HomeMy WebLinkAbout2001 Companion Ufe
COMPANION LIFE INSURANCE COMPANY
51 CLEMSDN ROAD, SUITE C, COLUMBIA, SC 29225
P.O. BOX 100102, COLUMBIA, SC 29202
(803) 735-1251
TERM LIFE, ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE POLICY
RENEWAL AT OPTION OF COMPANION LIFE
(NON-PARTICIPATING)
Policyholder: City of Jeffersonville
Date of Issue: February 1, 2001
Policy Number: 903 1~ 76537 001
Effective Date: February 1, 20Ol
S±ate of Delivery: Indiana
Policy Anniversary: February I
In consideration of the payment of the first premium, and of the statements and
agreements in the Group Application and individual applications, if any, of the
eligible empioyeea, Companion Life Insurance Company (herein called Companion
Life) agrees to insure eligible employees of the Policyholder (and their
eligible dependents, if any and if this Policy provides Dependent Life
Insurance). ("Eligible employees" is defined in the General Poiicy Provisions
section. "Eligible dependents'~ is defined in the Dependent Life Insurance
section.) Companion Life promises to pay benefits according to the terms of
this Policy. A copy of the Group Application is attached and made pa~t of this
Policy.
SubSect to the Policyholder Provisions and the Incontestability Provisions,
~his Policy may be renewed for successive renewal periods by the payment of the
premium set by us on each renewal date. The length of each renewal period will
be set by Companion Life, but will not be less than 12 months. ,
This Policy is deiivered in and governed by the laws of the State of Delivery
named above. PLEASE READ YOUR POLICY CAREFULLY.
For purposes of effective dates and ending dates under this Policy, ali days
begin and end at 12:01 a.m. Standard Time at the Policyhelder's address where
the Policy is delivered.
COMPANION LIFE INSURANCE COMPANY
GTP 635 (7/95)
M. Edward Sellers, President
SECTION
NUMBER
POLICY GUIDE
SECTION NAME
1
2
$
5
G
7
9
10
11
12
15
Iq
Policy Face Page
Policy Guide
Premium Rate Schedule
Policy Effective Date and Term
Actively a~ Work Provision
Definitions
Term Li~e Insurance Bene~i~
Accidental Death & D~smembe~men~ Benefit
Dependen~ Li~e Insurance Bene~i~
Beneficiary and SeAtlemen~ Options
Assignmen~
Short Term Disability Benefit
Change of Class or Earnings
When Individual [nsurance Begins
When Individual Insurance Ends
Premium Provisions
General Policy Provisions
BEGINNING
PAGE NUMBER
0.1
0.2
0.3
1.1
2.1
3.1
fi.1
5.1
6.1
7.1
8.1
9.1
10.1
ll.1
12.1
1~.1
/q.l
GTP 655 (7/95) 0.2
( Companion *
Life*
APPLICATION FOR GROUP LIFE, AD&D,
SHORT TERM AND LONG TERM DISABILITY INSURANCE, VOLUNTARY STD AND LTD
1. FUL~L LEGAL NAME OF~EMPLOYER (as it should aPpear in policy)
2. EMPLOYER'S FEDERAL TAX ID NUMBER
3. ADDRESS Street 50' ¢. (~,-~-4-,~Vd'. ~-~o~ ~.
Ci~ ~~5owv/~ Coun~
4. ADMINISTflATIVE COfl~ESPO~DENCE with the applicant should be ~ddressed to:
Name ~C rr ~d n F I~ (5 Title
5. NATURE OF BUSINESS~
6. REQUESTED EFFECTIVE DATE (12:01 a.m.):
7. PREMIUMS ARE TO BE PAID MONTHLY.
8. Are there subsidia~ or affiliate businesses covered under this plan? ~ Yes
If YES, please state name and nature of each subsidia~ or affiliate:
Telephone Number ( R'/,,~- ) ~ g~' - ~0~'
Area Code
Post Office Box Zip
State _~--~/D/,*//,/,,~ Zip
~' No
Are separate billings required? [] Yes ~ No If YES, please provide billing instructions:
9. Type of Administration: ~ Home Office-administered [] Self-administered
10. Will the requested insurance repJa,,ce existing insurance? ~] Yes [] No If YES, give coverage, name of existing carrier, and
proposed termination date: i¥1~--~poz- ,r~-,,~/ /~-~
11. The normal work week for full-time employees is ~ O hours.
Eligibility: All regular full-time employees working a minimum of ~ hours per week.
(The minimum work week for full-time employees to be eligible for benefits is 30 hours. Employees working less than 30 hours per week
may be acceptable for Life and STD. Contact Companion Life for approval. LTD requires a minimum of 30 hours per week.)
12. The employee waiting period for participation is:
[~,,~lone (effective on next billing date).
[] After days of continuous employment (30, 60, etc.).
[] After months of continuous employment (1, 2, etc.).
13. Current eligible employees are to be covered immediately.
14. Employees hired after the plan effective date are to be covered:
E~First of the month following completion of the waiting period.
[] Fifteenth of the month following completion of the waiting period.
15. Number of Eligible Employees:
16. Number of Enrolled Employees:
17. SCHEDULE OF BENEFITS (If space ~rovided is inadequate, please attach additional page.)
CLASSOEFINITIONS BASIC SUPPLEMENTAL SHORTTERM LONG TERM VOLUNTARY VOLUNTARY
(Describe Below) LIFE/AD&D LIFE/AD&D DISABILITY DISABILITY STD LTD
Percent of Premium Paid by Employer / ~ % % % % % %
11383) Rev. 5/99 COMPANION®
Maximum Monthly Benefit is not to exceed $
Maximum Benefit period will be:
[] To Age 65 (Reducing Benefit Duration)
[] 5 Years
[] 2 Years
Benefit integration will be as follows:
Optional Policy Features to be included are:
[] As specified in the proposal (please attach), or
[] Specified as follows:
oays.
