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Home My WebLink AboutContract No. 2015-2631SUN LIFE ASSURANCE COMPANY OF CANADA Policyholder: City of Columbia Heights Policy Number: 238404 -001 Policy Effective Date: October 1, 2014 Policy Anniversary: October 1, 2015 This Policy is delivered in Minnesota and is subject to the laws of that jurisdiction. Premiums are due and payable monthly on the first day of each month. Policy anniversaries will be annual beginning on October 1, 2015. Sun Life Assurance Company of Canada (Sun Life) agrees to pay the benefits in accordance with all provisions provided by this Policy for Employee Basic Life, Employee Basic Accidental Death and Dismemberment, Dependent Basic Life, Employee Optional Life, Employee Optional Accidental Death and Dismemberment, Dependent Optional Life Insurance and Dependent Spouse Optional Accidental Death and Dismemberment. This Policy is issued in consideration of the Application of the Policyholder, a copy of which is attached, and continued payment of premiums by the Policyholder. The following pages including any Riders, Endorsements or Amendments are a part of this Policy. For the purpose of effective dates and termination dates under this Policy, all days begin at 12:00 midnight and end at 11:59:59pm. Signed at Sun Life's U.S. Headquarters, One Sun Life Executive Park, Wellesley Hills, MA 02481. Dean A. Connor President and Chief Executive Officer THIS IS A LEGAL CONTRACT — READ YOUR POLICY CAREFULLY Group Term Insurance Policy Non - Participating 93P -LH.1 Sun ,1 Life- Financial 1 Table of Contents Page Numbers Section I Schedule of Benefits .......................................................................... ............................... 3 SectionII Definitions ......................................................................................... ............................... 9 Section III Eligibility and Effective Dates ........................................................... .............................14 Section IV Benefit Provisions .............................................................................. .............................17 Employee Life Insurance ................................................................... .............................17 Dependent Life Insurance .................................................................. .............................23 Employee and Dependent Spouse Optional Accidental Death and Dismemberment Insurance 26 Section V Termination Provisions ..................................................................... .............................31 Section VI General Policy Provisions .................................................................. .............................36 Section VII Claim Provisions ................................................................................ .............................38 SectionVIII Premiums... ......... .................. ..................................................................................... 41 93P- LH -T,SB Table of Contents October 1, 2014 Section I Schedule of Benefits ELIGIBLE CLASSES Employee Basic Life and Employee Basic Accidental Death and Dismemberment Insurance All Full -Time United States Employees working in the United States scheduled to work at least 40 hours per week. Dependent Basic Life Insurance All Full -Time United States Employees insured for Dependent Basic Life Insurance prior to September 1, 2000 working in United States scheduled to work at least 40 hours per week. Employee Optional Life Insurance All Full -Time United States Employees working in the United States enrolled in Employee Basic Life Insurance scheduled to work at least 40 hours per week. Employee Optional Accidental Death and Dismemberment and Dependent Optional Life Insurance All Full -Time United States Employees working in the United States enrolled in Employee Optional Life Insurance scheduled to work at least 40 hours per week. Dependent Spouse Optional Accidental Death and Dismemberment Insurance All Full -Time United States Employees working in the United States enrolled in Employee Optional Life and Dependent Spouse Optional Life Insurance scheduled to work at least 40 hours per week. WAITING PERIOD None 93P- LH -SCHED Schedule of Benefits Page No. 3 October 1, 2014 Section I Schedule of Benefits EMPLOYEE LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE BASIC INSURANCE CLASSIFICATION All Eligible Union Employees All Eligible Non -Union Employees CLASS LIFE AD &D $10,000 $10,000 $5,000 $5,000 93P- LH -SCHED Schedule of Benefits Page No. 4 October 1, 2014 Section I Schedule of Benefits OPTIONAL INSURANCE CLASSIFICATION I All Eligible Employees CLASS LIFE AD &D An Employee may elect one of the Following Options Option 1 An Employee may elect an amount of Optional Life Insurance in $10,000 increments. The minimum amount an Employee may elect is $20,000. Option 2 An Employee may elect an amount of Optional Life Insurance in $10,000 increments. The minimum amount an Employee may elect is $20,000. The Optional Maximum Benefit is the lesser of: - $500,000; or - 5 times the Employee's Basic Annual Earnings. (Applicable to Employees insured on September 30, 2014) An amount equal to the Employee's amount of Optional Life Insurance in force None The Guaranteed Issue Amount for Optional Life Insurance is the amount of Optional Life Insurance the Employee had in force on September 30, 2014. (Applicable to Employees hired on or after October 1, 2014) The Guaranteed Issue Amount for Optional Life Insurance is $100,000. An Employee's amount of Basic and Optional Life and Accidental Death and Dismemberment Insurance shown in the Schedule will reduce to 65°% when he attains age 65, to 50% when he attains age 70 and to 30% when he attains age 75. An Employee's Basic and Optional Life and Accidental Death and Dismemberment Insurance terminates at the Employee's retirement. Evidence of Insurability, satisfactory to Sun Life, will be required for any of the following reasons: an Employee who elects Basic Life Insurance only and subsequently elects Optional Life Insurance; or an Employee who elects an increase in his amount of Optional Life Insurance; or an Employee whose amount of Life Insurance is in excess of the Guaranteed Issue Amount. 93P- LH -SCHED Schedule of Benefits Page No, 5 October I, 2014 Section I Schedule of Benefits DEPENDENT LIFE AND DEPENDENT SPOUSE OPTIONAL ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE BASIC LIFE INSURANCE CLASSIFICATION 1 All Eligible Employees prior to September 1, 2000 Class Spouse Child under age 19 ** $2,000 $2,000* • the amount of Dependent Basic Life Insurance for a child under 14 days is None. • the amount of Dependent Basic Life Insurance for a child age 14 days but under 6 months is $500. ** to age 25 if the Employee's child is an enrolled full -time student and depends on the Employee for 50% or more of his support. (The amount of Dependent Basic Life Insurance cannot exceed 50% of the Employee's amount of Basic Life Insurance.) OPTIONAL LIFE INSURANCE CLASSIFICATION I All Eligible Employees CLASS Spouse 1 An Employee may elect an amount of Dependent Spouse Optional Life Insurance in $10,000 increments The Dependent Spouse Optional Maximum Benefit is $250,000. Child under age 19** An Employee may elect one of the following Options: Option I $5,000* Option II $10,000* An Employee may elect an amount of Dependent Spouse Optional Accidental Death and Dismemberment Insurance that equals the Dependent Spouse's amount of Optional Life Insurance in force. • the amount of Dependent Optional Life Insurance for a child under 14 days is None. • the amount of Dependent Optional Life Insurance for a child age 14 days but under 6 months is $1,000. *# to age 25 if the Employee's child is an enrolled full -time student and depends on the Employee for 50% or more of his support. (The amount of Dependent Optional Life Insurance cannot exceed 100% of the Employee's amount of Optional Life Insurance) The Guaranteed Issue Amount for Employees insured for Dependent Spouse Optional Life Insurance on September 30, 2014 is the amount of Dependent Spouse Optional Life Insurance the Employee had in force on September 30, 2014. 93P- LH- SCHED.2 Schedule of Benefits Page No. 6 October 1, 2014 Section I Schedule of Benefits The Guaranteed Issue Amount for Employees hired on or after October 1, 2014 for Dependent Spouse Optional Life Insurance is $20,000. A Dependent Spouse's amount of Optional Life Insurance terminates when the Dependent Spouse attains age 70. An Dependent Spouse's amount of Basic Life Insurance terminates when the Dependent Spouse attains age 70. Evidence of Insurability, satisfactory to Sun Life, will be required for an Employee's Dependent for any of the following reasons: an Employee who elects no Dependent Life coverage and subsequently elects Dependent Basic Life and/or Dependent Optional Life Insurance; or an Employee who elects Employee Basic Life Insurance only and subsequently elects Employee Optional Life and Dependent Optional Life Insurance; or an Employee who elects an increase in his amount of Dependent Optional Life Insurance; or an Employee whose amount of Dependent Spouse Optional Life Insurance is in excess of the Guaranteed Issue Amount. 93P- LH- SCHED.2 Schedule of Benefits Page No. 7 October 1, 2014 Section I Schedule of Benefits CONTRIBUTIONS Employees will not contribute to the cost of their Employee Basic Life and Employee Basic Accidental Death and Dismemberment Insurance. Employees will contribute to the cost of their Dependent Basic Life, Employee Optional Life, Employee and Dependent Spouse Optional Accidental Death and Dismemberment and Dependent Optional Life Insurance. INITIAL MONTHLY PREMIUM RATES Employee Basic Life Insurance Refer to Attachment A Employee Optional Life Insurance Refer to Attachment A Employee Basic Accidental Death and Dismemberment Insurance Refer to Attachment A Employee Optional Accidental Death and Dismemberment Insurance Refer to Attachment A Dependent Basic Life Insurance Refer to Attachment A Dependent Optional Life Insurance Refer to Attachment A Dependent Spouse Optional Accidental Death and Dismemberment Insurance Refer to Attachment A The initial monthly premium rates are guaranteed until September 30, 2017, unless otherwise specified in Section VIII, Premiums. See Section VIII, Premiums for more information. 