Policyholder: BOB JONES UNIVERSITY Group Number: GA0845 Class: All Full Time Eligible Employees. Voluntary Group Term Life Insurance

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1 Policyholder: BOB JONES UNIVERSITY Group Number: GA0845 Class: All Full Time Eligible Employees Voluntary Group Term Life Insurance

2 This is your Certificate of Insurance. It describes the coverage selected by you and your employer and is subject to the terms and provisions of the Voluntary Group Term Life Insurance Policy as issued to the policyholder/employer. Your Schedule of Benefits specifies the types and amounts of your coverage and other information relevant to your benefits. This certificate is issued in consideration of your enrollment application and the payment of premiums as provided. Monye Connolly, President THIS DOCUMENT IS VERY IMPORTANT Please read carefully and retain for future reference GREATER GEORGIA LIFE INSURANCE COMPANY Home Office: Atlanta, Georgia Form No. CSTM98-C (Rev. 6/1999)

3 Table of Contents TABLE OF CONTENTS... 1 SCHEDULE OF INSURANCE BENEFITS... 2 DEFINITIONS... 3 ELIGIBILITY AND EFFECTIVE DATES... 4 EMPLOYEE... 4 DEPENDENT... 4 EVIDENCE OF INSURABILITY... 4 DELAYED EFFECTIVE DATE... 5 LIFE INSURANCE PROVISIONS... 6 BENEFIT PROVISIONS... 7 WAIVER OF PREMIUM PROVISIONS... 7 CONVERSION PROVISIONS... 9 PORTABILITY PROVISIONS ACCELERATED DEATH BENEFIT PROVISIONS TERMINATION PROVISIONS EMPLOYEE INSURANCE DEPENDENT INSURANCE CLAIM PROVISIONS GENERAL PROVISIONS

4 VOLUNTARY GROUP TERM LIFE INSURANCE CERTIFICATE SCHEDULE OF INSURANCE BENEFITS A complete Schedule of Insurance is set forth in the Group Policy POLICYHOLDER S NAME: BOB JONES UNIVERSITY GROUP NO: GA0845 CLASS DESCRIPTION: All Full Time Eligible Employees INSURED EFFECTIVE DATE: As defined in the policy BENEFICIARY: As Indicated on Enrollment Application or subsequent change form. EMPLOYEE VOLUNTARY TERM LIFE BENEFITS BENEFIT AMOUNT: $25,000 Increments to $500,000 Maximum as Elected and Approved by Greater Georgia Life Insurance Company. GUARANTEE ISSUE AMOUNT: $150,000 up to Age 69. Age 70 and above All Amounts are Subject to Medical Evidence. REDUCTIONS Employee Benefits Reduce to 65% at Age 70, Further to 50% of Original Amount at Age 75. SPOUSE VOLUNTARY TERM LIFE BENEFITS BENEFIT AMOUNT: $25,000 Increments to $150,000 Maximum, not to Exceed 100% of Employee's Amount. GUARANTEE ISSUE AMOUNT: $25,000 Below Age 60. Age 60 and Above All Amounts are Subject to Medical Evidence REDUCTIONS Spouse Benefit Reduces the Same as Noted Above for Employee and is Based on Employee s Age. Spouse Benefits will Terminate at Employee s Age 75. CHILD VOLUNTARY LIFE BENEFITS BENEFIT AMOUNT: $5,000 to $10,000 REDUCTIONS Child Benefit Amount is $500 for Children from Age 14 Days to 6 Months and the Full Amount for Children Age 6 Months to Age 19 (Age 25 if Full Time Student). Dependent Benefits End when the Dependent ceases to meet the Definition of Dependent, or when the Employee s Benefit Terminates, if Earlier. All Benefits Terminate upon Retirement or Cessation of Full Time Active Employment. Greater Georgia Life Insurance Company Atlanta, Georgia Form No. 98-C (Rev. 6/1999) 2

