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HomeMy WebLinkAbout98-00437 Z 332 854 95': US Poslal SOIVlca Receipt for Certified Mail No Insurance Coverage Provided. . 00 nol use for Inlernatlonal Mall SOB reverse S.etaire M. Ball Sir", & Number ureat-West P,O.Box 2 47 pon~~.i:1~,:~PCod(h 06101-83 2 Postage $ 1 . 47 Certified Fee 1. 35 Special Delivery Fr.e Restricted OeHvery Fee on m Retum Receipt 5howilg 10 1 10 - Whom & 0,1. Ooiyored ' 'c Reo.m Rae'" 5>owilg ~ """"'. -2' O,~,&Ad<i"""'IAd<i... g TOTAL POslag. &Foos $ 3 . 92 CD C') Postmam or Dale E ~ January 26. 1998 In Q, {.....;..:,.. ,.:.,.....,f'....~." . t: ~. CornpIItt:.:em. 1 and/Ol 2 fOl additional Hf\Ik:... . .. , ,. Complet.1ttfnI3.,~4~.&b.; I I! . "llil:'~." 'Ii I . Print youfnam. and add,... on the reYI,.. ofthla'fonn 10 thet WI Cln I . retumthltCltdtoyou. -, ...../.-; "e .. Attach thII form to lhe ftont 0' the mallp'lc.. 01 on th4l.b.ck It .~C. 'doe. not permit. ," _ ", .'>, .' -I' .., Write '''ftICumRtctlpt RaqUllted" on the mtllplece belOw the .rtle" number . The Return Recefptwitl.how to whom the Irtk:1e WI' dtllvertd and the dill , 8, do've<Od,' ,", .. ,.. ' 'll 3. Artl,cl.Ad~ralSad to: , ,.ll Ms;'Claire M, Ball l sen,iorBenefit Manager 8 , Great-l-lest Group Disability Benefits P:O. Box 2847 Hartford; CT 06101-8382 -' II: Q !i "l.' , ';1'1 it j( j, I,~' 4b. S.rvlc. Typ. o Ragl.tor.d 0 In.ur.d I KID C.rtlfl.d DO CROD R I 1",: Expr... M.II .lUrn ec. pt for 1 7. Oat. of D.I"J!N 2 9 1998 ,1; 8., Addr.ss, .a'. Ad, dr...IOnly If requ..t.d J ; and fa. I. paldl ',', ."! u :, ,. I, ~! \ HIP i! i i! l' ' <" I I 1 ~ \ Ii!! \ ! .~ \ \';, I I;' I , t 1 I ',j " I .1.0 wish to recilv. th. following IIr:vJCII (for \ en' e,etr. f8e):i 1,11.1! i 1,,1\.). "" 1, 0 Addr....... Addre.. , ,2. 0 R..Ulctod D'lIv,ry , Consult oatmeater for fee. 4a. Artlcl. Numb.r Z 332 854 959 i il! 5, Signal . I ~ 8, Sign ur. I'R {\\ I I ' >- PS Form I.!I 1--..z.714 DOMESTIC RETURN RECEIPT' :,1 J , . i}{:;"P',.,';/' ",'", ~j~~\, f'}1~~::':! ~, ;!;\:;!j}("~i~< ff: ~;>l{t~g>- ,n......' ,~,) :,:{,~: 0:' t..O ,':I,t'.:',:~(\ - p.;-t. N l;:'_~;~;;';t> - '(!{". - .J~~:l~~ ,-.;7;\~I'~is~,.';:" c' ,-;.". .' . ....,.~.. __ " :. .i.."(,:,:; -, <: '.,;,- ,. . i~~:r~;,;:!(': : ~~~):;W;?~;::'.., IlJ ~ yel:.<'/."::' ~,~" .J:l<CII.',"" ',"" '1:: }~~".:::l' ~Wi ',:tEl,' : E-I tit "O..~'~~ ,~("~,~;JH (i !,~~,,~ r ' ,\",.0,,:10, ~ ~ '~~P!':~{. !j;;~;8E-1: ,::',1: - //', , .,U-'-" ~~4 ;.f;'(.-~ I " ~~~r~"fzl ~ '.:i~, .. ::>Zl" ,~.f.' .S ,','- :r"ii .~Z'I-I;""-" r;"" 0 . 1~\T.ii . :.l::': ,; ,:.;-~; ci' \ , ' . . E;' /. " , -'j '8~ ;is ;!.. ~ P..::J A~ ffi$ COo.. ' 9 (,) , , '::' ~.:tl -U-M ,0'+1 ,..u:: ~.r..f. , "', ,,':- r-I ...,p.. ~'"" ',0 '1.'," ", ;, ~. , it ~ ~ . ~'~ J ~\~ M , ~ ~ ~ ( ~ ~ ~ tl ~~ H fzl+l :s ~~ s:: ~ ~o~ E-IUS:: U rJlfzlGl ::- !31u~ ~i~ ; . .. ...::l " (\I) " ,~ \ ~~f~.-/'j iil j,''''i'~:.:''"..'; 1:1:I ..,' ': ~",' "'~' ,~'o;~: ,,~~""1 ;: "~ ~",", ,,.... ~;:J , ~J .. .f .. .' -- 'C-onr"d"r"lIon l" " . . ---- .'~. ;.:'~. .' o TABLE OF CONTENTS REPLACEMENT Of COVERAGE. . . . . . . . . . . , . . . . . . . . . . . . . . . . . , . , . . . . . . . . . . . " 1 DEFINED TERMS ..............,.............................,.",...,... ,,2 STAND^:RD PROVISIONS . . . , . . . , , . . , . . . , . . . . . . . . . . ... . . . . . . . . . . . . . . . . . . . . " 4 PREMIUMS ....,.............."...,.,..........................,....... 6 ELIGffiILITY FOR INSURANCE. . . . . . . . . , . " . . . , , . . . . . . . . . . . . . . . . . . . . . . . . . . . " 7 . , EFFECTIVE DATE OF INSURANCE. . . . . . . . , . . . . . , , . . . . . . . . . . . . . . . . . . , . . . . . . " 8 INSURING PROVISIONS .............."..,.....,...,......,.,..,;.."...., 9 SCHEDULE OF BENEms , . , . . , , . . , , , . , . . . . . . . . , . , . . . . . . . . . . , . . , . , . . . . . . " 13 PAYMENT OF BENEmS ......,."......,..,.,........,............ .'...., 17 TERMINATION OF INSURANCE,. .., .... .. " '.., '... ~... .',... , , '. '" ....,. " 18- CLAIM PROVISIONS. , , . , " '" . ..,..,. '" ..,. , '" , " , '" . , .. " . ,. . .,.. '" 19 CONDITIONAL CLAIM PA YMENTS ,.,',.".,',.......,.........,."..,..... 20 I 1/ -- C2!!LC.!.!~!!!.!.!2.n L1(<.!' , . :' .~: ....:;.;:~;'::;. DEFINED TERMS -. In thls Policy when the following defined tenus and elher terms which are defincd throughout Ihc Policy begin with a capitallctlenhcy will be Interpreted as dcfincd: if lhe same term is used In thls Policy but begins wilh a srnallletler. thc term will be llIterpreted as defined in ~ standard dictionary, Emplor.er, TIle tenn Employer means Ule Policyholder and all Affiliated Employcrs shown In lhe "Eligibility For Insurance" section, Employee. Thc term Employee means a regular full.time or pan-time employec of thc Employer If that Employee is legally domiciled in lhe United States, It does not include lhose who work less lhan 20 hours a week for the Employer. lhose who are employed on a temporary basis, or lhose whe are not compensated. Aetively.at,Work, An Emplor.ee will be considered to be Actively.at.Won: for the Employer on a day which is ene of the Employer s scheduled work days if: 1) hc is ~rforming all of the regular duties of his work for lhe Employcr lhat day on a full.time basis If he is a full-time Emp1eyee or on a part.time basis if he IS a part-timc Empleyee; and 2) he is at one of the Employer's places of business or at some location to which lhe Employer's business requires him to travel. An Employee will be deemed te be Actively.at,Work on a day which is not one of the Employer's scheduled won: days if he was Actively.at.Won: on lhe preceding scheduled work day. Earnings. The term Earnings has the following meanings: 1) With respect to coinmissioned Employees, monthly Earnings means the Employee's total earnings from lhe Employer for Ihe penod of 12 censecutive months ending on lhe preceding August IS, divided by 12. , If the Employee did not work for lhe Employer in his current class (full-time or pan.time) for that entire 12-month periOd or if lhe Employee did not work for the Employer on lhe preceding AUllUst 15. monthly Earnings will be !he Employee's target earnings as deteonined by the Policyholder and reported to !he Insurance Company, 2) With respect 10 other Employees. Earnings means the Employee's rate of pay as of lhe preceding August IS for his normal work week on lhat date, If lhe Employee did not work for the Employer in his current class (full-time or pan.time) on the preceding August IS, Earnings means his rate of pay for his nonnal won: week as of the date he was first employed by the Employer In that class. Any hours WOrked In excess of 40 will not be counted as part of a nonnal work week. Earnings wili not include bonuses. commissions, overtime or any other additional pay. Monthly Earnings will be determined by dividing 3Mual Earnings by 12, The amoum of Earnings for any Employee will be !he amount reponed 10 the Insurancc Company by the Employer and validated by the Insurance Company, Plan Year. The teml Plan Year means a calendar year, The first Plan Year begins on January J. 1993. Benefit Selection Per/ed. The term Benefit Selection Period means an 3Mual period, October 1st throuJ(h October 31sl, during which Employees have an oPponuniry to change coverage, The initial Benent Selection Period is October 1st through October 31st of 1992, as specified by the Policyholder_ The Pelicyholder must notify the Insurance Company of lhe dates of any Benefit Selection Period before it begins, i " , , 2 \ 234l4-LTD -- C2.!1[c~n.!12'!..!., STANDARD PROVISIONS - Consideration. The Policy is issued 10 Ule Policyholder In consider.ltion of the application and payment of lite first premium. Alllinanciallransactions will be conductcd In United St:Jtes dollm. The Contract, TIle entire contrnctls made up of litis Policy, 11m Application of lite Policyholder. a copy of which is attached. and any document In support of or altering Ul!l information on lite Application, Policy Cllanges. Changes may be made in lite Policy only by amendmcnt signed by lite President and lite Secretary of lite Insurance Company and aCCtpled by Ule Policyholder as evidenced by lite payment of premiums for periods after the effective date of such change, Statements not Warranlles. All statemenlS made by lite Policyholder or by an insured Employee will. In lite absence of fraud. be deemed represenutions and not warranties. No statement made by lite Policyholder or by any Employee lO oblaUl insur.1f1Ct will be used to avoid or reduce the insur.lllce unless it is made In wnting and Is signed by lite Policyholder or lite Employee and a copy is sent to the Policyholder or the Em~loyee, Certificate. The Insurance Company will issue to the Policyholder for delivery to each insured Employee an individual certificate. The Policyholder will be.responsible for distributing the certificates to Empfoyees. ' The certllicate