Certificate of Coverage
YOUR BENEFIT PLAN WA State Health Care Authority PEBB All Actively at Work employees of an Employing Agency, except for employees of an Employer Group that do not contract with the Policyholder for the insurance benefits described in this certificate Totally Disabled Patrolmen, Disability Leave Patrolmen and Disability Status Patrolmen deemed disabled in the line of duty by the Chief of Washington State Patrol (WSP) Basic Life Insurance Supplemental Life Insurance Dependent Life Insurance Basic Accidental Death and Dismemberment Insurance Supplemental Accidental Death and Dismemberment Insurance Dependent Accidental Death and Dismemberment Insurance Certificate Date: January 1, 2024 Certificate Number 18
WA State Health Care Authority PEBB 626 8th Avenue SE P.O. Box 42684 Olympia, WA 98504-2684 TO EMPLOYEES: All of us appreciate the protection and security insurance provides. This certificate describes the benefits that are available to you. We urge you to read it carefully. WA State Health Care Authority PEBB
Metropolitan Life Insurance Company 200 Park Avenue, New York, New York 10166 TERM LIFE WITH ACCELERATED BENEFIT & ACCIDENTAL DEATH AND DISMEMBERMENT CERTIFICATE OF INSURANCE Metropolitan Life Insurance Company (“MetLife”), a stock company, certifies that You and Your Dependents are insured for the benefits described in this certificate, subject to the provisions of this certificate. This certificate is issued to You under the Group Policy and it includes the terms and provisions of the Group Policy that describe Your insurance. PLEASE READ THIS CERTIFICATE CAREFULLY. This certificate is part of the Group Policy. The Group Policy is a contract between MetLife and the Policyholder and may be changed or ended without Your consent or notice to You. Policyholder: WA State Health Care Authority PEBB Group Policy Number: 164995-1-G Type of Insurance: Term Life with Accelerated Benefit & Accidental Death and Dismemberment Insurance MetLife Toll Free Number(s): For Claim Information FOR LIFE CLAIMS: 1-866-548-7139 THIS CERTIFICATE ONLY DESCRIBES TERM LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE. NOTICE REGARDING ACCELERATED BENEFIT OPTION (ABO) This accelerated life benefit does not and is not intended to qualify as long-term care under Washington state law. Washington state law prevents this accelerated life benefit from being marketed or sold as long-term care. If you receive payment of accelerated benefits from a life insurance policy, you may lose your right to receive certain public funds, such as Medicare, Medicaid, Social Security, Supplemental Security, supplemental security income (SSI), and possibly others. Also, receiving accelerated benefits from a life insurance policy may have tax consequences for you. We cannot give you advice about this. You may wish to obtain advice from a tax professional or an attorney before you decide to receive accelerated benefits from a life insurance policy. IN THE EVENT THERE IS A CONFLICT BETWEEN LANGUAGE APPEARING IN THE GROUP POLICY AND THE CERTIFICATE, THE LANGUAGE IN THE CERTIFICATE WILL CONTROL. FOR CALIFORNIA RESIDENTS: REVIEW THIS CERTIFICATE CAREFULLY. IF YOU ARE 65 OR OLDER ON YOUR EFFECTIVE DATE OF THIS CERTIFICATE, YOU MAY RETURN IT TO US WITHIN 30 DAYS FROM THE DATE YOU RECEIVE IT AND WE WILL REFUND ANY PREMIUM YOU PAID. IN THIS CASE, THIS CERTIFICATE WILL BE CONSIDERED TO NEVER HAVE BEEN ISSUED. FOR FLORIDA RESIDENTS: THE BENEFITS OF THE POLICY PROVIDING YOUR COVERAGE ARE GOVERNED PRIMARILY BY THE LAW OF A STATE OTHER THAN FLORIDA. GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 1
For Idaho Residents: TEN DAY RIGHT TO EXAMINE CERTIFICATE: You may return the certificate to Us within 10 days from the date You receive it. If You return it within the 10 day period, the certificate will be considered never to have been issued. We will refund any premium paid after We receive Your notice of cancellation. FOR MARYLAND RESIDENTS: THE GROUP INSURANCE POLICY PROVIDING COVERAGE UNDER THIS CERTIFICATE WAS ISSUED IN A JURISDICTION OTHER THAN MARYLAND AND MAY NOT PROVIDE ALL THE BENEFITS REQUIRED BY MARYLAND LAW. For Residents of North Dakota: If You are not satisfied with Your Certificate, You may return it to Us within 20 days after You receive it, unless a claim has previously been received by Us under Your Certificate. We will refund within 30 days of Our receipt of the returned Certificate any Premium that has been paid and the Certificate will then be considered to have never been issued. You should be aware that, if You elect to return the Certificate for a refund of premiums, losses which otherwise would have been covered under Your Certificate will not be covered. WE ARE REQUIRED BY STATE LAW TO INCLUDE THE NOTICE(S) WHICH APPEAR ON THIS PAGE AND IN THE NOTICE(S) SECTION WHICH FOLLOWS THIS PAGE. PLEASE READ THE(SE) NOTICE(S) CAREFULLY. Jeannette N. Pina Michel Khalaf Vice President and Secretary President GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 2
NOTICE FOR RESIDENTS OF TEXAS Have a complaint or need help? If you have a problem with a claim or your premium, call your insurance company or HMO first. If you can't work out the issue, the Texas Department of Insurance may be able to help. Even if you file a complaint with the Texas Department of Insurance, you should also file a complaint or appeal through your insurance company or HMO. If you don't, you may lose your right to appeal. Metropolitan Life Insurance Company To get information or file a complaint with your insurance company or HMO: Call: Corporate Consumer Relations Department at 1-800-438-6388 Toll-free: 1-800-438-6388 Email: [email protected] Mail: Metropolitan Life Insurance Company 700 Quaker Lane 2nd Floor Warwick, RI 02886 The Texas Department of Insurance To get help with an insurance question or file a complaint with the state: Call with a question: 1-800-252-3439 File a complaint: www.tdi.texas.gov Email: [email protected] Mail: MC 111-1A, P.O. Box 149091, Austin, TX 78714-9091 ¿Tiene una queja o necesita ayuda? Si tiene un problema con una reclamación o con su prima de seguro, llame primero a su compañía de seguros o HMO. Si no puede resolver el problema, es posible que el Departamento de Seguros de Texas (Texas Department of Insurance, por su nombre en inglés) pueda ayudar. Aun si usted presenta una queja ante el Departamento de Seguros de Texas, también debe presentar una queja a través del proceso de quejas o de apelaciones de su compañía de seguros o HMO. Si no lo hace, podría perder su derecho para apelar. Metropolitan Life Insurance Company Para obtener información o para presentar una queja ante su compañía de seguros o HMO: Llame a: Departamento de Relaciones Corporativas del Consumidor al 1-800-438-6388 GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 3
Teléfono gratuito: 1-800-438-6388 Correo electrónico: [email protected] Dirección postal: Metropolitan Life Insurance Company 700 Quaker Lane 2nd Floor Warwick, RI 02886 El Departamento de Seguros de Texas Para obtener ayuda con una pregunta relacionada con los seguros o para presentar una queja ante el estado: Llame con sus preguntas al: 1-800-252-3439 Presente una queja en: www.tdi.texas.gov Correo electrónico: [email protected] Dirección postal: MC 111-1A, P.O. Box 149091, Austin, TX 78714-9091 GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 4
