TABLE OF CONTENTS Section Page CERTIFICATE FACE PAGE .............................................................................................................................. 1 NOTICES ........................................................................................................................................................... 3 SCHEDULE OF BENEFITS ............................................................................................................................. 29 DEFINITIONS .................................................................................................................................................. 40 ELIGIBILITY PROVISIONS: INSURANCE FOR YOU ..................................................................................... 44 Eligible for PEBB Benefits ............................................................................................................................ 44 Date You Are Eligible for Insurance ............................................................................................................. 44 Enrollment Process ...................................................................................................................................... 44 Date Your Insurance Takes Effect ............................................................................................................... 44 Date Your Insurance Ends ........................................................................................................................... 47 ELIGIBILITY PROVISIONS: DEPENDENT LIFE AND DEPENDENT AD&D INSURANCE ............................ 48 Eligible for PEBB Benefits: Dependent Insurance ....................................................................................... 48 Date You Are Eligible For Dependent Insurance ......................................................................................... 48 Enrollment Process ...................................................................................................................................... 48 Date Insurance Takes Effect For Your Dependents .................................................................................... 49 Date Your Insurance For Your Dependents Ends ........................................................................................ 52 SPECIAL REQUIREMENTS FOR GROUPS PREVIOUSLY COVERED UNDER OTHER GROUP LIFE AND AD&D INSURANCE ......................................................................................................................................... 53 CONTINUATION OF INSURANCE WITH PREMIUM PAYMENT ................................................................... 55 For Developmentally or Physically Disabled Children .................................................................................. 55 For Family And Medical Leave ..................................................................................................................... 55 At Your Option: Portability ............................................................................................................................ 55 At Your Option: Continuation Of Your Life Insurance During A Labor Dispute ............................................ 58 At The Employing Agency's Option .............................................................................................................. 59 EVIDENCE OF INSURABILITY ................................................................................................................... 60 LIFE INSURANCE: FOR YOU ......................................................................................................................... 61 LIFE INSURANCE: FOR YOUR DEPENDENTS............................................................................................. 62 GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 27