will show the insurance protection provided under the Policy. It will set forth any changes In benelits due to aile and to whom b~nefits will be paid, Nothing in the certificate will change or void_ the terms of the Pohcy. Any certificate issued to any Employee wlio is eillter not entitled to or has ceased for any reason to be entitled to insurance coverage wili be null and void. If lite Policyholder delivers an Employer.produced handbook [0 insured Employees. and if any claim lItat would otherwise be denied or limited by the terms of the Policy, is increased or paid as a lCSU!1 of the Information contained in such handbook, lite Policyholder will be responsible fer reimbursing lite Insurance Company for lite amount of such claim or Increase in claim. Grace Period. If a premium is not paid when due. a Grace Peried of 31 days will be granted. The Policy will stay in force during the Grace Period unless lite Policyhelder requests lItat the Policy be canCtlled earlier, II no such request is made, the Insurance Company may continue lite Policy in force beyond lite end elf lite Grace Period, subject to cancellation at any time thereafter upon written notice to lite Pelicyholder. ' Male Pronoun. The male pronoun as used herein will be deemed to include the female, Anniversary Date. The first AnnivelOary Date will be January I. 1994. Subsequent AnnivelSaf)' Dates will occur en each January ISL Cancellation of Policy. The Policyholder may cancel this Policy by ~vlng written notice to lhe Insurance Company. The Policy will cancel on lite laler of lite dale ~ilied In lite notice or the date the notice is received by lite Insurance Company. Any premium due will be prorated Crom the due dale of lite fll"St unpaid premium to lite date the Policy cancels. The Insurance Company may cancel this Policy on any Premiwn Due Date by giving wrinen notiCt to the Pelicyholder at feast 31 days in advance if: 1) lite number of Employees insured is less lI1an 10: 2) lite Policyholder fails a. to furnish promptly any infonnation the Insurance Cempany may reasonably require or b, to perform any other obligations pertaining to litis Pelicy. Cancellation may take effect on any earlier date if boll1 the Policyholder and lite Insurance Company agree, It will be lite oblisation of thc PolicyhOlder to notify the Employees in writing of any cancellation. including cancellation under lite Grace Period proviSion, Within 30 days after the Policy cancels t)1e Policyholder Is required to notify lite Insurance Company of any claim Illcurrcd but not reponed while 4 234l4.LTD .... Conf~ru!!!r1-L. " '.. "1- .. ,., STANDARD PROv:r:SIONS Continued -. the Policy was In force; or else Ihe payment of such claim, Ulal may olherwise be valid, will be the direct and sole responsibility of Ihe Policyholder. Admiriistra lion and Insurance Data, The Policyholder agrees to administer the Policy in aCCordance wilh Ihe instructions fumJshed by Ihe Insurance Company. All books and records of the Policyholder conlalning information pertinent 10 this lnsur.mce will be Open 10 inspection by the InSUr.mce Company al any reasonable time. The POliCYholder, while perfonning any duty of administration under this Policy which pertains to Ihe insurance covernge of an Employee, inclUding the payment of premiums, wiU be deemed 10 be acting only as an agent for the Employee and not as an a~ent for the Insurance Company, The Insurance Company will deal solely with the Policyholder who will be deemed Ihe representative of each Employee. Any action taken by the Policyholder will be binding on the Employee, Mulliple Units or Affiliated Employers, The Insur.mce Company reserves the right 10 apply the proviSIOns of lhis Policy separately Ie each unit of Employees empleyed at separate locations of the Employer and to lhe .Emp~yees of each Affiliated Employer, Clerical Error. A clerical error or omission will not deprive an Employee of insurance, affect an Employee's amount of insur.mce or affect or continue Insurance which would nce olherwise be in force. m 1000 70 Gl 1000 9C5 , I , ') .1 , I j ( I I. , . I" . ,,. .;" t" .." " " , 5 I.:>, i ~ - ; i'...; fi~ 1',.'.'.; 23414-LTD -- C6nr~'!!!2rL!.&..' , , .....-, PREMIUMS Prcmium Paymcnt. The first premium will be due on the Effective Date. After Uta~ premiUms will be due monWy unless the Policyholder and Ute Insurance Company agree on some other meUlod of premium paymen~ Premiums arc payable in advance by lhe Policyholder atlhe office designalCd by ule litsur.mce Company. PrcmJum I?ue Date. AftJ:r lhe Effective Date. lhe Premium Due Date will be Ute first day of the month. Monthly Premium Rate. TIle Monthly Premium Rate for Option I is 0.16% of Ule Insurable Payron fer Option I. The MonWy Premium Rate for Option 2 is 0,27% of the Insurable Payroll for Option 2, Insurable Payrell. The Insurable Payroll for Option I is the sum of the insured monthly Earnings of each Employee insured for Option 1. The Insurable Payroll for Option 2 is the sum of lhe Insured monthly Earrungs of each Employee insured fer Option 2, Calculation ofPremJums. The monthly premium is calculated by multiplying the Monthly Premium Rate for each option by the Insurable Payroll for that option and adding the results. This amount will be mod ified by any premium adjustments or discounts lhen in effeet Ch~nges in Premium Rates. Any Monthly Premium Rate may be changed by the Insurance Company with aF least 60 days advance wrillen notice. But no change in rates will be made until January ,I. 1995 _ nor Will changes be made on anr date olher lhan a Premium Due Dale, However, at any ume lhe Insurance Company changes any 0 the provisions of this Policy to comply with lhe Policyholder's request or a new State or Federal Law, it willliave lhe right to immediately cnange any Monthly Premium Rate accordingly, Any premium adjustment will be prorated from Ule date of lhe event causing lhe adjustment to lhe next Premium Due Date, Simplified Accounting. For'a per.;on becoming insured or becoming eligible for an increase in the amolUlt of insurance. other than an increase caused by a change in lhe Schedule of Benefits, the premium will stan or increase on the Premium Due Date that corresponds with or next follows the dale the insurance or increas~ is effective. For a person whose insurance ceases, lhe premium will stop on lhe Premium Due Date that coincides with or next follows the date the insur.mce ceases. For a decrease in lhe amoUIl1 of insurance on a person, other lhan one caused by a change in the Schedule of Benefits. the premium will decrease on the Premium Due Date lhat coincides WIth or next follows lhe date of the decrease in insurance. Incorrect Premium Payment. Premiums paid in error will be refunded without interest when requested by the Polic)'holder. However. these premIUms are an integral part of the renewal premium and will not be refunded for more than a 6 month period, nor for any period before lhe last change in premium rates. GI 1000 llCl (V-3) 6 234l4-LTD ~... Conr~'!.!:I!.!!9!1...h.: .~ (. EFFECTIVE DATE OF INSURANCE Each Employce will become Insured on the dale he becomes eUglble for Ule Insur.l11ce,:-' If lIll Employee Is not Actively.al,Work on lhe dale hls Insurllllce would otherwise be effective. It will become effective on Ule ti~t day he Is again Actlvelf.at.Work. , ..'W .. or 1000 15CI (V-I) 8 23414-LTD 4- C!!!1l1~'!.!:'!.'l2'.!....h..: . , " INSURING PROVlSJONS Disability Benefits. If an Employee, while insured for Otis Long Teml Disability Insur.uii:e, becemes Disabled, (he Insurance Compnny will pay Ole Monthly Benefit in nn ameunt detennined from the Schedule of Benefits, Payment will be made when Ole Insurance Compnny receives satisfactory proof that: 1) the Employee became Disabled while insured: and 2) , the Disability continued thrOUglloUl nnd after the Qualifying Period. Disability or Disabled, An Employee will be considered Disabled if he is either Totally or Partially Disabled, Total Disability or Totally Disabled. An Employee wlll be considered Tot.ally Disabled if, as a direct result of an Injury or Sickness, he is unable te perform the material duties ef his Nonnal Occupation for any employer. Hewever. after Monthly Benefits are payable for 36 months, an Employee will be considered Totally Disabled only if he is unable to perform the material duties of any occupatien for which he is or may become suited based on his education, training or experience. Proof of Tot a! Disability will be satisfactory if it (1) is in writing and (2) consists of all medic:il, psychological, educational and vocational information which the Insurance Company considers pertinent te the claim: After a Tot.ally Disabled Employee has receive{! Monthly Benefits for 6 months, the Insurance' Company may re!juire that he submit, at such intervals as necessary, satisfactory proof ef the continuance of Tow Disability. _ Partial