1 PLAN DESCRIPTION for the Members of WORLDWIDE ASSURANCE FOR EMPLOYEES OF PUBLIC AGENCIES, INC. Underwritten by LIFE INSURANCE COMPANY OF NORTH AMERICA Philadelphia, Pennsylvania. A Stock Insurance Company, herein referred to as We, Our, or Us This Plan Description describes Your benefits available to You and Your eligible Dependents. All benefits are subject to the Limitations and Exclusions shown in the Description of Benefits. A person may be insured only once under the policy. LIFE INSURANCE Benefit Levels for Members and Associates Members Level 1 $ 25,000 Level 16 $400,000 Level 2 Level 3 $ 50,000 $ 75,000 Level 17 Level 18 $425,000 $450,000 Level 4 $100,000 Level 19 $475,000 Level 5 Level 6 $125,000 $150,000 Level 20 Level 21 $500,000 $525,000 Level 7 $175,000 Level 22 $550,000 Level 8 Level 9 $200,000 $225,000 Level 23 Level 24 $575,000 $600,000 Level 10 $250,000 Level 25 $625,000 Level 11 $275,000 Level 12 $300,000 Level 26 Level 27 $650,000 $675,000 Level 13 $325,000 Level 28 $700,000 Level 14 $350,000 Level 15 $375,000 Level 29 Level 30 $725,000 $750,000 DESCRIPTION OF BENEFITS You are eligible to apply to increase Your existing Member or Associate Member coverage if You are less than age 65 and currently insured under levels 1 to 29. Coverage is available in $25,000 increments from $25,000 to $750,000. Benefit Levels for Dependent Spouse/Domestic Partner Benefit Levels for Dependent Children Level Spouse Amount Level Live birth but less than 2 years 1 2 years but less than 5 years 5 years to 19 years* 1 $10,000 1 $1,000 $2,000 $2,500 2 $20,000 2 $2,000 $4,000 $5,000 3 $30,000 3 $3,000 $6,000 $7,500 4 $40,000 4 $4,000 $8,000 $10,000 5 $50,000 5 $5,000 $10,000 $12,500 6 $60,000 6 $6,000 $12,000 $15,000 7 $70,000 7 $7,000 $14,000 $17,500 8 $80,000 8 $8,000 $16,000 $20,000 9 $90,000 9 $9,000 $18,000 $22, $100, $10,000 $20,000 $25, $110, $120, $130, $140, $150, $160, $170, $180, $190,000
2 20 $200, $210, $220, $230, $240, $250,000 You are eligible to apply to increase Your existing spouse/domestic partner Dependent coverage if You are less than age 65 and currently insured under levels 1 to 24. Coverage is available in $10,000 increments from $10,000 to $250,000. Dependent spousal coverage is limited to a maximum of 50% of the Member or the Associate Member coverage. Dependent children benefits are at the same Benefit Levels as the Dependent Spousal/D/P Coverage levels. Levels 1 to 25 can be selected in the absence of Dependent Spousal/D/P coverage. * To age 26 if unmarried, and primarily supported by the Member or the Associate Member. Death Benefit If You or any covered Dependent die, We pay the coverage amount in force on Your date of death. Terminal Illness Benefit We will pay a Terminal Illness Benefit equal to 25% to 50% of the Death Benefit, provided We receive: (1) the written diagnosis and prognosis by two physicians licensed to practice in the United States; and (2) supportive evidence satisfactory to Us, including but not limited to radiological, histological or laboratory reports documenting Your or any covered Dependent s Terminal Illness. We may require, at Our expense, You or Your covered Dependent examination and a review of the documented evidence by a physician of Our choice. Limitations The amount paid will be reduced by any amount You or Your Dependents received under the Terminal Illness Benefit. The Terminal Illness Benefit is payable only once in Your or Your Dependents lifetime. Notice Benefits paid under the Terminal Illness provision will reduce the Death Benefit payable for life insurance. Benefits payable under the Terminal Illness Benefit may be taxable. If so, You or Your beneficiary may incur a tax obligation. As with all tax matters, You should consult with a personal tax advisor to assess the impact of this benefit. Terminal Illness is not payable if life insurance coverage under the Policy is not in force. In addition, Your Member or Associate Member benefit will reduce when You reach the age for the level of coverage shown below: Level 1: Age 80 $ 12,500 Levels 2: Age 75 - $ 25,000 Levels 3 & 4: Age 70 - $ 50,000 Age 75 - $ 25,000 Levels 5 to 8: Age 65 - $100,000 Age 70 - $ 50,000 Age 75 - $ 25,000 Levels 9 to 12: Age 60 - $200,000 Age 65 - $100,000 Age 70 - $ 50,000 Age 75 - $ 25,000 Levels 13 to 29: Age 60 - $250,000 Age 65 - $125,000 2