5 DEFINITIONS ACTIVE EMPLOYMENT means you must be working: 1. for your employer and paid regular earnings (temporary or seasonal employees are excluded); 2. at least the minimum number of hours shown in the Schedule of Benefits; and either 3. at your usual place of business; or 4. at a location to which your business requires you to travel. ACTIVE WORK or ACTIVELY AT WORK means you are performing the material duties of your own occupation at your usual place of business. You will be considered actively at work if: 1. you were absent from active work because of a regularly scheduled day off, holiday or vacation; provided, 2. you were actively at work on the last scheduled work day before the date of absence. ANNUAL EARNINGS means your annual compensation from your employer. It does not include bonuses, overtime pay or extra compensation other than commissions. Commissions will be averaged over the previous twelve months. BENEFICIARY means a person or entity named by you to receive death benefits. CHILD means a child born to you, a child legally adopted by you, and a child for whom you are the legal guardian. It also means a stepchild, foster child or other child who depends on you for support and lives with you in a regular parent/child relationship. CERTIFICATE means this document, which is given to you to explain the coverage selected by you and your employer. It is not a part of the entire contract of insurance. Where there are differences, the Group Policy takes precedence. Your Certificate Schedule of Benefits is included herein. CONFINED means that your dependent is confined because of injury or sickness in a hospital, home or elsewhere, and unable to carry on a substantial part of normal activities. CONTRIBUTORY means you must pay part of all of the cost of the insurance. DEPENDENT means your spouse, unless legally separated, and your unmarried child(ren) from age 14 days and who is less than age 19, or who is less than age 25 if attending an accredited college or school as a full-time student. It does not include a person who is a full-time member of the armed forces of any country, or any person who is eligible as an employee. DISABLED or DISABILITY refers to any disability which results from a sickness or injury that completely prevents you from engaging in any employment or occupation for which you are or become reasonably qualified due to education, training or experience. EMPLOYEE means a person in active employment with the Policyholder/Employer. EMPLOYER means the Policyholder/Employer, the entity to which the group term life insurance policy is issued. EMPLOYER EFFECTIVE DATE means the date the Insurer approves and accepts the employer s application for coverage. 3

6 EVIDENCE OF INSURABILITY means a statement or proof of an individual s current health and medical history upon which the Insurer will determine acceptance. GROUP POLICY means the group term life insurance policy issued by the Insurer to the Policyholder/ Employer identified by the group policy number. GRACE PERIOD means 31 days following any premium due date. GUARANTEE ISSUE AMOUNT is the maximum amount of life insurance available to eligible employees applying within 31 days of the date first eligible. This amount is based on the underwriting characteristics of each employer and is shown in the Group Policy. HOME OFFICE means the Greater Georgia Life Insurance Company. INSURED means the eligible employee or dependent covered under this plan. PHYSICIAN means a person who is: 1. operating within the scope of his/her license; and either 2. licensed to practice medicine and prescribe and administer drugs or to perform surgery; or 3. legally qualified as a medical practitioner and required to be recognized under the group policy for insurance purposes according to the insurance statutes or the insurance regulations of the governing jurisdiction. It does not include you or your spouse, daughter, son, father, mother, sister or brother. SCHEDULE OF BENEFITS means the document showing the eligible classes, the amounts of insurance and other relevant information pertaining to the plan of insurance applied for by your employer under the Group Policy. The specific amount of life insurance for you and your dependent is shown in the Certificate Schedule of Benefits. SERVICE WAITING PERIOD means the continuous length of time immediately before your date of eligibility during which you must be in an eligible class. The service waiting period is stated in the Schedule of Benefits. SPOUSE means your spouse, unless legally separated. It does not include a person who is a fulltime member of the armed forces of any country. Any spouse who is eligible under this group policy as an employee is not eligible for coverage as a spouse. 3