NOTICE FOR RESIDENTS OF LOUISIANA, NEW MEXICO, TEXAS AND UTAH The Definition Of Child Is Modified For The Coverages Listed Below: For Louisiana Residents (Accidental Death and Dismemberment Insurance): The term also includes Your grandchildren residing with You. The age limit for children and grandchildren will not be less than 26, regardless of the child’s or grandchild’s marital status, student status or full-time employment status. Your natural child, adopted child, stepchild or grandchild under age 26 will not need to be supported by You to qualify as a Child under this insurance. In addition, marital status will not prevent or cease the continuation of insurance for a mentally or physically handicapped child or grandchild past the age limit. For New Mexico Residents (Accidental Death and Dismemberment Insurance): The age limit for children will not be less than 25, regardless of the child’s student status or full-time employment status. Your natural child, adopted child or stepchild will not be denied accidental death and dismemberment insurance coverage under this certificate because: that child was born out of wedlock; that child is not claimed as Your dependent on Your federal income tax return; or that child does not reside with You. For Texas Residents (Life Insurance): The term also includes Your grandchildren. The age limit for children and grandchildren will not be less than 25, regardless of the child’s or grandchild’s student status or full-time employment status. Your natural child, adopted child or stepchild under age 25 will not need to be supported by You to qualify as a Child under this insurance. In addition, grandchildren must be able to be claimed by You as a dependent for Federal Income Tax purposes at the time You applied for Insurance. For Texas Residents (Accidental Death and Dismemberment Insurance): The term also includes Your grandchildren. The age limit for children and grandchildren will not be less than 25, regardless of the child’s or grandchild’s student status, full-time employment status or military service status. Your natural child, adopted child or stepchild under age 25 will not need to be supported by You to qualify as a Child under this insurance. In addition, grandchildren must be able to be claimed by You as a dependent for Federal Income Tax purposes at the time You applied for Insurance. GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 5
NOTICE FOR RESIDENTS OF LOUISIANA, NEW MEXICO, TEXAS AND UTAH (continued) For Utah Residents (Dependent Life or Dependent Accidental Death and Dismemberment Insurance): The age limit for children will not be less than 26, regardless of the child’s student status or full-time employment status. Your natural child, adopted child or stepchild under age 26 will not need to be supported by You to qualify as a Child under this insurance. The term includes a child who is incapable of self-sustaining employment because of a mental or physical handicap as defined by applicable law and who has been continuously covered under an Accidental Death and Dismemberment plan since reaching age 26, with no break in coverage of more than 63 days, and who otherwise qualifies as a Child except for the age limit. Proof of such handicap must be sent to Us within 31 days after: the date the Child attains the limiting age in order to continue coverage; or You enroll a Child to be covered under this provision; and at reasonable intervals after such date, but no more often than annually after the two-year period immediately following the date the Child qualifies for coverage under this provision. GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 6
NOTICE FOR RESIDENTS OF ALL STATES OTHER THAN WASHINGTON LIFE INSURANCE BENEFITS WILL BE REDUCED IF AN ACCELERATED BENEFIT IS PAID DISCLOSURE: The Life Insurance accelerated benefit offered under this certificate is intended to qualify for favorable tax treatment under the Internal Revenue Code of 1986. If this benefit qualifies for such favorable tax treatment, the benefit will be excludable from Your income and not subject to federal taxation. Tax laws relating to accelerated benefits are complex. You are advised to consult with a qualified tax advisor about circumstances under which You could receive an accelerated benefit excludable from income under federal law. DISCLOSURE: Receipt of an accelerated benefit may affect Your, Your Spouse’s or Your family’s eligibility for public assistance programs such as Medical Assistance (Medicaid), Aid to Families with Dependent Children (AFDC), Supplementary Social Security Income (SSI), and drug assistance programs. You are advised to consult with a qualified tax advisor and with social service agencies concerning how receipt of such payment will affect Your, Your Spouse’s and Your family’s eligibility for public assistance. GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 7
NOTICE FOR RESIDENTS OF ARKANSAS If You have a question concerning Your coverage or a claim, first contact the Policyholder or group account administrator. If, after doing so, You still have a concern, You may call the toll free telephone number shown on the Certificate Face Page. Policyholders have the right to file a complaint with the Arkansas Insurance Department (AID). You may call AID to request a complaint form at (800) 852-5494 or (501) 371-2640 or write the Department at: Arkansas Insurance Department Consumer Services Division 1 Commerce Way, Suite 102 Little Rock, Arkansas 72202 GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 8
NOTICE FOR RESIDENTS OF CALIFORNIA IMPORTANT NOTICE TO OBTAIN ADDITIONAL INFORMATION, OR TO MAKE A COMPLAINT, CONTACT THE POLICYHOLDER OR METLIFE AT: METROPOLITAN LIFE INSURANCE COMPANY ATTN: CONSUMER RELATIONS DEPARTMENT 500 SCHOOLHOUSE ROAD JOHNSTOWN, PA 15904 1-800-438-6388 IF, AFTER CONTACTING THE POLICYHOLDER AND/OR METLIFE, YOU FEEL THAT A SATISFACTORY SOLUTION HAS NOT BEEN REACHED, YOU MAY FILE A COMPLAINT WITH THE CALIFORNIA DEPARTMENT OF INSURANCE DEPARTMENT AT: DEPARTMENT OF INSURANCE CONSUMER SERVICES 300 SOUTH SPRING STREET LOS ANGELES, CA 90013 WEBSITE: http://www.insurance.ca.gov/ 1-800-927-4357 (within California) 1-213-897-8921 (outside California) GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 9
NOTICE FOR RESIDENTS OF CALIFORNIA If Your certificate includes an exclusion for the voluntary intake or use by any means of any drug, medication or sedative, unless it is taken or used as prescribed by a Physician (or a similar exclusion), We will adjudicate your claim as follows: We will exclude any Covered Loss as a consequence of being under the influence of any intoxicant or controlled substance unless administered on the advice of a Physician. GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 10
NOTICE FOR RESIDENTS OF GEORGIA IMPORTANT NOTICE The laws of the state of Georgia prohibit insurers from unfairly discriminating against any person based upon their status as a victim of family violence. GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 11
NOTICE FOR RESIDENTS OF IDAHO If You have a question concerning Your coverage or a claim, You may call the toll free telephone number shown on the Certificate Face Page. If You are still concerned after contacting MetLife, You should feel free to contact: Idaho Department of Insurance Consumer Affairs rd 700 West State Street, 3 Floor PO Box 83720 Boise, Idaho 83720-0043 1-800-721-3272 (for calls placed within Idaho) or 208-334-4250 or www.DOI.Idaho.gov GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 12
NOTICE FOR RESIDENTS OF ILLINOIS IMPORTANT NOTICE To make a complaint to MetLife, You may write to: MetLife 200 Park Avenue New York, New York 10166 The address of the Illinois Department of Insurance is: Illinois Department of Insurance Public Services Division Springfield, Illinois 62767 GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 13
NOTICE FOR RESIDENTS OF INDIANA Questions regarding your policy or coverage should be directed to: Metropolitan Life Insurance Company 1-800-438-6388 If you (a) need the assistance of the government agency that regulates insurance; or (b) have a complaint you have been unable to resolve with your insurer you may contact the Department of Insurance by mail, telephone or email: State of Indiana Department of Insurance Consumer Services Division 311 West Washington Street, Suite 300 Indianapolis, Indiana 46204 Consumer Hotline: (800) 622-4461; (317) 232-2395 Complaint can be filed electronically at www.in.gov/idoi GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 14
NOTICE FOR RESIDENTS OF MAINE You have the right to designate a third party to receive notice if Your insurance is in danger of lapsing due to a default on Your part, such as for nonpayment of a contribution that is due. The intent is to allow reinstatements where the default is due to the insured person’s suffering from cognitive impairment or functional incapacity. You may make this designation by completing a “Third-Party Notice Request Form” and sending it to MetLife. Once You have made a designation, You may cancel or change it by filling out a new Third-Party Notice Request Form and sending it to MetLife. The designation will be effective as of the date MetLife receives the form. Call MetLife at the toll-free telephone number shown on the face page of this certificate to obtain a Third-Party Notice Request Form. Within 90 days after cancellation of coverage for nonpayment of premium, You or any person authorized to act on Your behalf may request reinstatement of the certificate on the basis that You suffered from cognitive impairment or functional incapacity at the time of cancellation. GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 15
