Group Term Life Insurance

Transcription

1 Policyholder: Colorado Higher Education Insurance Benefits Alliance Trust Employer: Metropolitan State College Class: 01 or 02 Effective Date: Jan 01, 2009 Group Term Life Insurance With Accidental Death, Dismemberment and Loss of Sight Benefits Dependents' Group Life Insurance Benefits FORM NO

2 ANTHEM LIFE INSURANCE COMPANY Indianapolis, Indiana (herein called Anthem Life) hereby certifies that the insurance stated herein became effective for the Employee or Retiree, subject to the provisions of the Group Policy (referred to herein as the Policy) issued by Anthem Life to Colorado Higher Education Insurance Benefits Alliance Trust, which covers participants of Adams State College, Auraria Higher Education Center, Colorado School of Mines, Colorado State University System and Colorado State University Global Campus, Colorado State University Pueblo, Fort Lewis College, Metropolitan State College, University of Northern Colorado, and Western State College. Death proceeds are payable to the beneficiary upon the death of the Employee while insured under the Policy. Accidental Death and Dismemberment benefits and/or Dependents' Group Life Insurance benefits are provided only if shown in the Schedule of Benefits. John J. Gainor, President FORM NO

3 TABLE OF CONTENTS SCHEDULE OF BENEFITS... i GENERAL PROVISIONS... 1 AMOUNT OF INSURANCE... 6 BENEFICARY... 7 NOTICE OF CLAIM... 7 PAYMENT OF BENEFITS... 8 WAIVER OF PREMIUM BENEFIT... 9 CONVERSION PRIVILEGE RETIREE CONTINUATION ACCIDENTAL DEATH, DISMEMBERMENT, AND LOSS OF SIGHT BENEFITS DEPENDENTS' GROUP LIFE INSURANCE APPEAL PROCEDURES FORM NO

4 SCHEDULE OF BENEFITS Class 01 - Active Employees--Group Term Life, Accidental Death and Dismemberment, and Dependent Coverage: Employee's Current Age Amount of Insurance Under age 65 Two x annual base salary to a maximum benefit of $500,000* Age 65 through 69 Two x annual base salary to a maximum benefit of $50,000* Age 70 + $10,000 *Rounded up to the nearest $1,000. For clarification of Base Salary, refer to the "Definitions" in your Certificate. Annual salary will not include commissions. Employer Contribution The Employer contributes 100% of the premium for Class 01 Group Term Life Insurance with Accidental Death and Dismemberment Benefits. Dependent Coverage and Contribution: Spouse/Child Amount Contribution $2,000/$2,000 N/A Class 02 - Retirees--Group Term Life Insurance: DISCLAIMER: RETIREES ARE NOT ELIGIBLE FOR ANY ACCIDENTAL DEATH & DISMEMBERMENT BENEFITS. A retired Employee may select a lesser amount of coverage than that listed if desired. Retiree's Current Age Amount of Insurance Under age 70 Choice of $10,000 to $50,000 in increments of $10,000 Age 70 + $10,000 Employer Contribution The Employer contributes 0% of the premium for Group Term Life Insurance. FORM NO SCHEDULE (i)

5 GENERAL PROVISIONS A. IMPORTANT NOTICE. This Certificate does not modify or extend the liability of Anthem Life as set forth in the Policy. The SCHEDULE OF BENEFITS of this Certificate summarizes the insurance benefits and amounts provided by the Policy which are based on the Employer's selection. The benefits and amounts may be terminated or changed in accordance with the provisions of the Policy either as a result of a change in the Employee's/Retiree's status, or amendment or termination of the Policy B. ENTIRE CONTRACT STATEMENTS AMENDMENTS. The entire contract consists of the following: 1. the Policy and the Application of the Employer, a copy of which was attached when issued; and 2. the applications of the Employees or Retirees, if any. All statements made by the Employer or by any person insured shall be deemed representations and not warranties. No statement made by any person insured shall be used in any contest or in defense of a claim unless a copy of the instrument containing the statement is or has been furnished to the Employee or Retiree or his beneficiary. No statement made by any person insured relating to his insurability shall be used in contesting the validity of the insurance with respect to which such statement was made after such insurance has been in force prior to the contest for a period of two (2) years during such person's lifetime nor unless it is contained in a written statement signed by him. The Policy may change at any time by written agreement between the Employer and Anthem Life, without the consent of the Employees/Retirees insured or of their beneficiaries. Changes to the Policy are subject to the laws of Colorado. C. DEFINITIONS. As used in this Certificate and in the Policy: EMPLOYEE means all exempt faculty and administrative personnel of an Employer that are regularly scheduled to work at least.5 FTE and that are included on the payroll records of the Employer. Leased Employees, independent contractors and part-time Employees who work less than.5 FTE are not eligible. Eligible Employees on an authorized leave of absence not to FORM NO