93P- LH -SCHED Schedule of Benefits Page No. 8 October 1, 2014 Section II Definitions In this section Sun Life defines some basic terms needed to understand this Policy. All male terms include the female term, unless stated otherwise. For purposes of this Policy: Actively at Work means that an Employee performs all the regular duties of his job for a full work day scheduled by the Employer at the Employer's normal place of business or a site where the Employer's business requires the Employee to travel. An Employee is considered Actively at Work on any day that is not his regular scheduled work day (e.g. vacation or holiday), provided the Employee was Actively at Work on his immediately preceding scheduled work day and the Employee: is not hospital confined; or is not disabled due to an injury or sickness. An Employee is considered Actively at Work if lie usually performs the regular duties of his job at his home, provided the Employee can perform all the regular duties of his job for a full work day and could do so at the Employer's normal place of business if required to do so, and the Employee: is not hospital confined; or is not disabled due to an injury or sickness. Annual Enrollment Period means the period during the months of November and December of each year as designated by the Policyholder. Application means the document pertaining to the plan of insurance applied for by the Policyholder. This document is attached to this Policy. Certificate means a written booklet prepared by Sun Life which includes any Riders, Endorsements or Amendments, containing a summary of 1. the insurance benefits an Employee is entitled to; 2. to whom the benefits are payable; and 3. any limitations, exclusions or requirements that may apply. Contributory Insurance means insurance for which the Employee is required to pay all or part of the premium. Eligibility Date means the date or dates an Employee in an Eligible Class becomes eligible for insurance under this Policy. Classes eligible for insurance are shown in Section I, Schedule of Benefits. Employee means a person who is employed by the Employer within the United States, scheduled to work at least the number of hours shown in Section I, Schedule of Benefits, and paid regular earnings. If the Employee is working on a temporary assignment outside of the United States for a period of 12 months or less, the Employee will be deemed to be working within the United States. If the Employee is working outside of the United States for more than 12 months or other than on a temporary assignment, the Employee will not be considered an Employee under this Policy unless Sun Life approves the Employee in writing. Employer means City of Columbia Heights and includes any Subsidiary or Affiliated company named in the Application. Evidence of Insurability means a statement or proof of an Employee's or Dependent's medical history upon which acceptance for insurance will be determined by Sun Life. The Employee or Dependent must agree to submit to a paramedical examination andior provide copies of medical records, if requested by Sun Life. Sun Life will pay the cost of any paramedical examination ordered by Sun Life for the purpose of providing Evidence of Insurability. Grace Period means the 31 days following a premium due date. 93P- LH -DEF.6 Definitions Page No. 9 October 1, 2014 Section II Definitions Guaranteed Issue Amount means the maximum amount of insurance available under this Policy without Evidence of Insurability. If the Employee's or Dependent's amount of insurance exceeds the Guaranteed Issue Amount available under this Policy, any amount in excess of the Guaranteed Issue Amount is available to the Employee or Dependent only if he has furnished Evidence of Insurability to Sun Life and has been approved for any excess amount above the Guaranteed Issue Amount. Hospital or Institution means a facility licensed to provide full -time medical care and treatment under the direction of a full -time staff of licensed physicians. Initial Enrollment Period means: the period immediately prior to October 1, 2014 as designated by the Policyholder, for those Employees eligible for benefits on October 1, 2014; or the period of 31 days immediately after the Employee's Eligibility Date, for those Employees who become eligible for benefits after October 1, 2014. Injury means bodily impairment resulting directly from an accident and independently of all other causes. Any Injury must occur and any disability must begin while the Employee is insured under this Policy. Non- Contributory Insurance means insurance for which the premium is paid entirely by the Employer. Physician means an individual who is operating within the scope of his license and is either: 1. licensed to practice medicine and prescribe and administer drugs or to perform surgery; or 2. legally qualified as a medical practitioner and required to be recognized, under this Policy for insurance purposes, according to the insurance regulations of the governing jurisdiction. The Physician cannot be the Employee, his spouse or the parents, brothers, sisters or children of the Employee or his spouse. Policyholder means the entity to whom the Policy is issued. Pregnancy means childbirth, miscarriage, abortion or any disease resulting from or aggravated by the pregnancy. Retirement Plan means a program which provides retirement benefits to Employees and is not funded wholly by Employee contributions. The term will not include a 401(k) plan, a 403(b) plan, a profit sharing plan, a thrift plan, an individual retirement account (IRA), a tax sheltered annuity (TSA), a stock ownership plan, or a nonqualified plan of deferred compensation. Employer's Retirement Plan will include any Retirement Plan: 1. which is part of any federal, state, county, municipal or association retirement system; and 2. the Employee is eligible for as a result of employment with the Employer. Sickness means illness, disease or pregnancy. Any disability, because of Sickness, must begin while the Employee is insured under this Policy. U.S. Headquarters means Sun Life Assurance Company of Canada, Wellesley Hills, MA 02481. Waiting Period means the length of time immediately before an Employee's Eligibility Date during which he must be employed in an Eligible Class. Any period of time prior to the Policy Effective Date the Employee was Actively at Work for the Employer as a full -time Employee will count towards completion of the Waiting Period. The Waiting Period is shown in Section I, Schedule of Benefits. 93P- LH -DEF.6 Definitions Page No. 10 October 1, 2014 Section II Definitions The following Definitions are applicable to Life Insurance Beneficiary means the person (other than the Employer) who is entitled to receive death benefit proceeds as they become due under this Policy. A Beneficiary must be named by the Employee on a form acceptable to Sun Life and executed by the Employee. Optional Maximum Benefit means the largest amount of Optional Life Insurance available to an Employee under this Policy. The Optional Maximum Benefit is shown in Section I, Schedule of Benefits. Retirement means the first of the following to occur the effective date of the Employee's retirement benefits under: a. any plan of a federal, state, county, municipal or an association retirement system which the Employee is eligible as a result of his employment with the Employer; b. any Retirement Plan the Employer sponsors; or c. any Retirement Plan to which the Employer: i. makes contributions to; or ii. has made contributions. 2. the effective date of the Employee's retirement benefits under the Social Security Act or any similar plan or act. However, if the Employee meets the definition of Employee and is receiving retirement benefits under the Social Security Act or similar plan or act, the Employee will not be considered retired. Terminally III or Terminal Illness means an Employee's Sickness or physical condition that is certified by a Physician to reasonably be expected to result in death within twelve months or less. Total Disability or Totally Disabled for purposes of determining eligibility for Waiver of Premium means an Employee, because of Injury or Sickness, is unable to perform the material and substantial duties of any occupation for which he is or becomes reasonably qualified for by education, training or experience. 93P- LH -DEF.6 Definitions Page No. 11 October 1, 2014 Section II Definitions The following Definitions are applicable to Dependent Life Insurance Dependent means an Employee's: spouse; unmarried child from live birth to under age 19; unmarried child under age 25 who is enrolled as a full -time student and depends on the Employee for 50% or more of the child's support. An Employee's unmarried step - child, foster child or adopted child is included as a Dependent if he depends on the Employee for 50% or more of the child's support and is living with the Employee in a regular parent -child relationship. A child is considered adopted if he is in the legal custody of the Employee under an interim court order of adoption, whether or not a final adoption order is ever issued. Dependent does not include: any person who is insured as an Employee; or any person residing outside the United States, Canada or Mexico. This exclusion does not apply to a Dependent who resides with an Employee who is on a temporary work assignment outside the United States. If a child is: 1. incapable of self- sustaining employment because of mental retardation, developmental disability or physical handicap; and 2. dependent on the Employee for 50% or more of his support; that child will continue to be a Dependent under this Policy for as long as these two conditions exist. No person may be considered to be a Dependent of more than one Employee. Optional Maximum Benefit means the largest amount of Dependent Optional Life Insurance available to an Employee under this Policy. The Optional Maximum Benefit is shown in Section I, Schedule of Benefits. 93P- LH -DEF.6 Definitions Page No. 12 October I, 2014 Section II Definitions The following Definitions are applicable to Accidental Death and Dismemberment Insurance Accidental Bodily Injury means bodily harm caused solely by external, violent and accidental means which is sustained directly and independently of all other causes. AD &D means Accidental Death and Dismemberment. Dependent means an Employee's spouse. Dependent does not include: any person who is insured as an Employee; or any person residing outside the United States, Canada or Mexico. Insured Person means the Employee or the Employee's insured Dependent Spouse. 