Disability or Partially Disabled. An Employee will be considered Partially Disabled if, as a direct result of an Injury or Sickness, he is unable to perform the material duties ef his Normal Occupation on a full.time basis, but is: performing at least one of the materia! duties of his Nermal Occupation or another occupation en a part-time or full.time basis: and is 2) earning currently at least 20% less per month than his predisability Earnings, Normal Occupation. The Normal Occupation ef an Eml?loyee is 'the occupation, job or work he performed at the time he stopped :working just prior to a claun being made under this Policy, Qualifying Period. The Qualifying Peried will start with the first day an Employee is not Actively-at- Work due to Disability, It will cease with the earlier of: I) the end ef 180 days of continuous Disability; ,or 2) when Disability ends. I) If an Employee's Disability ceases for up to 14 days and then begins again due to the same Sickness or Injury, the period of Disability will be deemed continuous. In such case the Qualifying Period will be extended by the number of days during which Disability ceased. ,. - Benefit Payment Period. Benefit payments will start after the Qualifying Period ends if Disability continues after the Qualifying Period, Benefit payments will cease on the earliest date shown below: I) the date the Employee ceases te be Disabled or dies; 2) when the Employee is not under the continuous care of a physician or not receiving treaonent considered reasonable by the Insurance Company; 3) the date the Employee fails to: a. furnish proof of Ole continuance of Disability when requested by the Insurance Company; or b, submit to an examination requested by the Insurance Cempany; 9 23414.LTD -, CO'l!i!!!!.!!:'ll!2r.G.. j , " INSUIUNG PROVISIONS Conllnlled -- 4) On the Employee's 65th birthday With the 42nd monthly payment With the 36th monthly payment ' With the 30th monthly payment With the 24th monthly payment With tile 21st monthly payment With the 18th monthly payment With the 15th monthly payment er at age 70, whichever occurs first With the 12th monthly payment when the Employee's current monthly earnings equal or exceed 85% of IUs pre disability menthly EalTUngs. _ Recurrent and Concurrent Disabilities. Recurrent Disabilities that result from the same or a related Injury or Sickness will be considered ene disability if: I) the Employee has received benefits under this POUey; and 2) the Employee returns te full-time work and again becomes Disabled after less than 6 months of such full-tiI!Je work. Under 62 62 63 64 65 66 67 68 tile date payments cease based on tile Employee's age when tile payments began as shown below: \ Employee Age When Date Payments Cease rvl\c:;. (\ ,IJ'<' Benefit Began I' 'il ~ 1,1 \J 't ' , [\v.)j. ' 7: '\ 69 and ever 5) 3) Disability benefits under this PeHey have ceased by reason of item (5) above and within six months of receipt oC the last Monthly Benefit payment, the Employee suffers a reduction or loss of his Paniill ~isabiUty earnings. No new Qualifying Peried will apply to the later disability and Monthly Benefits will resume at the same level on the date the later disability llegins under the same terms and conditions that appUed to the earlier period ef disability. Concurrent Disabilities that result from an unrelated Injury or Sickness will be considered one dlsabilIcx. However, if the Employee returns to work for at least ene day between disabilities, the later disability will be considered a new one, subject to a new Qualifying Period. Rehabilitation Provision. The Insurance Company maintains an active rehabilitation depanment and provides rehabilitative services to claimants whom it feels will benefit from such services. The Insurance Company reserves the right to determine which claimants will benefit from rehabilitative services. Gllooo 17LTD32 Gllooo 17LTD34 011000 17LTD35 . - --- -,_.- 10 234l4-LTD ,- , ~ cOl1r,,~'!l!2~ ." " INSUIUNG l'ROVlS~ONS Contlnllcd -. ....~ Survivor Bcncfit. If an Emp'loycc dlcs whilc Monthly Bcnefits are being paid, a lump sum Survivor Benefit will be paid to thc EUgible Survivor or Survivors, PaYl11ent will be due on the last day eC Ule month oC the Employce's dcath and will be payablc whcn Ule (nsur.ll1CC Company receives due prooC oC the Empleyce's death and oC thc eUgiblUty oC Ule Survivor or Survivors. The Survivor Bcnefit will be paid te the swviving spouse, unless the spouse requests In writing that the benefit be paid to the cxecutor or admlnislr.llor ot the Employee's estate. IC there is no survivirig spousc on the date payment is due, payment will be made in equal shares to the surviving children. If there is no Ellgible Surviver en the date payment is due, no payment will be made, Monthly Survivor Benefit Payablc. Thc amount oC the Survivor Benefit payment will be equal to 300% eC the sum oC: the Monthly llenefil payment due Cor the last full month oC disabWty beCore the Employee's death: and 2) any amount by which such payment was reduced because of wage or profit received Cor work. Eligible Survivor. The Ellgible Survivors; in order oC-priority are: I) the surviving spouse ef the Employee; 2) any' swviving child of the Employee who is unma.rried and less than 21 years old, The lenn child will mean a child born of the Employee, a cliild legally adopted by the Employee or a stepchild of the Empleyee who had lived with the Employee in a normal parent-child relationship juS! prier to the Empleyee's deaUl or disability. I) GI 1000 l7LTD4 , (V -4) 12 23414-LTD Conrc~'!.!.!.<?,.!....!L ~ (' C~I~ (!~LlC) Lf'" SClIlmULE OF BENEFITS Each Employee who is Insured for: Option I An 3rriount equal to 50% of Ule Employee's monthly E3lJtings, up to a rt1aximwn of 59,536 of Schedulcd MonUlIy Bcnefits,,, Option 2 An amount equal to 70% of the Empleyee's monthly Earnings, up to a maximwn of 513.350 of Schcdulcd Monthly Benefits." *The maximum Schcdulcd MonUlIy Bcncfits shown above are bascd on the earning limllauon providcd by the IRS for retlremcnt plans, The rns adjusts this limitation cach year based on thc rns camings limitation. If an Employec nceds Infonnalion regarding this figurc, contact the Plm Administrator, ' , Schcdulcd Monthly Ilcricfil Initial Amounl,of Schcduled Month./y Bcncfit. The inWa! amount of an Employee's Scheduled Monthly Benefit is based on Option I and his monthly Earnings en the day he becomes insured, subject 10 the following exceptien: Each Employee who elects Optien 2 during the 1992 Benefit Selection Period will be insured for Option 2 and his initial amount of Scheduled Monlhly Benefit will be bascd on Option 2 and his monthly Earnings on the day he becomes insured, ' Monthly Bencfit Payablc. The amount of Monlhly Benefit payable for ari Employee who is Totally Disabled for any menth will be the Scheduled Menlhly Benefit for the option for which he is insured minus all Other Income Benefits to which the Employee is entiUed for the same month. The amount ef Monthly Benefit payable for m Employee who is Panially Disabled fer my month will be the lesser ef: I) 2) the Schedulcd Monthly Benefit for the option for which he is insured: or 100% of the Employee's monlhly Earnings minus income from the following sources for the same menth in which the Monlhly Benefit is payable: a. all Other Income Benefits; md the amOunlthe Employee's dependents receive, on the Employee's record under the United States Social Security Act or Railroad Retirement Act, Canadian Pension Plan or the Quebec Pension Plan or any similar plan or act: and c. all of the Employee's Other Earnings, The Monthly Benefit payable will not be less than 5100, b, Other Income Benefils. Other Income Benefits include any: I) Payments provided because of the Employee's disability under. a. any group disability plan or like plan for persons in a group; b. The United Slates Social Security Act or Railroad Retirement ACL the Canadian Pension Plan or the Quebec Pension Plan or ariy similar plan or aCL excluding any such payments to the Employee's dependents; 23414-LTD 13 .... : Confc..!!!:!.l!l.!.2r.L.hL_ .' . , I , SCIlEDULE OF BENEFITS Continued . c. any Worker's COl11penS:lllon or like law, including any such -payments Ie Ule Employee's dependents; any compulsory acl or law. d. ~ WltIl respeclte this number (I) provision, only benefits which arc paid or payable Cor the s:une . er related dlsabiJlly will be considered as OUler Income Benefits, 2) RClirement or pension benefits provided by tile Employer. 