6 exceed a 24 consecutive month period, including Employees on sabbatical and summer break, are included as Eligible Employees until the Employer notifies the Insurance Company of termination of eligibility. RETIREE means a Participant in the CHEIBA Trust Health Benefit Plan who satisfies all of the following requirements: (1) on or after January 1, 1999, terminates employment with a College on or after age 50 and prior to age 65, due to retirement; (2) who is immediately eligible to commence receiving retirement benefits under a qualified retirement plan sponsored by an Employer; (3) was covered by the CHEIBA Trust Health Benefit Plan immediately prior to retirement. USE OF A PERSONAL PRONOUN IN THE MASCULINE GENDER SHALL BE DEEMED TO INCLUDE THE FEMININE UNLESS THE CONTEXT CLEARLY INDICATES THE CONTRARY. ACTIVELY AT WORK, ACTIVE WORK OR ACTIVE SERVICE shall mean the active expenditure of time and energy in the services of the Employer. However, an Employee shall be deemed to be Actively at Work on each day of a regular paid vacation, or on a regular non-working day, on which he is not disabled provided he was Actively at Work on the last preceding working day. BASE SALARY for faculty members means the faculty member's academic year Base Salary rate exclusive of any additional compensation including but not limited to, non-base stipends, summer salary, overloads, or non-base merit awards. Base Salary for all other Employees means the Employee's annual salary rate exclusive of any additional compensation including but not limited to, non-base merit awards and/or non-base stipends. Base Salary for faculty and all other Employees does not include bonuses, overtime pay, extra compensation, early retirement incentives, or settlement agreements. D. EFFECTIVE DATES OF INSURANCE. An Employee's or Retiree's insurance will be effective as follows: If the Schedule of Benefits shows that Employee or Retiree insurance is non-contributory, an Employee's or Retiree's insurance will be effective on the next Premium Due Date after the day he becomes eligible. If the Schedule of Benefits shows that Employee or Retiree insurance is contributory, each Employee who both applies for insurance on a form approved by Anthem Life and agrees in writing to pay the required contributions, will become insured as follows: 1. If the Employee or Retiree applies within thirty (30) days of the date he first (1st) becomes eligible, he will be insured on the later of: FORM NO

7 a. the next Premium Due Date after the date he applies; or b. the next Premium Due Date after the date he becomes eligible. 2. If the Employee applies after: a. thirty (30) days from the date he first (1st) becomes eligible; or b. he previously elected to end his insurance, he must then furnish evidence of insurability at his own expense to Anthem Life before he may be considered for insurance. If Anthem Life approves insurance for that Employee or Retiree, he will become insured on the next Premium Due Date after the date of Anthem Life's approval. E. DEFERRAL OF EFFECTIVE DATE. If the Employee is not Actively at Work on the effective date shown in the Schedule of Benefits of this Certificate, the coverage shall become effective on the second (2nd) successive day he is Actively at Work again. F. TERMINATION OF INSURANCE. 1. The insurance of any Employee or Retiree (where applicable) shall automatically terminate immediately upon the earliest of the following dates: a. the end of the Insurance Month coincident with or next following the date after employment ends; or b. the end of the Insurance Month coincident with or next following the date of termination of the Employee's or Retiree's membership in the class or classes eligible for coverage under the Policy; or c. the effective date of an amendment to the Policy which terminates the insurance of the eligible class to which the Employee or Retiree belongs; or d. the date the Policy ends; or e. the date of expiration of the last period for which he has made any required contribution toward payment of premiums, except as otherwise noted in the Waiver of Premium Benefit summarized in this Certificate. 2. Cessation of Active Work by the Employee shall be deemed end of employment. However, insurance hereunder may not end automatically upon cessation of Active Work if such cessation is as a result of: a. Sickness or Injury. In the event of sickness or injury, the FORM NO

8 Employer may elect to continue coverage by continued payment of premium. Coverage may be continued for up to the end of the twelfth (12th) Insurance Month following the month in which absence because of sickness or injury commenced. b. Being Temporarily Laid Off. In the event of lay off, the Employer may elect to continue coverage by continued payment of premium for up to the end of the insurance month following the month in which lay off commenced. c. Regularly Scheduled Intercessions or Summer Breaks. Coverage may be continued provided that the Employer has continued or arranged for payment of premium for coverage throughout the intercession or summer break. d. Leave of Absence (other than mandated). In the event of such a leave of absence, the Employer may elect to continue coverage by continued payment of premium for up to the end of the third (3rd) Insurance Month following the month in which leave of absence commenced. e. Federal or State Mandated Leave of Absence. In the event of such leave of absence, the Employer may elect to continue coverage by continued payment of premium throughout the leave. If the premium is not paid, coverage will terminate. However, upon return to regularly scheduled active employment following a mandated leave, an Employee will be immediately eligible for all benefits in effect at the time such leave of absence commenced. No new eligibility/waiting periods or evidence of insurability requirements will be imposed. Any returning Employee who had not completed the required eligibility period will be given credit toward the completion of the Waiting Period from their date of employment to the date leave of absence commenced. Such Employees will become eligible for coverage upon completion of the Waiting Period. The Employer may continue coverage under this section acting according to rules which preclude individual selection. Insurance will automatically terminate without notice when premium payments for the insurance are discontinued by the Employer, provided the Employer is responsible for all or part of the premium payments. G. MISSTATEMENT OF AGE. In the event the age of any Employee or Retiree insured under the Policy has been misstated, the amount of insurance for such Employee shall be that determined in accordance with the terms of the Policy. There shall be an equitable adjustment of premiums made so that the Employer shall pay to Anthem Life the actual premiums at the true age FORM NO

