YOUR GROUP AD&D INSURANCE PLAN

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1 YOUR GROUP AD&D INSURANCE PLAN Policy Issued To: California State Firefighters' Employee Welfare Benefits Corporation Base AD&D Acct 1 6CC000 B

2 CONTENTS OUTLINE OF COVERAGE CERTIFICATION PAGE SCHEDULE OF BENEFITS MEMBER'S INSURANCE ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE Accidental Death & Dismemberment (AD&D) Insurance CLAIM PROCEDURES GENERAL PROVISIONS DEFINITIONS This certificate provides coverage for losses due to ACCIDENTS only. It does not provide insurance coverage for sickness or losses due to sickness. IF YOU HAVE A QUESTION ABOUT YOUR POLICY, IF YOU NEED ASSISTANCE WITH A PROBLEM, OR IF YOU HAVE QUESTIONS ABOUT A CLAIM, YOU MAY WRITE OR CALL US AT: ReliaStar Life Insurance Company P.O. Box 20 Minneapolis, Minnesota Telephone Number: (800) YOU WILL NEED TO PROVIDE YOUR POLICY NUMBER WITH ANY COMMUNICATION. IF YOU DO NOT REACH A SATISFACTORY RESOLUTION AFTER HAVING DISCUSSIONS WITH US, OR OUR AGENT OR REPRESENTATIVE, OR BOTH, YOU MAY CONTACT THE FOLLOWING UNIT WITHIN THE DEPARTMENT OF INSURANCE THAT DEALS WITH CONSUMER AFFAIRS: California Department of Insurance Consumer Communications Bureau 300 South Spring Street, South Tower Los Angeles, California Outside Los Angeles: HELP ( ) Los Angeles: (213) A00TCAS B (4-14) i

3 RELIASTAR LIFE INSURANCE COMPANY OUTLINE OF COVERAGE This outline is only a summary of certain provisions in your certificate. You must consult the policy and certificate for contract provisions regarding coverage. Accidental Death and Dismemberment (AD&D) Insurance Section(s) of Certificate BENEFITS... Schedule of Benefits Accidental Death and Dismemberment Insurance EXCEPTIONS, REDUCTIONS AND LIMITATIONS... Accidental Death and Dismemberment Insurance ELIGIBILITY and TERMINATION... Member's Insurance PREMIUMS: Information about your premium contribution for coverage may be obtained from the Policyholder. 1

4 RELIASTAR LIFE INSURANCE COMPANY Minneapolis, Minnesota ReliaStar Life Insurance Company (ReliaStar Life) certifies that it has issued the Group Policy listed below to the Policyholder. All benefits are controlled by the terms and conditions of the Group Policy. The Group Policy is on file in the Policyholder's office. You may look at the Group Policy there. Group Policy Number ASCPAI Policyholder California State Firefighters' Employee Welfare Benefits Corporation The certificate summarizes and explains the parts of the Group Policy which apply to you. This certificate is not an insurance policy. In any case of differences or errors, the Group Policy rules. This certificate replaces any other certificates ReliaStar Life may have given you under the Group Policy. Registrar 2

5 SCHEDULE OF BENEFITS Accidental Death and Dismemberment (AD&D) Insurance Full Amount of AD&D Insurance* MEMBER $10,000 *Insurance terminates on the Group Policy Anniversary date on or after your 70th birthday. 3

6 MEMBER'S INSURANCE Eligibility The member is eligible on the later of the following dates: The Group Policy's Effective Date. The date the member becomes a member as defined. For CSFA Staff Employees, the date of hire. The member must meet the following conditions to become insured: Be eligible for the insurance. Be actively performing the normal duties of your occupation. Be at least age 18 and under age 70 on the date of eligibility. Effective Date of Member's Insurance Insurance starts on the first day of the month on or after the date you become eligible for insurance. Termination of Insurance Your insurance stops on the earliest of the following dates: The last day of the month during which you are no longer eligible for insurance under the Group Policy. The date the Group Policy stops. The end of the period for which you paid premiums, if you do not make the next required premium contribution when due. The Group Policy Anniversary date on or after your 70th birthday. ReliaStar Life stops providing a specific benefit to you on the date that benefit is no longer provided under the Group Policy. Family and Medical Leave Act of 1993 Certain employers are subject to the FMLA. If you have a leave from active work certified by your employer, then for purposes of eligibility and termination of coverage you will be considered to be actively at work. Your coverage will remain in force so long as you continue to meet the requirements as set forth in the FMLA. 4

