Group Long Term Disability INSURANCE

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1 Get SOLID paycheck coverage With just your limited sick time or salary continuation program and no State Disability Insurance (SDI), Long Term Disability from the Club is more than optional it s vital! Fill out and return the application form or call a Club counselor at (800) Group Long Term Disability INSURANCE u Competitive rates u Pays to age 65 u Convenience of payroll deduction Whether you re disabled on or off the job u THE PLAN pays the difference between your other disability benefits and 70% of your gross salary, or 60% of your gross salary without other benefit sources. u THE PLAN pays to age 65 (if you become disabled before 60). u THE PLAN benefit payments are usually tax-free! Consult your tax advisor. City Employees Club of Los Angeles 311 South Spring Street, Suite 1300 Los Angeles, CA (800) This plan is underwritten by The United States Life Insurance Company in the City of New York, NAIC No domiciled in the state of New York with a principal place of business of One World Financial Center, 200 Liberty Street, New York, NY It is currently authorized to transact business in all states, plus DC, except PR. This summary is a brief description of benefits only and is subject to the terms, conditions, exclusions and limitations of Group Policy No. V-209,281, Form No. G Coverage may vary or may not be available in all states. The underwriting risks, financial and contractual obligations and support functions associated with products issued by The United States Life Insurance Company in the City of New York (United States Life) are its responsibility. R07/14 WEB-CA AG10649 (04/14) How would you pay the bills if you couldn t work?

2 CITY EMPLOYEES CLUB OF LOS ANGELES LTD INSURANCE Sign up for Group Long Term Disability Insurance from the Club. u Imagine the possibility of living on less than half of your pay! If you happen to suffer a long-term illness or injury, that s all you might get with the disability coverage you have now. Long Term Disability (LTD) benefits from the Plan BEGIN when you need them most. Just as your sick pay or salary continuation drops below 70% of your pre-disability pay, Long Term Disability Insurance starts helping to support you and your family as soon as your waiting period ends. Whether your disability happened on or off the job, the Plan will pay the difference between your other benefits and 70% of your gross salary. Even when your other sources are used up, we pay 60% of your gross salary to age 65, for as long as you are disabled. Take the next step now! Use the easy worksheet to see how Long Term Disability Insurance from the Club would complement your benefits. *Please consult your tax advisor. Your Club LTD benefits are usually tax-free!* Right now, you probably take home about 70% to 80% of your gross pay after taxes. Since you pay the premiums, the money you receive with LTD insurance is usually tax-free meaning your take-home pay stays very close to what it was before you were disabled. The plan covers partial disability, too. High quality, competitive premiums. LTD from the Club is underwritten by The United States Life Insurance Company in the City of New York. The most prominent independent ratings agencies continue to recognize The United States Life Insurance Company in the City of New York in terms of insurer financial strength. For current insurer financial strength ratings, please consult the website at Because the Club is a membership program of the Los Angeles City Employees Association, a not-for-profit association, you get The United States Life Insurance Company in the City of New York quality at an economical price. TO APPLY, just fill out the application and mail it today!

