OTHER RESPECTS THE MASTER APPLICATION AND POLICY REMAINS THE SAME.
This rider takes effect on July 1, 2011. It expires concurrently with the policy to which it is attached and is subject to all
the definitions, conditions and provisions of the policy not inconsistent herewith.
Attached to and made a part of Policy Number 10212TQ issued to City of Columbia Heights by the Continental
Casualty Company, General Office, Chicago, Illinois.
City of Columbia HQights
BY: G/ /� Fe-AS
(signature) (name printed)
t `f ! ! IG C t° f
Title (p ase print) `J Date
SRR -15288
SPV1AA -31-
Continental Casualty Company
CNA
333 S. Wabash Ave. A Stock Company
Chicago, Illinois 60604
WORLD WIDE COVERAGE RIDER
WORLD WIDE COVERAGE
What is World Wide Coverage?
If You become eligible to receive benefits under this Policy while You are traveling or living outside the United States,
benefits will be payable according to the terms of the Policy except that reimbursement will be based on a cash payment
instead of actual charges.
What is payable under this benefit?
We will pay a cash benefit as shown in Your Schedule of Benefits under "World Wide Coverage" for Long Term Care
services received outside the United States regardless of the provider, but subject to the conditions below. This payment
is in lieu of all benefit payment descriptions otherwise shown in Your Schedule.
What are the conditions of this benefit?
(a) Expenses must have been incurred outside the United States;
(b) As a condition for receiving all benefits under this Policy, You must have been certified by a Licensed Health Care
Practitioner as being Chronically Ill. For purposes of benefits paid under this Rider, We will recognize a foreign
country's determination of who may be a Licensed Health Care Practitioner, and certification or licensing of this
individual must comply with regulations of the jurisdiction in which care is received;
(c) All providers of care must meet licensing or certification requirements, if any, of the jurisdiction in which care is
received;
(d) We may do periodic reassessments of Your condition or require a physical exam by a physician as often as once per
month;
(e) Benefits will be payable in United States Currency.
This rider takes effect at 12:01 a. m. standard time at the address of the Holder on the Effective Date indicated in the
Schedule of Benefits of the Certificate to which it is attached; it expires concurrently with the Policy and is subject to all
the provisions, limitations, exclusions, and conditions of the Policy to the extent they are not inconsistent herewith.
Signed for the Continental Casualty Company at its Home Office, 333 S. Wabash Ave., Chicago, Illinois 60604.
Continental Casualty Company
tre.. ,.'..4 't re.u.
Chairman of the Board
GLTC- 3- R12 -XX -01
MUNICIPAL - POOL F"� .fi
June 24, 2011 a t 7 ,. )a
Ms. Linda Magee
City of Columbia Heights
590 40th Avenue NE
Columbia Heights, MN 55421
Re: CNA Group Long Term Care Plan Enhancements
Dear Linda:
CNA and Ochs, Inc. are pleased to announce several enhancements to the Municipal Pool Group Long Term
Care program. Plan enhancements will take place effective July 1, 2011 and will apply to all existing client
members of the Municipal Pool plan with no increases to the current premium rates.
Following is a brief description of the enhancements:
New Daily Maximum Benefits — The Municipal Pool plan will now have Daily Nursing Home benefit
options of $120, $150, $200, and $250. Current statistics show that the national average cost of care in
a skilled nursing home facility is $192 per day.
New Lifetime Maximum Option — The plan will now include a 2 -year (730x Factor) Lifetime Maximum
in addition to the current 3.4 and 5 -year options.
Waiting Period — The waiting period prior to receiving reimbursement for Long Term Care services will
need to be satisfied only once per lifetime.
New Worldwide Coverage Benefit — Now, covered care received while living or traveling outside of
the United States is eligible for reimbursement. Reimbursement will be based on a fixed daily cash
payment equal to 75% of the insured's maximum daily benefit.
Plan enhancements do require the execution of a new signed Master Application and Master Policy
amendment (Rider). Documents reflecting the July 1, 2011 changes to your group policy are enclosed.
Please sign the original Master Application and Master Policy amendment where indicated, and return
them directly to Ochs, Inc. in the postage paid return envelope as soon as administratively possible. A
copy for your records is also provided.
CNA will notify your group's current insureds by a personalized mailing to their homes early in July. This
mailing will include a Rider, identifying the July 1st enhancements, and instructions to attach the Rider to their
own Certificate of Coverage.
CNA will also be sending your office a small supply of new, revised Enrollment Kits. New enrollment kits have
RED printing on the outside envelope while the old kits have BLACK printing. P /ease recycle any old,
Municipal Pool Enrollment Kits.
Once again, we are excited to announce these enhancements and believe that they will be well received by
participating members of the Municipal Pool Group Long Term Care program. If you have any questions
please contact Ochs, Inc. at any time at 1 -800- 392 -7295.
Sincerely,
CNA Group Long Term Care
400 ROBERT STREET NORTH, SUITE 1880, SAINT PAUL, MINNESOTA 55101
651 - 665 -3789 800- 392 -7295 FAX: 651.665 -3791