9 of such Employee or Retiree. H. ASSIGNABILITY. Neither the Employee's/Retiree's Certificate nor the right to the insurance benefits is assignable. However, the Employee or Retiree may assign, to any person other than the Employer, the incidents of ownership in the Employee's/Retiree's insurance, if any. Anthem Life assumes no responsibility as to the validity or effect of any such assignment. I. ADDITIONAL INFORMATION. If further information about the insurance is desired, request should be made to the Employer. FORM NO

10 AMOUNT OF INSURANCE A. The amount of insurance is the amount shown in the Schedule of Benefits of this Certificate. The amount of insurance on each Employee or Retiree shall be determined in accordance with the classes described in the Schedule of Insurance contained in the Employer's Application for the Policy or in the latest of any revised schedules submitted by the Employer and accepted by Anthem Life to replace one (1) previously effective. B. The insurance provided in the Policy is term insurance. C. Any increase in the amount of insurance of an Employee due to a change in class shall become effective automatically on the Premium Due Date coincident with or next following the date of the change in class. However, if the Employee is not Actively at Work on the day the amount of his insurance would otherwise be increased, such increase shall not become effective until the first (1st) day of the Insurance Month following the date such Employee is again Actively at Work. D. Any decrease in the amount of insurance of an Employee due to a change in class shall become effective automatically on the Premium Due Date coincident with or next following the date of the change in class. FORM NO

11 BENEFICARY A. The beneficiary of the insurance is designated in the Employee's or Retiree's application for this insurance. B. The Employee or Retiree may change his designation of beneficiary by written request filed at the home office of Anthem Life through the Employer. Such change will take effect as of the date of execution of such request, whether or not the Employee or Retiree is living at the time of such filing. Anthem Life shall not be required to recognize a beneficiary designation unless furnished to it on its form provided for that purpose, or otherwise expressly accepted by it in writing and satisfactory to Anthem Life. Any payment made by Anthem Life before its receipt of notice of such change will fully discharge Anthem Life's obligation for such payment. If two (2) or more beneficiaries are designated and if the Employee or Retiree has not specifically provided otherwise, payment will be made equally to such beneficiaries or to the survivors or survivor of them. The beneficiary shall be a person other than the Employer. C. If any beneficiary predeceases the Employee or Retiree, his interest except as otherwise specifically provided by the Employee or Retiree will pass to the surviving beneficiaries equally. If no designated beneficiary survives the Employee or Retiree, the amount of insurance shall be payable, at the option of Anthem Life, to either: 1. the executors or administrators of the Employee's/Retiree's estate; or 2. to any one (1) or more of the Employee's/Retiree's surviving relatives: wife, husband, mother, father, child or children, brothers or sisters. Any such payment shall completely discharge Anthem Life's liability with respect to the amount of insurance so paid. NOTICE OF CLAIM Written notice of the death of the Employee or Retiree while covered under the Policy, either while in the Active Service of the Employer or during a period when the Waiver of Premium Benefit is in effect, must be given to Anthem Life within two (2) years after the date of death. If such notice is not given, Anthem Life will not be liable for any payment on account of such death. FORM NO

12 PAYMENT OF BENEFITS A. Immediately upon receipt of due proof of the death of an Employee or Retiree while insured under the Policy, Anthem Life will pay the amount of insurance then in force on the life of that Employee or Retiree to the designated beneficiary, subject to the further provisions of the Policy. B. If a beneficiary is a minor, or is otherwise incapable of giving a release for any payment made, Anthem Life may, at its option, and until claim is made by the legally authorized representative of such beneficiary, make payments of the amount payable to such beneficiary at a rate not exceeding fifty dollars ($50.00) per month to any person or institution appearing to Anthem Life to have assumed the custody and principal support of such beneficiary. Nothing herein shall preclude Anthem Life from making payments to or for the benefit of a minor beneficiary in accordance with the Facility of Payment or Delivery provision of the Colorado Probate Code when applicable or under the equivalent provision of the law of any other state when applicable. If any benefits hereunder shall be payable to the estate of an Employee or Retiree, Anthem Life may pay such benefits up to an amount not exceeding one-thousand dollars ($1,000.00) to any relative by blood or connection by marriage to the Employee or Retiree who is deemed by Anthem Life to be equitably entitled thereto. Any payment made by Anthem Life in good faith pursuant to any of the provisions of this paragraph shall fully discharge Anthem Life to the extent of such payment. C. Any person insured under the Policy whose insurance is not payable to his estate or to any trustee, partnership, or corporation or association may elect to have the proceeds of his insurance paid in installments (or, in case he shall not have done so, the beneficiary may so elect) by filing a satisfactory written request with Anthem Life. The amounts and terms of such installments shall be in accordance with those customarily offered by Anthem Life for settlement of group life insurance proceeds at the time of the election. FORM NO