3 CITY EMPLOYEES CLUB OF LOS ANGELES LTD INSURANCE Here s how Long Term Disability Insurance from the Club could help PROTECT your paycheck: DWP EMPLOYEES What you have through the DWP: Salary Continuation Up To 1 Year: 100% falling to only 40% of your salary One-Year Extended Salary Continuation: Just 33% of your salary Permanent Total Disability: Just 40% of your salary That s it. Don t forget, DWP employees don t qualify for State Disability Insurance (SDI). What you can ADD with the Club: Once your waiting period ends and your income drops below 70%, the Plan kicks in with the difference between your other disability benefits and 70% of your gross pay. If your income drops to 0, the Plan pays 60%. And it s usually tax-free! How much does it cost? (See premiums chart at right) 1. First, choose your waiting period. We recommend: Less than 10 years of service: 90 days 10+ years of service: 180 days 30+ years of service: 360 days Remember, the longer you can afford to wait, the more economical your premium will be. The waiting period starts the day your disability begins and runs concurrently with your other sick time or salary continuation benefits. If, during the waiting period, your disability stops for 30 days or less, the disability will be treated as continuous. The days you were not disabled will not count towards satisfying the waiting period. 2. Then complete the worksheet below: EXAMPLE YOU Waiting period 180 days days Yearly gross salary $ 48,000 $ Divide by 12 $ 4,000 $ Divide by 100 $ 40 $ Premium per $100 (from chart, right) X $.74 X $ Monthly deduction $ $ (Example: employee age 43, years of service.) Please consult your tax advisor. CITY* EMPLOYEES What you have through the CITY: Sick Time 3 Weeks To 10 Months: Depending on accumulated sick time Two-Year Taxable Disability Benefit: Just 50% of your salary Disability Retirement: Just 33% of your salary (and only after five years of service!) That s it. Don t forget, City employees don t qualify for State Disability Insurance (SDI). What you can ADD with the Club: Once your waiting period ends and your income drops below 70%, the Plan kicks in with 60% of your gross pay, or the difference up to 70% with Disability Retirement. And it s usually tax-free! How much does it cost? (See premiums chart at right) 1. First, choose your waiting period. We recommend: Less than 880 hours of 100% + 75% Sick Time: 90 days hours of 100% + 75% Sick Time: 180 days More than 1700 hours of 100% + 75% Sick Time: 360 days Remember, the longer you can afford to wait, the lower your premium will be. The waiting period starts the day your disability begins and runs concurrently with your other sick time or salary continuation benefits. If, during the waiting period, your disability stops for 30 days or less, the disability will be treated as continuous. The days you were not disabled will not count towards satisfying the waiting period. 2. Then complete the worksheet below: EXAMPLE YOU Waiting period 180 days days Yearly gross salary $ 48,000 $ Divide by 24 $ 2,000 $ Divide by 100 $ 20 $ Premium per $100 (from chart, right) X $.74 X $ Bi-weekly deduction $ $ (Example: employee age 43.) *Call a Club Counselor at (800) for Plan coordination with your Flex Benefits. The Club With additional coverage from the Club, you restore income you might lose without it! The Plan helps restore a portion of your income! The Plan will pay up to 70% or 60% of your gross salary to help refill a portion of your glass! Your Premium Per $100 PREMIUM per $100 of Income The Club AGE WAITING PERIOD 90 DAYS 180 DAYS 360 DAYS To 29 $0.68 $0.45 $ The amount of monthly benefit selected is the maximum benefit you will receive under the policy. The benefit will be reduced by any other benefits you are entitled to receive from sources, including amounts you re eligible for under Workers or Workmen s Compensation Law, occupational disease law or any other similar act or law; employer continuation/sick leave benefits; disability from any compulsory benefit act/law or group insurance plan; Social Security Disability benefit; or employer or governmental retirement plan.

4 u Additional group long term disability insurance coverage information: 1. Eligibility Requirements You are eligible to apply for this coverage if you are a member in good standing of the City Employees Club of Los Angeles and actively working full-time (at least 20 hours per week). You must be actively at work on the date the insurance is to take effect. If you are not, the insurance will take effect on the day you return to work. 2. Duration of Benefits Monthly benefits will be paid up to the maximum benefit period. The benefit will end on the date you fail to give required proof of continuing disability or verification of earnings, as needed, your disability ends, the maximum benefit period ends, or you die. Once the waiting period has been satisfied, benefits for a disability which begins prior to age 60 are payable to age 65. However, if your disability begins after age 60, the following schedule applies: if total disability begins prior to age 60: to age 65 if total disability begins at attained age: months months months months months months months months months 69 and over 12 months 3. Date Member s Insurance Ends Insurance will end at the earliest of: the date this policy ends; the date insurance ends for your class; the date the Los Angeles City Employees Association ceases to be a participating unit; the end of the period for which the last premium has been paid; or the date you cease to be actively at work on a full-time basis, except for a leave of absence. If you are on a leave of absence and continue to pay premiums, your insurance will be continued for up to 180 days immediately following the month in which your leave of absence begins. 4. Total Disability Total Disability means: during the waiting period and next 12 months, your complete inability to perform the material duties of your regular job. Your regular job is that which you were performing on the day before total disability began. after such 12 months, your complete inability to perform the material duties of any gainful job for which you are reasonably fit by training, education or experience. The total disability must be a result of an injury or sickness. To be considered totally disabled, you must also be under the regular care of a physician and must not be performing the duties of any gainful job. 5. Basic Monthly Pay Basic Monthly Pay means your monthly rate of pay from your employer. Such rate will be that in effect on the day before disability begins. Basic monthly pay does not include commissions, bonuses, overtime pay or other extra compensation. 6. Pre-existing Conditions PRE-EXISTING CONDITION means an injury or sickness for which you: incurred charges; received medical treatment; consulted a physician; or took prescribed drugs, within six months before you became insured. If disability is due to a pre-existing condition and it begins within 24 months of the date you become insured, no benefits will be paid unless you have not: incurred charges; received medical treatment; consulted a physician; or taken prescribed drugs for such condition, or any complication of it, for 12 continuous months, while insured. If disability is due to a pre-existing condition and it begins more than 24 months after the date you become insured, benefits will be paid as they accrue. LIMITED BENEFITS FOR ALCOHOLISM, DRUG ADDICTION, AND MENTAL, NERVOUS OR EMOTIONAL DISORDERS: If disability is due to alcoholism, drug addiction, or a mental, nervous or emotional disorder, or any combination of these, benefits will be paid for a maximum of 12 months per period of disability.