7 ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE Accidental Death & Dismemberment (AD&D) Insurance ReliaStar Life pays this benefit for covered losses due to a covered accident. All of the following conditions must be met: You are covered for AD&D Insurance on the date of the accident. The loss occurs within 365 days of the date of the accident. The cause of the loss is not excluded. Unless otherwise indicated, ReliaStar Life pays only one Full Amount for losses and benefits while the Group Policy is in effect. The Full Amount is shown on the Schedule of Benefits. For example, if you have a loss for which ReliaStar Life paid 50% of the Full Amount, ReliaStar Life pays no more than 50% of the Full Amount for the next loss. AD&D Benefit Covered Accident Resulting In: The benefit is: Loss of life... Full Amount Loss of both hands, both feet or sight of both eyes... Full Amount Loss of one hand and one foot... Full Amount Loss of speech and hearing in both ears... Full Amount Loss of one hand or one foot and sight of one eye... Full Amount Loss of one hand or one foot or sight of one eye... 50% of Full Amount Loss of speech... 25% of Full Amount Loss of hearing in both ears... 25% of Full Amount Loss of thumb and index finger of same hand... 25% of Full Amount Loss of hands or feet means loss by being permanently, physically severed at or above the wrist or ankle. Loss of sight means total and permanent loss of sight. Loss of speech and hearing means total and permanent loss of speech and hearing. Loss of thumb and index finger means loss by being permanently, physically, entirely severed. Unless otherwise indicated, ReliaStar Life does not pay a benefit for loss of use of one or both hands or feet, or thumb and index finger of the same hand. Death benefits are paid to your beneficiary. Unless otherwise indicated, all other benefits are paid to you. Safe Driver Benefit ReliaStar Life pays a Safe Driver benefit in addition to the AD&D benefit and subject to the exclusions listed below if you were: killed due to an automobile accident, and wearing a properly fastened safety belt at the time of the accident. For loss of: The benefit is: Life (with safety belt only)... An additional 10% of Full Amount of AD&D benefit Automobile means any self-propelled private passenger vehicle which has four or more tires and which is not being used for commercial purposes. Safety belt means a passenger restraint system properly installed in the vehicle in which you were riding. ReliaStar Life will not pay the Safe Driver benefit if the loss of life was caused directly or indirectly by any use of intoxicating liquors, marijuana, narcotic drugs, depressants or similar substances, whether or not prescribed by a doctor, by you or by the driver of the automobile in which you were riding. Safe Driver benefits are paid to your beneficiary. 5

8 ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE Accidental Death and Dismemberment Exclusions ReliaStar Life does not pay benefits for loss directly or indirectly caused by any of the following: An accident occurring before the Effective Date of the Group Policy. Suicide or intentionally self-inflicted injury, while sane or insane. Physical or mental illness. Bacterial infection or bacterial poisoning. Exception: Infection from a cut or wound caused by an accident. Riding in or descending from an aircraft as a pilot or crew member. Any armed conflict, whether declared as war or not, involving any country or government. An accident which occurs while in the military service for any country or government. An accident which occurs when you commit or attempt to commit a crime. Use of any drug, narcotic or hallucinogenic agent, unless prescribed by a doctor or taken as directed by a doctor or the manufacturer. Your intoxication. Intoxication means your blood alcohol content meets or exceeds the legal presumption of intoxication under the laws of the state where the accident occurred. 6

9 CLAIM PROCEDURES Submitting a Claim You or someone on your behalf must send ReliaStar Life written notice of the loss on which your claim will be based. The notice must include information to identify you, like your name, address and Group Policy number. be sent to ReliaStar Life or one of its licensed agents authorized to accept claims. be sent within 91 days after the loss for which claim is based has occurred or as soon as reasonably possible. Claim Forms ReliaStar Life or its authorized agent will send proof of loss claim forms to you or to the Policyholder to give to you. ReliaStar Life will send the forms within 15 days after ReliaStar Life receives your notice of claim. You or someone on your behalf must return the completed proof of loss claim forms to ReliaStar Life within 91 days of the loss. Even if you do not receive the forms, written proof of loss must be sent to ReliaStar Life within 91 days after the loss or as soon as reasonably possible. Written proof of loss includes details of how the loss occurred. Benefit Payments Benefits under the Group Policy are paid when proof of loss is received. Claims are paid in the order received. Payment of Proceeds Where indicated, ReliaStar Life pays proceeds to the beneficiary. If there is more than one beneficiary, each receives an equal share, unless you have requested otherwise, in writing. To receive proceeds, a beneficiary must be living on the earlier of the following dates: The date ReliaStar Life receives proof of your death. The tenth day after your death. If there is no eligible beneficiary or if you did not name one, ReliaStar Life pays the proceeds in the following order: 1. Your spouse or domestic partner. 2. Your natural and adopted children. 3. Your parents. 4. Your estate. The person must be living on the tenth day after your death. Overpayment If ReliaStar Life pays a benefit under the Group Policy and it is later shown that a lesser amount should have been paid, ReliaStar Life will be entitled to a refund of the excess. 7