3 Age 70 - $ 75,000 Age 75 - $ 50,000 Age 80 - $ 25,000 In addition, Your Spouse/D/P benefit will reduce when You reach the age for the level of coverage shown below: Levels 3 to 5: Levels 6 to 15: Age 70 $ 20,000 Age 60 $ 50,000 Age 70 $ 20,000 Levels 16 to 25: Age 60 $120,000 Age 65 $ 60,000 Age 70 $ 30,000 ACCIDENT INSURANCE FOR MEMBER OR ASSOCIATE MEMBER Levels Level 1 $ 5,000 Level 16 $ 80,000 Level 2 $ 10,000 Level 17 $ 85,000 Level 3 Level 4 $ 15,000 $ 20,000 Level 18 Level 19 $ 90,000 $ 95,000 Level 5 $ 25,000 Level 20 $100,000 Level 6 Level 7 $ 30,000 $ 35,000 Level 21 Level 22 $105,000 $110,000 Level 8 $ 40,000 Level 23 $115,000 Level 9 $ 45,000 Level 10 $ 50,000 Level 24 Level 25 $120,000 $125,000 Level 11 $ 55,000 Level 26 $130,000 Level 12 $ 60,000 Level 13 $ 65,000 Level 27 Level 28 $135,000 $140,000 Level 14 $ 70,000 Level 29 $145,000 Level 15 $ 75,000 Level 30 $150,000 We will pay benefits for any of the covered losses listed below, if You are insured under the Policy for Accident Insurance on the date of the covered Accident. The loss must: 1. be a result of bodily Injuries caused directly, and from no other causes, by a covered Accident; and 2. occur within 365 days of the covered Accident. Accidental Death and Dismemberment Benefit for Member or Associate Member If You suffer a covered loss, We will pay the Benefit Amount shown below for that loss. If multiple losses occur, only one Benefit Amount, the largest, will be paid for all losses due to the same covered Accident. Any loss of Life benefit will be reduced by any paid or payable Accidental Dismemberment benefit. However, if such Accidental Dismemberment benefit equals or exceeds the Loss of Life benefit, no additional benefit will be paid. Schedule of Covered Losses Covered Loss Benefit Amount Life. The Principal Sum Both Hands.The Principal Sum Both Feet The Principal Sum Entire Sight of Both Eyes The Principal Sum One Hand.One-Half the Principal Sum One Foot..One-Half the Principal Sum Entire Sight of One Eye.. One-Half the Principal Sum Loss of hand or foot means complete Severance through or above the wrist or ankle joint. Loss of sight means the total, permanent loss of sight of the eye. The loss of sight must be irrecoverable by natural, surgical or artificial means. Severance means the complete separation and dismemberment of the part from the body. 3
4 Limitations In addition, Your Accidental Death and Dismemberment benefit will reduce when You reach 60 years of age for the level of coverage shown below: Levels 9 to 12: $40,000 Level 13 to 30: $50,000 You are not eligible for the Accidental Death and Dismemberment Benefit and Common Carrier Accident Benefit, if You are 65 years of age or older. Common Carrier Accident Benefit for Member and Associate Member Levels Level 1 $ 10,000 Level 16 $160,000 Level 2 $ 20,000 Level 17 $170,000 Level 3 Level 4 $ 30,000 $ 40,000 Level 18 Level 19 $180,000 $190,000 Level 5 $ 50,000 Level 20 $200,000 Level 6 Level 7 $ 60,000 $ 70,000 Level 21 Level 22 $210,000 $220,000 Level 8 $ 80,000 Level 23 $230,000 Level 9 $ 90,000 Level 10 $100,000 Level 24 Level 25 $240,000 $250,000 Level 11 $110,000 Level 26 $260,000 Level 12 $120,000 Level 13 $130,000 Level 27 Level 28 $270,000 $280,000 Level 14 $140,000 Level 29 $290,000 Level 15 $150,000 Level 30 $300,000 We will pay the Common Carrier Accident Benefit, if You suffer any one of the covered losses shown in the Accidental Death and Dismemberment Benefit that result directly and independently of all other causes from, a covered Accident, that occurs while riding as a fare-paying passenger in, or being struck by, a Common Carrier. Riding includes getting into and out of the Common Carrier. Definition Common Carrier means: 1. a public conveyance, such as but not limited to a bus, ship, train, or aircraft licensed for hire to carry fare-paying passengers; or 2. a transport aircraft operated by the Air Mobility Command of the United states of America or a similar air transport service of another country. Limitations In addition, Your Common Carrier Benefit will reduce when You reach 60 years of age for the level of coverage shown below: Levels 9 to 12: $80,000 Levels 13 to 30: $100,000 You are not eligible for the Accidental Death and Dismemberment Benefit and Common Carrier Accident Benefit, if You are 65 years of age or older. LIFE INSURANCE EXCLUSIONS If You or Your covered Spouse/Domestic Partner commits suicide, while sane or insane, within 2 years from the date insurance under the Policy becomes effective, or the date the coverage is increased, the Life Insurance Benefits will be limited to a refund of the premiums paid on Your or Your Dependent s behalf. 4