3) Retirement benefits under Ule United States Social Security Act or Railroad RetIn:ment Act, the Canadian Pension Plan or the Quebec Pension Plan or any similar plan or act, excluding any such payments, 10 the Employee's dependents on the Employee's record, Any reCerence to payments provided under the United Stales Social Security Act will include benefits to which the Employee may llccome entitled, or Cor Partial Disability benefits any benefits to which his dependents may oecome entitIed. Cost oC living Increases which become' ~CCeetive after the first Monl1)ly Benefit is payable will not OJ: included in Other Income 'Benefits. "_ IC any Other Income Benefits, excluding Worker's Comper.sation or similar Jaw benefits, are paid to the Empleyee on any basis other than monUily, the Insurance Company will determine the monthly equivalent oC that payment and reduce each Monthly Benefit payable under this Policy by such amount, Any such benefits paid in a lump sum wiII be considered as paid in monthly :unounts over the period of time cevered by the lump sum payment. ' If any Worke~ Compensation or similar law benefits an: paid to the Empleyee on any basis other than monthly, the Insurance Cempany will determine the monthly equivalent of that payment:md reduce each Monthly Benefit payable under this Policy by, such :unoun~ Any such benefits paid In a lump sum will be considered as paid in monthly :unounts over a 5 year period or te the final payment date. whichever is eUrlier. Any lump sum, payments made will be considered paid only for disability unless the Empleyee gives the Insurance Company satisfactory proof to the contrary, Other Earnin gs. Other Earnings are the Employee's actual earnings in his Nonnal Occupation or another occupation, , Overpayment. If the Monthly Benefit for any month is overpaid, the Insurance Comp:my will bill the Empleyee for the :unount overpilid, If the Employee fails to make payment wilhin a reasonable time. the Insurance Company will hilve the right to recover the :unount overpaid from any future payments. If the Employee's Monthly Benefit ceases before the everpaid :unountis fully recovered. the Insurance Company will biII the Empleyee Cor the remainder, Such :unount will be due and payable jmmedial~ly. ' Social Securily. At the time an Employee submits Proof of Claim the Insurance Comp:my will require the Empleyee te apply for benefits under the Social Security Act if he is covered under th:U ilCt and to choose one of the following options: I) 10 have the Insurance Company deem the Social Security Benefit payable at an estimaled amounl and reduce his Monthly Benefit payment by that :unount buc not below S 100; or 2) to have ne reduction in his Monthly Benefit until the actua1 ilIT1eunt eC the Social Security Benefit is known, The Insurance CompilllY requires an Employee 10 appeal any denial of his Socia1 Securily Benefi~ At the time an Empleree requests such appeal, he should again choose one of the above eptions; if he fails to make an appea or fails to choose one oC the options, the Insurance Company wiU apply option (2). When the Insurance Company is advised of the final Social Security award or denial. the MonUlly Benefit pilid wiU be recalculilted 10 determine the :unount ef Monthly Benefic which woulll have been paid had 23414-LTD 14 ~ C~~~'!ll211..l:.-. -, ., . SCHEDULE OF lJENEFlTS Conlinued ' tJle Social Security decision been known whcn tJlC MonOdy Benefit was being paid. If tJ1C M6'nthly Benefit paid was less tJlanlt should have been, the [nsul'3l1ce Comp3l1Y will pay tJle Employee Ole dlfferenCl: WitJl Interest. If Ole MontJlly Benefit paid was more Ul3l11t should have bcen, the Employee wiII be required Ie pay Ule Insurance Comp3l1Y Ole difference, If any amount due the Insur3l1Cl: Comp3l1Y is not paid within a reasonable time, U1C [nsur3l1ce Comp3l1Y will withhold the Employee's Menthly Benefit payments to recever such ameunL If Ule Employee's MonOdy Benefits end,' any ameunt still due lJie Insurance Company will be due from Ule Employee or his estate. I( litis amount is not paid immediately, the Empleyee, hIs representatives or estate will be responsible for payment WiUI Interest and 3I1Y anomey's fces involved in cellecling U1C amount due, ' Change in Scheduled Monthly Benefit Due to Change in Oplion. TIle optJon (or which 311 Employce Is insured will be ch3l1gcd only if the Employee elects to ch3l1ge hJs option by signing a ch3l1ge form approved by the Policyholder 3I1d lJie Insul'3l1ce Comp3l1Y: 1) during an annual Benefit Selection Peried; or 2) within 31 days of a Qualificd Ch3l1ge In Family Status. , , If lJie Employec falls to sign a chan~e fonn approved by the Policyholder and the Insul'3l1ce Company, or j( he signs the fenn at 3I1Y other Ume, hJs option will not be changed. ' _ I( the Employee elects to change his option: I) duriag an annual Benefit Selection Period, his Scheduled Monthly Benefit will be changed en the first day of the Pl3l1 Year that nCll:t follows that Benefit Selection Period, 2) within 31 days of a Qualified Ch3l1ge In Family St:llUs. hJs Scheduled MonlJiIy Benefit will be changed on. the later of: a. the dare ef his election; or b, the date of Change in Status. However, any Increase in an Employee's Scheduled Monthly Benefit due to hJs change from Option I to Option 2 will not apply with regard to a dlsabiIJty caused by an Existing Condition. ell:ccpt after the Employee has been Actlvely-at- Work and insured for Option 2 for 12 consecutive months (rom the most recent effective date ef the increase. , , Change in Scheduled Monthly Benefit Due to Change in Earnings. If an Employee's monthly Earnings change (on any August 15th as pro,vided in the definition of Earnings), his Scheduled Monthly Benefit will change on the first day of the Plan Year that next follews that August 15th. However. if hJs monthly Earnings change because he changes from part-time to full-tUne or full-time to part-time status. his Scheduled Menthly Benefit will change on the dale of his change in status. Actively-at-Work Requirement Cor Increases in Scheduled Mo'nthly Benefit. If an Employee is net Actively-at- Work on the day his Scheduled Monthly Benefit would fer any reason etherwise be Ulcn:ased. it will not be increased until he is al:ain Actively-at-Work. If the Empleyee is on vacation and is nel disabled on the day he becomes eligible for an 1I1crease in his Scheduled Monthly Benefit. he will be deemed 10 be AClively-al-Work on the day he becomes so eligible. 23414-LTD 15 ., ~- Conr,,~'!ili?~ ( TERMINA nON OF IN~URANCE TIle insurance on 311 Employee will cease on Ule earliest dale below: I) the dale the Employee ceases to be in a Qass of Eligible Employees or ceases to quallfy as 311 Employee; . the last day for whieh the Employee has made any required contribution for lhe insurance; the date litis Policy terminates: the dale the Employee lerminaLCs employment The date the Employee ceases to be Actively-at- Work will be considered the date his employment terminates 3l1d lhe insurance will cease on that dale. However, if 311 Employee eeases to be Actively-at- Work due to a disability fer which Monthly Benefits are or may become payable, lhe insurance will continue during the Quallfying Period and during the peried for which Monthly Benefits are payable, The insurance wi1,I cease when Monthly Benefit payments stop, ... 2) 3) 4) ~ ~I , l I , I EXTENSION OF BENEFITS AFTER CANCELLA nON Subject to all ether terms and conditions of lhe Group Policy, payment of the Monthly Benefit will not be :iffected by cancellatien of litis Policy as long as the Disability began while litis Policy was in force,_ WAIVER OF PREMIUM ~ Premium for an Employee will be waived during the periOd Monthly Benefits are payable fer that Empleyee. GI 1000 29CI (V-2) '\ , ! i . . . ..:.. -;"_ _.-1--;._ . 18 23414.LTD . '" "~ ....-.......'" -- Confc.!!s.!:'!.!.!!!~ " CLAIM PRoVIsrqNS Proof of Claim. Satisfactory proof ef claim must be givcn 10 Ihe Insurance Company within 6 montJlS after tJle end of the Qu:ilifY1ng Period, If satisfactory proof of claim is not given In tJlatlime, lhe claim will not be lavalld If lt Is shown tJlat satisfactory proof of claim was given as soon as was reasonably possible and In no even~ except in the absence of legal capacity, laler tJlan I year from lhe time proof is olherwlse required. If lhen: Is an unreasonable delay in giving satisfaclory proof of claim, lhe claim will be Invalid" , Legal Actions. No action at law or in equity will be broughtlo recover on lhe Policy until at least 60 days after proof ef claim has been flIed wilh the Insurance Company, No action will be brou~ht at all unless brought within 3 years after lhe time within which proof of claim is required by the Pohcy, Time Limitations. If a-ay time limit set fOM in the Pelicy for gi~ing proof of claim, or for bringing any action at law er in equity is less than lhat pctmitted by the law of lhe Slate in which lhe Employee lives when lhe Policy is Issued. then the time limit proVIded in the Policy is extended 10 agree wilh lhe minimum pennHIed by lhe law of that Slate. Medical Examination. The Insurance Company, at Irs own expense, will have lhe right to examine any persen for whom claim Is pending or in progress as often as may be reasonable, Vocational Assessment. The Insurance Company will have the right to require any person for whom- claim is pending or in progress to undergo a vocatienal assessment by a qualified vocational counselor. nus assessment will be at lhe Insurance Company's expense, 01 1000 31CI .