7 ELIGIBILITY AND EFFECTIVE DATES EMPLOYEE Eligible Classes All employees meeting the requirements stated in the Group Policy Schedule of Benefits are eligible for coverage. Date of Eligibility You will become eligible upon completion of the Service Waiting Period shown in the Group Policy Schedule of Benefits. Employee s Effective Date of Insurance An eligible employee becomes insured on the later of the following dates: A. if you enroll prior to becoming an eligible employee - on the first day of the month following the date of eligibility and deduction of the first monthly premium; B. if you enroll within 31 days after becoming eligible - on the first day of the month following enrollment and deduction of the first monthly premium; C. if you enroll 31 days or more after becoming eligible - on the first day of the month following the Insurer s approval of evidence of insurability and deduction of the first monthly premium. DEPENDENT Date of Eligibility You shall become eligible for Dependent Life Insurance on the later of: A. the date you become insured; or B. the date you acquire a dependent, if you are insured for Employee Insurance. Only the members of the classes shown in the Group Policy Schedule of Benefits are eligible. Effective Date Each eligible dependent shall become insured on the later of the following dates: A. the date you become insured, if applications are received for both your insurance and the dependent insurance prior to the date you become eligible or within 31 days thereafter; B. if applications are received more than 31 days after the date you become eligible for Dependent Life Insurance, on the first day of the month following the Insurer s approval of evidence of insurability and deduction of the first monthly premium. EVIDENCE OF INSURABILITY Evidence of insurability is required: A. if you or your spouse s insurance is being applied for within 31 days of first becoming eligible and the amount exceeds the Guarantee Issue Amount as identified in the Policy Schedule of Benefits; B. if you or your spouse s insurance is being applied for more than 31 days after you first become eligible; and/or C. as noted below related to insurance amount increases. 4

8 If you or your spouse were insured under the employer s prior voluntary group term life policy on the day before the effective date of this group policy, you will not have to submit evidence of insurability to become insured for the same amount of coverage under this policy. However, evidence of insurability may be required for increases in the amount of life insurance under this group policy as outlined below. Insurance Amount Increases Due to Change(s) in Family Status You may initially enroll or, if already enrolled, may increase your insurance amount one increment within 31 days of a change in family status without submitting satisfactory evidence of insurability. You may also increase your spouse s insurance amount one increment without submitting satisfactory evidence of insurability at this time. These increases are available provided they do not exceed the Guarantee Issue Amount or other amount limitations identified in the Policy Schedule of Benefits. A change in family status is defined as: 1. marriage; or 2. addition of a child through birth or adoption. Other Insurance Amount Increases You may increase your insurance amount one increment (in addition to increases related to a change in family status noted above) during annual re-enrollment without submitting satisfactory evidence of insurability. You may also increase your spouse s insurance amount one increment without submitting satisfactory evidence of insurability at this time. These increases are available provided they do not exceed the Guarantee Issue Amount or other amount limitations identified in the Policy Schedule of Benefits. DELAYED EFFECTIVE DATE Employee: The effective date of any initial, increased or additional insurance for you will be delayed if you are not in active employment because of an injury, a sickness, a temporary layoff or a leave of absence on the date that insurance would otherwise be effective. The initial, increased or additional insurance will start on the day following the date you return to active work. Dependent: The effective date of any initial, increased or additional insurance will be delayed for your dependent if your dependent is confined because of an injury or a sickness or not able to carry on the regular activities customary of a person in good health of the same age and sex. The initial, increased or additional insurance will start on the date your dependent is no longer confined, and/or is restored to a condition of good health. 5