Minimum Monthly Benefit is $
[] Primary and Family Social Security (standard)
[] Primary Social Security
H. Pre-Existing Condition Exclusion: (10-25 Lives)
Standard: 12/6/24 not available in CO, FL, GA, MD, MS, PA, SO, WA, Wl
FL & PA: 3/6/12
Others: 12/12
(26+ Lives) '
Standard: 3/6/12
30. VOLUNTARY LONG TERM DISABILITY BENEFITS [] Yes E~-No
[] Companion Cornerstone Plan
A. Maximum Benefit period will be: [] Two Years/Reducing Benefit Duration or [] Five Years/Reducing Benefit Duration
B. Elimination Period: [] 90 days or [] 180 days
C. All employees receive coverage equal to 50% of their earnings to a maximum monthly benefit of $3,000.
[] Companion Prime Plan
A. Maximum Benefit period will be: [] Five Years/RBD (All Causes) or [] Five Years/RBD for Sickness, Age 65/RBD for injury
B. Elimination Period: [] 90 days or [] 180 days
C. All employees receive coverage equal to 60% of their earnings to a maximum monthly benefit of $5,000.
31. SPECIAL REQUESTS/INSTRUCTiONS:.
PLEASE READ CAREFULLY
Quotations were based on the proposal data submitted to Companion Life. Final premium rates will be determined on the basis of the actual
composition of the group of persons who become insured.
f the 'n't'a deposit is at least equal to the first month's premium, and ~f the requested 'nsurance is acceptable under Companion Life's cur-
rent rules and pract ces nsurance under the terms of the policy shall be effective on the effective date requested. Otherwise, insurance
becomes effective only when a policy is de vered and accepted in writing. In the interim, liability is limited to a return of the original
deposit. Only Comj~anion Life's home office has the authority to guarantee the acceptability of the requested insurance.
32. INITIAL DEPOSIT (Minimum first month's premium is required.): $ ~ ~ ~ I. I ~
33. Are all the employees to be insured for Disabili~ income covered by Workers Compensation? ~ Yes ~ NO
If NO, explain:
34. Have you explained to the employer that an employee not actively at work on the policy effective date will not be covered until such em-
ployee returns to active work full time unless approved in writing by an underwriter or officer of Companion Life?
~ Yes [] No Remarks:
35. Is there another group insurance plan(s) which duplicates any of the benefits applied for with this application that will remain in force
or be placed concurrently with this plan(s)? [] Yes ,~3 No If YES, please describe the benefit amounts and purpose(s) of
this plan(s):
36. Is Agent or Broker licensed in the State of this group for the types of insurance solicited? ¢ Yes [] No
37. To the best of the Agent's or Broker's knowledge, replacement ~;~ is [] is not involved with this transaction.
38. Print name of Agent/Broker ~,,~','~,~¢ ~..~-P~?,E--¢~- ~¢',~¢,'~-- License No.
39. Signature of Agent/Broker.~- ~ ~ _~//~.. _:~-~ Bate
FRAUD WARNING (Not App cable in AZ, FL, MD, 0R, VA): Any person who knowingly and with intent to defraud any insurance com-
pany or other person f es an application for insurance or a statement of c a m containing any materially false information or conceals
for the purpose of misleading, information concerning any fact mater a thereto commits (in TX may be committing) a fraudulent
insurance act, which is a crime and subjects (in KS, which may be determined by a court of law to be a crime which.subjects) such
person to criminal and civil penalties.
FRAUD WARNING (FL only): Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of
claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree.
18. Are there any ineligible classes or divisions? [] Yes [~ No If YES, please describe:
19. Are any eligible employees disabled at this time? [] Yes [] No If YES, please describe:
20. is a Section125 Plan in effect? ~ Yes [] No
Indicate which Companion Life Benefits will be subject to the Section 125 Plan?
[] Life & AD&D [] STD [] LTD [] Dental []Voluntary Life [] Voluntary STD []Voluntary LTD []Voluntary Dental [] None
21. BASIC LIFE AND AD&D BENEFITS reduce as follows (select one):
[] 35% at age 65, 50% at age 70. Benefits terminate when employee is no longer actively at work.
[] 35% at age 65, 50% at age 70, and then 75% at age 75. Benefits terminate when employee is no longer actively at work.
[] 50% at age 70, and then 70% at age 75. Benefits terminate when employee is no longer actively at work.
[] % at age __ and then % at age and then % at age . Benefits terminate when employee is no longer
actively at work.
22. SUPPLEMENTAL LIFE AND AD&D BENEFITS reduce as follows (select one): [] 35% at age 65, 50% at age 70. Benefits terminate when employee is no longer actively at work.
[] 35% at age 65, 50% at age 70 and then 75% at age 75. Benefits terminate when employee is no longer actively at work.
[] 50% at age 70 and then 70% at age 75. Benefits terminate when employee is no longer actively at work.
23. THE REDUCTION SCHEDULES above must be the same as shown in your quotation; otherwise, the rates quoted are subject to review.