93P- LH -DEF.5 Definitions Page No. 13 October 1, 2014 Section III Eligibility and Effective Dates A. Eligible Classes The class(es) eligible for insurance are shown in Section I, Schedule of Benefits. B. Eligibility Date An Employee in an Eligible Class will be eligible for insurance on the latest of the following dates: I. October 1, 2014; or 2. the Employee's first day of employment. An Employee in an Eligible Class will be eligible for Dependent Life Insurance on the latest of the following dates: 1. the date he is insured for Employee Basic Life Insurance for Dependent Basic Life Insurance; or 2. the date he is insured for Employee Optional Life Insurance for Dependent Optional Life Insurance; or 3. October 1, 2014; or 4. the date the Employee first acquires a Dependent. C. Effective Date of Insurance During each enrollment period an Employee may make written application for insurance benefit plan choices. Initial Enrollment Period An Employee will be insured, subject to the Delayed Effective Date of Insurance, on the date he is eligible on or after written application is made for insurance provided Evidence of Insurability is not required. If Evidence of Insurability is required for any amount of insurance, the Employee is insured for that amount of insurance, subject to the Delayed Effective Date of Insurance, on the date Sun Life approves the Evidence. If an Employee does not make a written application for insurance, he will be insured for Employee Basic Life and Employee Accidental Death and Dismemberment Insurance only. A Dependent will be insured for Dependent Basic Life Insurance, subject to the Delayed Effective Date of Insurance, on the latest of: - the date the Employee is eligible for Dependent Basic Life Insurance; or - the date the Employee makes a written application for Dependent Basic Life Insurance, if he applies during the Initial Enrollment Period. A Dependent will be insured for Dependent Optional Life Insurance, subject to the Delayed Effective Date of Insurance, on the latest of: the date the Employee is eligible for Dependent Optional Life Insurance; or the date the Employee makes a written application for Dependent Optional Life Insurance, if he applies during the Initial Enrollment Period; or the date the Dependent's Evidence of Insurability is approved by Sun Life, if required. If an Employee does not make a written application for Dependent Basic Life Insurance within the Initial Enrollment Period, the Dependent will not be insured. If an Employee does not make a written application for Dependent Optional Life Insurance within the Initial Enrollment Period, the Dependent will not be insured. No change in plan options may be made until: - the annual enrollment period; or the Employee has a Family Status Change. 93P- LH- ENROLL Eligibility and Effective Dates Page No. 14 October 1, 2014 Section III Eligibility and Effective Dates Annual Enrollment Period During each annual enrollment period an Employee may apply for a change in his plan options. If during the Annual Enrollment Period the Employee increases his amount of insurance, the Employee will be insured, subject to the Delayed Effective Date of Insurance, for the increase on the later of: - the October 1st following the Employee's election; or - the date Sun Life approves the Employee's Evidence of Insurability. If during the Annual Enrollment Period the Employee increases his Dependent's amount of insurance, the Dependent will be insured, subject to the Delayed Effective Date of Insurance, for the increase on the later of: the October 1 st following the Employee's election; or the date Sun Life approves the Dependent's Evidence of Insurability. Decreases in any amount of insurance will take effect on the October 1 st following the Employee's election. An Employee who does not make any changes during the Annual Enrollment Period will continue to be insured for the plan option previously elected. No change in plan options may be made until the next Annual Enrollment Period, except if the Employee has a Family Status Change. Family Status Change When an Employee has a Family Status Change he may make a change in his plan options within 31 days of the change in Family Status. Such changes must be on account of and consistent with the reason that the change was permitted. A change in the plan of insurance is consistent with a Family Status Change only if the change is necessary or appropriate as the result of the Family Status Change. A Family Status Change is one of the following events: the Employee's marriage or divorce; the birth of a child of the Employee; the adoption of a child by the Employee; the death of the Employee's spouse or child; the commencement or termination of employment of the Employee's spouse; the change from part-time to full -time employment by the Employee or the Employee's spouse; the change from full -time to part-time employment by the Employee or the Employee's spouse; the taking of an unpaid leave of absence by the Employee or the Employee's spouse; - a significant change in the health coverage of the Employee or the Employee's spouse as a result of the spouse's employment. If, due to the Family Status Change, the Employee increases his amount of insurance, the Employee will be insured, subject to the Delayed Effective Date of Insurance, for the increase on the latest of: the date the Employee makes a written application for the change in plan options; or the date the Employee's Family Status changed; or the date Sun Life approves the Employee's Evidence of Insurability, if required. If, due to the Family Status Change, the Employee increases his Dependent's amount of insurance, the Dependent will be insured, subject to the Delayed Effective Date of Insurance, for the increase on the latest of: the date the Employee makes a written application for the change in plan options; or the date the Employee's Family Status changed; or the date Sun Life approves the Dependent's Evidence of Insurability, if required. 93P -LH- ENROLL Eligibility and Effective Dates Page No. 15 October 1, 2014 Section III Eligibility and Effective Dates If, due to the Family Status Change, the Employee decreases his or his Dependent's amount of insurance, the Employee or Dependent will be insured for the decrease on the date the Employee makes a written application for the change in plan options. Delayed Effective Date of Insurance The Effective Date of any initial, increased or additional insurance will be delayed for an Employee if he is not Actively at Work. The initial, increased or additional insurance will become effective on the date the Employee returns to an Actively at Work status. The Effective Date of any initial, increased or additional insurance will be delayed for a Dependent if he is hospital confined. The initial, increased or additional insurance will become effective on the date the Dependent is no longer hospital confined. Hospital confined does not apply to a newborn child. Reinstatement of Insurance An Employee previously insured under this Policy will become insured, subject to the Delayed Effective Date of Insurance, on the date he is eligible. The Employee will be enrolled in the same plan option elected prior to his termination if he becomes insured again within 12 months. An Employee may apply for an increase in his amount of insurance after coverage is reinstated, but the Employee must submit Evidence of Insurability. The increased amount of insurance will not be effective until Sun Life approves the Employee's Evidence of Insurability. A change in the plan options can only be made at the Annual Enrollment Period or after a Family Status Change. All Other Changes in Insurance Changes in an Employee's amount of insurance due to a change in Employee's age will take effect on the first of the month following the date of change. Changes in an Employee's amount of insurance due to a change in Employee's class will take effect immediately upon the date of change. However, any increase in insurance will be subject to any Evidence of Insurability requirements and the Delayed Effective Date of Insurance provision. 93P -LH- ENROLL Eligibility and Effective Dates Page No. 16 October 1, 2014 Section IV Benefit Provisions Employee Life Insurance Death Benefit If Sun Life receives Notice and Proof of Claim that an Employee dies while insured, then subject to the Exclusions, Sun Life will pay the amount of Life Insurance in force on the Employee's date of death. Basic Life Insurance The amount of Basic Life Insurance is the Employee's Basic amount of insurance as determined in Section I, Schedule of Benefits. The amount of Basic Life Insurance is subject to any age reductions or terminations shown in Section I, Schedule of Benefits. If a former Employee had converted his Basic Life Insurance under the Conversion Privilege of this Policy, his amount of Basic Life Insurance will be reduced by the amount of any insurance remaining in force under that individual policy. Optional Life Insurance The amount of Optional Life Insurance is the lesser of: 1. the Employee's Optional amount of insurance elected (as determined in Section I, Schedule of Benefits); or 2. the Employee's Guaranteed Issue Amount for Optional Life Insurance (shown in Section I, Schedule of Benefits), plus any amount of insurance that Evidence of Insurability has been approved by Sun Life in excess of the Guaranteed Issue Amount for Optional Life Insurance. In no event shall an Employee's Optional Life Insurance exceed the Optional Maximum Benefit (shown in Section I, Schedule of Benefits).. The amount of Optional Life Insurance is subject to any Evidence of Insurability requirements, age reductions or terminations shown in Section I, Schedule of Benefits. If a former Employee had converted his Optional Life Insurance under the Conversion Privilege of this Policy, his amount of Optional Life Insurance will be reduced by the amount of any insurance remaining in force under that individual policy. Exclusions If the Employee's cause of death is suicide: 1. No amount of Optional Life Insurance is payable if the suicide occurs within 24 months after the Employee's Optional Life Insurance is effective. Any period of time the Employee was insured for the same amount of Optional Life Insurance under the previous insurer's group Life policy will count towards completion of the 24 months. 2. No increased or additional amount of Optional Life Insurance is payable if the suicide occurs within 24 months after the increased or additional amount of Optional Life Insurance is effective. 3. No amount of Optional Life Insurance in excess of the Guaranteed Issue Amount is payable if the suicide occurs within 24 months after the amount in excess of the Guaranteed Issue Amount is effective. Waiver of Premium Provision 93P- LH- LIFE.2 Life Benefit Provision Page No. 17 October 1, 2014 Section IV Benefit Provisions Employee Life Insurance Total Disabilities that begin before age 70 If Sun Life receives Notice and Proof of Claim that an Employee becomes Totally Disabled: while insured; and before his 70th birthday; and before his retirement; the amount of Life Insurance will continue for that Employee: from the date of Total Disability without further payment of premiums for Total Disabilities that begin before age 65; from the date of Total Disability without further payment of premiums for a period of one year for Total Disabilities that begin on or after age 65. The Employee must apply for Waiver of Premium no later than 12 months after the Employee ceases to be Actively at Work. Proof of Claim is required no later than 15 months after the Employee ceases to be Actively at Work. Sun Life may require periodic proof of the continuance of Total Disability. All amounts of life insurance under this Waiver of Premium Provision are subject to the same Policy terns and conditions including subsequent reductions and terminations at specified ages and /or at retirement as would have been applicable had the Employee not been Totally Disabled. This amount will be further reduced by the amount of any individual policy issued to the Employee pursuant to the Conversion Privilege of this Policy unless that individual policy is exchanged for a full refund of premiums paid. Sun Life has the right to designate a Physician to examine the Employee when and as often as may be reasonably required. The Waiver of Premium for an Employee