9 LIFE INSURANCE PROVISIONS EMPLOYEE Benefit Upon receipt of due proof of your death while insured under this group policy, the Insurer will pay to your beneficiary the benefit amount in effect on the date of death. Suicide Exclusion Benefits are not payable for loss of life due to suicide if the insured s group life insurance has been in force for less than two years. Facility of Payment The Insurer may, at its option, pay up to $ of the benefit to any person it believes is entitled to receive payment. To be entitled, such person must have incurred expense in connection with the last illness or burial. The Insurer will not be liable to the extent of the amount so paid. Beneficiary The Insurer will pay benefits for loss of life to the beneficiary named by you on the enrollment application if living at the employee s death. Two or more surviving beneficiaries will share benefits equally, unless otherwise specified. If there is no beneficiary named or surviving, your estate will be the beneficiary. Change of Beneficiary You may change a Beneficiary by filing written notice with your employer. Once received by your employer, the change will take effect as of the date on the request subject to any action taken by the Insurer before the change notice was received by your employer. Consent of Beneficiary If you do not initially name your dependent as beneficiary, the Insurer will require written consent of your spouse to name or change the beneficiary in community property states. DEPENDENT Payment of Benefits Upon receipt of due proof that your dependent died while insured under this group policy, the Insurer will pay the benefit amount for which the dependent was insured. Suicide Exclusion Benefits are not payable for loss of life due to suicide if the insured s group life insurance has been in force for less than two years. Beneficiary The Insurer will pay benefits for loss of life to you, if living; otherwise, your estate will be the beneficiary. 6

10 BENEFIT PROVISIONS WAIVER OF PREMIUM PROVISIONS EMPLOYEE Benefit The Insurer will waive the life insurance premium for you if you become disabled. Proof will be required that you: A. become disabled prior to age 60. B. have been continuously disabled for six months; and C. were continuously insured: 1. for at least 12 months under this group policy prior to becoming disabled; or 2. under this group policy from your effective date. After the Insurer approves Waiver of Premium, no further premium payments will be due until you recover or fail to furnish proof of disability as required. Amount of Insurance to Be Continued The Insurer will continue the amount of Employee Life Insurance and Spouse Life Insurance in effect on the day you became disabled, except insurance continued under the Portability Provision. All reductions and termination provisions in effect on your last day of active employment will apply to the continued amount. Notice of Disability You must submit written notice of disability to the Insurer within three months after you have been continuously disabled for six months. Continuation of Waiver Premium The Insurer will extend the waiver of premium benefit for further periods of one year if: A. you remain disabled; and B. you submit proof of continuing disability during the three months before the end of such one year period. Such proof must be submitted in writing. At any time during the waiver of premium period, the Insurer may, at its own expense, require a physical examination of you as often as reasonably necessary. If you die after giving proof of disability to the Insurer, further proof must be furnished showing your remained disabled until death. Cancellation of the Individual Policy If you have been issued an individual policy under the Conversion Provision: A. the individual policy must be returned to the Insurer without claim; and B. the premiums paid for that policy will be refunded. Otherwise, there will be no waiver of premium. 7

11 Termination of Waiver of Premium Waiver of Premium will end on the earliest of the following dates: A. the date you are no longer disabled; or B. the date you do not submit to an examination when required; or C. the date you fail to give proof of continuing disability; or D. the date you attain age 65. Continuation of Insurance after Termination A. Continuation under this Group Policy You may continue life insurance under this group policy when you return to active work in an eligible class and continue to pay premiums. B. Continuation under the Conversion Provision You may convert the life insurance under the Conversion Provision if the waiver of premium ends and this insurance doesn t continue in force. C. Effect of Termination or Amendment Insurance will not be affected by termination or amendment of the group policy or your employer s participation under the group policy after you become disabled. Payment of Benefits If you die while premiums are being waived, benefits will be paid in accordance with the Employee Life Insurance Provisions. SPOUSE Waiver of Premium Provision Spouse life premiums may be waived for your spouse if: A. your spouse s insurance was in force before you became disabled; and B. your life insurance premiums are being waived. NOTE: You or your spouse s life insurance premiums will not be waived if the spouse becomes disabled. Employee and spouse premiums are only waived if you become disabled. Dependent children are not eligible under the Waiver of Premium provision. Termination of Waiver of Premium for Spouse Waiver of premium for the spouse will terminate on the first of the following to occur: A. your premiums are no longer being waived; B. your spouse ceases to be a legal spouse as defined in this group policy; C. the spouse life benefits under this group policy are terminated; or D. your death. Your spouse may convert the life insurance under the Conversion Provisions if the waiver of premium ends and insurance doesn t continue in force. DEFINITIONS Insurance means you and your spouse s life insurance under your employer s plan, except insurance continued under the Portability Provisions. 8

