FORT DEARBORN LIFE Insurance Company

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1 FORT DEARBORN LIFE Insurance Company (A stock life insurance company herein called "We", "Us", "Our") Chicago, Illinois Administrative Office: 2400 Lakeside Blvd. Richardson, TX Policyholder: The University of Texas System Policy Number: GFZ Policy Effective Date: September 1, 2009 Anniversary Date: September 1, 2012 We agree with the Policyholder to insure certain eligible Employees of the Policyholder. We promise to pay benefits for loss covered by the Policy in accordance with its provisions. The Policyholder should read this Policy carefully and contact Fort Dearborn Life Insurance Company promptly with any questions. Policyholder means the Employer to whom the Policy is issued and who sponsored the coverage for its Employees. Employer means the Policyholder and includes any division, subsidiary, or affiliated company named in the Policy. Employee means a person working for the Employer at a usual place of business. POLICY EFFECTIVE DATE AND TERM The Policy takes effect on the Policy Effective Date stated above subject to any participation requirement stated in the Policy. All insurance periods will be computed from that date. The Policy remains in force for the period for which premium has been paid. It may be renewed for further successive periods by payment as stated in the Policy. All periods of insurance begin and end at 12:01 A.M., Standard Time, at the Policyholder's address as stated in the Policy, and on the Application. Signed for Fort Dearborn Life Insurance Company Secretary President THIS IS NOT A POLICY OF WORKERS' COMPENSATION INSURANCE. THE EMPLOYER DOES NOT BECOME A SUBSCRIBER TO THE WORKERS' COMPENSATION SYSTEM BY PURCHASING THIS POLICY, AND IF THE EMPLOYER IS A NON-SUBSCRIBER, THE EMPLOYER LOSES THOSE BENEFITS WHICH WOULD OTHERWISE ACCRUE UNDER THE WORKERS' COMPENSATION LAWS. THE EMPLOYER MUST COMPLY WITH THE WORKERS' COMPENSATION LAW AS IT PERTAINS TO NON-SUBSCRIBERS AND THE REQUIRED NOTIFICATIONS THAT MUST BE FILED AND POSTED. Group Voluntary Long-Term Disability Policy Participating THIS IS NOT A WORKERS' COMPENSATION POLICY 2-LTDP-705 UT 109 Rev 4/17/09

2 IMPORTANT NOTICE To obtain information or make a complaint: You may call Fort Dearborn Life Insurance Company's toll-free telephone number for information or to make a complaint at You may also write to Fort Dearborn Life Insurance Company at: st Street, Downers Grove, IL You may contact the Texas Department of Insurance to obtain information on companies, coverages, rights or complaints at You may write the Texas Department of Insurance: P. O. Box Austin, TX FAX #(512) Web: PREMIUM OR CLAIM DISPUTES: Should you have a dispute concerning your premium or about a claim, you should contact the company first. If the dispute is not resolved, you may contact the Texas Department of Insurance. ATTACH THIS NOTICE TO YOUR POLICY: This notice is for information only and does not become a part or condition of the attached document. AVISO IMPORTANTE Para informacion o para someter una queja: Usted puede llamar al numero de telefono gratis de Fort Dearborn Life Insurance Company para informacion o para someter una queja al Usted tambien escribir a Fort Dearborn Life Insurance Company al: st Street, Downers Grove, IL Puede comunicarse con el Departmento de Seguros de Texas para conseguir informacion acerca de companias, coberturas, derechos o quejas al Puede escribir al Departamento de Seguros de Texas: P. O. Box Austin, TX FAX #(512) Web: DISPUTAS SOBRE PRIMAS O RECLAMOS: Si tiene una disputa concerniente a su prima o a un reclamo, debe comunicarse con la compania primero. Si no se resuelve la disputa, puede entonces comunicarse con al Departamento de Seguros de Texas. UNA ESTE AVISO A SU POLIZA: Este aviso es solo para proposito de informacion y no se convierte en parte o condicion del documento adjunto