ceases on the earliest of: the date he ceases to be Totally Disabled, the date he fails to furnish any required Proof that he continues to be Totally Disabled. the date he fails to submit to any required Examinations. any period the Employee is not under the regular and continuing care of a Physician providing appropriate treatment by means of examination and testing in accordance with the disabling condition. the date he retires. the date he attains age 65 or 12 months, whichever is later, for Total Disabilities beginning before age 65. the first anniversary of the beginning of Total Disability for Total Disabilities beginning on or after age 65. An Employee is deemed to be retired when he receives any compensation from a Retirement Plan of the Employer or when the Employee attains age 70, whichever occurs first. An Employee's rights to continued benefits pursuant to this Waiver of Premium Provision are determined on the date Total Disability begins. These rights are subject to the terms of this Policy and will not be affected by subsequent amendment or termination of this Waiver of Premium Provision. Accelerated Benefit Sun Life will pay an Accelerated Benefit to the Employee at the Employee's request, if Sun Life receives satisfactory proof of the Employee's Terminal Illness. To be eligible for the Accelerated Benefit an Employee must: (Applicable to Employees employed on or before October 1, 2014) 93P- LH- LIFE.2 Life Benefit Provision Page No. 18 October 1, 2014 Section IV Benefit Provisions Employee Life Insurance - have been Actively at Work on October 1, 2014 and insured under the Life Insurance Benefit Provision for at least 60 days. Any period of time the Employee was insured for similar benefits under the previous insurer's group life policy will be used to satisfy this requirement; (Applicable to Employees employed after October 1, 2014 ) - have been insured under the Life Insurance Benefit Provision for at least 60 days; (Applicable to All Employees) be certified as Terminally Ill with a life expectancy of twelve months or less; submit a written request to Sun Life while the Employee's Life Insurance is in force; be insured for at least $20,000 of Life Insurance; have a signed acknowledgment and agreement to pay the Accelerated Benefit from any applicable absolute assignee, irrevocable beneficiary, or former spouse if the former spouse was required to be the beneficiary as part of a divorce decree. Sun Life may confirm the diagnosis of a Terminal Illness with a medical examination performed by a Physician of Sun Life's choice. The Accelerated Benefit is an amount up to 75% of the applicable amount of Life Insurance in force as of the date Sun Life receives a written request to provide an Accelerated Benefit, The Accelerated Benefit will be paid as a single lump sum. The maximum amount of the Accelerated Benefit is $500,000. The minimum amount of the Accelerated Benefit that can be requested is $10,000. The Accelerated Benefit may be elected only once during the lifetime of the Employee. If the Employee has received accelerated life insurance benefits under any other group insurance policy, that Employee is precluded from receiving up to that amount from Sun Life, as an Accelerated Benefit or as a Death Benefit. If an Employee receives an Accelerated Benefit payment, the amount of Life Insurance remaining in force will be reduced by an amount equal to the Accelerated Benefit paid. The remaining amount of life insurance is subject to the same Policy terms and conditions including subsequent reductions and terminations at specified ages and/or at retirement as would have been applicable had the Employee not received an Accelerated Benefit. If the Employee is eligible for Waiver of Premium, the amount of life insurance remaining in force on which premiums are waived will be based on the reduced amount of life insurance. If the Employee subsequently converts his amount of life insurance, the amount eligible for conversion will be based on the reduced amount of life insurance. Continuation of Life Insurance (Portability) If an Employee's Life insurance ceases due to termination of his employment or layoff, the Employee may elect to continue coverage on his own life, up to the amount of insurance that ceased. The premium for the continued coverage will not exceed the rate charged for a similarly situated class of actively working employees insured under this Policy. Sun Life reserves the right to change the premium rate on any premium due date after the first 18 months of continued coverage. 93P- LH- LIFE.2 Life Benefit Provision Page No. 19 October 1, 2014 Section IV Benefit Provisions Employee Life Insurance If an Employee elects to continue coverage of any amount of Life Insurance, he may also elect to continue any amount of Accidental Death and Dismemberment Insurance and Dependent Life Insurance that ceased due to termination of employment or layoff. An Employee is considered to be laid off from employment if there is a reduction in hours to the point where the Employee is no longer eligible for coverage under the group life insurance policy. This, however, does not include discharge or termination due to gross misconduct. Notice Requirements Upon termination or layoff, the Employer will provide notice of the right to continue coverage to the Employee. The notice will be sent via first class mail to the Employee's last known address. The notice will state the monthly premium due, the mode of payment, and the address at which the premium must be paid. Election to Continue Coverage If an Employee elects to continue coverage, the Employee must notify Sun Life in writing and pay the first premium within 60 days after insurance ceases. The 60 day election period begins on the date insurance would otherwise cease, or on the date the Employee receives notice of the right to continue coverage, whichever is later. Death Within the Election Period If an Employee or Dependent dies within the 60 day election period, a benefit will be paid, upon receipt of Notice and Proof of Claim, whether or not application for the continuation of coverage or payment of the first premium has been made. The benefit is the amount of insurance the Employee would have been eligible to continue for himself or his Dependent. Responsibility of the Employee Every Employee electing to continue his Life Insurance shall pay to the Employer, on a monthly basis, the cost of continuing his or his Dependent's Life Insurance. Termination of Continued Coverage Coverage continued under this provision will terminate on the earliest of the following: the date for which the last premium has been paid by the Employee; or the expiration of 10 years following the date continued coverage commences; or the date this Policy terminates. When continued coverage terminates, the Employee or Dependent will have the right to convert the amount of coverage to an individual policy. 93P- LH- LIFE.2 Life Benefit Provision Page No. 20 October 1, 2014 Section IV Benefit Provisions Employee Life Insurance Conversion Privilege Benefit If all or part of an Employee's Life Insurance ceases or reduces due to: termination of his employment; or termination of his membership in an Eligible Class; or the Employee's retirement; or - the Employee reaching a specified age; or - the Employee changing to a different Eligible Class; or - termination of the Employee's Waiver of Premium continuation; or - the Employee's continuation period ending during layoff or an approved leave of absence; then the Employee may apply for an individual policy on his own life up to the amount that ceased. If the amount of Life Insurance that ceased is 510,000 or more, the minimum amount of the individual policy must be $10,000. 2. If all or part of the Employee's Life Insurance ceases or reduces due to: reduction of the amount of Life Insurance in an Eligible Class by an amendment to the Life Insurance Benefit Provision; or termination of the Life Insurance Benefit Provision; or termination of this Policy; or termination of an Eligible Class by an amendment to the Life Insurance Benefit Provision; then the Employee may apply for an individual policy on his own life. The maximum amount of the policy will be the lesser of: - $2,000; or - the amount that ceased, reduced by the amount of any life insurance the Employee is eligible for under any group policy within 31 days after his Life Insurance ceased. The Employee will be issued an individual policy without Evidence of Insurability. Application for the Individual Policy 1. written application must be made to Sun Life along with payment of the first premium, within the 31 day period (the 31 day conversion period) following the date the insurance ceases or reduces. If the Employee is not given notice by the Employer of this conversion privilege within 15 days following the date his insurance ceases or reduces, the Employee shall have an additional 15 days to exercise this conversion privilege. In no event will this conversion privilege be extended beyond 30 days following the 31 day conversion period. 2. the individual policy may be any plan of life insurance, including term insurance, available for conversion by Sun Life at the attained age and amount requested, but without disability or other supplemental benefits. 3. the premium will be the rate Sun Life charges for the standard class of risk and age to which the Employee belongs on the effective date of the individual policy. 4. the effective date of the individual policy will be the day after the 31 day conversion period. Death Within 31 Days If the Employee dies during the 31 day conversion period, a benefit will be paid upon receipt of Notice and Proof of Claim, whether or not application for the individual policy or payment of the first premium has been made. The benefit is the amount of Life Insurance the Employee would have been eligible to convert. 93P- LH- LIFE.2 Life Benefit Provision Page No. 21 October 1, 2014 Section IV Benefit Provisions Employee Life Insurance Continuity of Coverage In order to prevent loss of coverage for an Employee when this Policy replaces a group Life policy the Employer had in force with another insurer immediately prior to October 1, 2014, Sun Life will provide the following coverage. Employees not Actively at Work on October 1, 2014 An Employee may become insured under this Policy on October 1, 2014, subject to all of the following conditions: 1. he was insured under the prior insurer's group Life policy immediately prior to October 1, 2014; and 2. he is not Actively at Work on October 1, 2014; and 3. he is a member of an Eligible Class under this Policy; and 4. premiums for the Employee are paid up to date; and 5. he is not receiving or eligible to receive benefits under the prior insurer's group Life policy. Any Life benefit payable will be the lesser of: the Life benefit payable under this Policy; or the Life benefit payable under the prior insurer's group Life policy had it remained in force. All other provisions of Sun Life's Policy will apply. 