NOTICE FOR MASSACHUSETTS RESIDENTS CONTINUATION OF ACCIDENTAL DEATH AND DISMEMBERMENT (AD&D) INSURANCE 1. If Your AD&D Insurance ends due to a Plant Closing or Covered Partial Closing, such insurance will be continued for 90 days after the date it ends. 2. If Your AD&D Insurance ends because: You cease to be in an Eligible Class; or Your employment terminates; for any reason other than a Plant Closing or Covered Partial Closing, such insurance will continue for 31 days after the date it ends. Continuation of Your AD&D Insurance under the CONTINUATION OF INSURANCE WITH PREMIUM PAYMENT subsection will end before the end of continuation periods shown above if You become covered for similar benefits under another plan. Plant Closing and Covered Partial Closing have the meaning set forth in Massachusetts Annotated Laws, Chapter 151A, Section 71A. GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 16
NOTICE FOR RESIDENTS OF MINNESOTA This is a life insurance policy which pays accelerated death benefits at your option under conditions specified in the policy. This policy is not a long-term care policy meeting the requirements of sections M.S.62A.46 to 62A.56 or chapter 62S. GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 17
. NOTICE FOR RESIDENTS OF MISSOURI ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE EXCLUSIONS If You reside in Missouri the exclusion for "suicide or attempted suicide" is as follows: "suicide or attempted suicide while sane" GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 18
NOTICE FOR RESIDENTS OF NEW MEXICO If a Child is insured for Accidental Death and Dismemberment Insurance under this certificate and You are not the custodial parent, notify Us that such is the case and provide Us with the name and address of the custodial parent. After receipt of such notice We will: (1) provide such information to the custodial parent as may be necessary for the Child to obtain benefits through that insurance; (2) permit the custodial parent or the provider, with the custodial parent's approval, to submit claims for covered services without the approval of the non-custodial parent; and (3) make payments on claims submitted in accordance with Paragraph (2) of this subsection directly to the custodial parent, the provider or the state Medicaid agency. If You are required by a court or administrative order to provide Accidental Death and Dismemberment Insurance for a Child, and You are eligible to provide such insurance for that child, We will: (1) permit You to enroll a Child who is otherwise eligible for such insurance without regard to any enrollment season restrictions; (2) if You are enrolled but fail to make application to obtain insurance for such Child, We will enroll the Child for insurance upon application of the Child's other parent, the state agency administering the Medicaid program or the state agency administering 42 U.S.C. Sections 651 through 669, the child support enforcement program; and (3) We will not disenroll or eliminate insurance for such Child unless the insurer is provided satisfactory written evidence that: (a) the court or administrative order is no longer in effect; or (b) the Child is or will be enrolled in comparable health insurance through another insurer that will take effect not later than the effective date of disenrollment. We will not impose requirements on a state agency that has been assigned the rights of an individual eligible for medical assistance under the Medicaid program and insured for Accidental Death and Dismemberment Insurance with Us that are different from requirements applicable to an agent or assignee of any other individual so insured. GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 19
NOTICE FOR RESIDENTS OF PENNSYLVANIA Accidental Death and Dismemberment Insurance for a Dependent Child may be continued past the age limit if that Child is a full-time student and insurance ends due to the Child being ordered to active duty (other than active duty for training) for 30 or more consecutive days as a member of the Pennsylvania National Guard or a Reserve Component of the Armed Forces of the United States. Insurance will continue if such Child: re-enrolls as a full-time student at an accredited school, college or university that is licensed in the jurisdiction where it is located; re-enrolls for the first term or semester, beginning 60 or more days from the child’s release from active duty; continues to qualify as a Child, except for the age limit; and submits the required Proof of the child’s active duty in the National Guard or a Reserve Component of the United States Armed Forces. Subject to the Date Insurance For Your Dependents Ends subsection of the section entitled ELIGIBILITY PROVISIONS: INSURANCE FOR YOUR DEPENDENTS, this continuation will continue until the earliest of the date: the insurance has been continued for a period of time equal to the duration of the child’s service on active duty; or the child is no longer a full-time student. GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 20
NOTICE FOR RESIDENTS OF TEXAS THE INSURANCE POLICY UNDER WHICH THIS CERTIFICATE IS ISSUED IS NOT A POLICY OF WORKERS’ COMPENSATION INSURANCE. YOU SHOULD CONSULT YOUR EMPLOYER TO DETERMINE WHETHER YOUR EMPLOYER IS A SUBSCRIBER TO THE WORKERS’ COMPENSATION SYSTEM. GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 21
NOTICE FOR RESIDENTS OF UTAH Notice of Protection Provided by Utah Life and Health Insurance Guaranty Association This notice provides a brief summary of the Utah Life and Health Insurance Guaranty Association ("the Association") and the protection it provides for policyholders. This safety net was created under Utah law, which determines who and what is covered and the amounts of coverage. The Association was established to provide protection in the unlikely event that your life, health, or annuity insurance company becomes financially unable to meet its obligations and is taken over by its insurance regulatory agency. If this should happen, the Association will typically arrange to continue coverage and pay claims, in accordance with Utah law, with funding from assessments paid by other insurance companies. The basic protections provided by the Association are: Life Insurance o $500,000 in death benefits o $200,000 in cash surrender or withdrawal values Health Insurance o $500,000 in hospital, medical and surgical insurance benefits o $500,000 in long-term care insurance benefits o $500,000 in disability income insurance benefits o $500,000 in other types of health insurance benefits Annuities o $250,000 in withdrawal and cash values The maximum amount of protection for each individual, regardless of the number of policies or contracts, is $500,000. Special rules may apply with regard to hospital, medical and surgical insurance benefits. Note: Certain policies and contracts may not be covered or fully covered. For example, coverage does not extend to any portion of a policy or contract that the insurer does not guarantee, such as certain investment additions to the account value of a variable life insurance policy or a variable annuity contract. Coverage is conditioned on residency in this state and there are substantial limitations and exclusions. For a complete description of coverage, consult Utah Code, Title 3 lA, Chapter 28. Insurance companies and agents are prohibited by Utah law to use the existence of the Association or its coverage to encourage you to purchase insurance. When selecting an insurance company, you should not rely on Association coverage. If there is any inconsistency between Utah law and this notice, Utah law will control. To learn more about the above protections, as well as protections relating to group contracts or retirement plans, please visit the Association's website at www.utlifega.org or contact: Utah Life and Health Insurance Guaranty Assoc. Utah Insurance Department 60 East South Temple, Suite 500 3110 State Office Building Salt Lake City UT 84111 Salt Lake City UT 84114-6901 (801) 320-9955 (801) 538-3800 A written complaint about misuse of this Notice or the improper use of the existence of the Association may be filed with the Utah Insurance Department at the above address. GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 22