--... .. . .-- 19 23414-LTD ~ ..~..- ,-- , ~...... ConrC~.!!!.U2f~.' . '-'~i {'--. No benefits will be paid when Ule Employee's disability results fmmlnJuries received by,.or as U1e result of, acuons for which a ulird pany Is liable except a.~ pmvided below, However, If U1e liability of Ute third pany is satisfied in an amount less Ulan Ule benefits pmvlded by lhis Policy, Ule Insurance Company wlU pay an amount which Is equal 10 lhe difference, If U1e Employee Is disabled as a result of Ule actions of a ulird pany, and in Ule opinlen of lhe Insurance Company, such Olin! par:tr may be liable, lhe Insurance Company will pay lhe amount of benefits olherwise payable under this Policy. However, lhe Empleyee must first agree m writing to refund Ie lhe Insurance Company at lhe time of liability of such third pany. is saosfied, whelher by settlement, judgement, arbitrauon er olherwlse, lhe lesser of: ,. (A) lhe amount aetually paid by lhe Insurance Company under this Policy for lost income: or (8) the amount equal, to lhe sum adiUauy received fmm the third pilrty for lost income, Such an agreement by an Employee to refund payments by lhe Insurance Company will not constitute assignment of any pclOonal injury rights, CONDI110NAL CLAIM ~A YMENT~ , . ~, r ! (V-2) i I ~ ~ or 1000 31C2 ., .-- -- .... ....:.:- ..... . .... .... , I ! I. ! I " .. -"'- -... -- .__........-':- . . ...._.:..__.-a:._~~-?"'1..~~ 20 23414-LTD G--::::. Great:-West: LIFE 0\ ANNUITY INSURANCE COMPANY 8505 East Orchard Road Englewood, CO 80111 Tel, (303) 689.3000 Address mail to: P.O. Box 1080. Denver, CO 80201 POLICYHOLDER . " POLICY NUMBER - CONFED- - GWL&A EFFECTIVE DATE OF ORIGINAL CONTRACT PLAN TYPE FORM NUMBER BELLSOUTH CORPORATION 23414-LTD 254873GDH January I, 1993 LONG TERM DISABILITY INSURANCE F-4303 . .:....1. .'. .. .'~':.' . ~: .: Great-West Life & Annuity Insurance Company ("Great-West") has assumed the above referenced policy and has agreed to comply with and pc rform all the rights, obligations, and liabilities under this policy to the extent of claims incurred after September I, 1994, with the same effect as if Great-West had directly issued the policy. Claims incurred after September I, 1994, and arising under this policy may be filed directly with Great-West. Claims incurred prior to September I, 1994, are the responsibjlity of Confeder;ltion Life Insurance Company ("V.S,") in Rehabilitation. As of January I, 1995, Great-West will administer the above-referenced pc;licy in accordance with the terms and conditions ddscribed therein . until said policy tenninates, It is provided, however, that for the first twe years of benefit payments for an eligible claim, such payments will be funded entirely by l3ellSouth Cerporatioll ("BellSouth"), It is further provided thaC Great-West will provide Administrative Services for eligible claims funded by BellSeuth, as specified in the Services Contract issued by Gn:at-West te BellSouth, Great-West Life & Annuity Insurance Cempany By: (A2~ Si~-;a~j', .t!I(;.a, Tille: 6A.tt./p' ,IA J fO/JAA./t..;!' t)/'L.~A-r~,vV.s 3/;.J.-/y( Date: '. DONNA J, FLOCK, PlaintilT v, GREAT-WEST LIFE & ANNUITY INSURANCE COMPANY, Defendant . IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION. LAW NO. 98-437 CIVIL TERM NOTICE OF FILING OF NOTICE OF REMOVAL The Defendant, Great-West Life & Annuity Insurance Company, provides this notice to the Court of Common Pleas, Cumberland County, Pennsylvania that this action has been removed to the United States District Court for the Middle Disl c f Pennsylvania, A copy of the Notice of Removal is attached hereto as Exhibit U A, U Dale: February 19, 1998 ILLlAMS & OTTO Attorneys for Defendant, Great-West Life & Annuity Insurance Company ~ . CERTIFICATE OF SERVICE I, Denise L, Nye, an authorized agent of Marts on, DeardorO: Williams & Otto, hereby certify that a cepy of the foregoing Notice of Filing of Notice of Removal was served this date by depositing same in the Post Office at Carlisle, P A, first class mail, postage prepaid, addressed as follows: Wayne F, Shade, Esquire 53 West POl11fret Street Carlisle, P A 17013 MARTS ON, DEARDORFF, WILLIAMS & OTTO By Cfa / J/J{ Denise L, Nye" Ten East High Street Carlisle, P A 170 I 3 (7 I 7) 243-3341 Dated: February 19 1998 F.IfILE&'\DATAFILE\GENDQC9IMlbJ.I.NUT -, Exhibit A Il.iI,UII"II""1 ",,,,,u:'i.. @ ... 11l1l , ~H..rilfJ )1 Ii " ~/ . CERTIFICATE OF MAILING 'I It is hereby certified that a true copy of the feregeing NOTICE OF REMOVAL was Wayne F. Shade, Esquire S3 West Pomfret Street Carlisle, PA 17013 ~, I j delivered by first class mail te: '" MARTSON, DEARDORFF. Wll..LIAMS & OTTO AltOmey~efendant Great-West Life ',. By ~"""';:~ '}.~. ~~~ Thomas G, Collins, Esquire A Member of the Finn I.D, Ne, 17837 Ten East High Street Carlisle, PA 17013-3093 (717) 243-3341 , , ,\ , I Date: February 19, 1998 j F:\fTLZS\DATAfU.r:\(]IlH00C9I\n6).!.IU!JoC I f l, :f1 /,>,.,' ~ l .- :1' I( . " Ii :; 3 ii, I' t! 11. f' ,'. .' -- Corifcdcrll'tlon .:;. ". . ---- J.~~': ' " . TABLE OF CONTENTS REPLACElvIE~ OF COVERAGE. . .. " . " '" .'.. ... . .. . . ... . . . . . . . . . .... . .. . .. 1 DEFINED 'I"ERMS ........................................................ ~2 STANDA;RD PROVISIONS.... ... ................ '" .'....... _............... 4 PREMIUMS ........ . . . . . . . . . . . . . . . . . . . . . . . . . . . . _ . . . . . . . . . . . . . . . . . . . . . . .. 6 EL1GmILITY FOR INSURANCE. . . . . , . . . . .'. . . . . . . , . . . . . . . , . . . , . . , . , . . . . . . . . .. 7 . . EFfEcrIVE DATE OF INSURANCE. . , . . . . . . . . . . . , . . . . , . . . . . . . . . . . , . . , . . . . . . .. 8 INSURING PROVISIONS ..............................'....,......;...,..... 9 SCHEDULE OF BENEFTrS . . . . . . . , . . , . . , . . . . , . . . . . , . . . . . . . . . . . . . . . . , , . . . . .. 13 PAYMENT OF BENEFITS .......,.,......,........,......."........ .'.,... 17 TERMINATION OF INsiJRANCE . . . . . . . . . . ... .. . . . . . . : . . . ... . . . . . . . . . . . . . , . . .. 18 _ CLAIM PROVISIONS. . . . . " . . . . . . . . . . . . . . , . . . . . . . , . . . . . . . . . . . . . . , . . , , . . , .. 19 CONDITIONAL CLAIM PAYMENTS ....,....,.............,................. 20 i' ii II '( .:-'. -- Con;e~'!ili!.n LIft" . ~ ' ..,.. '::':.;:":1;~r:;:. DEFINED TERMS -. In lhls PeUcy when the feUowing defined terms and ether terms which are defined throughoutlhe PoUcy begin with a capitallerter lhey will be Interpreted as defllled: if lhe same lerm Is used In lhIs Policy but begins with a smalllerter. lhe term will be Illterpn:ted as defined in ~ standard dictiomuy. ' , Emplo1.er. The term Employer means the Policyholder and all Affilialed Employers shown in the "Eligibillcy For Insurance" section. Employee. The term Employee means a regular full.r1me or pan.time employee of lhe Employer if that Employee is legally domiciled In lhe United StaICS. It docs not include lhose who work less than 20 hours a week for the Employer. those who arc employed on a temporary basis. or those who are not compensated. , Aclively.at.Work. An Emplo~ee will be considered 10 be Actively.at.Work for the Employer 011 a day which is one of the Employer s scheduled work days if: ' I) he Is ~rforming all of the regular duties of his work for lhe Employer thac day on a full.time basis If ~e Is a full.time Employee or on a part'lime basis If he IS a pan'lime Empleyee: and 2) he is ac ene of the Employer's places of business or at some location te which the Empleyer's business requires him 10 travel. An Employee will be deemed to be Acr1vely.ac-Work on a day which is net one of the Employer's scheduled work days if he was Actively.at.Work on the preceding scheduled work day. Earnings. The term Earnings has lhe following meanings: I) With respecc co coinmissioned Employees, monthly Earnings means the Employee's lOcal earnings from the Employer for lhe penod of 12 consecutive months ending on lhe preceding Augusc IS. divided by 12. . If the Empleyee did not work for the Employer in his cumnt class (full.time or pan.time) for that entire 12.month jlCriod or if lhe Employee did noc work for the Employer on !he pn:ceding Au~sc IS, menthly Earnings will be the Employee's target earnings as determined by the Pelicyholder and reponed to the Insurance Company, 2) With respecc co other Employees. Earnings means the Employee's rate of pay as of the preceding August IS fer hiS nennal work week on thac date. rf the Empleyee did nec work for the Empleyer in his cumnt class (full-time or pan.lime) on the preceding August IS, Eall1ings means his rate of pay for his normal work week as of the dar.c he was firsc employed by the Employer in thac class. Any hours worked in excess ef 40 will not be counted as pan of a nonnal work week. Earnings will nec include bonuscs, commissions. oven/me or any other additional pay. Monlhly Earnings will be determined by dividing annual Earnings by 12. The amount of Earnings for any Empleyee will be the amount reponed to the Insurance Company by the Employer and validar.cd by the Insurance Company, Plan Year. The term Plan Year means a calendar year. The fillic Plan Year begins on Janu:uy I. 1993. Benefit Selection Period. The Cerm Benefic Selection Period means an annual period, October 1st through Ocrober 31s[, during which Employees have an epportuniry to change ceverage. The initial Bcnenc Selection Period is Ocrober Isc lhrciugh October 31st of 1992. as specified by the Policyholder. The Pelicyholder must notify the Insurance Company of the dales ef any Benefit Selection Period befere ic begins, 2 23414-LlD . . -- Confe~'!.!.!2'!..!