5 A P P L I C A T I O N 7. Exclusions/Limitations No monthly benefit will be paid for disability due to intentionally self-inflicted injury; war or an act of war; or committing a crime or an attempt to do so. Successive periods of disability will be considered one period of disability unless they are due to unrelated causes or separated by a return to full-time work for six or more continuous months. A separate waiting period will apply for each separate period of disability. 8. Additional Benefit The plan also covers partial disability if you are unable to perform the material duties of your regular job, but you are able to perform at least one of these duties on a part-time basis, or at least one, but not all, of these duties on a full-time basis. The maximum benefit for partial disability is the monthly benefit that would be payable to you during total disability LESS the wages you earn while partially disabled. Partial disability benefits are payable until the earliest of the end of the maximum benefit period for total disability or the date you earn 70% or more of your basic monthly pay. Group Long Term Disability INSURANCE Instructions: Complete the application by filling in the white areas. Sign and date the application and the Payroll Deduction Authorization. (Keep the MIB Disclosure Notice for your records.) Mail the completed application and Payroll Deduction Authorization form to: City Employees Club of Los Angeles 311 S. Spring St., Ste Los Angeles, CA If you have questions or need assistance, please call a Club counselor at (800) START protecting your income today! Programs underwritten by The United States Life Insurance Company in the City of New York

6 Application for Group Disability Insurance Underwritten by: The United States Life Insurance Company in the City of New York (Herein called the Company) Please print or type all information requested. Please complete all sections of the application to avoid delays. Name of Association City Employees Club of Los Angeles Social Security # Employee s Full Name (First, Middle, Last) Age Height ft. in. Weight lbs. EMPLOYEE INFORMATION Home Address City Date of Birth / / Employee s Current Annual Salary Sex $ Place of Birth SALARY MUST BE COMPLETED Cell Phone No. ( ) Hire Date / / Are you now, and have you been for the last 90 days, performing all of the duties of your regular occupation for at least 30 hours per week for your present employer? State Job Title ZIP Home Phone No. ( ) Yes No If no, please provide explanation: WAITING PERIOD Waiting Period (check one): 90 days 180 days 360 days Name and Address of Member/Applicant s Physician Physician s Phone No. ( ) PLEASE ANSWER THESE BRIEF QUESTIONS To the best of your knowledge and belief: 1. Have you ever had or been treated for (Circle specific disorders experienced): a. Disease or disorder of the heart, murmur, chest pain, rheumatic fever, elevated blood pressure, stroke, aneurysm or transient ischemic attack?... YES NO b. Injury, pain or disorder of the neck or back? Sciatica? Any disabling injury or disorder of the bones, joints or muscles? Connective tissue disorder?... YES NO c. Arthritis, chronic pain, chronic fatigue, fibromyalgia, bursitis or rheumatism, or any other neurological disorder?... YES NO d. Dizziness, epilepsy, convulsions, recurrent headaches, glaucoma, cataract or other disorder of the eyes or ears?... YES NO e. Disease or disorder of the rectum? Vascular or blood disorder?... YES NO f. Diabetes or elevated glucose? Sugar or albumin in urine? Thyroid or other glandular disorder?... YES NO g. Ulcer, or disorder of stomach, liver, gall bladder or pancreas? Colitis, Hepatitis, or other disorder of small or large intestine?... YES NO Question No. Condition Date Occurred h. Prostate disorder? Nephritis, nephrosis or other kidney disease or disorder?... YES NO i. Menstrual, uterine or ovarian disorder? Complications of pregnancy? Disorder of the breast?... YES NO j. Bronchitis, emphysema, sleep apnea, difficult breathing, or other respiratory disease or disorders?... YES NO k. Cancer, tumor or mass? Deformity or loss of limb? Congenital defect? Disease or disorder of the lymphatic system?... YES NO l. Mental or emotional problem requiring help of a physician, psychologist or counselor?... YES NO m. A surgical operation? Or a surgical operation advised but not performed?... YES NO n. Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex (ARC) or disorders of the immune system?... YES NO o. Alcohol or drug abuse?... YES NO 2. Have you during the past 5 years, consulted any physician or other practitioner or been confined or treated in any hospital or similar institution, for any reason other than those stated above?... YES NO 3. Are you now taking prescription medication or receiving medical attention?... YES NO For Yes answers to questions 1-3 above, please provide details in the space provided below. If more space is needed, use a separate sheet of paper, signed and dated. If additional information is attached, check Yes.... YES Duration Degree of Recovery Names & Addresses of Physicians Hospitals/Clinics Consulted