24. AD&DBENEFITS J~ Yes [] No
25. BASIC LIFE AND AD&D guaranteed issue amount: $
26. DEPENDENT LIFE BENEFITS [] Yes [] No
A. Spouse Amount: $
B. Maximum Child Amount: $
C.' Coverage for children continues until age
D. Percent of Premiums paid by Employer:
SUPPLEMENTAL LIFE guaranteed issue amount: $
(Cannot exceed 50% of employee's Life amount)
(Cannot exceed 50% of employee's Life amount)
., or to age if a full-time student.
%
27. SHORT TERM DISABILITY (STD) BENEFITS
A.
B.
C.
D.
[] Yes ,~ No
Benefits are payable from day accident and
First Day Hospital Coverage: [] Yes [] No
Full Maternity coverage is included.
(Excludes Occupational injury or sickness)
day sickness for maximum of
weeks.
For Benefits expressed as a Flat Amount, the Maximum Benefit will be the lesser of the Flat Amount or 70% of weekly earnings.
28. VOLUNTARY STD
A.
B.
C.
E.
F.
G.
H.
[] Yes ~ No
In order for a group to enroll in Voluntary STD, an employer-paid Companion Life Group Term Life insurance program must be implemented.
Enrollment minimum of 10 employees or 15% of Group required, whichever is greater.
[] $100 flat weekly benefit, or
[] 60% of weekly earnings to ($100 minimum)
Benefits are payable from first day accident and eiahth day sickness for a maximum of weeks (choice of 13 or 26 weeks).
Full Maternity coverage is included.
A 6/12 Pre-existing Condition limitation applies:
Voluntary STD coverage excludes Occupational injury or sickness.
The coverage is not available if another STD program from Companion Life is in force.
SECTION 1
POLICY EFFECTIVE DATE AND TERM
The Effective Date of this Policy is shown on the Group Application. This
Policy will stay in force for as long as the proper premium is ~aid; however,
either the Policyholder or Companion Life may cancel this Policy on any Premium
Due Date by telling the other in writing at least 31 days prior to such Premium
Due Date.
SECTION 2
ACTIVELY AT WORK PROVISION
"Active, Full-Time Employee" means an employee who performs all of the duties
of his or her job with the Policyholder. This job may be at either:
1. the Policyholder"s normal place of employmentj or
2. at some other place to which the regular business operations of the
Policyholder require that person to go.
"'Full-time", means an employee must be:
1. scheduled to work for the Policyholder at least 40 hours each week; and
2. on the regular payroll of the Policyholder for that work.
"Active work"" is work performed as an active, full-time employee. '"Actively at
work~" means being engaged at active work.
GTP 633 (7/95) 1.1A 2.1
SECTION
DEFINITIONS
"Earnings" means the InsuredWs rate of earnings from the PolicyhoIder in effect
immediately prior to the date a claim begins. It does not include bonuses,
overtime pay and other extra compensation other than commissions. Commissions
will be averaged over the 1Z month period prior to the date a claim begins.
"TotaI Disability" or "Totally Disabled" means any disability that:
1. Segins while this Policy is in force as to the Insured.
Z. Results from injury or sickness.
Prevents the Insured from engaging in any occupation for which he or she is
or becomes quaIified by education, training, or experience.
Requires the Insured to be under the regular care and attendance of a
Iicensed physician.
"Group Application" means the application for this Policy signed by the
Policyholder.
"Schedule of Benefits" means the description of benefits set forth in the
Group Application.
"Insured" means an eligible employee who is insured under this Policy.
"Insured Dependent" means an Insured's eligible spouse and/or child(Pen) who
are insured under this Policy~ if this Policy provides Dependent Life
Insurance.
"The date the Insured retires" or t~retirement~' means the effective date of the
retirement pension benefits under any plan o~ a federal, state, county or
municipal retirement systems, if such pension benefits include any credit
for employment with the Policyholder;
2. retirement pension benefits under any plan which the Policyholder sponsors,
or makes or has made contributions;
retirement benefits under the United States Social Security Act of 1935, as
amended, or under any similar plan or act.
"Physician" means a medical doctor or surgeon licensed to render services in
accordance with the laws of the state where such services are rendered. The
term "physician~' will also include a licensed medical practitioner whose
services are required by law to be recognized on the same basis as if they had
been performed by a Iicensed medical doctor. Such practitioner must be acting
within the scope of his or her license. Physician does not include the
Insured; or a member of the Insured's immediate family (spouse, daughter, son
father, mother, sister, or brother).
GTP 633 (7/95) 3.1
SECTION q
TERM LIFE INSURANCE BENEFIT
If an Insured dies while insured under this Policy, Companion Life will pay
the applicable Life Insurance Benefit shown in the Schedule of Benefits.
Part 1
CONTINUATION OF BASIC TERM LIFE INSURANCE BENEFIT_
DURING TOTAL DISABILITY
EXTENSION OF BASIC TERM LIFE INSURANCE BENEFIT
In the event of termination of employment, a death benefit will be paid if the
Insured dies while Totally Disabled provided that the disability:
I. began while the person was both insured under this Policy and under age 60;
and
2. has been continuous until death; and
3. began within I2 months of the date of death.
WAIVER OF BASIC TERM LIFE INSURANCE PREMIUM BENEFIT
If an Insured becomes Totally DisabZed, prior to age 60, Companion Life will
waive premium for the Basic Term Life Insurance Benefit. The waiver of premium
will began on the first of the month following 12 consecutive months of Total
Disability. The Insured must file written notice within IZ months after the
date of Total Disability to be eligible for this benefit.