~;' ,. STANDARD PROVISIONS Consideration. The Pelicy Is Issued to the Policrholder in consideration of Ihe applicarion and payment of Ihe Ii~t premium. All financiallransacllons will be Conducted in United States doliars. The Contract, The entire contract is made up oC this Policy.lhe Application of the Policrholder, a cepy eC which Is attached. and any document in support of or a1lering the information on Ihe Application. Policy Changes. Olanges m~y be made in Ihe Policy only by amendment signed by the President and the Secret3/}' ef Ihe Insurance COmpany and accepted by the Policyholder as evidenced by the payment of p(l:miums fer periods after Ihe effective date of such change. . Statements not Warranlies. All statements made by the Policyholder er by an insu(l:d Employee will, in Ihe absence of fraud. be deemed repn:sentations and not wammties. No statement made by the Policyholder or bf any Employee to obtam insurance will be used to avoid or reduce the insuooce unless it is made in wnting and is signed by Ihe Policyholder or the Empleyee and a copy is sent to the Policyholder or the Eml?loyee. Certificate. The Insurance Company will issue to Ihe Pelicyholder for delivery to each Insu(l:d Employee an individual certificate. The Policyholder will !lercsponsiblefordistributing the certificates 10 Empfeyees" The certificate will show Ihe insurance protection provided under the'Policy. It will set Cenh any changes in lienefits due to af:e and to whom benefits, will be paid. Nothing in the certificate will thange or void_ the terms of the Pellcy. Any certificate issued to any Employee who is either net entitled to or has ceased for any reason to be entitled to insurance coverage will be null and veid. If the Policyholder delivers an Employer-produced handbook to insured Employees, and if any claim that weuJd otherwise be denied er limited by the terIllS oC the Policy, is increased or paid as a rmllt of Ihe information contained in such handbook. the Policyholder will be responsible fer reimbursing the Insurance Company for the amount ef such claim or maease in claim. Grace Period. If a premiwn is not !laid when due, a Grace Period ef 31 days will be granted. The Policy will Slay in ferce during Ihe Grace Period unless the Policyholder m}Uests that the Policy be cancelled earlier. If no such request is made. the Insurance Company may continue the Policy in forte beyond the end Of the Grace Per/ed. subject to canccllatien at any time thereafter upon written oetice to the Pelicyholder. ' Male Pronoun. The male pronoun as used he(l:in will be deemed to include Ihe female. Anniversary Date. The first Annivers3/}' Dale win be Janual)' I, 1994. Subsequent Armivemry Dates will occur on each January ISL Cancellation of Policy. The Policyhelder may canccllhis Policy by ~ving written notice to the Insurance Company. The Policy will cancel on the laler oC the date ~i1ied 10 the notice or the date the notice is received by the Insurance Cempany. Any premium due Will be prorated from the due dau: oC Ihe rust unpaid premium to the date the Policy cancels. The Insurance 'Company may cancel this Polig on any Pll:miwn Due Date by giving written notice to the Policyhelder at least 31 days in advance iC: I) the number ef Employees insured is less than 10; 2) the Pelicyhelder fails a. to fumisl1 promptly any information the Insurance Company may reasonably Il:quire er b. te perl'orm any other obligations pcnaining to this Policy. Canceliatien may take effect on any earlier date if both lhe Policyholder and the Il1SIIrance Cempany agree, It will be Ihe obli~alion of the Policyholder to notify Ihe Employees in writing eC any cancellation. including cancellation under Ihe Grace Period proviSIOn. Within 30 days after the Policy cancels Ihe Pelicyholder is required to notify the Insurance Company of any claim Ulcum:d but not reponed while 4 23414-LTD .~-. ...- Conr"~n..!l.2'!..!:&.' , '" . , ",. PREMIUMS Premium Payment. The first premium will be due on ll1e Ef(ective Dale. After ll1at. premiums will be due monthly unless the Policyholder and ll1e Insul'3l1ce Company agree en some other metllOd of premium payment. Prcmlums arc payable in advance by the Policyhelder atll1e effice designared by ll1e lilSl1lOOCe Company. Premium I;>ue Date. Aftcr !lIe Effective Dare, the Premium Due Dalli will be ll1e ti~t day o(ll1e month. Monthly Prerruum Rate. The Menthly Premium Rale Cor Option lis 0,16% of the Insurable Payron Cor Option 1. The Monthly Premium Rate (or Option 2 is 0.27% eC the Insurable Payroll Cer Oplien 2, Insurable Payroll. The Insurable Payroll (or Option 1 is ll1e sum oC.ll1e insured monthly Eamlngs of each Employee insured Cor Option 1. The Insurable Payroll (or Option 2 is the sum of the insured monthly Earitlngs oC each Employee insured Cor Option 2. Calculation or Premiums. The monthly premium is calcuJared by multiplying ll1e Monthly Premium Rate ror each option by the Insurable Payroll (or that eptien and adding the results. l11is amount will be medilied by any premium adjusanents er discounts then in effect. Ch~~ges'in Premium Rates. Any Monthly Premium Rare ~ay be changed by the Insul'3l1ce cOmpany with at least 60 days advance wrinen notice. But. no change in rates will be made until January 1. 1995 _ nor will changes be made on any dare o!her ll1an a Premium Due Date. However. at any time the Insurance Company changes any of the provisions oC this Policy 10 comply with the Policyholder's rcquest or a new Stare or Federal Law, it willllave ll1e right 10 immediately cfiange any Monthly Premium Rate accordingly. Any premium adjustment will be prorated from the date oC the event causing the adjusunent 10 the next Prcmlum Due Dale. Simplified Accounting. Fer'a person beceming insured or becoming eligible (or an increase in !he amOUl\t oC insurance. other than an incn:ase caused by a change in the Schedule o( Benefits, the premium will start er incn:ase on the Premium Due Date that corresponds with or lIeJCt Collows the date the insurance or increas~ is effective. Fer a person whose insurance ceases, lhe plemium will SlOp on' the Premium Due Dare lhat coincides with or next Collows lhe dare the insurance ceases. For a decrease in the ameunt of insurance on a pcrsen, other than one caused by a change in the Schedule oC Benefits. the premium will decrease on the Premium Due Dare lhat coincides WIth or next (ollows the dale of lhe decrease in insurance. Incorrect Prerruum Payment. Pn:mlums paid in error will be n:funded wilhout inten:st when Jeq1Iesled by the Policyholder. However. lhese premlwns are an integral pan of lhe renewal premium and will not be refunded Cor more than a 6 month period. nor (or any period before the last change in premium rates. GI 1000 IlCl (Y.3) 6 234l4-LTD " \ '; , ~ Conre~'!..!.!$!.n c ': ' ,- " " ....... ," ELIGrnn.m FOR IN~URANCE Each Employee in one olthe Qasses ef Eligible Employees. shown below. will become eligible lor Employee Insurance on the dar.c he compler.cs the Waltin~ Period. il any. An Em(:lloyee who was Insured under lhls Pollcy before bUI whose insurance ceased Will have 10 satisfy lIle New Employee Walling Period 10 become eligible again However, if any Employcc's insu(3/1ce ceased because he was no longer In a Oass ol Eligible Employees he will not have 10 satisfy any Walling Petiod il he again becemes a member o'l a Oass ol Eligible Employees within 12 monthS alter his insUrance ceased, Walling Period. A waltin~ period will be completed when an Employee Is continueusly Actlvely.al.Werle for the length olthe Walung Period, The Waiting Period is until lhe.Jim day elthe calendar month lollewing er coinciding with the completion of 6 months ol continuous employment. , Affiliated Employers. , BellSeuth Advanced Networks, Inc. BeI1South Advertising and Publishing COlpOrntion BclISouth Cellular (ACC) BeUSeuth CeUular (BMI) . BeUSeuth Enterprises, loe. BeUSouth Infonnation Networks. loc. BclISouth Infonnalion Systems, Inc. BeUSouth Inlematienal, Ine. BeUSouth Resources. Ine. Cooperative Healthcare Netwerks Intelligent Media Ventures. Inc. Inr.clligent Messaging Svcs., Inc. L,M. BellY and Company MoblIeComm RAM/BSE Paging Company. L.P. Sciehtilic Software, lIle. Sr.cvens Graphics, Inc. ' SunIlnk Corporation TechSouth, Inc. BeUSouth Asia Pacitic Enterprises Classes of Eligible Employees. All Eml?loyees exclUding non.managemenl 'employees of BellSouth Advenising and Publishing Corporaoon. GI 1000 l3Cl 7 23414.LTD '. . , ' ~ Conr~~'!.!!2n L,' " .