12 CONVERSION PROVISIONS Conversion Benefit When all or part of an insured s life insurance ends, as outlined below, the insured may convert to an individual policy without submitting evidence of insurability. The insured must apply in writing and pay the first premium within 31 days after this insurance ends. Insured, for conversion purposes, means you or your spouse covered under this group policy. Dependent children are not eligible for the Conversion Benefit. The insured may apply for an individual policy of life insurance to replace all or a part (for amount see below) of the life insurance that ceases because of: 1. termination of your employment; 2. your death; 3. cessation of eligibility in a Class under this policy; and if such insurance has been in force five years or more: 4. termination of this policy; 5. amendment of this policy so as to terminate the insurance of this class of insureds. Scheduled reductions in the amount of insurance, because of reaching a stated age, are not convertible. If insurance was continued under the Waiver of Premium or Continuation During Absences provision, application and premium payment must be made within 31 days after such benefit ceases. Amount of Individual Policy 1. If termination is for reason 1, 2, or 3 above, the maximum amount convertible is the full amount terminating. 2. If termination is for reason 4 or 5, the full amount that would have been convertible is reduced by the amount of any life insurance for which you or your Spouse becomes eligible under this policy or other group policy within 31 days after termination. The amount which may be converted is the smaller of the remainder of the full amount after such reduction, or $2, Nature of Individual Policy The insured may apply for any form of individual policy, except term insurance or preferred risk plans. The plan must be one that the Insurer offers for sale at that time for the age and amount applied for. It will contain no benefit for disability or other supplementary benefits. The premium will be the rate the Insurer then charges for the form and amount of the individual policy. The insured s class of risk and age attained on the effective date of the policy will be used. The effective date of the policy will be at the end of the 31 day conversion period. 31-Day Continuance of Death Benefit The Insurer will pay a death benefit under this group policy equal to the amount of life insurance that could have been converted if the insured is entitled to purchase an individual policy, and dies within the 31-day conversion period. The death benefits will be paid even if no one applied for the conversion policy. The individual policy, if the insured applied for it, will not become effective and the premium paid will be refunded. 9

13 PORTABILITY PROVISIONS Continuation of Insurance Benefit You may continue your and your spouse s insurance if your employment terminates. To be eligible to continue insurance, you must meet the following requirements on the date employment terminates: 1. you are not disabled; and 2. you are not retired. Your spouse s life insurance may not be continued if your life insurance is not continued. Dependent children are not eligible for the Portability coverage. Insurance means your and your spouse s life insurance issued under the employer s plan. Application and Premium Payment You must apply to the Insurer, in writing, within 31 days after the date employment ends. You must pay the required premium. The premium rate will be the same rate applicable to your employer. Any rate changes which become effective for your employer will become effective for you on the same date. The first premium payment must be made no later than 31 days after the date the insurance would otherwise terminate. Amount of Insurance The amount of insurance you may continue is the amount in effect on the date your employment terminates. You may continue any lesser amount in multiples of $10, ($5, increments for your spouse); however, the amount you continue for your spouse may not exceed 100% of your continued amount. Once elected, you may not change the amounts of insurance continued under these provisions. The reduction and termination provisions stated on the Schedule of Benefits, in effect on the date your employment terminates, will still apply to this insurance. When Insurance Ends Insurance continued under this provision ends automatically on the earliest of: 1. the date the last period ends for which you made a premium payment; or 2. the date the group policy terminates; or 3. the date you become a full-time member of the armed forces for any country. When your insurance under this provision ends, you and your spouse will be eligible to convert the insurance to an individual policy under the Conversion Provisions of this group policy. Group Policy Provisions The Waiver of Premium provisions will not apply to insurance continued under these provisions. Except as provided above, insurance continued under this provision is subject to all other terms of the group policy. With respect to any notice you are required to provide to your employer under other provisions of the group policy, you must provide such notice to the Insurer while the insurance is continued. Exclusions for Continuation of Portability Insurance cannot be continued under this provision if your insurance terminates because the group policy terminates. 10