7 AUTHORIZATION QUESTIONS (cont.) 4. Do you have any disability insurance in force or pending (including group coverage)?... YES NO If YES, please indicate companies and amounts. 5. Will this coverage applied for, replace any insurance in force now?... YES NO If YES, please indicate which insurance and the amount being replaced. AUTHORIZATION AND DECLARATION OF EACH PERSON GIVING A STATEMENT OF INSURABILITY I hereby authorize any licensed physician, medical practitioner, pharmacy, pharmacy benefit manager and other sources, hospital, clinic, or other medical or medically related facility, insurance company, the MIB, Inc., formerly known as the Medical Information Bureau, or other organization, institution or person that has any records or knowledge of me or my health, to give to the Company or its reinsurers any such information. Such information will pertain to my employment, or other insurance coverage and medical care, advice, treatment or supplies for any physical or mental condition. This includes information obtained in connection with the preparation or procurement of an investigative consumer report as defined under the Fair Credit Reporting Act(s). To facilitate the rapid submission of such information, I authorize all said sources, except the MIB, Inc., to give such records or knowledge to any agency employed by the Company to collect and transmit such information. I understand that this information will be used by the Company solely to determine eligibility for insurance. I understand that I may revoke this authorization at anytime by giving written notice to the Company. I agree that such revocation will not affect any action, that any source has taken in reliance upon this authorization. I understand this authorization will be valid for 24 months from the effective date of coverage, if not revoked earlier. I know that I should retain a copy of this authorization for my records. I agree that a photocopy of this authorization is as valid as the original. To the best of my knowledge and belief, all statements made above are true and complete. I understand that my application for group insurance will be accepted or declined on the basis of these statements. Insurance will take effect only if a certificate is issued based on this application and the first premium is paid in full (a) during the lifetime of all proposed insureds; and (b) while there is no change in the insurability or health of such person from that stated in the application. IMPORTANT NOTICE Any person who knowingly and with intent to defraud any insurance company, files or causes to be filed, a claim for payment of a loss, containing any false or incomplete information commits a fraudulent insurance act that may be a crime and may subject such person to incarceration, fines and denial of benefits. A copy of this application will be attached to and made a part of your certificate. SIGNATURE of Employee/Member Date Signed G _ CA AG10649 (04/14) Group Policy No. LTD V-209,281 CLUB MEMBERSHIP NEW POLICYHOLDERS: Club membership fees will be automatically deducted. Club Membership: As a new policyholder, you will automatically be enrolled as a member of the City Employees Club of Los Angeles, a membership program of the Los Angeles City Employees Association. Membership is required to participate in group-rated insurance programs. Membership is limited to active or retired employees of the City of Los Angeles and the Department of Water and Power. As a member of the City Employees Club of Los Angeles, you will have access to many Club-only benefits and programs including:* Discount Tickets Through the Club Store Buy tickets by phone, mail, or by the Club website at Theme parks and attractions Movies most major screens Plays, musicals, the arts, sports events More Discounts and Savings Enjoy exclusive Club savings from Club partner businesses Monthly Alive! Newspaper Births, weddings, retirements, deaths Free classifieds Retiree s