93P- LH- LIFE.2 Life Benefit Provision Page No. 22 October 1, 2014 Section IV Benefit Provisions Dependent Life Insurance Death Benefit If Sun Life receives Notice and Proof of Claim that a Dependent dies while insured, then subject to the Exclusions, Sun Life will pay the amount of Life Insurance in force on the Dependent's date of death. Basic Life Insurance The amount of Basic Life Insurance is the Dependent's amount of Basic Life Insurance elected by the Employee in the Schedule (as detennined in Section I, Schedule of Benefits). The amount of Dependent Basic Life Insurance is subject to any terminations shown in Section I, Schedule of Benefits. If a Dependent had previously converted his Basic Life Insurance under the Conversion Privilege of this Policy, his amount of Dependent Basic Life Insurance will be reduced by the amount of any insurance remaining in force under that individual policy. Optional Life Insurance The amount of Dependent Optional Life Insurance is the lesser of: 1. the Dependent's amount of Optional Life Insurance elected by the Employee in the Schedule (as determined in Section I, Schedule of Benefits), or 2. the Guaranteed Issue Amount (shown in Section I, Schedule of Benefits), plus any amount of insurance that Evidence of the Dependent's Insurability has been approved by Sun Life in excess of the Dependent's Guaranteed Issue Amount. In no event shall a Dependent's Optional Life Insurance exceed the Optional Maximum Benefit shown in Section I, Schedule of Benefits The amount of Dependent Optional Life Insurance is subject to any Evidence of Insurability requirements or terminations shown in Section I, Schedule of Benefits. If a Dependent had previously converted his Optional Life Insurance under the Conversion Privilege of this Policy, his amount of Dependent Optional Life Insurance will be reduced by the amount of any insurance remaining in force under that individual policy. Exclusions If the Dependent Spouse's cause of death is suicide: 1. No benefit is payable if the suicide occurs within 24 months after the Dependent Spouse's initial Effective Date of Insurance. Any period of time the Dependent Spouse was insured under the previous insurer's group Life policy will count towards completion of the 24 months. 2. No amount of Dependent Spouse Optional Life Insurance is payable if the suicide occurs within 24 months after the Dependent Spouse's Optional Life Insurance is effective. Any period of time the Dependent Spouse was insured for the same amount of Optional Life Insurance under the previous insurer's group Life policy will count towards completion of the 24 months. 3. No increased or additional amount of Dependent Spouse Life Insurance is payable if the suicide occurs within 24 months after the increased or additional amount of Dependent Spouse Life Insurance is effective. 93P- LH- DLIFE.2 Dependent Life Benefit Provision Page No. 23 October 1, 2014 Section IV Benefit Provisions Dependent Life Insurance Conversion Privilege Benefit If all or part of a Dependent's Life Insurance ceases or reduces due to: termination of the Employee's employment; or termination of the Employee's membership in an Eligible Class; or the Employee's retirement; or the Employee reaching a specified age; or the Employee changing to a different Eligible Class; or the Employee's death; or the Dependent no longer meeting the definition of a Dependent; then the Employee or Dependent may apply for an individual policy on the Dependent's life up to the amount that ceased. If the amount of Life Insurance that ceased is $10,000 or more, the minimum amount of the individual policy must be $10,000. 2. If the Dependent's Life Insurance ceases due to: - termination of the Dependent Life Insurance Benefit Provision; or - termination of this Policy; or - termination of an Eligible Class by an amendment to the Dependent Life Insurance Benefit Provision; then the Employee or Dependent may apply for an individual policy on the Dependent's life. The maximum amount of the policy will be the lesser of: $2,000; or the amount that ceased, reduced by the amount of any life insurance the Dependent is eligible for under any group policy within 31 days after his Life Insurance ceased. The Dependent will be issued an individual policy without Evidence of Insurability. Application for the Individual Policy I . written application must be made to Sun Life along with payment of the first premium, within the 31 day period (the 31 day conversion period) following the date the insurance ceases or reduces. If the Dependent is not given notice by the Employer of this conversion privilege within 15 days following the date his insurance ceases or reduces, the Dependent shall have an additional 15 days to exercise this conversion privilege. In no event will this conversion privilege be extended beyond 30 days following the 31 day conversion period. 2. the individual policy may be any plan of life insurance, including term insurance, available for conversion by Sun Life at the attained age and amount requested, but without disability or other supplemental benefits. 3. the premium will be the rate Sun Life charges for the standard class of risk and age to which the Dependent belongs on the effective date of the individual policy. 4. the effective date of the individual policy will be the day after the 31 day conversion period. Death Within 31 Days If the Dependent dies during the 31 day conversion period, a benefit will be paid upon receipt of Notice and Proof of Claim, whether or not application for the individual policy or payment of the first premium has been made. The benefit is the amount of Life Insurance the Dependent would have been eligible to convert. 93P- LH- DLIFE.2 Dependent Life Benefit Provision Page No. 24 October 1, 2014 Section IV Benefit Provisions Dependent Life Insurance Continuity of Coverage In order to prevent loss of coverage for an Employee's Dependent when this Policy replaces a group Life policy the Employer had in force with another insurer immediately prior to October 1, 2014, Sun Life will provide the following coverage. Dependents subject to the Delayed Effective Date of Insurance on October 1, 2014 An Employee's Dependent may become insured under this Policy on October 1, 2014, subject to all of the following conditions: 1. the Dependent was insured under the prior insurer's group Life policy immediately prior to October 1, 2014 and 2. the Dependent is subject to the Delayed Effective Date of Insurance on October 1, 2014; and 3. the Employee is a member of an Eligible Class under this Policy; and 4. premiums for the Dependent are paid up to date; and 5. the Dependent is not receiving or eligible to receive benefits under the prior insurer's group Life policy. Any Dependent Life benefit payable will be the lesser of: the Dependent Life benefit payable under this Policy; or the Dependent Life benefit payable under the prior insurer's group Life policy had it remained in force. All other provisions of Sun Life's Policy will apply. 93P- LH- DLIFE.2 Dependent Life Benefit Provision Page No, 25 October 1, 2014 Section IV Benefit Provisions Employee and Dependent Spouse Accidental Death and Dismemberment Insurance If Sun Life receives Notice and Proof of Claim that an Insured Person: dies from accidental drowning while insured; or sustains an Accidental Bodily Injury while insured, which results in loss of life, sight or limb within 365 days of the date of that injury; or sustains a loss of life, sight or limb within 365 days due to an accidental exposure to the elements while insured; Sun Life will pay, subject to the Exclusions, the following percentage of Accidental Death and Dismemberment Insurance shown in Section I, Schedule of Benefits that was in force on the date of the Accidental Bodily Injury for the following losses: Life......................................................................................................................................... ............................... 100% Sightof one eye ......................................................................................................................... ............................... 50% Onelimb ...................................................................................................................................... ............................50% Speechand hearing .................................................................................................................. ............................... 100% Speechor hearing ......................................................................................................................... ............................50% Thumb and index finger ofthe same hand ....................................................................................................................... ............................... 25% Quadriplegia... ........................................... .................................... ...................................................................... 100% Paraplegia................................................................................................................................. ............................... 75% Hemiplegia............................................................................................................................... ............................... 50% The maximum amount of Accidental Death and Dismemberment Benefit payable for losses resulting from any one accident is 100 %. Loss of limb means severance of hand or foot at or above the wrist or ankle joint. Loss of sight, speech or hearing must be total and irrecoverable. Loss of thumb and index finger means severance through or above the metacarpophalangeal joints. Quadriplegia means the total and permanent paralysis of both upper and lower limbs. Paraplegia means the total and permanent paralysis of both lower limbs. Hemiplegia means the total and permanent paralysis of the upper and lower limbs on one side of the body. Business Travel Benefit Sun Life will pay an additional Business Travel Benefit if an Employee's loss of life occurs while traveling on business for the Employer. The Business Travel Benefit for Basic Accidental Death and Dismemberment Insurance is the lesser of: $25,000; or 25% of the amount of Basic Accidental Death Benefit payable. The Business Travel Benefit for Optional Accidental Death and Dismemberment Insurance is the lesser of - $25,000; or 93P- LH- AD &D.2 Accidental Death and Dismemberment Benefit Provision Page No. 26 October 1, 2014 Section IV Benefit Provisions Employee and Dependent Spouse Accidental Death and Dismemberment Insurance - 25% of the amount of Optional Accidental Death Benefit payable. Business Travel means traveling to another location to conduct the Employer's business other than the Employee's normal workplace. Business Travel starts from the time the Employee leaves his place of residence to commence the Employer's business until the Employee returns to his place of residence. Business Travel does not include personal deviations; nor Employee vacations. Personal Deviation means an activity that is not reasonably related to the Employer's business and not incidental to the business trip. An Employee's