5 If a Dependent Child commits suicide within 2 years from the date Your insurance under the policy becomes effective, or the date the dependent coverage was increased and is survived by other Dependent Children under the same certificate, no refund of premiums will be made. ACCIDENT INSURANCE We will not pay Accident Insurance benefits for a loss that results, directly or indirectly, from any of the following circumstances. 1. suicide, attempted suicide, or whenever You Injure yourself on purpose. 2. voluntary self-administration of any drug or chemical substance not prescribed by, and taken according to the directions of, a doctor. (Accidental ingestion of a poisonous substance is not excluded.). 3. sickness, disease or bodily infirmity; medical or surgical treatment; or bacterial or viral infection, no matter how contracted. (This does not include bacterial infection that is the natural and foreseeable result of an accidental bodily Injury or accidental food poisoning.). 4. war or any act of war, whether or not declared. 5. commission of or Active Participation in a riot or Terrorist Act. 6. commission of a felony. 7. aviation or travel or flight (including getting in or out, on or off) in any aircraft or device which can fly above the earth's surface if A. the aircraft or device is being used: 1) for test or experimental purposes; or 2) by or for any military authority. (Aircraft flown by the U.S. Military Airlift Command (MAC) or similar service of another country are not excluded); or 3) for travel, or is designed for travel, beyond the earth's atmosphere; or (This exclusion applies whether the aircraft or device is owned, leased, operated or controlled as defined); or B. You are: 1) serving as a pilot or crew member (or student taking a flying lesson) and is not riding as a passenger; or 2) hang-gliding; or 3) parachuting, except where the You have to make a parachute jump for self-preservation. Owned Aircraft means an aircraft to which You hold legal or equitable title. You can use, alter or sell the property as desired. "Leased Aircraft" means an aircraft You do not own. You may use the aircraft as desired for the term of the written lease. The time of the lease must be longer than a few days or one or two trips. You cannot alter or sell the aircraft without the consent of the owner. Operated or Controlled Aircraft means an aircraft You do not own, but is leased, rented or borrowed for more than 10 straight days. You can use it as desired, but cannot alter or sell the aircraft without consent of the owner. Chartered Aircraft means an aircraft You do not own. It will be hired for one purpose or one trio or for general use. The time You have it may not exceed 10 straight days nor more than 15 days in any one year. One or more aircraft hired on a regular or frequent basis are not chartered. 8. an Injury for which You are entitled to benefits from Worker's Compensation or occupational disease law; an Injury that is work related. 9. an Injury that is the result of Your being intoxicated (intoxication shall be determined according to the laws of the jurisdiction in which the Injury occurred). 10. an Injury caused by/due to prolonged exposure to dangerous substances, cumulative trauma, or repetitive motion. 11. an Injury while doing police duty as a member of a military organization. DEFINITIONS Accident means an Accident is a sudden unforeseeable external event that causes bodily injury to You while coverage is in force under the Policy. Dependent includes the following persons: "Domestic Partner" where available means a person of the same or opposite sex, who meets all of the following criteria: 1. he or she shares Your permanent residence; 2. he or she has resided with You continuously for at least one year and is expected to continue to reside with You indefinitely; 3. he or she is financially interdependent with You in each of the following ways: a. they hold one or more credit or bank accounts, including a checking account, as joint owners; b. they own or lease their permanent residence as joint tenants; c. the Domestic Partner has named or is named by You as a beneficiary of life insurance or under a will; d. they have each agreed in writing to assume financial responsibility for the welfare of the other; 4. they have signed a domestic partner declaration with You, if You reside in a jurisdiction that provides for domestic partner declarations; 5. neither of them have signed a domestic partner declaration with any other person within the last 12 months; 5