NOTICE FOR RESIDENTS OF VIRGINIA IMPORTANT INFORMATION REGARDING YOUR INSURANCE In the event You need to contact someone about this insurance for any reason please contact Your agent. If no agent was involved in the sale of this insurance, or if You have additional questions You may contact the insurance company issuing this insurance at the following address and telephone number: MetLife 200 Park Avenue New York, New York 10166 Attn: Corporate Consumer Relations Department To phone in a claim related question, You may call Claims Customer Service at: 1-800-275-4638 If You have been unable to contact or obtain satisfaction from the company or the agent, You may contact the Virginia State Corporation Commission’s Bureau of Insurance at: Bureau of Insurance Life and Health Division P.O. Box 1157 Richmond, VA 23218-1157 1-804-371-9691 - phone 1-877-310-6560 - toll-free 1-804-371-9944 - fax www.scc.virginia.gov - web address [email protected] – email Written correspondence is preferable so that a record of Your inquiry is maintained. When contacting Your agent, company or the Bureau of Insurance, have Your policy number available. GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 23
NOTICE FOR RESIDENTS OF WEST VIRGINIA FREE LOOK PERIOD: If You are not satisfied with Your certificate, You may return it to Us within 10 days after You receive it, unless a claim has previously been received by Us under Your certificate. We will refund within 10 days of our receipt of the returned certificate any Premium that has been paid and the certificate will then be considered to have never been issued. You should be aware that, if You elect to return the certificate for a refund of premiums, losses which otherwise would have been covered under Your certificate will not be covered. GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 24
NOTICE FOR RESIDENTS OF WISCONSIN KEEP THIS NOTICE WITH YOUR INSURANCE PAPERS PROBLEMS WITH YOUR INSURANCE? - If You are having problems with Your insurance company or agent, do not hesitate to contact the insurance company or agent to resolve Your problem. MetLife Attn: Corporate Consumer Relations Department 200 Park Avenue New York, New York 10166 1-800-438-6388 You can also contact the OFFICE OF THE COMMISSIONER OF INSURANCE, a state agency which enforces Wisconsin’s insurance laws, and file a complaint. You can contact the OFFICE OF THE COMMISSIONER OF INSURANCE by contacting: Office of the Commissioner of Insurance Complaints Department P.O. Box 7873 Madison, WI 53707-7873 1-800-236-8517 outside of Madison or 608-266-0103 in Madison. GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 25
NOTICE This non-insurance benefit does not constitute an insurance funded prearrangement contract, pursuant to RCW 18.39.255. Employees who become insured for MetLife Supplemental Life Insurance and/or non- contributory Basic Life Insurance under the Group Policy are eligible to receive discounts of up to 10% off the service provider’s standard price for certain funeral services including funeral, cremation and cemetery products and services provided by a third party national network of funeral and funeral planning providers while such insurance remains in effect. Employees who become insured for MetLife Supplemental Life Insurance and/or non-contributory Basic Life Insurance will also have access to funeral planning resources including funeral planning tools and concierge services provided by the same national network of providers. MetLife has arranged for these services and discounts to be provided to Employees and their spouses for no additional premium. A Digital Estate Planning Platform is included with Supplemental Life Insurance at no additional cost. MetLife has arranged for this Platform to be provided by MetLife Legal Plans, Inc., a MetLife affiliate. The Platform will be made available to Employees and their Spouses so they can create estate planning documents through legalplans.com/estateplanning. GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 26
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
TABLE OF CONTENTS (continued) Section Page LIFE INSURANCE: ACCELERATED BENEFIT OPTION (ABO) FOR YOU ................................................... 63 LIFE INSURANCE: ACCELERATED BENEFIT OPTION (ABO) FOR YOUR SPOUSE OR STATE- REGISTERED DOMESTIC PARTNER ........................................................................................................... 65 LIFE INSURANCE: CONVERSION OPTION FOR YOU ................................................................................. 67 LIFE INSURANCE: CONVERSION OPTION FOR YOUR DEPENDENTS .................................................... 69 ELIGIBILITY FOR CONTINUATION OF CERTAIN INSURANCE WHILE YOU ARE TOTALLY DISABLED . 71 ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE ..................................................................... 73 ADDITIONAL BENEFIT: SEAT BELT USE .................................................................................................. 75 ADDITIONAL BENEFIT: AIR BAG USE ....................................................................................................... 76 ADDITIONAL BENEFIT: CHILD CARE ........................................................................................................ 77 ADDITIONAL BENEFIT: CHILD EDUCATION............................................................................................. 78 ADDITIONAL BENEFIT: SPOUSE OR STATE-REGISTERED DOMESTIC PARTNER EDUCATION ...... 79 ADDITIONAL BENEFIT: HOSPITAL CONFINEMENT ................................................................................ 80 ADDITIONAL BENEFIT: COMMON CARRIER ........................................................................................... 81 FILING A CLAIM: CLAIMS FOR LIFE INSURANCE BENEFITS .................................................................... 82 FILING A CLAIM: CLAIMS FOR ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS .................... 83 GENERAL PROVISIONS ................................................................................................................................. 84 Assignment ................................................................................................................................................... 84 Beneficiary .................................................................................................................................................... 84 Entire Contract .............................................................................................................................................. 85 Incontestability: Statements Made by You ................................................................................................... 85 Misstatement of Age ..................................................................................................................................... 85 Conformity with Law ..................................................................................................................................... 85 Physical Exams ............................................................................................................................................ 86 Autopsy ......................................................................................................................................................... 86 GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 28
SCHEDULE OF BENEFITS This schedule shows the benefits that are available under the Group Policy. You and Your Dependents will only be insured for the benefits: for which You and Your Dependents become and remain eligible; which You elect, if subject to election; and which are in effect. The amount of Insurance that We will pay for any insurance to which You make premiums will be decreased by the amount of any premiums due and unpaid to Us for that insurance. How We Will Pay Benefits Unless the Beneficiary requests payment by check, when the Certificate states that We will pay benefits in "one sum", “lump sum” or a "single sum", We may pay the full benefit amount: by check; by establishing an account that earns interest and provides the Beneficiary with immediate access to the full benefit amount; or by any other method that provides the Beneficiary with immediate access to the full benefit amount. Other modes of payment may be available upon request. For details, call Our toll free number shown on the Certificate Face Page. BENEFIT BENEFIT AMOUNTS AND HIGHLIGHTS Life Insurance For You Basic Life Insurance Basic Life Insurance is Portability Eligible Insurance For Active Employees .................................................. $35,000 Accelerated Benefit Option ............................................... Up to 80% of Your Basic Life amount not to exceed $28,000 Supplemental Life Insurance Plan 1: Supplemental Life Insurance is Portability Eligible Insurance Plan 1: All employees of an Employing Agency who elected Employee-Paid Life Insurance coverage in a multiple of $10,000 for coverage effective on or after January 1, 2017. All new employees on or after January 1, 2017 who elect Employee-Paid Life Insurance coverage are An amount, elected by You, which enrolled in Plan 1. ...................................................... is a multiple of $10,000 Minimum Supplemental Life Benefit ................................. $10,000 Maximum Supplemental Life Benefit ............................ $1,000,000 Maximum Amount Allowed Without Evidence of Insurability .......................................................................... $500,000 GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 29