place of residence will change to the location of the Business Travel if an Employee's stay at that location exceeds 60 days. Seat Belt /Air Bag Benefit Sun Life will pay an additional Seat Belt-Air Bag Benefit if an Insured Person dies as a result of an automobile accident and an Accidental Death Benefit is payable under this Policy. Seat Belt Benefit The Seat Belt Benefit is payable if the Insured Person was wearing a seat belt at the time of the accident. The Seat Belt Benefit is 25% of the amount of Basic Accidental Death Benefit payable or $25,000, whichever is less. The Seat Belt Benefit is 25% of the amount of Optional Accidental Death Benefit payable or $25,000, whichever is less. Sun Life must receive satisfactory written proof that the Insured Person's death resulted from an automobile accident and that the Insured Person was wearing a seat belt at the time of the accident. A copy of the police report is required, Air Bag Benefit The Air Bag Benefit is payable if a Seat Belt Benefit is payable and the Insured Person was positioned in a seat protected by a Supplemental Restraint System which inflated on impact. The Air Bag Benefit is 10% of the amount of Basic Accidental Death Benefit payable or $5,000, whichever is less. The Air Bag Benefit is 10% of the amount of Optional Accidental Death Benefit payable or $5,000, whichever is less. Sun Life must receive satisfactory written proof that the Insured Person's death resulted from an automobile accident and that the Supplemental Restraint System properly inflated. A copy of the police report is required. Seat Belt means a properly installed seat belt, lap and shoulder restraint, or other restraint approved by the National Highway Traffic Safety Administration. Supplemental Restraint System means a factory installed air bag which inflates for added protection to the head and chest areas. Automobile means a motor vehicle licensed for use on public highways. Helmet Benefit 93P- LH- AD &D.2 Accidental Death and Dismemberment Benefit Provision Page No. 27 October 1, 2014 Section IV Benefit Provisions Employee and Dependent Spouse Accidental Death and Dismemberment Insurance Sun Life will pay an additional Helmet Benefit if an Insured Person dies as a result of a Motorcycle accident and an Accidental Death Benefit is payable under this Policy. The Helmet Benefit is payable if the Insured Person was wearing a Helmet at the time of the accident and the driver of the Motorcycle held a valid drivers license with a Motorcycle endorsement. The Helmet Benefit is 50% of the amount of Basic Accidental Death Benefit payable or $25,000, whichever is less. The Helmet Benefit is 50% of the amount of Optional Accidental Death Benefit payable or $25,000, whichever is less. Sun Life must receive satisfactory written proof that the Insured Person's death resulted from a Motorcycle accident and that the Employee was wearing a Helmet at the time of the accident. A copy of the police report is required. Helmet means a protective head covering made of a hard material to resist impact and which is approved by the American National Safety Institute (ANSI) andior Snell. Motorcycle means a motor vehicle licensed for use on public highways which requires a Motorcycle endorsement on a drivers license to operate the vehicle. Disappearance Sun Life will presume, subject to no objective evidence to the contrary, that an Insured Person is dead and has died as a result of an Accidental Bodily Injury if: 1. an Insured Person disappears as a result of an accidental wrecking, sinking or disappearance of a conveyance in which the Insured Person was known to be a passenger; and 2. the body of the Insured Person is not found within 365 days after the date of the conveyance's disappearance. Bereavement Counseling Benefit If an Accidental Death Benefit is payable, Sun Life will pay a Bereavement Counseling Benefit during an Insured Persorr`'� Immediate Family Member's period of bereavement for up to 12 months after an Insured Persons death. The Bereavement Counseling Benefit equals the Immediate Family Member's incurred expenses reduced by any reimbursement the Immediate Family Member receives from other sources. The Maximum Bereavement Counseling Benefit payable is $250 per Immediate Family Member, to a maximum of $1,000 or $2,000 if the Employee is insured for Optional AD &D Insurance and is per insured's death. Immediate Family Member means an Employee, an Employee's spouse or an Employee's child under age 19 or age 25 if a full -time student. Written Proof of the actual out of pocket counseling expenses incurred must be submitted to Sun Life prior to payment. Dependent Education Benefit If an Employee Accidental Death Benefit is payable under this Policy, an Employee's Dependent may be eligible for a Dependent Education Benefit. A Dependent Child is eligible for an Education Benefit if the Dependent Child enrolls as a full -time student at a post- secondary school before reaching age 25 and within 1 year after the Employee's date of death. 93P- LH- AD &D.2 Accidental Death and Dismemberment Benefit Provision Page No. 28 October ], 2014 _ - Deleted: ] [Insured Person] Deleted: ] [Insured Person's] Deleted; ] [Insured Person] � Deleted: ] []nsurcd Person's] _ _ J Section IV Benefit Provisions Employee and Dependent Spouse Accidental Death and Dismemberment Insurance The annual Dependent Child's Education Benefit is the lesser of: Incurred Expenses; or $2,500 or $5,000 if the Employee is insured for Optional AD &D Insurance; or 5% of the Employee's amount of Basic Accidental Death Benefit payable plus 5% of the Employee's amount of Optional Accidental Death Benefit payable. The Dependent Child Education Benefit is payable at the end of each semester per dependent child, for a maximum of four consecutive years per child. Proof of the child's enrollment and Incurred Expenses are required each semester prior to payment of the benefit. Incurred Expenses include tuition, fees, cost of books, room and board, transportation and any other costs paid directly to the school. A Dependent Spouse is eligible for an Education Benefit if the Dependent Spouse enrolls in any school for the purpose of retraining or developing skills needed for employment within 1 year after the Employee's date of death. The Dependent Spouse's Education Benefit is equal to the expenses paid directly to such school or $3,000 or $6,000, if the Employee is insured for Optional AD &D Insurance, whichever is less. Proof of enrollment and expenses are required prior to payment of the benefit. Exclusions No Accidental Death or Accidental Dismemberment payment will be made for a loss which is due to or results from: suicide while sane or insane. intentionally self - inflicted injuries. bodily or mental infirmity or disease of any kind, or infection unless due to an accidental cut or wound. the Employee committing or attempting to commit a felony. active participation in a war (declared or undeclared) or active duty in any armed service during a time of war. active participation in a riot, rebellion, or insurrection. injury sustained from any aviation activities, other than riding as a fare - paying passenger. the Insured Person's voluntary use of any narcotic, unless administered on the advice of a Physician. the Insured Person's operation of any motorized vehicle while intoxicated. Intoxicated means under the influence of alcohol as evidenced by a blood alcohol level in excess of the legal intoxication limit in the jurisdiction where the accident occurred. For the purposes of this Exclusion, "Motorized Vehicle" includes, but is not limited to, automobiles, motorcycles, boats and snowmobiles. 93P- LH- AD &D.2 Accidental Death and Dismemberment Benefit Provision Page No. 29 October 1, 2014 Section IV Benefit Provisions Employee and Dependent Spouse Accidental Death and Dismemberment Insurance Continuity of Coverage In order to prevent loss of coverage for an Employee when this Policy replaces a group AD &D policy the Employer had in force with another insurer immediately prior to October 1, 2014, Sun Life will provide the following coverage. Employees not Actively at Work on October 1, 2014 An Employee may become insured under this Policy on October 1, 2014, subject to all of the following conditions: I . he was insured under the prior insurer's group AD &D policy immediately prior to October 1, 2014; and 2. he is not Actively at Work on October 1, 2014; and 3. he is a member of an Eligible Class under this Policy; and 4. premiums for the Employee are paid up to date; and 5. he is not receiving or eligible to receive benefits under the prior insurer's group AD &D policy. Any AD &D benefit payable will be the lesser of the AD &D benefit payable under this Policy; or the AD &D benefit payable under the prior insurer's group AD &D policy had it remained in force. All other provisions of Sun Life's Policy will apply. 93P- LH- AD &D.2 Accidental Death and Dismemberment Benefit Provision Page No. 30 October 1, 2014 Section V Termination Provisions Termination of Employee's Insurance An Employee will cease to be insured on the earliest of the following dates: 1. the date this Policy terminates. 1 the date the Employee is no longer in an Eligible Class. 3. the date the Employee's Class is no longer included for insurance. 4. the last day for which any required premium has been paid. 5. the last day of the month in which the Employee retires. 6. the last day of the month in which employment terminates. Ceasing to be Actively at Work will be deemed termination of employment, except: a. insurance will be continued for an Employee absent due to a disability during any period the premium is being waived under this Policy. K the Policyholder may continue the insurance by paying the required premiums, subject to the following: i. insurance may be continued for up to I month after the Employee has been temporarily laid off. ii. insurance may be continued for up to I month after the Employee has been given an approved leave of absence. iii. insurance may be continued for up to 3 months of the Employee's paid vacation iv. For Life and Accidental Death and Dismemberment Insurance - insurance may be continued for up to 12 months after an Employee is absent from work due to Injury or Sickness. The Policyholder in all of the above situations must act so as not to discriminate unfairly among Employees in similar situations. 7. the date the Employee requests, in writing, to have his insurance terminated. 8. the date the Employee ceases to be Actively at Work due to a labor dispute, including any strike, work slowdown, or lockout. 