- , " ,. Each Empleyee will become insured on the dale he becomes eligible (or the insurance.,':.' If an Eml'loyee is not Actively-at. Worle on the date his insurance would etherwise be effecllve. It will become effective en the first day he is again Acllve!r-at-Work. . . ..,.. .. Gr 1000 ISCI (V-I) EFFECTIVE DATE OF INSURANCE (.,' 1 . ,t ,j,' ;':'f 8 23414.LID -, ~ C2!lL"..!!!!!.n.lli!,rLb.. ~ . . " INSURING PROVIS~ONS Disability Benents, U an Employee, while Insured for this Long Term Disability Insuiance, becomes Disabled, the Insurance Company will pay the Monlhly Benefit In an ameunt determined from the Schedule of BenefllS. Payment will be made when the Insurance Company receives satisfactory proof that: I) the Empleyee became Disabled while Insured: and 2) 'lhe Disability continued throughout and after the Qualifying Period, Dlsablllly or Disabled. An Employee will be considered Disabled if he Is either ToL1lJy or Panlally Disabled. Tolal Disability or Totally Disabled. An Employee wlll be considered Tellllly Disabled If, as a direct result of an Injury or Sickness. he Is unable to ~rfonn the material duties of hls Nonnal Occupation for any empleyer. However. after Monthly Benefits are payable fer 36 months. an Employee will be cons Ide fed Totally Disabled only if he is unable to pelform lhe material duties ef anT occu~ation for which he Is or may beceme suited based on his education, training or experience, Proef 0 TOlal Disability will be satisfactory If It (1) is in writing and (2) consists of all medical. psychological. educational and vocationallnCennation which the Insurance Company considen peninent to the claim: Alter a Totally Disabled Empleyee has received Menthly Benefits for 6 monlhs,lIie Insurance' Compan)' may re!jWre lhat he submit. at such intervals as necessary, satisfacrory proof of the centinilance of Total Disability. _ Partial Disability or Partially Disabled. An Employee will be considered Partiall)' Disabled if. as a direct result of an Injury er Sickness. he is unable to pelfonn the material duties ef hls Nennal Occupation en a full.time basis. but is: I) perfonninll' at least one of the material duties of his Nonnal Occupation or another occupatien on a pan-ume or full.time basis: and is 2) earnIng CUllClltly at least 20% less per month than his predlsability Earnings. Normal Occupation. The Nennal Occupation of an Eml?loyee is -me occupatit'n. job or worle he perfonned at the time he stopped :-"orlclng just prior to a c1il1I11 bcing made under lhls PoUcy. Qualifying Period. The ~ualifying Period will stan wilh the first day an Employee is not Actively.at- Worle due te Disability. It will cease with the earlier ef: I) the end ef 180 days ef continuous Disability; ,or 2) when Disabillty ends. If an Employee's Dlsabllll}' ceases fer up ro 14 days and then begins again due to the same Sickness er Injury, lIie period of Disability will be deemed continuous. In such case the Qualifying Period will be extended by lhe number of days during which Disability ceased. " - Benefit Payment Period. Benefit payments will Stalt after the Qualifying Period ends if Disability continues after lhe Qualifying Period. Benefit payments will cease on the earliest date shown below: I) the date the Employee ceases to be Disabled or dies: 2) when lhe Employee is not under the continuous care ef a physician er net receiving treaanent considered reasonable by the Insurance Cempany: 3) lhe date the Employee falls ro: a, furnish proof of the continuance of Disability when requested by the Insurance Company: er b, submit to an examination requested by the Insurnnce Company; 9 23414.LTD .... .. t , " -., ConrC!~.!.'!.!.!2~' .! _. ~.., ., .' INSURING PROvrsIONS Continued 4) S) On lhe Employee's 65th birthday Wilh lhe 42nd monthly payment Wilh lhe 36th monthly payment . Wilh lhe 30th monthly payment With lhe 24th monthly payment Wilh the 21st monthly payment With lhe 18th monthly payment Wi!h !he 15th monthly payment or at age 70, whichever occurs first ,Witl.1lhe 12th monthly payment when' the EmplOYcc's CUrrent mont!!ly earnings equal or exceed 85% of 11is predisability monthly Earrungs. _ the date payments cease based on lhe Employee's age when the payments began as shown '1" below: , n. \ ... I ~~~~~ II i::ti ' ~v- , Dale Payments Cease Employee Age When Benefit Began Under 62 62 63 64 65 66 67 68 69 and over Recurrent and Concurrent Disabilities. Rccum:m Disabilities that result from the same or a rclaled Injury or Sickness will be considered one disability if: I) the Empleyee has received benefits',under this Policy: and 2) the Empleyee returns to full-time worle and again becomes Disabled after less lhan 6 months of such full-liI!'e worle. 3) Disability benefits under !his Policy have ceased by reason of item (5) above and within six menths of receipt of the last Monthly Benefit payment. lhe Empleyee,suffers a reduction or less of his Panial ~sability earnings, No new Qualifying PeriOd will apply to the later disability and Monthly Benefits will resume at the same level on the date the later disability begins under lhe same terms and conditions that applied to lhe earlier period of disability. ConCUlTCnt Disabilities that result from an unrcIated Injury or Sickness will be considered one disabilitJ.'. However, if the Empleyee returns to worle for at lease one day between disabilities. the later disability will be considered a new ene, subjcct to .a new Qualifying Period. Rehabilitation Provision. The Insurance Company maintains an active rehabilitation deparoncnt and lllOvides rchabilitative services to claimants whem It feels will benefit hom such services. The Insurance Company reselVes the right to determine which claimants will benefit from rehabilitative selVices. 011000 I7LTD32 Gr 1000 I7LTD34 GI 1000 l7LTD3S - --- -.-.- IO 23414-LTD " . , , ~ Conr,,~'!.!.!2~ .. .. . ...." to Clh{. ( (ju() Lc.-f" SCHEDULE OF BENEFITS Scheduled Monthly Benefit Each Employee who is insun:d fer. Option I An asriount equal (0 50% of Ihe Emllleyee's monthly Earnings. up lO a maximwn of 19.536 of Scheduled Monthly BenefilS... An amount equal 10 70% of lhe Eml'loyee's monthly Earnings, up lO a maximwn ef 113.350 of Scheduled MonUlly BenefilS... .The maximum Scheduled MonUlly BenefilS shown above arc based on the eamlng limitation provided by the IRS for relirement plans, The IRS adjusts Utis Iimi!.1lion each year based on lhe IRS earnings limilation. IC an Employee needs infonnalion n:garding Utis figure, conlaCI the Plan Adminislralor, Initial Ainouni of Scheduled Morilh.lY Benefit. The initial amoun~ o(an Employee's S~heduled Monlhly Benetit is based on Option I and his monlhly Earnings on lhe day he becemes insun:d. subjecl lO the fellewing exceptien: ' Oplion 2 Each Employee who eleclS Option 2 during lhe 1992 Benefit Seleclion Period will be insun:d for Oplien 2 and his initial amount of Scheduled MonUlly Benefil will be based en Oplion 2 and his monUlly Earnings on lhe day he becomes insun:d. .. Monlhly Benefit Payable. The amount of MonUlly Benefit payable for ari Employee who is Tolally Disabled for any menth will be the Scheduled MonUlly Benefil for \he option for which he is insured minus all Other Income BenefilS Ie which lhe Employee is entitled for lhe same month. The 'ameunt of Menthly Bc:nefil payable for an Employee who is Partially Disabled for any month will be the lesser of: ' I) 2) the Scheduled MonUlly Benefit for the option for which he is insured; or 100% oC the Employee's monUlly Earnings minus income from the follewing sources for the same month in which the Monlhly Benefit is payable: a. all Other Income BenefilS; and the amount the Employee's dependenlS receive, on the Employee's record under the Uniled Slales Social Security Act or Railroad Retirement Act. Canadian Pension Plan or the Quebec Pensien Plan or any similar plan or act; and c, all ef \he Employee's Olher Earnings, The MonUlly Benefit payable will nOI be less than 1100. b. Other Income Benelils. Other Income Benefits include any: 1) Payments provided because of Ihe Empleyee's disabilily under: a. any group disabilily plan or like plan for persons in a group; b. The Uniled S!.1lcs Social Securily ACI or Railroad Retirement Acr. lhe Canadian Pension Plan or the Quebec Pensien Plan or any similar plan or acr. excluding any such paymenlS 10 the Employee's dependenls; 23414-LTD 13 " " r - C';nfe..!!!!!.'