SCHEDULE OF BENEFITS (continued) Accelerated Benefit Option ............................................... Up to 80% of Your combined Basic Life and Supplemental Life amount not to exceed $500,000 Plan 2: Supplemental Life Insurance is Portability Eligible Insurance Plan 2: All employees of an Employing Agency who did not elect Employee-Paid Life Insurance coverage in a multiple of $10,000 for coverage An amount You previously elected on or after January 1, 2017. These employees under Your Employing Agency’s retained coverage amounts elected prior to previous life insurance plan which January 1, 2017 that were not in a multiple of doesn’t match the MetLife plan $10,000 ...................................................................... design Accelerated Benefit Option ............................................... Up to 80% of Your combined Basic Life and Supplemental Life amount not to exceed $500,000 ESTATE RESOLUTION SERVICES The following Estate Resolution Services are provided at no additional cost to individuals insured for Group Supplemental Life Insurance coverage as described below. If You are eligible to receive these Estate Resolution Services and You, Your Spouse, or State-Registered Domestic Partner (for the Will Preparation Service) or You, Your Spouse, State-Registered Domestic Partner, or a Beneficiary (for the Probate Service) would like to speak with a representative from MetLife Legal Plans or get the name of a Plan Attorney that you can speak with about these Services, please call (800) 821-6400. Will Preparation Service If You elect Group Supplemental Life Insurance coverage, a Will Preparation Service (the “Service”) will be made available to You, through a MetLife affiliate (the “Affiliate”), while Your Group Supplemental Life Insurance coverage is in effect. This Service will be made available at no cost to You. It enables You to have a will prepared for You and Your Spouse or State-Registered Domestic Partner free of charge by attorneys designated by the Affiliate. If You have a will prepared by an attorney not designated by the Affiliate, You must pay for the attorney’s services directly. Upon Proof of such payment, You will be reimbursed for the attorney’s services in an amount equal to the lesser of the amount You paid for the attorney’s services and the amount customarily reimbursed for such services by the Affiliate. Probate Service If You become insured for Group Supplemental Life Insurance coverage and You, Your Spouse, or State- Registered Domestic Partner die while such Group Supplemental Life Insurance coverage is in effect, a probate benefit (the “Benefit”) will be made available to Your estate in the event of Your death or to Your Spouse or State-Registered Domestic Partner's estate in the event of Your Spouse or State-Registered Domestic Partner's death. Such benefit will be made available through a MetLife affiliate (“Affiliate”). The Benefit provides for certain probate services to be made available, free of charge by attorneys designated by the Affiliate. If probate services are provided by an attorney not designated by the Affiliate, the estate of the deceased must pay for those attorney’s services directly. Upon Proof of such payment, the estate of the deceased will be reimbursed for the attorney’s services in an amount equal to the lesser of the amount such estate paid for the attorney’s services and the amount customarily reimbursed for such services by the Affiliate. This Benefit will be provided at no cost to You and will end on the date Your Group Supplemental Life Insurance coverage ends. GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 30
SCHEDULE OF BENEFITS (continued) Accidental Death and Dismemberment Insurance (AD&D) For You: Basic AD&D Basic Accidental Death and Dismemberment Insurance for You is NOT Portability Eligible Insurance Full Amount For Basic AD&D ......................................... $5,000 Additional Benefits: Seat Belt Benefit ............................................................ Yes Air Bag Use Benefit ........................................................ Yes Child Care Benefit .......................................................... Yes Child Education Benefit .................................................. Yes Spouse or State-Registered Domestic Partner Education Benefit ........................................................... Yes Hospital Confinement Benefit ......................................... Yes Common Carrier Benefit ................................................ Yes The Common Carrier Benefit is an amount equal to the Full Amount. Schedule of Covered Losses for Basic Accidental Death and Dismemberment Insurance All amounts listed are stated as percentages of the Full Amount. Covered Losses Loss of life .................................................................................... 100% Loss of a hand permanently severed at or above the wrist but below the elbow ....................................................... 50% Loss of a foot permanently severed at or above the ankle but below the knee ....................................................... 50% Loss of an arm permanentl y severed at or above the elbow ....... 50% Loss of a leg permanently severed at or above the knee ............ 50% Loss of sight in one eye ............................................................... 50% Loss of sight means permanent and uncorrectable loss of sight in the eye. Visual acuity must be 20/200 or worse in the eye or the field of vision must be less than 20 degrees. Loss of any combination of hand, foot, or sight of one eye, as defined above .............................................................................. 100% Loss of the thumb and index fin ger of same hand ....................... 25% Loss of thumb and index finger of same hand means that the thumb and index finger are permanently severed through or above the third joint from the tip of the index finger and the second joint from the tip of the thumb. Loss of speech and loss of hearing ............................................. 100% Loss of speech or loss of hearing ................................................ 50% Loss of speech means the entire and irrecoverable loss of speech that continues for 6 consecutive months following the accidental injury. Loss of hearing means the entire and irrecoverable loss of hearing in both ears that continues for 6 consecutive months following the accidental injury. GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 31
SCHEDULE OF BENEFITS (continued) Paralysis of both arms and both legs ........................................... 100% Paralysis of both legs ................................................................... 50% Paralysis of the arm and leg on either side of the body ............... 50% Paralysis of one arm or leg .......................................................... 25% Paralysis means loss of use of a limb, without severance. A Physician must determine the paralysis to be permanent, complete and irreversible. Brain Damage .............................................................................. 100% Brain Damage means permanent and irreversible physical damage to the brain such that permanent supervision or assistance is required to maintain existence. Such damage must manifest itself within 365 days of the accidental injury, require a hospitalization of at least 5 days and persists for 12 consecutive months after the date of the accidental injury. Coma ..........................................................................1% monthly beginning on the 7th day of the Coma for the duration of the Coma to a maximum of 60 months Coma means a state of deep and total unconsciousness from which the comatose person cannot be aroused. Such state must begin within 365 days of the accidental injury and continue for 7 consecutive days. If You are age 65 or Older Your Continuation Eligible Insurance as described in the section entitled ELIGIBILITY FOR CONTINUATION OF CERTAIN INSURANCE WHILE YOU ARE TOTALLY DISABLED will be reduced as follows: th On Your 65 birthday, the amount of Your Continuation Eligible Insurance will be reduced to $3,500. th On Your 70 birthday, the amount of such insurance will be reduced to $3,000. Supplemental AD&D Plan 1: Supplemental Accidental Death and Dismemberment Insurance for You is NOT Portability Eligible Insurance Plan 1: All employees of an Employing Agency who elected Employee-Paid Life Insurance coverage in a multiple of $10,000 for coverage effective on or after January 1, 2017. All new employees on or after January 1, 2017 who elect Employee-Paid Life Insurance coverage are enrolled in Plan 1 .................. . An amount, elected by You, which is a multiple of $10,000 Minimum Supplemental Accidental Death and Dismemberment Full Amount ........................................ $10,000 Maximum Supplemental Accidental Death and Dismemberment Full Amount ...................................... $250,000 GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 32