3 IMPORTANT INFORMATION ABOUT COVERAGE UNDER THE TEXAS LIFE, ACCIDENT, HEALTH AND HOSPITAL SERVICE INSURANCE GUARANTY ASSOCIATION Texas law establishes a system, administered by the Texas Life, Accident, Health and Hospital Service Insurance Guaranty Association (the "Association"), to protect policyholders if their life or health insurance company fails to or cannot meet its contractual obligations. Only the policyholders of insurance companies which are members of the Association are eligible for this protection. However, even if a company is a member of the Association, protection is limited and policyholders must meet certain guidelines to qualify. (The law is found in the Texas Insurance Code, Article D.) BECAUSE OF STATUTORY LIMITATIONS ON POLICYHOLDER PROTECTION, IT IS POSSIBLE THAT THE ASSOCIATION MAY NOT COVER YOUR POLICY OR MAY NOT COVER YOUR POLICY IN FULL. Eligibility for Protection by the Association When an insurance company which is a member of the Association is designated as impaired by the Texas Commissioner of Insurance, the Association provides coverage to policyholders who are: residents of Texas at the time that their insurance company is impaired and residents of other states, ONLY if the following conditions are met: 1. The policyholder has a policy with a company based in Texas; 2. The company has never held a license in the policyholder's state of residence; 3. The policyholder's state of residence has a similar guaranty association; 4. The policyholder is not eligible for coverage by the guaranty association of the policyholder's state of residence. Limits of Protection by the Association Accident, Accident and Health, or Health Insurance: up to a total of $200,000 for one or more policies for each individual covered. Life Insurance: net cash surrender value up to a total of $100,000 under one or more policies on any one life; or death benefits up to a total of $300,000 under one or more policies on any one life. Individual Annuities: net cash surrender amount up to a total of $100,000 under one or more policies owned by one contractholder. Group Annuities: net cash surrender amount up to $100,000 in allocated benefits under one or more policies owned by one contractholder; or net cash surrender amount up $5,000,000 in unallocated benefits under one contractholder regardless of the number of contracts. THE INSURANCE COMPANY AND ITS AGENTS ARE PROHIBITED BY LAW FROM USING THE EXISTENCE OF THE ASSOCIATION FOR THE PURPOSE OF SALES, SOLICITATION, OR INDUCEMENT TO PURCHASE ANY FORM OF INSURANCE. When you are selecting an insurance company, you should not rely on coverage by the association. 2-LTDP-705 UT 109

4 Texas Life, Accident, Health and Hospital Service Insurance Guaranty Association 301 Congress, Suite 500 Austin, Texas Texas Department of Insurance P.O. Box Austin, Texas LTDP-705 UT 109

5 TABLE OF CONTENTS PROVISION Premium Premium Rate Guarantee Policy Termination Additional Provisions ATTACHMENTS: Master Application Certificate of Insurance 2-LTDP-705 UT 109

6 PREMIUM How is the initial premium calculated? Initial Premium is calculated by multiplying the total insured Monthly Earnings, divided by 100, by $ When is premium paid? The Policy is issued in consideration of the payment in advance of premium on the billing mode indicated on the Application. The initial premium is calculated at the premium rate stated above. Payment must be made by the premium due date as shown on the Application. If an addition, termination or change in insurance takes place other than on a regular due date, any premium adjustment will take effect on the next due date. Is premium payable while an Insured receives benefits? We will waive premium for an Insured Employee during the period of Disability for which the LTD Monthly Benefit is payable under the Policy. Premium payment is required during the Insured Employee's Elimination Period. During this period, the Insured Employee's insurance will remain in force. Is there a grace period for premium payment? We will allow a grace period of 90 days for the payment of any premiums due except the first. Insurance coverage shall continue in force during the grace period unless the Policyholder has given Us advance written notice of cancellation in accordance with the terms of this Policy. If premium is not received by the end of the grace period, this Policy will terminate as of the last date for which premium was paid. The Policyholder is liable for premium due on coverage provided during the grace period. If We receive written notice during the grace period that the Policy is to be canceled, We will cancel it as of the later of: 1. the date requested in the cancellation notice; or 2. the date We receive such notice. The Policyholder must pay a pro rata premium for any coverage provided during the grace period. PREMIUM RATE GUARANTEE What is the initial premium rate guarantee? A change in premium rates will not take effect before September 1, However, We may change premium rates if the risk assumed changes. Premium rates may change if the following occurs: 1. a change in the policy design; 2. a change in the terms of the Policy; 3. addition or deletion of a division, subsidiary or affiliated company; 4. a change in the laws or regulations or other government action which applies to the Policy; 5. for reasons other than 1-5 above such as but not limited to a change in factors bearing on the risk assumed. The Policyholder must furnish notice and documentation satisfactory to Us within 31 days of the occurrence of any event which would cause a change in rates as described above. If the Policyholder fails to provide such timely notice, we will apply new rates retroactively to the date of the event. We will notify the Policyholder in writing at least 210 days in advance of any premium rate changes. A change may take effect on an earlier date if both the Policyholder and We agree. 2-LTDP-705 UT 109 6

7 POLICY TERMINATION Who may cancel the Policy or a plan under the Policy? The Policy or a plan under the Policy can be canceled by the Policyholder with 31 days written notice delivered to Us. This Policy will terminate for any of the following reasons: 1. If the Policyholder fails to pay any premium within the 90-day Grace Period, this Policy will terminate in accordance with the terms set forth in the Grace Period provision. 2. We may terminate this Policy on any premium due date if: a. the Policyholder fails to perform any of its obligations that relate to the Policy; or b. the Policyholder does not promptly provide Us with information that is reasonably required; or c. fewer than 10 Employees are insured under the Policy. If We cancel the Policy, for reasons other than the Policyholder s failure to pay premium, a written notice will be delivered to the Policyholder at least 90 days prior to the cancellation date. Termination of this Policy under any conditions will not prejudice any claim for a loss which is incurred while this Policy is in force. ADDITIONAL PROVISIONS What happens if an inadvertent error occurs? Clerical error or omission by Us to the Policyholder will not: 1. Prevent You from receiving coverage, if You are entitled to coverage under the terms of the Policy; or 2. Cause coverage to begin or coverage to continue for You when the coverage would not otherwise be effective. If the Policyholder gives Us information about You that is incorrect, We will: 1. Use the facts to decide whether You have coverage under the Policy and in what amounts; and 2. Make a fair adjustment of the premium. Will certificates be issued? We will deliver certificates of insurance to the Policyholder for issuance to each Insured Employee. The certificates will describe the benefits, to whom they are payable, the Policy limitations and where the Policy may be inspected. What is considered to be the entire contract? This entire Policy consists of: 1. all Policy provisions and any amendments and/or attachments issued; 2. the Certificate of Coverage; and 3. the Policyholder s signed Application; and 4. the Employee s signed enrollment forms. 2-LTDP-705 UT 109 7