With respect to the Insured, this Waiver of Premium Benefit shall end on the
earliest of the foIlowing=
1. on the date the Insured~s Total Disability ends;
on the 91st day after Companion Life requests proof of continuous Total
Disability~ provided the Insured fails to furnish Companion Life with such
proof during such 9] day period;
3. on the Premium Due Date immediateIy prior to the Insured~s 65th birthday;
on the effective date of any individuai life insurance policy obtained in
accordance with Part 2, Right to Convert;
5. on the date the Insured retires.
AMOUNT OF BASIC TERM LIFE INSURANCE BENEFIT CONTINUED
The Basic Term Life Insurance Benefit which is continued during Total
Disability is the applicabIe amount of Basic Term Life Insurance in force as to
the Insured on the date such Insured~s Total Disability begins (subject to any
reductions shown in the Schedule of Benefits).
This Continuation of Basic Term Life Insurance Benefit During Total Disability
does not appIy to the Accidental Death and Dismemberment Benefit.
GTP 655 (7/95) ~.!
Part 2
RIGHT TO CONVERT
If an Insured is no longer eligible for part or all of the Life Insurance
Benefit provided by this Policy, such Insured is entitled to apply to Companion
Life for an individual policy of life insurance, without submitting evidence of
insurability provided:
The policy applied for:
A. is a type of individual life policy, other than term or universal life~
then being issued by Companion Life; and
does not include Accidental Death and Dismemberment, Short Term
Disability or other Supplemental benefits; and
2. The amount of life insurance applied for under such individual life policy
is in accordance with the Amount To Convert provision below; and
The Insured agrees to pay the premium for such individual life policy. The
premium will be based on the following, as of the effective date of such
individual life policy:
A. Companion Life's usual rate for the amount and type of individua! life
policy;
B. the Insured"s attained age; and
The Insured applies and pays the first premium for such individual life
policy within 31 days following termination or reduction of the Life
Insurance Benefit under this Policy. Such individual life policy ~ill
become effective on the first day folloNing the end of such 31 day period.
AMOUNT TO CONVERT
This conversion privilege is allowed for the Term Life Insurance that ceases as
described in items i. and 2.
The Insured may convert all or part of the amount of Life Insurance Benefit
the Insured is no longer eligible for due to:
A. reductions resulting from attainment of a specific age, as shown in the
Schedule; or
B. loss of the individual eligibility.
GTP 6~5 (7/95) 9.2
If the Insured has been insured under this Policy for at least 5 years, the
lesser of Ghe amounts shown in (i) or (ii) below may be converted if the
Insured is no longer eligible due Go:
A. termination of this Policy~ or
B. termination of the class of Insureds to which the Insured belongs~ or
C. reduction of benefiGs for Ghe class of Insureds to which the Insured is
a member.
(i)
(ii)
~10,000.00, or
All or parG of the amount for which the Insured is no longer eligible.
This amounG will be reduced by the amount of any life insurance for
which Ghe Insured becomes eligible to receive under a group policy
issued or reinsGated by Companion Life or any other insurer during Ghe
thirGy-one day period immediately following GerminaGion of insurance
under Ghis Policy.
If Ghe Insured dies during Ghe conversion period the maximum amount of Term
Life Insurance which the Insured would have been entitled Go have issued shall
be payable as a claim under Ghis Policy; whether or not application for the
individual policy or Ghe payment of Ghe first premium has been made.
The rights or benefits granted under Ghis provision are in lieu of any other
rights or benefits granGed under Ghis Policy.
ParG 3
SUICIDE EXCLUSION
With respect Go the Life Insurance Benefit, in Ghe event an Insured, while sane
or insane (in Missouri while sane), dies from inGenGionally self-inflicted
injuries or any attempts thereaG, within two years from the effective date of
coverage, Companion Life's liability shall be only to return premiums paid
under this Policy as Go such Insured.
The Suicide Exclusion will nog apply Go Ghe Insured who:
1. is actively at work on Ghe effective date of this Policy; and
2. was insured for Group Life Insurance under Ghe prior carrier's policy on
its termination daGe.
GTP 633 (7/95) ~.3
Part q
THE ACCELERATED BENEFITS PROVISION
THE BENEFIT
The Insured with a medically determined terminal conditEon would be elEgEble to
receive the foilowing accelerated benefit:
Fifty percent (5OX) of the Basic Term Life Insurance benefit in effect on
the InsuredWs last day of active work up to a maximum Ensured amount of
~lOOjOOO. The maximum payable under thEs benefit is $50,D08.
An "Accelerated Benefit" covered under this Policy Es a benefit payable;
to the Insured. If, during hEs or her lifetime, the Insured sustains a
termEnal conditEon, as defined in this provisEon, the Insured or his or her
legal representative may request a lump-sum accelerated death benefEt
payable once during the lifetime of the Insured, and
Z, which reduces the death benefit otherwise payabIe under this PolEcy, and
which is payable upon the occurrence of a single quaIifyEng event whEch
results in the payment of a benefit amount fixed at the tEme of
acceleration.
TAX TREATMENT
BenefEts paEd under thEs provisEon may be taxable. The Insured or his or her
benefEcEary may incur a tax obIEgatEon. As with ail tax matters, an Insured
should consuit with his or her personaI tax advEsor and/or attorney.
DEFINITION OF TERMINAL CONDITION
"Terminal ConditEon" means that the Insured has a medically determinable
condition with no reasonable prospect of cure, whEch can be expected to resuit
in death wEthin IZ months of the date of disabElity. The proof of TermEnal
ConditEon satisfactory to Companion LEfe must be certified by the Insured's
attending physician and one other physician.
CompanEon Life reserves the rEght to have the Insured examined at its expense
by one or more physEcians of its choice in connection with a request for
AcceIerated Death BenefEt for TermEnai ConditEon.