13 WAIVER OF PREMIUM BENEFIT DISCLAIMER: RETIREES ARE NOT ELIGIBLE FOR ANY WAIVER OF PREMIUM BENEFITS. A. Life insurance benefits will be continued without premium payment for one (1) year from the date satisfactory proof of total disability has been received by Anthem Life if: 1. an insured Employee becomes totally disabled prior to age sixty (60); and 2. he remains totally disabled for at least nine (9) months; and 3. such proof of total disability is furnished in writing to Anthem Life at its home office after six (6) months and within nine (9) months following the onset of such disability; and 4. such proof is submitted to Anthem Life no later than twelve (12) months after the end of premium payments for the Employee; and 5. such proof is submitted on the initiative of the Employee or his personal representative without the necessity of Anthem Life requesting it. B. Life insurance benefits will be continued without premiums for further periods of one (1) year if: 1. the Employee remains totally disabled; and 2. proof of such total disability is furnished in writing to Anthem Life during the three (3) month period prior to each anniversary of the date of the original proof; and 3. such proof is submitted on the initiative of the Employee or his personal representative without the necessity of Anthem Life requesting it. C. The amount of insurance to be extended under the Waiver of Premium Benefit will be the amount of insurance in force on the life of the Employee as determined under the applicable provisions of the Policy. In no event will the amount of insurance exceed the amount in force on the date disability commences. FORM NO

14 D. Anthem Life has the right to have the Employee examined at any time during the period of claimed disability. The Waiver of Premium Benefit shall expire immediately and without notice if at any time consent to make such examination is refused by the Employee, his physician or his beneficiary. E. If the Employee dies within one (1) year after the last date for which premium was paid for his life insurance but before proof of his total disability was furnished to Anthem Life, the amount of his life insurance as determined in C. above will be paid by Anthem Life to his beneficiary if due proof of his death, and that he was totally disabled from the date of cessation of premium payments to the date of his death, is received by Anthem Life at its home office not more than one (1) year after his death. F. If the Waiver of Premium Benefit expires as provided hereunder, insurance of the Employee will be continued only if regular premium payments for him are promptly resumed. However, if his employment with the Employer has then been terminated, he will be entitled to apply for a policy of life insurance in accordance with Paragraph A. under Conversion Privilege, as though employment had terminated at the date of expiration of the Waiver of Premium Benefit. G. If an individual policy of life insurance has become effective in accordance with the Conversion Privilege of the Policy, or in accordance with any supplement to the Policy, the Waiver of Premium Benefit shall be applicable only if such individual policy is surrendered to Anthem Life without claim other than for return of the premiums paid thereon, less any indebtedness. FORM NO

15 CONVERSION PRIVILEGE A. An Employee may convert to an individual policy of life insurance if: 1. the Employee's employment ends; or 2. his classification changes to a class which is not eligible for life insurance. The amount of such policy shall not exceed the amount of his life insurance which was discontinued for the above reasons. B. An Employee or Retiree who has been continuously insured under the Policy for at least five (5) years may convert to an individual policy of life insurance if: 1. all life insurance under the Policy is terminated; or 2. the Policy is amended making the class of Employees or Retirees of which he is a member ineligible for life insurance. The amount of such policy shall not exceed the lesser of: a. the amount of life insurance which was discontinued for whichever of the reasons in 1. and 2. above is applicable, less an amount for which the Employee or Retiree is or becomes eligible under the Policy or any other group policy within thirty-one (31) days after the date his life insurance ended; or b. two-thousand dollars ($2,000.00). C. Issue of the individual policy will be subject to all of the following conditions: 1. Written application for the individual policy and the first (1st) premium therefor must be received by Anthem Life within thirty-one (31) days after the date on which the Employee's or Retiree's insurance under the Policy ends. 2. The individual policy will be in any one (1) of the forms issued by Anthem Life, except a policy of term insurance. The policy shall be without disability or other supplementary benefits. FORM NO