8 STATE SUPPLEMENT The following policies apply only to those individuals in your group insurance program who reside in the referenced states. Arizona and Maine Except as otherwise permitted by law, we will not disclose collected personal information about an individual to a nonaffiliated third party with whom we jointly offer products without giving the individual an opportunity to tell us that he or she does not want us to share his or her personal information. Minnesota and Montana Except as otherwise permitted by law, we will not disclose collected personal information about an individual to a nonaffiliated third party with whom we jointly offer products without obtaining the individual s written authorization. Montana Upon written request, an individual who has authorized the collection of health information is entitled to receive a record of Fort Dearborn s disclosures of any of his medical record information made within the preceding 3 years. Oregon An individual has the right to authorize disclosure of his or her personal information to an insurance company. An Oregon resident can exercise this right by requesting an authorization form in writing. Our address is: Fort Dearborn Life Insurance Company Administrative Office: 2400 Lakeside Blvd. Richardson, TX

9 PRIVACY NOTICE THIS NOTICE REQUIRES NO ACTION ON YOUR PART. IT IS DESIGNED TO HELP YOU UNDERSTAND HOW WE PROTECT YOUR PERSONAL INFORMATION. Insured's private records and those of their covered family members are safe with us. We have a longstanding policy that maintains the confidentiality of your personal data necessary to administer insurance and to provide service. It is widely known that many companies sell the names of customers to others. We do not sell or rent the name or records of our insureds to any other organization or business concern. Confidentiality and Security We implemented policies and procedures to protect the confidentiality of personal information. We maintain physical, electronic, and procedural safeguards to protect personal data from unauthorized access and unanticipated threats or hazards. Information That May Be Collected We receive personal information on insurance applications, claim forms, and other forms. In addition, we may receive information from health care providers through the course of managing insurance transactions. We also have personal information from transactions with us, our affiliates, and certain third parties with whom we have service or joint marketing agreements. These third parties may include our reinsurers, insurance administrators, consultants, medical information bureaus, and other insurers with whom we do business. Generally, we receive personal information by telephone, in writing or through a computer. This includes information about policies, premiums, and claims. If we need more information from medical professionals or consumer reporting agencies, it must be authorize by the insured. Independent Insurance Agents The independent insurance agents authorized to sell our products are not our employees. Since these agents are subject to the same privacy laws that govern us, these agents may have privacy obligations that are independent of ours. Information We May Disclose We regard all personal information as confidential. We will not disclose personal information unless we are allowed or required by law or if we are told we can by the insured. We only make those disclosures that are necessary to administer insurance products, to effect transactions made in the ordinary course of our business and to pay claims. We may provide personal information only to our affiliates, agents, joint marketing partners, and certain third parties such as insurance administrators, reinsurers, consultants, and regulatory or governmental authorities. We work with our affiliates and outside firms to help with administrative and other insurance services and marketing. As permitted by law, these affiliates and firms may use certain identifying and non-medical information. Our affiliates are subject to the same policies regarding privacy of your information as we are. Our policy is to require our vendors and third party administrators to pledge to maintain the confidentiality of personal information and abide by all applicable privacy laws. These firms are prohibited from using or disclosing personal information given to us for any purpose other than the work they are performing or as required by law. Further Information Insureds have the right to obtain access to recorded personal information in our possession or control, to request correction if it is believed the information may be inaccurate and to add a rebuttal statement to the file if there is a dispute. Each insured has the right to know the reasons for an adverse underwriting decision. Previous adverse underwriting decisions may not be used as the basis for subsequent underwriting decisions unless we make an independent evaluation of the underlying facts. Further, each insured has the right, with very narrow exceptions, not to be subjected to pretext interviews. Even if our relationship ends, we pledge to maintain our privacy policy and practices. 9

10 If you have any questions about our privacy policy, please write us at. Fort Dearborn Life Administrative Office: 2400 Lakeside Blvd. Richardson, TX The following is a list of entities that this notice applies to, as of March 1, 2005: Fort Dearborn Life Insurance Company Colorado Bankers Life Insurance Company And their affiliates: Dental Network of America Medical Life Insurance Agency Industry Savings Plans, Inc. Combined Services, LLC Health Care Service Corporation, a Mutual Legal Reserve Company 10

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