SCHEDULE OF BENEFITS (continued) Plan 2: Supplemental Accidental Death and Dismemberment Insurance for You is NOT Portability Eligible Insurance Plan 2: All employees of an Employing Agency who did not elect Employee-Paid Life Insurance An amount You previously elected coverage in a multiple of $10,000 for coverage on or under Your Employing Agency’s after January 1, 2017. These employees retained previous life insurance plan which coverage amounts elected prior to January 1, 2017 doesn’t match the MetLife plan that were not in a multiple of $10,000 ........................... design Additional Benefits: Seat Belt Benefit ............................................................ Yes Air Bag Use Benefit ........................................................ Yes Child Care Benefit .......................................................... Yes Child Education Benefit .................................................. Yes Spouse or State-Registered Domestic Partner Education Benefit ........................................................... Yes Hospital Confinement Benefit ......................................... Yes Common Carrier Benefit ................................................ Yes The Common Carrier Benefit is an amount equal to the Full Amount. Schedule of Covered Losses for Supplemental Accidental Death and Dismemberment Insurance All amounts listed are stated as percentages of the Full Amount. Covered Losses Loss of life .................................................................................... 100% Loss of a hand permanently severed at or above the wrist but below the elbow ....................................................... 50% Loss of a foot permanently severed at or above the ankle but below the knee ....................................................... 50% Loss of an arm permanently severed at or above the elbow ....... 50% Loss of a leg permanently severed at or above the knee ............ 50% Loss of sight in one eye ............................................................... 50% Loss of sight means permanent and uncorrectable loss of sight in the eye. Visual acuity must be 20/200 or worse in the eye or the field of vision must be less than 20 degrees. Loss of any combination of hand, foot, or sight of one eye, as defined above .............................................................................. 100% Loss of the thumb and index finger of same hand ....................... 25% Loss of thumb and index finger of same hand means that the thumb and index finger are permanently severed through or above the third joint from the tip of the index finger and the second joint from the tip of the thumb. Loss of speech and loss of hearing ............................................. 100% Loss of speech or loss of hearing ................................................ 50% Loss of speech means the entire and irrecoverable loss of speech that continues for 6 consecutive months following the accidental injury. GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 33
SCHEDULE OF BENEFITS (continued) Loss of hearing means the entire and irrecoverable loss of hearing in both ears that continues for 6 consecutive months following the accidental injury. Paralysis of both arms and both legs ........................................... 100% Paralysis of both legs ................................................................... 50% Paralysis of the arm and leg on either side of the body ............... 50% Paralysis of one arm or leg .......................................................... 25% Paralysis means loss of use of a limb, without severance. A Physician must determine the paralysis to be permanent, complete and irreversible. Brain Damage .............................................................................. 100% Brain Damage means permanent and irreversible physical damage to the brain such that permanent supervision or assistance is required to maintain existence. Such damage must manifest itself within 365 days of the accidental injury, require a hospitalization of at least 5 days and persists for 12 consecutive months after the date of the accidental injury. Coma .................................................................. 1% monthly beginning on the 7th day of the Coma for the duration of the Coma to a maximum of 60 months Coma means a state of deep and total unconsciousness from which the comatose person cannot be aroused. Such state must begin within 365 days of the accidental injury and continue for 7 consecutive days. Dependent Life Insurance: Spouse or State-Registered Domestic Partner Dependent Life Insurance Plan 1: Life Insurance for Your Dependents is Portability Eligible Insurance Plan 1: All employees of an Employing Agency who elected Employee-Paid Life Insurance coverage in a multiple of $5,000 for coverage effective on or after January 1, 2017. All new employees on or after January 1, 2017 who elect Employee-Paid Life Insurance coverage are enrolled in Plan 1 ................... An amount, elected by You, which is a multiple of $5,000 Minimum Spouse or State-Registered Domestic Partner Life Benefit ....................................................... $5,000 Maximum Spouse or State-Registered Domestic Partner Life Benefit ....................................................... The lesser of 50% of Your Supplemental Life Benefits or $500,000 Maximum Amount Allowed Without Evidence of Insurability ..................................................................... $100,000 Accelerated Benefit Option ........................................... Up to 80% of Your Dependent Life amount not to exceed $400,000 GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 34
SCHEDULE OF BENEFITS (continued) Spouse or State-Registered Domestic Partner Dependent Life Insurance Plan 2: Life Insurance for Your Dependents is Portability Eligible Insurance Plan 2: All employees of an Employing Agency who did not elect Employee-Paid Life Insurance An amount You previously elected coverage in a multiple of $5,000 for coverage on or under Your Employing Agency’s after January 1, 2017. These employees retained previous life insurance plan which coverage amounts elected prior to January 1, 2017 doesn’t match the MetLife plan that were not in a multiple of $5,000 ............................. design Accelerated Benefit Option ........................................... Up to 80% of Your Dependent Life amount not to exceed $400,000 Child Dependent Life Insurance Life Insurance for Your Dependents is Portability Eligible Insurance For each of Your Children ............................................. An amount, elected by You, which is a multiple of $5,000 Minimum Child Life Benefit ........................................... $5,000 Maximum Child Life Benefit ......................................... $20,000 Dependent Accidental Death and Dismemberment Insurance (AD&D): Amount for Dependent AD&D Dependent Accidental Death and Dismemberment Insurance is NOT Portability Eligible Insurance For Spouse or State-Registered Domestic Partner ... An amount, elected by You, which is a multiple of $10,000 Minimum Dependent Accidental Death and Dismemberment Amount for Your Spouse or State-Registered Domestic Partner ..................... $10,000 Maximum Dependent Accidental Death and Dismemberment Amount for Your Spouse or State-Registered Domestic Partner .................... $250,000 For each of Your Children .......................................... An amount, elected by You, which is a multiple of $5,000 Minimum Dependent Accidental Death and Dismemberment Amount for Your Child(ren) ...... $5,000 Maximum Dependent Accidental Death and Dismemberment Amount for Your Child (ren) ..... $25,000 GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 35