14 ACCELERATED DEATH BENEFIT PROVISIONS Benefit The Insurer will make an Accelerated Death Benefit payment to an insured who becomes terminally ill. The amount of the Accelerated Death Benefit payment will be based on the following: 1. Employee The life insurance benefit amount in effect on your last day of active work. 2. Spouse The life insurance benefit amount in effect on the day a physician provides certification that your spouse s death is anticipated to occur within 12 months of that certification date. The above amounts will reflect age or retirement reductions as shown in the Schedule of Benefits. Benefit Amount The Accelerated Death Benefit will be the lesser of: 1. up to 50% of the life insurance benefit amount in effect on the day before the insured s disability; or 2. $125,000 The Accelerated Death Benefit payment will be paid in one lump sum and will reduce the life insurance benefit payable under the group policy by the amount of the Accelerated Death Benefit. If the insured should die after a request is submitted but before the Accelerated Death Benefit is paid, the insured s life insurance benefit will be paid as if no request had been submitted. Only one Accelerated Death Benefit will be paid to an Insured. Conditions The Insurer must receive proof that: 1. the insured was covered for life insurance under this group policy on the date of disability; and 2. diagnosis was made and disability began prior to the insured s 60th birthday; and 3. the physician has certified the disability; and 4. your anticipated life expectancy is 12 months or less from the date of the physician s certification; or 5. your spouse s anticipated life expectancy is 12 months or less from the date of the physician s certification; and 6. the insured was continuously covered for at least one year under this group policy prior to becoming terminally ill or from the employer effective date. THE AMOUNT OF YOUR GROUP TERM LIFE INSURANCE WILL BE REDUCED BY THE AMOUNT OF ACCELERATED DEATH BENEFIT PAID. AN ACCELERATED DEATH BENEFIT MAY OR MAY NOT BE TAXABLE. SEEK ADVICE FROM YOUR PERSONAL TAX ADVISOR. 11

15 Proof of Diagnosis The insured, or the insured s legal representative if the insured is unable to submit the request, must submit, at the insured s expense, satisfactory proof of diagnosis as terminally ill. This notice must be in the form of a Physician s signed certification. The Insurer may, at its expense, require a second opinion by a Physician of its choice. Should there be a difference of opinion between these Physicians, a third opinion will be obtained from a mutually acceptable Physician. The opinion of this Physician will be binding on both parties. Exceptions The Accelerated Death Benefit will not apply: 1. to any intentionally self-inflicted injuries or suicide attempts; 2. if the required group life premium is due and unpaid; 3. to any coverage with a face amount of less than $15,000.00; 4. if the insured has irrevocably assigned the applicable group life insurance benefits or has named an irrevocable beneficiary, unless notarized permission is received from the assignee or beneficiary; 5. when all or a portion of the insured s life insurance benefits are paid as a part of a divorce settlement; or 6. if the insured s group life insurance has been in force for less than one year, unless the group life benefit has been in force from the policy effective date and the policy has been in force less than one year. Waiver of Premium If the Accelerated Death Benefit is paid to you, subsequent premium for you and your spouse s life insurance under this group policy will be waived and the Waiver of Premium Provisions will apply. Should you recover and no longer be deemed terminally ill, premium payments will resume unless you qualify under the Waiver of Premium benefit of this group policy. Waiver of Premium provisions do not apply if your spouse receives an Accelerated Death Benefit payment. You must continue to pay premiums for the insurance remaining in force. Termination of the Accelerated Death Benefit This provision will terminate for you and your spouse on the earliest of the following dates: 1. the date your group policy terminates; 2. the date you retire; 3. the date you die; 4. the date you receive an Accelerated Death Benefit payment; or 5. the date you continue coverage under the Portability or Conversion Provisions for this group policy. This provision will terminate for your spouse on the earliest of the following dates: 1. the date your spouse receives an Accelerated Death Benefit Payment; or 2. the date your spouse continues coverage under the Conversion Provisions of this group policy; or 3. the date your eligibility for Accelerated Death Benefits terminates. Your eligibility for Accelerated Death Benefits will not terminate because the spouse s eligibility terminates. 12