10 GENERAL PROVISIONS Health Insurance Assignment You may not transfer to anyone else ownership of any certificate issued under the Group Policy. insurance under the Group Policy. Legal Action Legal action may not be taken to receive benefits until 60 days after the date proof of loss is submitted according to the requirements of the Group Policy. Legal action must be taken within 3 years after the date proof of loss must be submitted. If the Policyholder's state requires longer time limits, ReliaStar Life will comply with the state's time limits. Exam and Autopsy When reasonably necessary, ReliaStar Life may have you examined while a claim is pending under the Group Policy. ReliaStar Life pays for the initial exam. If not forbidden by state law, ReliaStar Life may have an autopsy made if you die. Incontestability Your insurance has a contestable period starting with the effective date of your insurance and continuing for 2 years while you are living. During that 2 years, ReliaStar Life can contest the validity of your insurance because of inaccurate or false information received relating to your insurability. Only statements that are in writing and signed by you can be used to contest the insurance. 8

11 DEFINITIONS Accident, Accidental Injury bodily injury resulting from a sudden, violent, unexpected and external event. ReliaStar Life considers all injuries received in one accident as one accidental injury. Infection resulting from a cut or wound caused by an accident is also an accidental injury. Accidental injury does not include poisoning, disease or any other type of infection, except as stated above. Active Work, Actively at Work the employee is physically present at his or her customary place of employment with the intent and ability of working the scheduled hours and doing the normal duties of his or her job on that day. Close Relative you, your spouse, your domestic partner, and a child, brother, sister, or parent of you or your spouse or domestic partner. Doctor a person, other than a close relative, licensed to practice medicine in the state in which treatment is received and providing treatment or advice in accordance with the license. State law may require that benefits be paid for professional services of a practitioner other than a medical doctor. If so, the term doctor also includes persons recognized as qualified to treat the accidental injury for which claim is made, by the state in which treatment is received. Domestic Partner another adult with whom you have a Declaration of Domestic Partnership registered with the California Secretary of State. A copy of the certified registration may be required as proof. Group Policy the written group insurance contract between ReliaStar Life and the Policyholder. Member Member includes: A member in good standing of the California State Firefighters' Association (CSFA) and an employee of a California fire department or agency; An active staff member of CSFA; An active employee in a Participating Unit, who is not a member in good standing of CSFA, and whose Participating Unit pays 100% of the cost of Plan 2 Insurance* under the Group Policy for all employees in the Participating Unit; A retired employee in a Participating Unit (a) whose Participating Unit pays 100% of the cost of Plan 2 Insurance* for all employees and retirees in the Participating Unit, and (b) who was enrolled as a member of CSFA for at least two consecutive years immediately prior to retirement; or An active state officer, state committee chairperson, state committee member or state deputy directory of CSFA, or a member of the Board of Directors of the Policyholder, who is a member of CSFA's Select Group. *Plan 2 Insurance is basic life insurance under Group Policy ASSNLFG that your participating unit may make available to active and retired members. You are not a member if you are a full-time member of the armed forces of any country. Participating Unit includes: California State Firefighters Association; CSFA's Select Group; or An independent Firemen's/Firefighter's Association which has been approved for participation under the Group Policy by the Policyholder and ReliaStar Life. Policyholder California State Firefighters' Employee Welfare Benefits Corporation. ReliaStar Life ReliaStar Life Insurance Company, at its Home Office in Minneapolis, Minnesota. Sickness any physical illness. Spouse the legal husband or wife of a member. Written, In Writing signed, dated and received at ReliaStar Life's Home Office in a form ReliaStar Life accepts. You, Your a person insured for Member's Insurance under the Group Policy. 9