GTP 653 (7/95) ~.~
ELIGIBILITY REQUIREMENTS
Aii eIigible actively at-work fulI ~ime employees who have been covered under
the Basic Term Life Insurance are eIigibie for ±he Accelerated Benefit. The
benefi~ terminates at ~he earlies~ of:
l. when the Insured's Basic Term Life ~erminates, or
2. a~ attained age 76, or
a~ retirement from employment.
In order to be eIigibIe for this benefit, the Insured mus~ have been
continuously covered for a~ Ieast one year under this Policy prior ~o
sustaining a terminal condition, or covered under this Policy from ±he PoIicy
Effective Da~e.
EFFECTIVE DATE OF THE ACCELERATED BENEFITS
The Accelerated Benefi~ provision shall be effective for accidents on the
PoIicy Effective Date. The Accelerated Benefit prevision shall be effective
for illness thirty (30) days FoIlowing the PeIicy Effective Date.
EXCLUSIONS AND LIMITATIONS
The Acceiera~ed Benefit wiI1 not app[y:
1. ~o any self-inflicted injuries or suicide a~tempts~
~o any Supplemental Term Life Insurance benefits, incIuding Dependent Life,
nor to any Accidental Death and Dismemberment benefi~s~
if an Insured is totally disabled on his or her Effective Date of coverage~
4. to a Basic Term Life Insurance benefi~ that has been assigned;
S. ~o a Basic Term Life Insurance benefi~ payable ~o an irrevocabIe
beneficiary;
6. ~o a Basic Term Life Insurance benefit with a face amount of less than
~lO,OOO;
7. if ~he required Basic Term Life Insurance premium is due end unpaid.
GTP 633 (7/95) ~.5
CONVERSION
The amount of Basic Term Life Insurance that may be converted is ~he Insured's
Basic Term Life Insurance reduced by ~he Accelerated Benefi~ amoun~ paid.
REDUCTIONS
If a benefit reduces in accordance with a reduction provision the ~o~al amount
payable to ~he Insured wil] no~ be affected by the advanced payment.
FREQUENCY
Only one Accelerated Benefi~ paymen~ will be made to an Insured
TERMINATION
This provision will ~erminate for the Insured on the earliest of the following
da~es:
I. the date the Policyholder ~erminates coverage under ~his Policy;
2. the date this Policy terminates;
the da~e the Insured retires;
the date the Insured dies~
5. the da~e the Insured receives an Acceierated Benefit payment~ or
6. the date the Insured continues coverage under the Conversion Provisions
~his Policy.
GTP 65S (7/95) ~.6
SECTION 5
Part
ACCIDENTAL DEATH AND DISMEMBERMENT BENEFIT
If an Insured suffers any of the following losses, Companion Life will pay the
indicated percentage of the Principal Sum, provided such loss:
resuits from injury and independently of all other causes, which injury is
caused by an accident that occurs while this benefit is in force as Ko the
Insured; and
2. occurs within 90 days of that accident. The Principal Sum is shown in the
Schedule of Benefits.
Loss of Life
Loss of Both Hands or Both Feet
Loss of Entire Sight of Both Eyes
Loss of One Hand and One Foot
Loss of One Hand and the Entire Sight of One Eye
Loss of One Foot and the Entire Sight of One Eye
Loss of One Hand or One Foot
Loss of Entire Sight of One Eye
100%
100%
100%
100%
lOO%
100%
50%
50%
1. with reference to hand or foot, complete loss of the use of the hand, or
foot; and
2. with reference to eye, irrecoverable loss of the entire sight thereof.
If the Insured suffers more than one of the above losses as a result of the
same accident, the benefit provided under this provision will be paid oniy for
the greatest loss,
If loss of Life results while an Insured was riding as a fare-paying passenger
in or upon a public conveyance being opera,ed by a licensed common carrier for
passenger service, the Accidental Death benefits provided under the Policy wilI
be increased. The additional benefit payable will be the lesser of:
1. 100% of the Principal Sum shown in the Schedule of Benefits; or
2. ~100,000.
GTP 6~5 (7/95) 5.1
ACCIDENTAL DEATH AND DISMEHBERHENT BENEFIT EXCLUSIONS
This Policy does not provAde bane~A~ ~r any ibS~ caused by or resu[tAng from:
I. Declared or undeclared war or any act of war;
ServAce in the armed forces of any country or international authority;
SuicAde or intentiona[Zy seIf-AnflActed injury whether the Insured was sane
or insane (An HAssourA whale sane) at the time of the suAcide or Anjury;
Flying in an aArcraft owned, operated~ leased or chartered by the Po[Acy-
hoider;
5. PartAcipatAon An, or in consequence of having partAcApated An, the
commAssion of any felony;
6. Sickness or dAsease, ptomaAne or bacterial infectAon (except Anfect~ons
occurrAng through an accidental cut or wound);
7. Intentionally taking a narcetAc, drug, barbiturate, hallucAnogenic drug,
alcohol er any combination of these ~hen not part of a profess&onal medAcal
treatment plan.
The Accidental Death and DAsmemberment BenefAt As not available to Insured
Dependents.
Part 2
SEAT BELT BENEFIT
The Accidental Death benefits provided under this PolAcy NAIl be increased if,
as a result of driving or rAdAng An a prAvate passenger automobile, the Insured
dies as a result of an automobile accident.
The addAtAonal benefAt payable NAIl be the Iesser of:
1. lOOZ of the Principal Sum shown An the Schedule of Benefits; or
2. ~10,000.