9. the date the Employee enters active duty in any armed service during a time of war (declared or undeclared). While this Policy is in force, the Policyholder may continue an Employee's coverage pursuant to the Family and Medical Leave Act of 1993, as amended or continue coverage pursuant to a state required continuation period (if any). While this Policy is in force, the Policyholder may continue an Employee's coverage pursuant to the Uniformed Services Employment and Reemployment Rights Act (USERRA). Continuation of Coverage for Life Insurance Any Employee insured for Life Insurance who is voluntarily or involuntarily terminated (including retirement) or laid off from employment and, as a result of such termination or layoff no longer is insured for Life Insurance may, if this Policy remains in force for any active Employees, elect to continue his Life Insurance under this Policy. An Employee is considered to be laid off from employment if there is a reduction in hours to the point where the Employee is no longer eligible for coverage under the group life insurance policy. This, however, does not include discharge or termination due to gross misconduct. This right of continuation also is extended to any of the Employee's dependents who were insured for Dependent Life Insurance under this Policy at the time the Employee's coverage ceased. Responsibility of the Employee Every Employee electing to continue his Life Insurance shall pay to the Employer, on a monthly basis, the cost of continuing his Life Insurance. Duration of Continued Coverage 93P- LH- TERM.] Termination — Employee Page No. 31 October 1, 2014 Section V Termination Provisions The Employee is eligible to continue his Life Insurance until the Employee obtains Group Life Insurance under another group policy, or for a period of 18 months after termination of employment or layoff, whichever is shorter. Conversion to an Individual Policy After the continued Life Insurance ceases, the Employee (or any insured Dependents) are eligible to convert their life insurance. Refer to the Conversion Privilege section of the Employee (or Dependent) Life Insurance Benefit provision. 93P- LH- TERM. 1 Termination — Employee Page No. 32 October 1, 2014 Section V Termination Provisions Termination of Dependent's Insurance A Dependent will cease to be insured on the earliest of the following dates 1. the date this Policy terminates. 2. the date the Employee ceases to be insured. 3. the date the Employee is no longer in an Eligible Class for Dependent Insurance. 4, the last day of the month in which the Dependent ceases to qualify as a Dependent. 5. the last day for which any required premium has been paid for insurance on the Dependent. G. the date the Employee requests, in writing, to have his Dependent Insurance terminated. 7. the date the Employee dies. 8. the last day of the month in which the Dependent Spouse attains age 70 for Dependent Spouse Optional Life Insurance. 9. the date the Dependent enters active duty in any armed service during a time of war (declared or undeclared). 10. the last day of the month in which the Employee retires. 93P- LH- TERM.] Tenmination — Dependent Page No. 33 October 1, 2014 Section V Termination Provisions Termination of Policy This Policy will terminate for any of the following reasons: 1. If the Policyholder fails to pay any premium within the Grace Period, this Policy will tenninate on the last day of the Grace Period. 2. The Policyholder may terminate this Policy by advance written notice delivered to Sun Life at least 31 days prior to the termination date. This Policy will not terminate during any period for which premium has been paid. The Policyholder will be liable to Sun Life for all premiums due and unpaid for the full period this Policy is in force. 3. Sun Life may terminate this Policy on any premium due date by giving written notice to the Policyholder at least 31 days in advance if: a, the number of insured Employees is less than 10; or b. less than 100% of the Employees eligible are insured for Non - Contributory Insurance; or c. less than 55% of the Employees eligible are insured for Optional Life Insurance; or d. the Policyholder fails to: i. furnish promptly any information Sun Life may reasonably require; or ii. perform any other obligations pertaining to this Policy. 4. Sun Life may terminate this Policy on any Policy Anniversary= by giving written notice to the Policyholder at least 60 days in advance. Termination of this Policy may take effect on an earlier date when both the Policyholder and Sun Life agree. If this Policy is terminated and the Policyholder notifies Sun Life that the Policy will not be replaced with substantially similar coverage, termination will not take effect until the earlier of: a) 30 days following notice of cancellation to all Employees and Dependents, pursuant to the requirements of Minnesota Insurance Code §60A.85; or b) 120 days following the requested effective date of termination. 93P- LH- TERM.1 Termination— Policy!Benefit Page No. 34 October 1, 2014 Section V Termination Provisions Termination of Benefit Provision A Benefit Provision will terminate for any of the following reasons: 1. The Policyholder may terminate a Benefit Provision by advance written notice delivered to Sun Life at least 31 days prior to the termination date. The Benefit Provision will not terminate during any period for which premium has been paid. The Policyholder will be liable to Sun Life for all premiums due and unpaid for the full period that Benefit Provision is in force. 2. Sun Life may terminate a Benefit Provision on any premium due date by giving written notice to the Policyholder at least 31 days in advance if: a. the number of insured Employees for that Benefit is less than 10; or b. less than 100% of the Employees eligible are insured for Non - Contributory Insurance; or c. less than 55% of the Employees eligible are insured for Optional Life Insurance; or d. the Policyholder fails to furnish promptly any information which Sun Life may reasonably require. 3. Sun Life may terminate any Benefit Provision on any Policy Anniversary by giving written notice to the Policyholder at least 60 days in advance. Termination of a Benefit Provision may take effect on an earlier date when both the Policyholder and Sun Life agree. 93P- LH -TERM1 Termination - Policy?Benefit Page No. 35 October 1, 2014 Section VI General Policy Provisions A. Statements All statements made in any Application are considered representations and not warranties. No representation by: 1. the Policyholder in applying for this Policy will render it void unless the representation is contained in the Application; or 2. any Employee in applying for insurance under this Policy will be used to reduce or deny a claim unless a copy of the Employee's written application for insurance is or has been given to the Employee or the Employee's beneficiary, if any. B. Entire Contract - Policy Changes 1. This Policy is the entire contract. It consists of. a. all of the pages of the Policy; b. the attached Application of the Policyholder; c. each Employee's written application for insurance (Employee retains his own copy). 2. This Policy may be changed in whole or in part. Only an executive officer of Sun Life may approve a change. The approval must be in writing and endorsed on or attached to this Policy. 3. Any other person, including an agent, may not change this Policy or waive any part of it. C. Employee's Certificate Sun Life will provide a Certificate to the Policyholder for delivery to each Employee. The Certificate is intended to provide a brief explanation of the Policy benefits, but it does not form a part of this Policy. If the terns of a Certificate and this Policy differ, this Policy will govern. D. Furnishing of Information - Access To Records 1. The Employer will furnish at regular intervals to Sun Life: a. information relative to individuals: i. who qualify to become insured; ii. whose amounts of insurance change; and/or iii. whose insurance terminates. b. any other information about this Policy that maybe reasonably required. The records which, in the opinion of Sun Life, are material to the insurance, will be opened for inspection by Sun Life at any reasonable tone. 2. Clerical error or omission will not: a. deprive an individual of insurance; b. affect an individual's amount of insurance; or e. effect or continue an individual's insurance which otherwise would not be in force. The Policyholder's or Employer's failure to report notice or proof of claim in a timely manner shall not constitute clerical error. 93P- LH -GENP General Policy Provisions Page No. 36 October 1, 2014 Section VI General Policy Provisions E. Misstatement of Age If the age of an individual is not accurate: 1. an equitable adjustment of premium will be made; and 2. the true age will be used to detennine if and in what amount insurance is valid under this Policy. If the amount of the benefit is dependent upon an individuals age, (as shown in Section I, Schedule of Benefits), the benefit will be the amount an individual would have been entitled to if his correct age was known. If an adjustment results in a refund of premium, the refund will not exceed a period of more than 12 months. F. Examination and Autopsy Sun Life, at its own expense, has the right to have any person, whose Injury or Sickness is the basis of a claim: 1. examined by a Physician, other health professional or vocational expert of its choice; and/or 2. interviewed by an authorized Sun Life representative. This right may be used as often as reasonably required. Sun Life has the right, in the case of death, to request an autopsy where not prohibited by law. G. Legal Proceedings No legal action may start: 1. until 60 days after Proof of Claim has been given; nor 2. more than 3 years after the time Proof of Claim is required. H. Workers' Compensation This Policy is not in lieu of, and does not affect, any requirement for coverage by Workers' Compensation Insurance. Incontestability Policyholder The validity of this Policy shall not be contested, except for non - payment of premium, after it has been in force for two years from the Policy Effective Date. Individual No statement made by an individual, relating to his insurability for an initial, increased or additional amount of insurance, will be used in contesting the validity of that insurance, after such initial, increased or additional amount of insurance has been in force for a period of two years during the individual's lifetime. This statement must be contained in a form signed by that individual. 