12 NOTICE OF PROTECTION PROVIDED BY CALIFORNIA LIFE AND HEALTH INSURANCE GUARANTEE ASSOCIATION This notice provides a brief summary regarding the protections provided to policyholders by the California Life and Health Insurance Guarantee Association ( the Association ). The purpose of the Association is to assure that policyholders will be protected, within certain limits, in the unlikely event that a member insurer of the Association becomes financially unable to meet its obligations. Insurance companies licensed in California to sell life insurance, health insurance, annuities and structured settlement annuities are members of the Association. The protection provided by the Association is not unlimited and is not a substitute for consumers care in selecting insurers. This protection was created under California law, which determines who and what is covered and the amounts of coverage. Below is a brief summary of the coverages, exclusions and limits provided by the Association. This summary does not cover all provisions of the law; nor does it in any way change anyone s rights or obligations or the rights or obligations of the Association. Persons Covered COVERAGE Generally, an individual is covered by the Association if the insurer was a member of the Association and the individual lives in California at the time the insurer is determined by a court to be insolvent. Coverage is also provided to policy beneficiaries, payees or assignees, whether or not they live in California. Amounts of Coverage The basic coverage protections provided by the Association are as follows. Life Insurance, Annuities and Structured Settlement Annuities For life insurance policies, annuities and structured settlement annuities, the Association will provide the following: Life Insurance 80% of death benefits but not to exceed $300,000 80% of cash surrender or withdrawal values but not to exceed $100,000 Annuities and Structured Settlement Annuities 80% of the present value of annuity benefits, including net cash withdrawal and net cash surrender values but not to exceed $250,000 The maximum amount of protection provided by the Association to an individual, for all life insurance, annuities and structured settlement annuities is $300,000, regardless of the number of policies or contracts covering the individual. Health Insurance The maximum amount of protection provided by the Association to an individual, as of April 1, 2011, is $470,125. This amount will increase or decrease based upon changes in the health care cost component of the consumer price index to the date on which an insurer becomes an insolvent insurer. R-08222b 1 of 2 (9/11)

13 COVERAGE LIMITATIONS AND EXCLUSIONS FROM COVERAGE The Association may not provide coverage for this policy. Coverage by the Association generally requires residency in California. You should not rely on coverage by the Association in selecting an insurance company or in selecting an insurance policy. The following policies and persons are among those that are excluded from Association coverage: A policy or contract issued by an insurer that was not authorized to do business in California when it issued the policy or contract A policy issued by a health care service plan (HMO), a hospital or medical service organization, a charitable organization, a fraternal benefit society, a mandatory state pooling plan, a mutual assessment company, an insurance exchange, or a grants and annuities society If the person is provided coverage by the guaranty association of another state. Unallocated annuity contracts; that is, contracts which are not issued to and owned by an individual and which do not guaranty annuity benefits to an individual Employer and association plans, to the extent they are self-funded or uninsured A policy or contract providing any health care benefits under Medicare Part C or Part D An annuity issued by an organization that is only licensed to issue charitable gift annuities Any policy or portion of a policy which is not guaranteed by the insurer or for which the individual has assumed the risk, such as certain investment elements of a variable life insurance policy or a variable annuity contract Any policy of reinsurance unless an assumption certificate was issued Interest rate yields (including implied yields) that exceed limits that are specified in Insurance Code Section (b)(2)(C) NOTICES Insurance companies or their agents are required by law to give or send you this notice. Policyholders with additional questions should first contact their insurer or agent. To learn more about coverages provided by the Association, please visit the Association s website at or contact either of the following: California Life and Health Insurance California Department of Insurance Guarantee Association Consumer Communications Bureau P.O. Box 16860, 300 South Spring Street Beverly Hills, CA Los Angeles, CA (323) (800) Insurance companies and agents are not allowed by California law to use the existence of the Association or its coverage to solicit, induce or encourage you to purchase any form of insurance. When selecting an insurance company, you should not rely on Association coverage. If there is any inconsistency between this notice and California law, then California law will control. R-08222b 2 of 2 (9/11)

14 Plan Arranged and Administered by: Myers-Stevens & Toohey Co., Inc Marguerite Parkway Mission Viejo, CA CA License No or fax ReliaStar Life Insurance Company

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