GTP 655 (7/95) 5.Z
CONDITIONS
Companion Life must receive proof that:
1. the Insured was insured for Accidental Death and Dismemberment benefits
under this Policy; and
according to the official vehicle accident reportj the Insured was wearing
a properly installed seat belt or lap and shoulder restraint, or any other
National Highway Traffic Safety Administration approved restraint at the
time of the accident.
EXCLUSION
This additional benefit will not be paid if:
1. the Insured was driving while impaired by alcohol or drugs; or
2. the driver of the automobile in which the Insured was riding was driving
while impaired by alcohol or drugs.
DEFINITION
A "private passenger automobile"~ is a four-wheel private passenger car, station
wagon~ vanj truck or jeep-type automobile. It is not:
1. a taxi, bus or any other vehicle being used for public conveyance;
Z. used in off-road activities; or
3. used in testing racing or endurance contests, either amateur or
professional.
Part 5
PAYMENT OF BENEFITS
Upon receipt of due proof of loss, the Accidental Death and Dismemberment
benefit will be paid to the [nsured, if living; otherwise, to the beneficiary.
All Claim Provisions and Beneficiary and Settlement Provisions apply to this
coverage.
GTP 655 (7/95) 5.5
SECTION 6
DEPENDENT LIFE INSURANCE BENEFIT
NOT PROVIDED
GTP 653 (7/95) 6.1
SECTION 7
BENEFICIARY AND SETTLEMENT OPTIONS
Part 1
BENEFICIARY DESIGNATION
The beneficiary or beneficiaries of an Insured shall be that person or persons
indicated on the Insured's individual application for insurance. This
application will be filed with the PolicyhoIder. The beneficiary of an Insured
Dependent, if this Policy provides Dependent Life Insurance, shall be the
Insured.
Part 2
CHANGE OF BENEFICIARY
Unless the Insured has made an irrevocable assignment of benefits, the
beneficiary may be changed by sending a written request to the Home Office of
Companion Life. When such request is received by Companion Life, the change of
beneficiary shall take effect as of the date of execution of the written
request~ but without prejudice to Companion Life on account of any payment
previously made by Companion Life.
Part
CONSENT OF BENEFICIARY
If the Insured does initially name the spouse as beneficiary, Companion Life
will require written consent of the spouse to name or change the beneficiary in
community property states.
Part
PREFERENTIAL BENEFICIARY
If the Insured has died and no beneficiary is living or named, Companion Life
may, at its option, pay the benefits to the Insured~s estate or to the
following surviving relatives of the Insured:
The Insured's:
1. Spouse;
2. Child or Children~
Parent(s);
Brothers and sisters; or
5, Executors or administrators.
Companion Life w/il not be liable to the extent of any payment so made, unless
it receives written notice of a vaIid claim by some other person before payment
is made.
GTP 633 (7/95) 7.1
Part 5
MINOR BENEFICIARY
If the beneficiary is a manor or, An the opinAon of Companion Life, is not able
to give valid release for any payment due~ CompanAon Life may~ at Ars optAon
and until claim As made by the duly appoAnted guardian, pay the benefAt to the
person or entity who appears to have assumed the care and support of the
beneficAary. Benefits An thAs event will be made in monthly payments of not
more than $50 each.
Companion LAfe wall not be liable to the extent of any payment so made in good
faith.
Part
MORE THAN ONE BENEFICIARY
If the Insured named more than one benefAciary~ the applAcable amount of
insurance shall be paid to the beneficiaries who survive the Insured~ in equal
shares, unless the Insured has specifAed a dAfferent proportion.
Part 7
NO BENEFICIARY
If the beneficiary predeceases the Insured or if the Insured does not designate
a beneficAary, then the applicable amount of life insurance will be paid to the
estate of the Insured.
Part 8
SETTLEMENT OPTIONS
An Insured may elect or change a settlement optAon by filing a written request
with Companion Life. The settlement options available will be those offered by
CompanAon LAfe when the option is chosen. If an Insured does not request a
settlement optAon, the beneficiary may do so after the Insured's death.
GTP 653 (7/95) 7.2
SECTION 8
1.
ASSIGNMENT
The Insured may make an irrevocable assignment of ~nterest under this
Policy. The assignment=
A. must be made in Nr~t~ng an a form approved by Companion Life;
B. must be an absoIute assignment that transfers all rights except those
of an ~rrevocabIy named beneficiary; and
C. must not be a collateral assignment.
Assignment of interest conveys aZI r~ghts of ownership. These include the
r~ght to change the beneficiary, receive payment of c~aims and assign the
insurance.
Companion Li~e is not responsible for the validity or results of the
assignment.
GTP 6SS (7/95) 8.1
SECTION 9
SHORT TERM DISABILITY BENEFIT
NOT PROVIDED
GTP 63~ (7/953 9.I
SECTION 12
WHEN INDIVIDUAL INSURANCE ENDS
The insurance will end with respect to an Insured on the earliest of the
following:
1. When this Policy is cancelled;
2. When the insurance is cancelled for the class of insureds to which the
Insured belongs;
The beginning of the period for which premium is not paid as to the
Insured;
The date the Insured is no longer actively working on a full-time basis in
any class or classes insured under this Policy; unless (and only with
respect to the Basic Term Life Insurance Benefit, if provided by this
Policy) the Continuation of Basic Term Life Insurance Benefit During Total
Disability applies.
SECTION
PREMIUM PROVISIONS
PREMIUM PAYMENT: Premiums are payable at ~he Home Office of Companion Life on
or before each premium due date.