16 13

17 Definitions Accelerated Death Benefits are benefits payable to terminally ill insureds during the insured s lifetime when life expectancy is 12 months or less. Accelerated Death Benefit Payment is the lesser of a percentage of the insured s life insurance benefit or a stated maximum, to be paid if the insured is eligible under this provision. Life Insurance Benefit means the amount of life insurance requested and approved by the Insurer on your most recent enrollment application, taking into account any reductions due to age or retirement. Insured, under this provision, means you or your spouse covered under this group policy. Dependent children are not eligible for the Accelerated Death Benefit. Terminally Ill means an irreversible medical condition which, in the medical judgment of a physician, and approved by the Insurer, will directly result in a life expectancy of twelve months or less from the date of the Physician s statement. 14

18 TERMINATION PROVISIONS TERMINATION OF INDIVIDUAL S INSURANCE EMPLOYEE INSURANCE When Employee Life Insurance Ends. Your life insurance ends on the earliest of the following: 1. the date the group policy is terminated; 2. the date you are no longer in an eligible class; 3. the date your class is no longer included for insurance; 4. the end of the month for which the last required employee premium contribution has been paid; or 5. the date your employment terminates. Employment will be considered terminated if you cease active employment except as outlined in the section entitled Continuation of Employee Insurance During Absences. Continuation of Employee Insurance During Absences Your insurance may be continued in the following situations: 1. A Temporary Layoff or Leave of Absence. Your life insurance and your spouse s life insurance may be continued until the employer stops paying premiums for you or otherwise cancels the insurance. Such insurance will not continue for more than 3 months past your last day of active work. Upon written request from the employer, the Insurer may agree in writing to continue the insurance for an additional number of months during the layoff or leave of absence. 2. Injury or Sickness. Your life insurance and your spouse s life insurance may be continued while you remain disabled as a result of an injury or sickness. Such insurance will not continue past the earlier of: a. six months from the date you were no longer actively at work unless your employer obtains the consent of the Insurer in writing for a longer period; or b. the date your employer stops paying premium for you or otherwise cancels the insurance. You must pay the premium to your employer during this period in order to continue during injury or sickness. DEPENDENT INSURANCE When Dependent Life Insurance Ends. Your dependent s life insurance ends on the earliest of the following: 1. the date your insurance ends; or 2. the date you become ineligible; or 3. the date your employment ends; or 4. the date your dependent ceases to be a legal dependent as defined in this group policy or 5. the date your dependent enters the Armed Forces of any country; or 6. the date the group policy is canceled. 15