Corner News that matters Department of the month Opinion column, movie reviews Latest Club information Group-Rated Insurance Products Term Life Insurance Spouse Life Insurance The famous Refund Check Long Term Disability Insurance Short Term Disability Insurance Long Term Care Insurance Cancer Insurance Group-Rated Accidental Death & Dismemberment Insurance Group-Rated Auto and Homeowners Insurance Pet Insurance Legal Services Plan Accident Insurance Identity Theft Protection More Benefits Free notary service Scholarships Employee of the Year Award *Club benefits and programs may change from time-to-time. Payroll Deduction Authorization In addition to payroll/pension deductions for group benefits, if any, you will receive all Club benefits for a payroll/pension deduction of only $4.50 per month (active employees) or $2.50 per month (retired). You authorize these monthly deductions by signing the Payroll Deduction Authorization form. Annual membership fees of $54.00 for active employees or $30.00 for retired employees include $24.00 for a one-year, non-deductible subscription to the Alive! newspaper. Name: City Department #: (5 or 6 digits) City Employee #: DWP Employee #: Controller City of Los Angeles, or Fire and Police Pension, or City Employees Retirement System, or Paymaster Department of Water and Power I hereby authorize the deduction from my salary or pension of amounts sufficient to cover premiums/membership fees on any of my group benefits provided by City Employees Club of Los Angeles. In the event any premiums should change due to age, increase in salary or benefits, or a general rate increase for the entire Association, I authorize you to make such change upon notification from the City Employees Club of Los Angeles and such deduction to remain in force until canceled by me in writing. Sign Here City/DWP Employee Date / / City Employees Club of Los Angeles 311 South Spring Street, Suite 1300 Los Angeles, CA info@cityemployeesclub.com FOR OFFICE USE ONLY Code Deduction COMPLETE AND MAIL TO: City Employees Club of Los Angeles, 311 South Spring Street, Suite 1300, Los Angeles, CA 90013

8 MIB DISCLOSURE NOTICE (Retain for your records) Information regarding your insurability will be treated as confidential. The United States Life Insurance Company in the City of New York or its reinsurers may, however, make a brief report thereon to the MIB, Inc., formerly known as Medical Information Bureau, a not-for-profit membership organization of insurance companies, which operates an information exchange on behalf of its members. If you apply to another MIB member company for life or health insurance coverage, or a claim for benefits is submitted to such a company, MIB, upon request, will supply such company with the information about you in its file. Upon receipt of a request from you, MIB will arrange disclosure of any information in your file. Please contact MIB at If you question the accuracy of the information in MIB s file, you may contact MIB and seek a correction in accordance with the procedures set forth in the Federal Fair Credit Reporting Act. The address of MIB s information office is 50 Braintree Hill Park, Suite 400, Braintree, Massachusetts The United States Life Insurance Company in the City of New York, or its reinsurers, may also release information from its file to other insurance companies to whom you may apply for life or health insurance, or to whom a claim for benefits may be submitted. Information for consumers about MIB may be obtained on its website at Note: Canadian Members should continue to use the following address: 330 University Avenue, Suite 501, Toronto, Ontario, Canada, M5G 1R7, tel. no NOTICE AS REQUIRED UNDER THE FAIR CREDIT REPORTING ACT(s) Detach Before Mailing This is to inform you that as part of our procedure for processing your insurance application, an investigative consumer report may be requested for the preparation of a report whereby information is obtained through personal interviews with your neighbors, friends or others with whom you are acquainted or who may have knowledge of any such items of information. This inquiry includes information as to your character, general reputation, personal characteristics, and mode of living. You have the right to make a written request to be informed as to whether or not such a consumer report was requested, and if such report was requested, the name and address of the consumer reporting agency to whom the request was made. You may receive a copy of this report by contacting such agency.