SCHEDULE OF BENEFITS (continued) Additional Benefits: Seat Belt Benefit ........................................................... Yes Air Bag Use Benefit ........................................................ Yes Child Care Benefit .......................................................... NONE Child Education Benefit .................................................. NONE Spouse or State-Registered Domestic Partner Education Benefit ........................................................... NONE Hospital Confinement Benefit ......................................... Yes Common Carrier Benefit ................................................ Yes The Common Carrier Benefit is an amount equal to the Full Amount. Schedule of Covered Losses for Dependent Accidental Death and Dismemberment Insurance All amounts listed are stated as percentages of the Full Amount. Covered Losses Loss of life ................................................................................... 100% Loss of a hand permanently severed at or above the wrist but below the elbow ...................................................... 50% Loss of a foot permanently severed at or above the ankle but below the knee ...................................................... 50% Loss of an arm permanently severed at or above the elbow ...... 50% Loss of a leg permanently severed at or above the knee ........... 50% Loss of sight in one eye .............................................................. 50% Loss of sight means permanent and uncorrectable loss of sight in the eye. Visual acuity must be 20/200 or worse in the eye or the field of vision must be less than 20 degrees. Loss of any combination of hand, foot, or sight of one eye, as defined above ............................................................................. 100% Loss of the thumb and index finger of same hand ...................... 25% Loss of thumb and index finger of same hand means that the thumb and index finger are permanently severed through or above the third joint from the tip of the index finger and the second joint from the tip of the thumb. Loss of speech and loss of hearing ............................................ 100% Loss of speech or loss of hearing ............................................... 50% Loss of speech means the entire and irrecoverable loss of speech that continues for 6 consecutive months following the accidental injury. Loss of hearing means the entire and irrecoverable loss of hearing in both ears that continues for 6 consecutive months following the accidental injury. GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 36
SCHEDULE OF BENEFITS (continued) Paralysis of both arms and both legs .......................................... 100% Paralysis of both legs .................................................................. 50% Paralysis of the arm and leg on either side of the body .............. 50% Paralysis of one arm or leg ......................................................... 25% Paralysis means loss of use of a limb, without severance. A Physician must determine the paralysis to be permanent, complete and irreversible. Brain Damage ............................................................................. 100% Brain Damage means permanent and irreversible physical damage to the brain such that permanent supervision or assistance is required to maintain existence. Such damage must manifest itself within 365 days of the accidental injury, require a hospitalization of at least 5 days and persists for 12 consecutive months after the date of the accidental injury. Coma ........................................................................ 1% monthly beginning on the 7th day of the Coma for the duration of the Coma to a maximum of 60 months. Coma means a state of deep and total unconsciousness from which the comatose person cannot be aroused. Such state must begin within 365 days of the accidental injury and continue for 7 consecutive days. GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 37
SCHEDULE OF BENEFITS (continued) Portability Eligible Life Insurance Supplemental Life Insurance and Basic Life Insurance: Portability Eligible Life Insurance For You: In any combination of Basic Life and Supplemental Life Insurance: Minimum Portability Eligible Life Insurance Amount ...................... $10,000 Maximum Portability Eligible Life Insurance Amount ..................... The lesser of Your total Life Insurance in effect on the date You elect to Port or $2,000,000 If Your Portability Eligible Insurance ends due to the end of the Group Policy or the amendment of the Group Policy to end the Portability Eligible Insurance, the maximum amount of insurance that You may Port is the lesser of: the amount of Your Portability Eligible Insurance that ends under the Group Policy less the amount of life insurance for which You become eligible under any group policy issued to replace this Group Policy; or $10,000. Life Insurance For Your Spouse or State-Registered Domestic Partner: Portability Eligible Spouse or State-Registered Domestic Partner Life Insurance: Minimum Portability Eligible Spouse or State-Registered Domestic Partner Life Insurance Amount ........................................................................................... $2,500 ($10,000 when porting Spouse or State-Registered Domestic Partner Life Insurance alone) Maximum Portability Eligible Spouse or State-Registered Domestic Partner Life Insurance Amount ........................................................................................... The lesser of Your total Spouse or State-Registered Domestic Partner Life Insurance in effect on the date You elect to Port or $250,000 If Your Portability Eligible Insurance or Your Portability Eligible Dependent Insurance ends due to the end of the Group Policy or the amendment of the Group Policy to end the Portability Eligible Insurance or Your Portability Eligible Dependent Insurance, the maximum amount of insurance that You may Port is the lesser of: the amount of Your Portability Eligible Insurance or Your Portability Eligible Dependent Insurance that ends under the Group Policy less the amount of life insurance for which You become eligible under any group policy issued to replace this Group Policy; or $10,000. GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 38
SCHEDULE OF BENEFITS (continued) Life Insurance For Your Children: Portability Eligible Child Life Insurance: Minimum Portability Eligible Child Life Insurance Amount .......................................................... $1,000 Maximum Portability Eligible Child Life Insurance Amount .......................................................... The lesser of Your total Child Life Insurance in effect on the date You elect to Port or $25,000 If Your Portability Eligible Insurance or Your Portability Eligible Dependent Insurance ends due to the end of the Group Policy or the amendment of the Group Policy to end the Portability Eligible Insurance or Your Portability Eligible Dependent Insurance, the maximum amount of insurance that You may Port is the lesser of: the amount of Your Portability Eligible Insurance or Your Portability Eligible Dependent Insurance that ends under the Group Policy less the amount of life insurance for which You become eligible under any group policy issued to replace this Group Policy; or $10,000. GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 39