PREMIUM DUE DATE: The first premium will be due on the Policy effective date
and on the same day of each subsequent month unless the Policyholder and
Companion Life agree on some other method of premium payment.
CHANGES IN PREMIUM RATES: The monthly premium rates may be changed by
Companion Life from time to time if it gives the Policyholder at least 31 days
advance written notice. No such change will be made until 1Z months after the
Policy Effective Date except when the Policyholder requests it.
INCORRECT PREMIUM PAYMENT: Premiums paid in error for a person who is not
eligible to be insured will be refunded without interest when requested by the
Policyholder. These premiums will not be refunded for any period before the
last Policy anniversary date.
GRACE PERIOD: If, before any premium due date except the first, the
Policyholder has not given written notice to Companion Life that ~his Policy
is to be terminated, a grace period of 31 days will be given in which to pay
the premium then due. This Policy will stay in effect during that time. If
any premium is not paid by the end of the grace period, this policy will
automatically terminate at the end of the grace period; except that if the
Policyholder has given written notice in advance of an earlier date of
termination, this Policy will terminate as of the earlier date.
GTP 633 (7/95) 12.1 ~ 13.1
SECTIO~ 10
CHANGE OF CLASS OR EARNINGS
If a change in an Insured"s class or earnings would increase the amount of the
benefits entitled to be received under this Policy, such increase in benefits
will become effective on the Premium Due Date following such change, provided:
1. Notice of the change is given to Companion Life within 30 days of the
change.
2. Such increase in benefits does not exceed ~he Guarantee issue Amount,
stated in the Group Application.
If notice is not given within the required time or the increase in benefits
would exceed the Guaranteed Issue Amount, stated in the Group Application, such
increase in benefits:
1. Hus~ be approved by Companion Life; and
2. Will become effective on the Premium Due date following Companion Life's
approval.
If the Insured is not at work full-time due to injury or sickness on the date
an increase in benefits is due to begin, such increase in benefits will not
begin until the Insured returns to fulI-time work.
If a change in an Insured's class or earnings would decrease the amount of
benefits entitled to be received under this Policy, such decrease in benefits
will become effective on the Premium Due Date following the change.
SECTION 11
WHEN INDIVIDUAL INSURANCE BEGINS
To become insured, eligible employees must make written application to
Companion Life. Coverage wiZl begin on the Premium Due Date, shown in the
Group Application for benefits, following ~he date Companion Life approves the
application. Companion Life may require evidence of insurability before
approving ~he application.
If an eligible employee is not at full-time work due to an injury or sickness
on the date insurance is due to begin, it will not begin until return to full-
~ime work.
GTP 633 (7/95) 10.1 & 11.1
SECTION
GENERAL POLICY PROVISIONS
ENTIRE CONTRACT: This Policy, with the Policyholderts Application, the
individual applicationsj if anyj and Amendments~ if any~ is the entire contract
between the Policyholder and Companion Life. Ail statements made by the
Policyholder or the persons insured wiii be deemed representations and not
warranties. No change in this Policy will be valid until approved by a
Companion Life officer. This approval must be endorsed on or attached to this
Policy. No agent may change this Policy or waive any of its provisions.
INCONTESTABILITY: The validity of this Policy may not be contested, except for
nonpayment of premium~ after it has been in force for two years from its
Effective Da~e. No sta~emen~ made by an Insured may be used ~o reduce or deny
a claim or to contest the validity of the insurance unless ail of the
following are true:
1. The insurance has been in effect for a period of two years or less.
2. The statement is in a written instrument signed by the Insured.
copy of the written instrument has been given to the Insured or the
Insured"s beneficiary.
POLICY REINSTATEMENT: In the event that this Policy is terminated because
premiums were not paid within the grace periodj Companion Life may reinstate
this Policy at its sole optionj and may charge an additionai reinstatement fee
if it wishes to do so. If Companion Life does not elect to reinstate this
Policy~ it is not required to do so.
NOTICE OF CLAIM: Written notice of claim must be given within 30 days after a
covered loss begins, or as soon as reasonably possible. The notice may be
given to Companion Life at P.O. Box IOOZOZ, Columbia, SC 29Z§Z. Notice should
include information which identifies the Insured or Insured Dependent and this
Policy.
CLAIM FORMS: When Companion Life receives notice of claim, forms for filing
proof of loss wiii be sent to the claimant. If these forms are not sent
within 15 days, the claimant will meet the proof of loss requirements if,
within 90 days after the loss began, he or she gives Companion Life ~ri~ten
proof of the nature and extent of the loss.
GTP 633 (7/95) 14.1
PROOFS OF LOSS: Written proof of loss must be given to Companion Life
90 days after the loss begins. Companion Life will not deny nor reduce any
claim Af At was not reasonably possible to give Companion Life such proof in
the time required. In any event~ proof mus~ be given to Companion Life
I year after it is due~ unless the claimant is legally incapable of doing so.
Companion Life has the righ~ to require proof of the continuance of total
disability at any ~ime during the first two years after receipt of initial
proof of ~otal disability; and thereafter~ once a year.
PAYMENT OF CLAIMS: Benefits provided by this Policy will be paid ~o ~he
beneficiary determined in accordance with Section 7 of this Policy, entitled
BENEFICIARY AND SETTLEMENT OPTIONS.
TINE OF CLAIR PAYMENTS: Shor~ Term Disability Benefit claims (if this Policy
provides a Shor~ Term Disability Benefit) will be paid weekly as of ~he dates
required, Claims for other benefits wall be paid no~ more than 60 days al±er
receip~ by Companion Life of written proofs of loss.