93P- LH -GENP General Policy Provisions Page No. 37 October 1, 2014 Section V11 Claim Provisions A. Notice and Proof of Claim Sun Life must receive Notice and Proof of Claim prior to any payment under this Policy. Notice of Claim for Death Claim - written notice of claim must be given to Sun Life no later than 30 days after date of death for Life Waiver of Premium - written notice of claim must be given to Sun Life no later than 12 months after the Employee ceases to be Actively at Work. for Accidental Dismemberment - written notice of claim must be given to Sun Life no later than 12 months after the Insured Person's date of loss. for all other claims - written notice of claim must be given to Sun Life no later than 12 months after the Insured Person's date of loss or within 12 months after the date the expense is incurred. If notice cannot be given within the applicable time period, Sun Life must be notified as soon as it is reasonably possible. When Sun Life has received written notice of claim, Sun Life will send the forms for proof of claim. If the forms are not received within 15 days after written notice of claim is sent, proof of claim may be sent to Sun Life without waiting for the form. 2. Proof of Claim for Death Claim - proof of claim must be given to Sun Life no later than 90 days after date of death for Life Waiver of Premium - proof of claim must be given to Sun Life no later than 15 months after the Employee ceases to be Actively at Work. for Accidental Dismemberment - proof of claim must be given to Sun Life no later than 15 months after the Insured Person's date of loss. for all other claims - proof of claim must be given to Sun Life no later than 15 months after the Insured Person's date of loss or within 15 months from the date the expense is incurred. If it is not possible to give proof within these time limits, it must be given as soon as reasonably possible. Proof of claim may not be given later than one year after the time proof is otherwise required unless the individual is legally incompetent. Proof of Claim must consist of: a description of the loss or disability; the date the loss, disability or expense occurred; and the cause of the loss, disability or expense. Proof of Claim may include, but is not limited to, police accident reports, autopsy reports, laboratory results, toxicology results, hospital records, x -rays, narrative reports, or other diagnostic testing materials as required. Proof of Claim for disability must include evidence demonstrating the disability including, but not limited to, hospital records, Physician records, Psychiatric records, x -rays, narrative reports, or other diagnostic testing materials as appropriate for the disabling condition. Proof must be satisfactory to Sun Life. 93P- LH- CLAIM.3 Claim Provisions Page No. 38 October 1, 2014 Section VII Claim Provisions Sun Life may require as part of the Proof authorizations to obtain medical and non - medical information. Proof of the Employee's continued disability and regular and continuous care by a Physician must be given to Sun Life within 30 days of the request for proof. B. Insurer's Authority The Plan Administrator has delegated to Sun Life its entire discretionary authority to make all final determinations regarding claims for benefits under the benefit plan insured by this Policy. This discretionary authority includes, but is not limited to, the determination of eligibility for benefits, based upon enrollment information provided by the Policyholder, and the amount of any benefits due, and to construe the terms of this Policy. Any decision made by Sun Life in the exercise of this authority, including review of denials of benefit, is conclusive and binding on all parties. Any court reviewing Sun Life's determinations shall uphold such determination unless the claimant proves that Sun Life's determinations are arbitrary and capricious. C. Notice of Decision on Claim A written notice of decision on a claim will be sent within a reasonable time after Sun Life receives the claim but not later than 45 days after receipt of the claim. If a decision cannot be made within 45 days after Sun Life receives the claim, Sun Life will request extensions of time as permitted under U.S. Department of Labor regulations. Any request for extension of time will specifically explain: 1. the standards on which entitlement to benefits is based; 2. the unresolved issues that prevent a decision on the claim; and 3, the additional information needed to resolve those issues. If a period of time is extended because the claimant failed to provide necessary information, the period for making the benefit determination is tolled from the date Sun Life sends notice of the extension to the claimant until the date on which the claimant responds to the request for additional information. The claimant will have at least 45 days to provide the specified information. D. Review Procedure If all or any part of a claim is denied, the claimant may request in writing a review of the denial within 180 days after receiving notice of denial. The claimant may submit written comments, documents, records or other information relating to the claim for benefits, and may request free of charge copies of all documents, records and other information relevant to the claimant's claim for benefits. Sun Life will review the claim on receipt of the written request for review, and will notify the claimant of Sun Life's decision within a reasonable time but not later than 45 days after the request has been received. If an extension of time is required to process the claim, Sun Life will notify the claimant in writing of the special circumstances requiring the extension and the date by which Sun Life expects to make a determination on review-. The extension cannot exceed a period of 45 days from the end of the initial review period. If a period of time is extended because the claimant failed to provide necessary information, the period for making the decision on review is tolled from the date Sun Life sends notice of the extension to the claimant until the date on which the claimant responds to the request for additional information. E. Time of Payment of Claims 93P- LH- CLAIM.3 Claim Provisions Page No. 39 October 1, 2014 Section VII Claim Provisions When Sun Life receives satisfactory Proof of Claim, benefits payable under this Policy will be paid immediately for any period for which Sun Life is liable. F. Payment of Claims Benefits payable upon the death of the Employee are payable to the Beneficiary living at the time (other than the Employer). Unless otherwise specified, if more than one Beneficiary survives the Employee, all surviving Beneficiaries will share equally. If no Beneficiary is alive on the date of the Employee's death, payment will be made to the Employee's estate. Accidental Death and Dismemberment benefits are payable as shown above unless otherwise specified in the Accidental Death and Dismemberment Benefit Section. All other benefits payable during the lifetime of the Employee are payable to the Employee. If a benefit is payable to the Employee's estate, an Employee who is a minor, or an Employee who is not competent, Sun Life has the right to pay up to $5,000 to any of the Employee's relatives whom Sun Life considers entitled. If Sun Life pays benefits in good faith to a relative, Sun Life will not have to pay those benefits again. If a Beneficiary is a minor or is not competent, Sun Life has the right to pay up to $1,000 to the person or institution that appears to have assumed custody and main support, until the appointed legal representative makes a formal claim. If Sun Life pays benefits in good faith to a person or institution, Sun Life will not have to pay those benefits again. G. Amendment or Termination of Benefit Provision An Employee's rights to any disability benefits are determined on the date the Employee's disability begins. The right is subject to the terms of this Policy in effect on the date disability begins and will not be affected by subsequent amendment or termination of this Policy. H. Change of Beneficiary If this Policy replaces existing coverage under the Employer's group life insurance plan, Employees' nominations of Beneficiaries under the plan will remain in force unless changed by the Employee. All nominations of Beneficiaries are revocable unless otherwise stated by the Employee. Any request for change of Beneficiary must be in a written form and will take effect as of the date the Employee signs and files the change with the Employer. If Sun Life has taken any action or made payment prior to receiving notice of that change, the change of Beneficiary will not affect any action or payment made by Sun Life. The consent of the Beneficiary is not required to change any Beneficiary unless the Beneficiary designation has been irrevocable. I. Assignments The Employee is pennitted to assign all his rights under this Policy. Any assignment must be in a written form and will take effect as of the date the Employee signs and files the assignment with the Employer. Sun Life will honor an Employee's prior assignment of rights and benefits under the Employer's plan, whether or not this Policy is specified in the Assignment. If Sun Life has taken any action or made payment prior to receiving notice of that change, the assignment will not affect any action or payment made by Sun Life. Sun Life will not be responsible for the legal, tax or other effects of any assignment. J. Methods of Payment The Death Benefit may be payable by a method other than a lump sum. The available methods of payment will be based on the benefit options offered by Sun Life at the time of election. 93P- LH- CLAIM.3 Claim Provisions Page No. 40 October 1, 2014 Section V111 Premiums A. Premium Rates Sun Life determines its initial or any subsequent monthly premium rate on the basis of the coverage being provided. After the initial monthly premium rate has been in effect until September 30, 2017, Sun Life has the right to recalculate any premium rate. However, Sun Life has the right to recalculate the initial or any subsequent monthly premium rate when any of the following occurs: 1. the terms of this Policy are changed, including but not limited to the Schedule of Benefits; or 2. a new Division, Subsidiary or Affiliated Company of the Policyholder is added to or deleted from this Policy; or 3, the number of Employees insured changes by 25% or more from the number of Employees insured on the Policy Effective Date or the immediately preceding Policy Anniversary Date; or 4. one or more class(es) are added to or deleted from this Policy. No premium rate may be increased unless Sun Life notifies the Policyholder at least 31 days in advance of the increase. Premium rate increases may take effect on an earlier date when both Sun Life and the Policyholder agree. B. Payment of Premiums 1. All premiums due under this Policy, including adjustments, if any, are payable by the Policyholder on or before the respective due dates at Sun Life's U.S. Headquarters or at another location designated by Sun Life. The due dates are specified on the first page of this Policy. 2. The premiums due under this Policy on each premium due date are based upon the premium rates in effect for the benefit provided. The premium due is the sum of the monthly premiums for all insured Employees and Dependents for all benefits. 3. Premiums payable to Sun Life will be paid in United States dollars on the premium due date. 4. The premium for additional or increased insurance becoming effective during a Policy month will be charged from the next premium due date. 5. The premium for insurance terminated during a Policy month will cease at the end of the Policy month in which such insurance terminates. 6. Except for fraud, premium adjustments, refunds or charges will be made for only: a. the current Policy Year; and b. the prior Policy Year. C. Grace Period The Grace Period is 31 days following a premium due date. During the Grace Period the Policy shall continue in force, unless the Policyholder has given Sun Life written notice to discontinue this Policy. hi any event, premiums are payable for any period of time the Policy remains in force. 93P- LH -PREM Premiums Page No. 41 October 1, 2014