16 3. The premium for the individual policy will be determined by Anthem Life from its then current rates. The rate is based on the Employee's/Retiree's attained age at his birthday nearest to the date of issue of the individual policy, the class of risk to which he then belongs, and the form and amount of the individual policy. 4. Insurance under the individual policy will not become effective until the end of the thirty-one (31) day period described in 1. above. 5. No proof of insurability will be required. D. Upon receipt of due proof at its home office of the death of an Employee or Retiree during the thirty-one (31) day period within which he could have made application for an individual policy of life insurance under the above provisions, Anthem Life will pay to the beneficiary as a claim under the Policy the maximum amount for which an individual policy could have been issued to him under these provisions, whether or not the Employee/Retiree had made application for an individual policy. If the Employee/Retiree had made application for an individual policy, the designation in that application of a beneficiary different from the beneficiary under the Policy shall, notwithstanding any other provision of the Policy, effect a change of beneficiary under the Policy to the beneficiary designated in that application. FORM NO

17 RETIREE CONTINUATION A. When an Employee retires on or after January 1, 1997, the Retiree may elect to continue Group Term Life Insurance under the terms of the Policy by paying premiums quarterly, semiannually, or annually direct to Anthem Life. Upon electing to continue coverage, the Retiree may elect coverage in amounts as specified on the Schedule of Benefits. Any amount of insurance which is discontinued as a result of the change in class may be converted in accordance with the terms of the Policy. B. To be eligible for Retiree coverage, an Employee must meet the following conditions: 1. he must be insured under the Policy prior to electing continuation; and 2. the Employee must retire in an eligible class; and 3. he must submit an application for coverage and the first (1st) premium within thirty-one (31) days of termination of employment; and 4. the Employee must not have exercised a right to convert except for amounts discontinued due to a change in class. C. Retiree coverage terminates at the earliest of the following: 1. upon the termination of the Policy; or 2. upon an amendment to the Policy making Retirees ineligible for coverage; or 3. upon the return to work with the Employer while the Policy is still in force; or 4. upon the failure to pay the required premiums when due. D. Coverage under this section and any converted amounts does not include Accidental Death and Dismemberment or Dependent coverage. In addition, the Waiver of Premium Benefit is not provided after coverage under this section becomes effective. E. Upon termination of coverage under this section, insured persons may convert coverage to an individual policy in accordance with the Conversion Privilege provision. The amount of such policy will not exceed the amount of his life insurance which was discontinued for any of the above reasons. FORM NO

18 DISCLAIMER: RETIREES ARE NOT ELIGIBLE FOR ANY ACCIDENTAL DEATH & DISMEMBERMENT BENEFITS. ACCIDENTAL DEATH, DISMEMBERMENT, AND LOSS OF SIGHT BENEFITS BENEFITS If an Employee suffers any of the losses below as a result of injury, Anthem Life will pay the amount of insurance specified for the loss in the Schedule of Indemnities below, upon receipt of due proof that: A. the injury occurred while the Employee was insured under this coverage; and B. the loss occurred within ninety (90) days after the injury; and C. the loss resulted directly and solely from the injury and independently of all other causes. Schedule of Indemnities Principal Sum for Loss of: Life Both Hands Both Feet One Hand and One Foot Sight of Both Eyes One Hand and Sight of One Eye One Foot and Sight of One Eye One Half of the Principal Sum for Loss of: Sight of One Eye One Hand One Foot Loss of hands or feet shall mean loss by severance at or above the wrist or ankle joint, and loss of sight shall mean total and irrecoverable loss of sight. The amount of Principal Sum for each Employee shall be equal to the amount of life insurance of the Employee as shown in the Schedule of Benefits of this Certificate. The total amount payable for all losses resulting from any one (1) accident shall not exceed the Principal Sum. FORM NO

19 LIMITATIONS No benefit will be paid for any loss which results directly or indirectly from, and not independent of: A. suicide or attempted suicide, or intentionally self-inflicted injury, while sane or insane; B. disease of the body or mental infirmity, or as a result of medical or surgical treatment or diagnosis therefor; C. ptomaines or bacterial infection (except pyogenic infection which occurs through or with an accidental cut or wound); D. war or insurrection or any act attributable thereto; or E. travel or flight in any aircraft while a member of the crew thereof; or while engaged in any way in the operation of the aircraft, or while giving or receiving any kind of training or instruction. CLAIMS Written notice of injury on which claim is based must be given to Anthem Life within twenty (20) days after the date of such injury. Such notice given by or on behalf of the Employee to Anthem Life at its main administrative office (refer to back cover), or to any authorized agent of Anthem Life, with particulars sufficient to identify the insured Employee, shall be deemed to be notice to Anthem Life. Failure to give notice within the time provided herein shall not invalidate nor reduce any claim if it shall be shown not to have been reasonably possible to give such notice and that notice was given as soon as was reasonably possible. Anthem Life, on receipt of such notice, will furnish to the Employee or to the Employer for delivery to the Employee, such forms as are usually furnished by it for filing proof of loss. If such forms are not furnished within fifteen (15) days after receipt of such notice by Anthem Life, the Employee shall be deemed to have complied with the requirements hereof as to proof of loss upon submitting, within the time fixed herein for filing proof of loss, written proof covering the occurrence, character and extent of loss to which the claim is made. Written proof of loss must be furnished to Anthem Life at its main administrative office (refer to back cover) within ninety (90) days after the date of the loss for which claim is made. Failure to furnish such proof within such time shall not invalidate nor reduce any claim if it shall be shown not to have been reasonably possible to furnish such proof and that such proof was furnished as soon as was reasonably possible, and in no event, except in the absence of legal capacity, later FORM NO