19 CLAIM PROVISIONS Notice of Claim Written notice of claim must be given within 30 days after a covered loss occurs or begins or as soon after that as possible. The notice must be sent to the Insurer at its Home Office. The terms of the notice shall clearly identify the employee. Claim Forms When a notice of claim is received, the Insurer will furnish forms for filing proofs of loss. If the forms are not furnished within 10 days after receipt of such notice, a written statement from the employee as to the nature and extent of the loss, sent to the Insurer within the time limit stated in the Proof of Loss section below, will be deemed proof of loss. Proof of Loss Written proof must be given within 90 days after the date of loss. Failure to furnish proof within the time frame required will not void or reduce a claim if the proof is furnished as soon as it is reasonably possible to do so. Except in the event of legal incompetence, this extension of the time limit shall in no event exceed one year. A written notice will be mailed in fifteen working days from the time we receive the written proof of loss if the proof is inadequate to permit payment of the claim. This notice will state the reasons the claim is denied and will list the documents or information needed to process the claim. Time of Payment of Claims (For other than Term Life Insurance) We will pay claims that we owe immediately after we receive proof of loss. Where we have requested additional documents or information, we will pay the benefits immediately when we receive the required documents or information. If the claim is denied, we will give the reasons within fifteen working days from the time we receive the required documents or information. Interest at 18% per year will be paid on any benefits not paid in accord with the above provisions. Payment of Claims We will pay benefits for the loss of life as set out in the beneficiary provision. We will pay any other benefits due at the employee s death of either the beneficiary or the employee s estate, at our option. We will pay all other benefits to the employee. If any benefits are payable to the employee s estate, to a minor, or to a person not competent to give a valid release, we may pay up to $100 per month of such benefits to any relative by blood or marriage of the employee or beneficiary who seem to be entitled to it; or we may pay up to $500 of such benefits to any person appearing to us to be entitled thereto by reason of having incurred expenses incident to the last illness or death of the person insured. We will be discharged from all liability to the extent of such payment. The unpaid balance will bear interest at 6% per year. Physical Examination The Insurer, at its own expense, will have the right to examine the employee for whom claim is pending as often as it may reasonably require. 16

20 GENERAL PROVISIONS Incontestability The Insurer will not contest the group policy after it has been in force two years from the date of issue except for failure to pay premium. No statement made by an insured will be used to deny a claim after the person s coverage has been in force for a period to two years during the insured s life; then only if the statement is made in writing and signed by the insured. Statements Not Warranties All statements made by the Policyholder/Employer or by an insured will, in the absence of fraud, be deemed representations and not warranties. No statement made by the Policyholder/Employer or by the insured to obtain insurance will be used to void or reduce the insurance, unless: 1. it is made in writing; and 2. it is signed by the Policyholder/Employer or the insured; and 3. a copy is sent to the Policyholder/Employer, the insured or the beneficiary. Clerical Error Clerical error will not void insurance otherwise validly in force nor will it keep in force insurance which otherwise would cease. Assignment You may assign all rights in and to the life insurance. An assignment will transfer your interest and the interest of any beneficiary to the assignee. Any such assignment will remain in force until changed by the assignee. No assignment will be in effect until filed with, and approved by, the Insurer. The Insurer is not responsible for the validity or sufficiency of any assignment. The beneficiary provisions will not apply for coverage that has been assigned. Misstatement of Age If an insured s age has been misstated, an equitable adjustment will be made in the premium. If the amount of the benefit is dependent upon an insured s age, the amount of the benefit will be the amount an insured would have been entitled to if the correct age were known. Workers Compensation Not Included The group policy is not in lieu of Workers Compensation coverage and does not relieve any employer of the need to provide such coverage. Legal Action No attempt to recover on the group policy through legal actions may be made until at least 60 days after written proof of loss has been furnished as required by the group policy. No such action may be started later than three years from the time written proof of loss is required to be furnished. Conformity With Laws Any policy provision which, on the policy effective date, is in conflict with the laws of the place of issue, is amended to comply with the minimum requirements of the law. Dual Coverage Precluded No person may be insured under this group policy as: 1. An employee of more than one employer; or 2. Both an employee and a spouse. 17

21 Post Office Box Columbus, Ohio (800) Form No. CSTM98-C (Rev. 6/1999) Greater Georgia Life Insurance Company, Inc. is a wholly owned subsidiary of Blue Cross and Blue Shield of Georgia, an Independent Licensee of the Blue Cross Blue Shield Association. Registered Mark of the Blue Cross Blue Shield Association.

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