!.!!2'.'...!d... . ' (- , , SCIIlmULE OF lIENEFlTS Conlinued , any Worker's Com(lCns~lion or like bw. including any such payments 10 Ule Employee's dependenls: d, any compulsory ael or law, c, ~ Wi!h respeCllo !his number (I) provision, only benelits which arc paid or pay~ble for the same ' or relaled disabilily will be considered as Other Income Benelits. 2) Retirement or pension benelils provided by the Employer. J) Retiremcnt benelits under the United Slates Social SeeurilY Act or Railro~d ReUrcment Act, the Canadian Pension Plan or the Quebec Pension Plan er any similar plan or ael, excluding any such paynu:nts,IO the Employee's dependents on lhc Empleyee's record. Any reference Ie paym!=nlS provided under the Uniled Slales Secial SceurilY Act will include benclilS to which the Employee may I)ccome enUtled, or for Partial Disability benefits any benefits 10 which his dependenlS may become enliUed. Cosc of Ilving increases ~tiicli become' ~ffe~tive aIler the liisc Menl/Jly Benelic ,is payable will not ~ included In Olher Inceme 'Benefits. , _ If any Other Income Benefits, excluding Worker's CompensaUon or similar law benelits. are paid to the Employee on any basis elher than monll\ly,the Insurance Company will determine lhe monthly cquivalent of thac paymenc and reduce each Menthly Benelic payable under lhis Policy by such amount. Any such benelits paid in a lump sum will be considered as paid in monlhly amounts over the period of lime covered by the lump sum payment. ' If any Worke~ Compensalien or similar law benelilS arc p~id 10 !he Emfleyee on any basis other lhan monlhly. the Insurance Cempany will delcnnine the monlhly equivalenc 0 !hac paymenc and reduce each Monlhly Benefic parable under this PoUey by, such amount. Any such benefits paid in a lump sum will be considered as paid in monlhly amounlS over a 5 year period or 10 lhe final p'a]1l1enl d~le, whichever is ellrlier. Any lump swn, payments made will be considered paid only {or disabllily unless the Employee gives the lnsul'llllce Company satisfaclOry proof 10 the conlrary, O!her Earnings. Olher Earnings are lhe Empleyee's aClUal earnings in his Nermal OccupaUon or another occupation. , Overpaymenl. I{ the Menthly Benelil {or any mon!h is everpaid, lhe Insurance Cempany will bill the Employee {er the amount overpaid. If thc Empleyee fails 10 make payment wilhin a reasonable lime, the Insurance Company will have the right 10 recever the amounl ov~rpaid {rom any future payments. If the Empleyce's Menlhly Benelit ceases liefore the overpaid amount is fully recovered.lhe Insurance Company will bill the Empleyee {or the remainder. Such ameunl will be due and payable immediat~ly. ' Social Seeurily. At !he time an Employee submilS Proof o{ Caim !he Insurance Company wiII n:quirc lhe Employee to al'ply (er benefilS under the Social Security Act ie he is covered under thai act arid 10 choose one of lhe rolIewing opliens: I) 10 have lhe Insurance Company deem the Social Security Benelit payable at an eslimaled amount and reduce his Monlhly Benelil payment by that amount but not below SIOO; or 2) to have no reduclion in his Monlhly Benelil unlilthe actual ameunt ef the Social Security Bene/it is known. The Insurance Company requires an Employee 10 appeal any denial ef his Secial Security BeneliL At lhe time an Empleyee requeslS such appeal, he sheuld again choose one ef the above opUons; ie he {ails 10 make an appeal or {ails 10 choose one of the opllons. the Insurance Company will apply option (2). When the Insurance Cempany is advised of the linal Social Security award or denial. the MonUdy Benefit paid will be recalculated 10 delennine the amounl ef Monlhly Benelit which would have been paid had . , . , 2J4I4-LTD 14 " . ':"'"', -- - Conr"~'!..!.!2n L' . t. t. SCHEDULE OF BENEFlTS Conlinued . lhe Secial Security decisien been known when lhe Monlhly Benefit was being paid. IflheMonlhly Benefit paid was less than It should have been, the Insurance Company will pay the Employee lhe difference with mterest. IC lhe Monthly Benefit paid was more lhan It should have Ocen. the Employee will be !ClJIIlred to pay the Insur.lllce Company the difference. If any amount due the Insurance Cempany is not paid within a reasonable lime, the Insurance Cempany will withhold the Employee's Monlhly Bcnclit payments to recover ,such amount If the Employee's Monlhly Benefits end,'any ameunt still due lhe lnsur.lllce Company will be due from the Employee or his estate. If lhIs amount Is not paid immediately, the Empleyee, his representatives or estate will be responsible for payment with interest and any anomey's fees Involved In collecling the amount due. ' , Change in Scheduled Monthly Benefit Due to Change in Option. The eption for which an Employee is insured will be changed only if the Employee elects to change his option by signing a change fonn approved by the Pollcyhold~r and the Insurance Company: I) during an annual Benefit Selection Period; or 2) wilhln 31 days of a Qualified Change in Family Status. If the 'Employe~ fails to si&n a chan~e fonn approved by the Policyholder and the Insurance Company. or if he signs the fenn a~ any other Ume, his option will hot be changed. , . _ If the Employee elects to change his option: , I) during an annual Benefit Selection Period. his Scheduled Monthly Benefit will be changed on the fir.;t day of the PI:m Year that ne~t follows that Benefit Selection Period. within 31 days of a Qualified Change in Family St:ltus. his Scheduled Monlhly Benefit will be changed on, the later of: a. the date of his election; or b, the date ef O1~ge in Status. However. any increase in an Employee's Scheduled Monlhly Benefit due to his change from Option I to Oplion 2 will not apply with regaro to a disability caused by an Existing CenditioJ1, except after the Empleyee has been Actlvely.at.Werle and insured for Option 2 for 12 consecutive months flOrn the mest recent effective date of the increase. . 2) Change in Scheduled Monthly Benefit Due to Change in Earnings. If an Employee's monthly Earnings change (en any August 15th as pro,vided in the definitIon of Earnings). his Scheduled Menthly Benefit will change on the first day of the Plan Year that next follows that August 15th. However, if his menlhly Earnings change because he changes from part.tIme 10 full.tUne or fuIl.time 10 part.lime status. his Scheduled Menthly Benefit will change on the dale of his change in status. Actlvely-at-Work Requirement for Increases in Scheduled Mo'nthly BenefiL If an Employee is net Actively-at- Werle en the day his Scheduled Monthly Benefit would fer i reason etherwise be Ulcreased, It will not be increased until he is a~aln Actively-at-Work. If the Em eyee is on vacation and is net disabled on the day he becomes eligible for an mcrease in his Sched ed Menthly Bcnefit, he will be deemed to be Actively-at-Werle on the day he becomes se eligible. 23414-LTD IS ()--w Great:-West: LIFE & ANNUITY INSURANCE COMPANY 8505 East Orchard Road Englewood, CO 80111 Tel. (303) 689.3000 Addre.. mal 10: P.O. Box 1000. [)enver, CO 00201 POLICYHOLDER ., POLICY NUMBER. CONFEO - GWL&A EFFECTIVE DATE OF ORIGINAL CONTRACT PLAN TYPE FORM NUMBER BELLSOUTH CORPORA nON 23414-LTD 254873GDH January I, 1993 LONG TERM DISABILITY INSURANCE F-4303 .:':':....:......: .......:.:.... ~:".: .. Great-West Life & Annuity Insurance Company ("Great-West") has assumed the above referenced policy and has agreed to comply with and perform all the rights. obligations. and liabilities under this'policy to the extent of claims incurred after September I. 1994. with the same effect as if Great-West had directly issued the policy. Claims incllrred after September 1. 1994. and arising under-this policy may be filed directly with Great-West. Claims incurred prior to September 1, 1994, are the responsibility of Confeder;llion Life Insurance Company ("U.S.") in Rehabilitation. As of January I. 1995. Great-West will administer the above-referenced policy in accordance with the terms and conditions dci$cribed therein until said policy terminates. It is provided, however. that for the first two years of benefit payments for an eligible claim, such payments will be funded entirely by l3ellSouth Corporation ("BellSouth"). It is further provided tha( Great-West will provide Administrative Services for eligible claims funded by BellSouth. as specified in the Services Contract issued by Gn:at-West to BellSouth. Great-West Life & Annuity Insurance Company By: (A~Z Si'g;a::r ..~. ..... - ~r;.I2-, 6At:l.J~ ~A I ro.4AN~ it" OrL.~Ar",^,.J Title: . 3/1-'].-17 ( Date: t;: r-- ?,- ;, ,.,: .. t..S. ~; w8 ~ ;-)~1 U(.5 -- 6~~ .~. ~ reo.. a.. ()~ l.l..r:!; ~n 0" :",':ffl CI.; jL_. ~L\.. f;'-7 0:) tiHD . 0:: tt.J w eno.. ;.:=: u- :::1 1I_ CO ::> 0 CTI U " Ii .' ,-. .:. , -_....~._,.....