20 than one (1) year from the date proof is otherwise required. No action in law or in equity shall be brought to recover Accidental Death and Dismemberment Benefits prior to the expiration of sixty (60) days after proof of loss has been filed in accordance with the above requirements, nor shall such action be brought at all unless brought within three (3) years from the expiration of the time within which proof of loss is required. If any time limitation above with respect to giving notice of claim, furnishing proof of loss, or bringing an action in law or in equity is less than that permitted by the law of the state in which the Employee resides at the time this Certificate is issued, such limitation is extended to agree with the minimum permitted by such law. EXAMINATION AND AUTOPSY Anthem Life, at its expense, shall have the right and opportunity to examine the person of the Employee when and so often as it may reasonably require during the pendency of a claim. Anthem Life may also request to make an autopsy in case of death where it is not prohibited by law. PAYMENT OF BENEFITS All Accidental Death and Dismemberment indemnities will be paid immediately upon receipt of due proof. The benefit for loss of life of the Employee is payable to the beneficiary if surviving the Employee, otherwise to the estate of the Employee; all other benefits are payable to the Employee. FORM NO

21 DEFINITIONS DEPENDENTS' GROUP LIFE INSURANCE The term "Dependent" means: A. An Employee's legal spouse, who is less than age seventy (70), excluding in any case any person: 1. who is an Employee as defined; or 2. whose evidence of insurability, furnished in accordance with provisions hereof, is not accepted by Anthem Life as satisfactory; or 3. who is in active military service. B. An Employee's unmarried child(ren) over 14 days of age and who are primarily dependent upon the Employee for support and maintenance until the end of the month of their 25th birthday, or of any age who are medically certified by a physician as disabled. Dependents must also satisfy the requirements of the Internal Revenue Code to qualify as tax dependents of the Employee for, as applicable, medical and dental plan purposes or life insurance purposes, and satisfy the eligibility requirements for coverage under a Benefit Plan. A Dependent may also include a child for whom the Employee is required to provide health benefits pursuant to a court order or qualified medical child support order. A Dependent shall also include any dependent which is required by State insurance law to be covered or offered coverage under any insurance contract issued to the Trust for a Benefit Plan. "Personal Insurance" means the insurance provided by the Policy with respect to the Employee's own life. "Dependent's Insurance" means the insurance provided by the Supplementary Contract with respect to the Employee's Dependent. In the event that both husband and wife are covered under the Policy as Employees, any child or children shall, if otherwise qualified hereunder, be considered as Dependents of the husband only. ELIGIBILITY OF AN EMPLOYEE FOR DEPENDENTS' INSURANCE FORM NO

22 An Employee shall be eligible for Dependents' Insurance on the latest of the following dates: A. the effective date of the Supplementary Contract; or B. the date the Employee becomes eligible for Personal Insurance under the Policy; or C. the date the Employee first (1st) acquires a Dependent; provided that to be eligible for Dependents' Insurance on his life, a spouse must be under seventy (70) years of age on the date such insurance would otherwise become effective under the Supplementary Contract. EFFECTIVE DATE OF INSURANCE An Employee must be insured for Personal Insurance in order to be insured for Dependents' Insurance. Application for Dependents' Insurance by an Employee must be for all Dependents which the Employee has on the date of such application. Except as otherwise provided in the Supplementary Contract, Dependents' Insurance shall become effective in accordance with the provisions of the Policy relating to the effective dates of Personal Insurance, as though the application for Dependents' Insurance is an application of an eligible Employee for Personal Insurance. If an Employee acquires a Dependent while insured for Dependents' Insurance, such Dependent shall become insured automatically. In any instance when a Dependent is confined as a bed patient in a hospital on the date insurance on his life would otherwise become effective, such insurance will become effective on the date such Dependent is discharged from the hospital. AMOUNT OF INSURANCE The amount of insurance which shall be in force under the Supplementary Contract shall be in accordance with the Schedule of Benefits below. Any increase in the amount of insurance by reason of change in classification shall be effective automatically on the date of such change. Schedule of Benefits Dependents Amount of Insurance Spouse $2,000 Children 14 days to 6 months $200 Age 6 months to 25 $2,000 FORM NO