PHYSICAL EXAMINATIONS AND AUTOPSY: Companion Life at its own expense will have
the righ~ and opportunity to have ~he Insured examined as often as reasonably
necessary while a cIaim is pending. Companion Life at its own expense may have
an autopsy made (during ~he period of contestabAlity)~ unless prohibited by
law. If ~he Insured fa/Is ~o submA~ proof of con±inuAng Total Disability when
required; or fails ~o be examined medically when required, no further benefit
wall be provided for that Total Disability.
LEGAL ACTIONS= No legaI action may be brought ~o recover on ~his Policy before
60 days after written proof of loss has been ~urnished~ as required by this
Policy. No such action may be brough~ after 6 years from the ~Ame written
proof of loss is required to be furnished.
NON-PARTICIPATION: This Policy will not share in any earnings of Companion
Life.
MISSTATEMENT OF AGE: If an Insured's or Insured Dependent's age has been
mAssta~ed~ benefits payable for such Insured or Insured~s Dependent wall be
what the premium paid would have purchased a~ the correct age. This benefit
wall be subject to the applicable Policy maximums.
EMPLOYEE ELIGIBILITY: Active full-time Employees of the Policyholder
(Employer) who:
1. are in a class of employees de,ermined by conditions of employment, which
is agreed upon as eligible by ~he Policyholder and Companion Life; and
have been continuously employed during ~he minimum service period, as shown
in the Group Application, immediately preceding ~heir individual effective
da~es of insurance.
Full-time means regularly working a minimum of ~0 hours per week at ~he
Policyholder's usual and customary place of business for each employee.
GTP 6~ (7/95)
DUAL COVERAGE PRECLUDED:
No person may be insured under this Policy as:
1. A dependent of more than one employee; or
2. BoGh an employee and a dependent,
EXAMINATION OF POLICYHOLDER'S RECORDS: Companion Life will be allowed to
examine the records of Ghe Policyholder relaGAng to this Policy. This may be
done at any reasonable GAme up Go 2 years alger the cancelIaGion of this
Policy, or until seGtlement of all claims~ whichever As later.
CERTIFICATES: Companion Life wall issue a Certificate of Insurance for each
Insured. It will describe:
1. The benefits Go which an Insured (or Insured Dependent, if this Policy
provides Dependent Life Insurance) As entAGled under this Policy;
2. To whom such benefits are payable; and
The 1imitaGions and requiremenGs of this Policy.
ERISA: If Ghis Policy is an integral part of an employee welfare beneffG plan
subject to Ghe provisions of the Employee Retirement Income Security Act of
1974, as amended (ERISA)~ Companion LAfe is a claim fAducAary. As claim
fiduciary~ Companion Life shall have Ghe discretionary authority to determine
eligibliGy for benefiGs and Go consGrue Ghe Germs of that parG of Ghe ERISA
plan represented by this Contract. Any judicial review of a decision of
Companion Life shall be conducted under the arbAGrary and capricious sGandard
of review wAGh deference given Go Ghe claim fiduciary~s decision.
SPENDTHRIFT CLAUSE: To the extent allowed by law, no benefit of the Policy is
subjecG to the claim or legal process of a creditor of an Insured or a
beneficiary.
RECORDS AND ESSENTIAL DATA: The Policyholder will keep a record o~ all
Insureds. This record will contain all o~ the data that is specified by
Companion Life.
CONFORMITY WITH STATE STATUTES: Any provision o~ this Policy which, on its
Effective DaGe, is in conflict with Ghe laws of the stage An which this Policy
is delAveredj As amended to conform Go Ghe minimum requirements of such laws.
GTP 633 (7/95) lq.3
,pOLICY TERNINATION: The Policyholder may terminate this Policy by giving
CompanAon LAfe at least 51 days prior ~rAtten notice.
Companion Life may termAnate thAs Po[icy as of any premAum due date by givAng
at least 31 days advance wrAtten notice to the PolAcyholder Af any of the
following occurs:
1. If on a non-contrAbutory plant less than lOOZ of the elAgible employees
are insured under this Policy.
If on a contrAbutory plan, less than 75Z of the elAgAble employees are
insured under this PolAcy.
5. If less than 15 eligAble employees are Ansured under this Policy.
4. If less than the mAnAmum required by la~ are Ansured under this Policy.
CompanAon LAfe may terminate this PolAcy at any time after At has been in
effect for 12 months by givAng advance written notice to the Policyholder.
Termination ~ill take effect on the later of the date stated in the notice or
~l days ~rom the date of mailing such notice.
The PolAcy ~All terminate at the end of the grace period Af premiums have not
been paid by that date.
ALLOCATION OF AUTHORITY: Except for those functAona which the Policy
specAfically reserves to the Policyholder, CompanAon Life has full and
e×clusAve authorAty to control and manage thAs PolAcy, to admAnister claims
and to Anterpret this Policy and resolve all questions arAsing An the
adminAstration~ interpretation and applAcatAon of thAs PolAcy.
Companion Li~e~s authorAty Ancludes, but is not limAted to:
1. The right to resolve all matters when a revAew has been requested;
The rAght to establish and enforce rules and procedures for the
admAnistration of the group polAcy and any claims under Atj and
The right to determine:
A. eligibility for Ansurance;
C. the amount of benefAts payable; and
the suffAcAency and the amount o~ informatAon Companion Life may
reasonably requAre to determine A~ ~ or C above.
Subject to the review procedures o4 the group policy, any decision CompanAon
Life makes in the exercAse of thAs authority is conclusive and binding.
GTP 655 (7/95) 14.4