6 6. neither of them is less than 18 years of age; 7. neither of them is currently legally married to any other person; 8. neither of them is a blood relative any closer than would prohibit legal marriage. Dependent Child means a member s unmarried child who is: 1. Live Birth, but less than 19 years old; or more years old, but less than 26 years old and primarily supported by the Member; or or more years old and primarily Supported by the Member and incapable of self-sustaining employment by reason of mental or physical handicap. Proof of the child's condition and dependence must be submitted to Us within 31 days after the date the child ceases to qualify as a Dependent for the reasons listed above. During the next two years We may, from time to time require proof of the continuation of such condition and dependence. After that, We may require proof no more than once a year. Spouse means Your current legal spouse or former spouse. Injury means any bodily harm which results directly or indirectly of all other causes from an Accident. All injuries sustained in one Accident, including all related conditions and recurring symptoms of the Injuries will be considered one Injury. Principal Sum means the amount of Insurance in force for You. Terminal Illness means You or any covered Dependent has a prognosis of 12 months or less to live, as diagnosed by a physician. You or Your means the member of Worldwide Assurance for Employees of Public Agencies, Inc. WHEN COVERAGE BEGINS Your coverage will be effective on the date We receive Your completed Application and You provide any required evidence of insurability satisfactory to Us, and We receive the initial premium payment. WHEN COVERAGE ENDS Your coverage will end on the earliest of: 1. the date the Policy is terminated by Us; 2. the date You are no longer a member of Worldwide Assurance for Employees of Public Agencies, Inc.; 3. the day after the end of the period for which premiums are paid; 4. the date You enter into the armed forces of any country at war, including the United States, whether declared or undeclared, unless You are an activated member of the Reserves or national Guard components of the armed forces and You are not considered to be a member of the armed forces on a full-time basis; 5. for purposes of Life Insurance and Terminal Illness Benefits, a. the date You become 85 years of age/or; b. the date Your Spouse/Domestic Partner becomes 85 years of age. 6. the date Your Dependent is no longer an eligible Dependent 7. for purposes of Accident Insurance, the date You become 65 years of age. CONVERSION PRIVILEGE FOR LIFE INSURANCE You or any covered Dependent may convert all or any portion of your Life Insurance under the Policy if: 1. You or Your Dependent is no longer in an eligible; 2. the Policy is terminated; 3. Your or Your Dependent Spouse s insurance is reduced based on attained age, or a change in class. (In this case, the member may convert the amount of the reduction.) 4. For Dependent Spouse/Domestic Partner, the dissolution of marriage/domestic partnership; or 5. Your Dependent Child attains the maximum age. 6
7 To apply for conversion insurance, within 31 days after coverage under the policy ends, You and any covered dependent must: (1) submit an application to Us, and (2) pay the required premium. No medical examination is required under the policy. Conversion coverage will become effective on the 31st day after the date coverage under the Policy ends, provided: (a) the application has been received by Us; and (b) the required premium has been paid. The Insured is only eligible for one Conversion Privilege with Us. QUESTIONS? For assistance in completing Your application, call toll-free during weekdays from 9 a.m. to 5 p.m. Eastern time. This Plan Description is a brief description of the important features of the insurance plan. It is not a contract of insurance. The terms and conditions of coverage are set forth in the Policy, AGL-1203, issued to the Worldwide Assurance for Employees of Public Agencies, Inc under policy form TL (WP) in Virginia. The policy is subject to the laws of the state in which it was issued. Coverage may not be available in all states or certain terms and conditions may be different if required by state law. Please keep this material as a reference. waepa.pd
Who is Eligible for Coverage? PERSONAL ACCIDENT INSURANCE You, the Employee, are eligible for coverage, if you are an active full-time or part-time employee of Hanford Employee Welfare Trust (HEWT) sponsoring
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