23 In no event shall coverage of a Dependent exceed the amount of insurance in force under the Policy on the Employee. PAYMENT OF BENEFITS Subject to the terms and conditions of the Policy and the Supplementary Contract, Anthem Life will pay, in one (1) lump sum, the amount of any insurance as determined by the Schedule of Benefits contained herein on the life of any insured Dependent of an Employee covered by the Policy, immediately upon receipt of due proof of the death of such Dependent while such insurance is in force. Any sum payable by Anthem Life as a death claim shall be paid at its home office to the Employee, if living, otherwise to the Employee's personal representative, in accordance with the terms of the Supplementary Contract. TERMINATION OF INSURANCE The Dependents' Insurance of any Employee shall automatically cease: A. upon termination of the Employee's Personal Insurance; or B. upon termination of the Supplementary Contract; or C. upon termination of the Policy; or D. at the end of the period for which such Employee made his last premium contribution under the Supplementary Contract if he shall fail to make any required premium contribution when due. The insurance of an Employee under the Supplementary Contract with respect to any Dependent shall, in any case, automatically cease on the date the Dependent ceases to be a Dependent as defined herein. However, an insured Dependent child who is incapable of self-sustaining employment by reason of disability and who is chiefly dependent upon the Employee for support and maintenance, may continue to be covered under the Policy beyond age twenty-five (25) for as long as such incapacity and dependency continue, provided Dependents' Insurance otherwise remains in effect under the terms of the Policy. CONVERSION PRIVILEGE A. A spouse whose entire amount of life insurance is discontinued because: 1. the Employee's employment for insurance purposes is terminated; or FORM NO

24 2. the classification of the spouse is changed to a class in which he is ineligible for life insurance under this coverage; or 3. of the death of the Employee, will be entitled to have an individual policy of life insurance issued to him by Anthem Life, in an amount which shall not exceed the amount of his life insurance which discontinued for whichever of the reasons in 1., 2., or 3. above is applicable. B. A spouse whose entire amount of life insurance is discontinued because of: 1. the termination of the Supplementary Contract; or 2. an amendment making the class of which the spouse is a member ineligible for life insurance, and who had then been continuously insured under the Policy for at least five (5) years will be entitled to have an individual policy of life insurance issued to him by Anthem Life, in an amount which shall not exceed the amount of his life insurance which was discontinued for whichever of the reasons in 1. or 2. above is applicable, less any amount for which he is eligible or becomes eligible under the Policy or any other group policy within thirty-one (31) days after the date his insurance was discontinued. C. Issue of the individual policy will be subject to all of the following conditions: 1. No evidence of insurability shall be required. 2. Written application for the individual policy and the first (1st) premium therefor must be delivered or mailed to Anthem Life within thirty-one (31) days after the date on which the spouse's insurance under this coverage was discontinued. 3. The individual policy will be in any one (1) of the forms, then customarily issued by Anthem Life, except a policy of term insurance, and shall be without disability or other supplementary benefits. 4. The premium for the individual policy will be determined by Anthem Life from its then current rates, based upon the attained age of the spouse at his birthday nearest to the date of issue of the individual policy, upon the class of risk to which he then belongs, and upon the form and amount of the individual policy. FORM NO

25 5. Insurance under the individual policy will not become effective until the end of the thirty-one (31) day period described in 2. above. D. Upon receipt of due proof at its home office of the death of a spouse during the thirty-one (31) day period within which he could have made application for an individual policy of life insurance under the Conversion Privilege, Anthem Life will pay to the beneficiary as a death benefit the maximum amount for which an individual policy could have been issued to him under that provision, whether or not he had made application for an individual policy. E. This Conversion Privilege is not applicable to the insurance on a Dependent child. ASSIGNMENT This Certificate and any riders therein and the Dependents' Insurance described herein are non-assignable. NON-DUPLICATION OF BENEFITS If a Dependent has been insured under the Policy as an Employee and is eligible for conversion following the termination of such insurance, insurance on such Dependent under the Supplementary Contract shall not become effective until the thirty-second (32nd) day following termination of insurance on the spouse's life under the Supplementary Contract. APPEAL PROCEDURES A claim denial may be appealed by the group, employee or beneficiary. The appeal must be in writing and should indicate the reason it is believed that the claim decision was incorrect. Any additional documentation not previously furnished should also be included. Please send all appeal letters to: Anthem Life Claims Center Attn: Claims Manager P.O. Box Columbus, OH FORM NO

26 DISCLAIMER: RETIREES ARE NOT ELIGIBLE FOR TERMINAL ILLNESS ACCELERATED BENEFITS. ANTHEM LIFE INSURANCE COMPANY (herein called Anthem Life) Indianapolis, Indiana Certificate Rider Terminal Illness Accelerated Benefits Anthem Life will pay an Accelerated Benefit in the event an Employee, herein called Covered Person, becomes Terminally Ill while this Rider and the Group Policy under which it is issued are in force. Benefits are subject to the terms of this Rider. Definitions "Accelerated Benefit" means the amount of life insurance that will be paid in advance of a Covered Person's death if the Covered Person is Terminally Ill. The amount of the Accelerated Benefit will be determined as described under the Benefit Section below. "Administrative Fee" is four percent (4%) of the Accelerated Benefit. It is payable at the time of distribution of the Accelerated Benefit. "Covered Person" means the Employee insured under the Policy. "Physician" means the attending Physician of a Covered Person, other than the Covered Person's spouse, parent, child, brother or sister and other than a hospital resident or intern, who is licensed to practice medicine. "Terminally Ill" means that a Covered Person has been diagnosed as having a medical condition that will cause the Covered Person to have a life expectancy of six (6) months or less. The Covered Person must provide Anthem Life proof that satisfies Anthem Life of the limited life expectancy. Such proof must include a certification by a Physician. Anthem Life reserves the right to obtain a medical opinion from a second (2nd) Physician at our expense. The opinion of the second (2nd) Physician will be final. Benefit If a Covered Person is Terminally Ill, Anthem Life will pay an Accelerated Benefit to the Covered Person. The Accelerated Benefit will be a percentage of the amount of life insurance in force on the life of the Terminally Ill Covered Person. The Administrative Fee will be deducted from the Accelerated Benefit proceeds. FORM NO ADB CERTIFICATE RIDER 22

27 The Accelerated Benefit payable will be as chosen by the Covered Person when a claim is made under this Rider. Only one (1) Accelerated Benefit may be paid per Covered Person. The Accelerated Benefit may not exceed the lesser of: (a) fifty percent (50%) of the life insurance in force on the Covered Person's life; or (b) two-hundred and fifty thousand dollars ($250,000.00). The Accelerated Benefit will be paid in one (1) lump sum. The Terminally Ill Covered Person's life insurance amount will be reduced by the Accelerated Benefit. In the event an Accelerated Benefit becomes payable, the Terminally Ill Covered Person will automatically qualify for the Waiver of Premium Benefit under the Policy. Receipt of Accelerated Benefits may be taxable. Assistance should be sought from a personal tax advisor. Conditions The payment of an Accelerated Benefit is subject to the following conditions: 1. The Terminal Illness diagnosis must be made: (a) after the Covered Person's Terminal Illness Accelerated Benefit Certificate Rider effective date if the medical condition is due to an accident; or (b) at least thirty (30) days after the Covered Person's Certificate Rider effective date if the medical condition is due to an illness. 2. The written consent of any assignee or irrevocable beneficiary must be given to Anthem Life. 3. This benefit provides for the accelerated payment of life insurance proceeds. It is not meant to cause a Covered Person to involuntarily invade proceeds ultimately payable to the named beneficiary. The Accelerated Benefit will be made available to a Covered Person on a voluntary basis only. Therefore: a. If a Covered Person is required by law to use this option to meet the claims of creditors, whether in bankruptcy or otherwise, the Covered Person is not eligible for this benefit. b. If a Covered Person is required by a government agency to use this option in order to apply for, obtain or keep a government benefit to entitlement, the Covered Person is not eligible for this benefit. Anthem Life will send the Covered Person and the Employer a statement showing any effect the payment of an Accelerated Benefit will have on the life insurance and premium applicable to the Covered Person. FORM NO ADB CERTIFICATE RIDER 23

28 Incontestability This Rider shall be incontestable after this Rider has been in force during the Covered Person's lifetime for two (2) years from its effective date. Policy Provisions This Rider is subject to the terms and conditions of the Group Policy which are not in conflict with the terms of this Rider. Effective Date This Rider is effective at the same time as the Group Policy effective date, unless a different date is shown. However, if on the effective date, a Covered Person is not Actively at Work or is having premiums waived under the Waiver of Premium Benefit, the Covered Person's coverage under this Rider will not become effective until the date the Covered Person returns to work or is no longer having premiums waived. Termination This Rider will terminate as to all Covered Persons on the earlier of: 1. termination of the Group Policy; or 2. cancellation of this Rider by the Employer. This Rider will terminate as to any Covered Person on the earlier of: 1. lapse or termination of the Covered Person's coverage under the Group Policy; or 2. payment of an Accelerated Benefit on behalf of such Covered Person; or 3. the Covered Person dies. This Rider does not change, waive or extend any part of the Policy, other than as set forth above. ANTHEM LIFE INSURANCE COMPANY John J. Gainor, President FORM NO ADB CERTIFICATE RIDER 24

29 ATTACH FUTURE AMENDMENTS HERE It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds, shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. FORM NO