DEFINITIONS As used in this certificate, the terms listed below will have the meanings set forth below. When defined terms are used in this certificate, they will appear with initial capitalization. The plural use of a term defined in the singular will share the same meaning. Actively at Work or Active Work means that You are performing the usual and customary duties of Your job. This must be done at: • Your Employing Agency’s place of business; • An alternate place approved by Your Employing Agency; or • A place which the Employing Agency’s business requires you to travel. You will be deemed to be Actively at Work during weekends or Employing Agency’s approved paid leave of absence, approved leave under the federal Family and Medical Leave Act (FMLA), approved leave under Washington’s Paid Family and Medical Leave Program, holidays, business closures, or while on approved leave of absence without pay, or You qualify for and elect to continue coverage when You lose Your eligibility for the employer contribution toward PEBB benefits during certain types of leave. If You are a benefits eligible seasonal employee who works a season of 9 months or more, You will be deemed to be Actively at Work during Your off season. If You are a benefits eligible faculty anticipated to work half time or more the entire instructional year or equivalent nine-month period, You will be deemed to be Actively at Work for each month of the instructional year. If You are a benefits eligible faculty who are hired on a quarter/semester to quarter/semester basis, You will be deemed to be Actively at Work each quarter/semester in which You are working half-time or more. If You are a benefits eligible faculty who works an average of half-time or more throughout the entire instructional year or equivalent nine month period and work each quarter/semester of the instructional year or equivalent nine month period, You will be deemed to be Actively at Work during summer or Your off quarter/semester. If You are a benefits eligible faculty who averages half-time or more in each of the two preceding academic years and You are eligible to receive an uninterrupted employer contribution, You will be deemed to be Actively at Work until You are no longer eligible for the employer contribution. If You are a faculty who loses eligibility for the employer contribution and regains it if You return to a faculty position where it is anticipated that You will work half-time or more for the quarter/semester no later than the twelfth month after the month in which You lost eligibility for the employer contribution, You will be deemed to be Actively at Work on the first day of the month in which the quarter/semester begins. Beneficiary means the person(s) to whom We will pay insurance as determined in accordance with the GENERAL PROVISIONS section. Certificateholder means an Actively at Work employee, Totally Disabled Patrolman, Disability Leave Patrolman, Disability Status Patrolman who is insured under the Group Policy. Child means the following: For Dependent Life Insurance, a child who is at least 14 days old through the last day of the month in which the child turns age twenty-six with the exception listed below. Children are defined as: Children based on establishment of a parent-child relationship as described in state statues, except when parental rights have been terminated; Children of the Certificateholder’s Spouse, based on the Spouse’s establishment of a parent-child relationship, except when parental rights have been terminated. The stepchild’s relationship to the Certificateholder (and eligibility as a dependent) ends on the same date the marriage with the Spouse ends through divorce, annulment, dissolution, termination, or death; Children for whom the Certificateholder has assumed a legal obligation for total or partial support in anticipation of adoption of the child; GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 40
DEFINITIONS (continued) Children of the Certificateholder’s State-Registered Domestic Partner based on the State-Registered Domestic Partner’s establishment of a parent-child relationship, except when parental rights have been terminated. The child’s relationship to the Certificateholder (and eligibility as a dependent) ends on the same date as the Certificateholder’s legal relationship with the State-Registered Domestic Partner ends through divorce, annulment, dissolution, termination, or death; Children specified in a court order or divorce decree for whom the Certificateholder has a legal obligation to provide support or health care coverage; Extended dependent in the legal custody or legal guardianship of the Certificateholder, the Certificateholder’s Spouse, or the Certificateholder’s State-Registered Domestic Partner. The legal responsibility is demonstrated by a valid court order and the child’s official residence is with the custodian or guardian. Extended dependent child does not include a foster child unless the Certificateholder, the Certificateholder’s Spouse, or the Certificatholder’s State-Registered Domestic Partner has assumed a legal obligation for total or partial support in anticipation of adoption; and Children of any age with a developmental or physical disability that renders the child incapable of self- sustaining employment and chiefly dependent upon the Certificateholder for support and maintenance provided such condition occurs before the age of twenty-six. For the purposes of determining who may become covered for insurance, the term does not include any person who is a Certificateholder. for Dependent Accidental Death and Dismemberment Insurance, a child who is at least 14 days old through the last day of the month in which the child turns age twenty-six with exception noted below. Children are defined as: Children based on establishment of a parent-child relationship as described in state statues, except when parental rights have been terminated; Children of the Certificateholder’s Spouse, based on the Spouse’s establishment of a parent-child relationship, except when parental rights have been terminated. The stepchild’s relationship to the Certificateholder (and eligibility as a dependent) ends on the same date the marriage with the Spouse ends through divorce, annulment, dissolution, termination, or death; Children for whom the Certificateholder has assumed a legal obligation for total or partial support in anticipation of adoption of the child; Children of the Certificateholder’s State-Registered Domestic Partner based on the State-Registered Domestic Partner’s establishment of a parent-child relationship, except when parental rights have been terminated. The child’s relationship to the Certificateholder (and eligibility as a dependent) ends on the same date as the Certificateholder’s legal responsibility with the State-Registered Domestic Partner ends through divorce, annulment, dissolution, termination, or death; Children specified in a court order or divorce decree for whom the Certificateholder has a legal obligation to provide support or health care coverage; Extended dependent in the legal custody or legal guardianship of the Certificateholder, the Certificateholder’s Spouse, or the Certificateholder’s State-Registered Domestic Partner. The legal responsibility is demonstrated by a valid court order and the child’s official residence is with the custodian or guardian. Extended dependent child does not include a foster child unless the Certificateholder, the Certificateholder’s Spouse, or the Certificatholder’s State-Registered Domestic Partner has assumed a legal obligation for total or partial support in anticipation of adoption; and Children of any age with a developmental or physical disability that renders the child incapable of self- sustaining employment and chiefly dependent upon the Certificateholder for support and maintenance provided such condition occurs before the age of twenty-six. For the purposes of determining who may become covered for insurance, the term does not include any person who is a Certificateholder. GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 41
DEFINITIONS (continued) Common Carrier means a government regulated entity that is in the business of transporting fare paying passengers. The term does not include: chartered or other privately arranged transportation; taxis; or limousines. Dependent(s) means Your Spouse or State-Registered Domestic Partner and/or Child who meet the eligibility requirements in state statute, except surviving Spouses, surviving State-Registered Domestic Partners and surviving Dependent Children of emergency service personnel who are killed in the line of duty. Employee-Paid Insurance means insurance for which the Policyholder requires You to pay any part of the premium. Employee-Paid Insurance includes: Supplemental Life Insurance, Supplemental Accidental Death and Dismemberment Insurance, Dependent Life Insurance and Dependent Accidental Death and Dismemberment Insurance. Employer-Paid Insurance means insurance for which the Policyholder does not require You to pay any part of the premium. You may pay the premium for Basic Life Insurance and Basic Accidental Death and Dismemberment Insurance while on an approved Leave of Absence. Employer-Paid Insurance includes: Basic Life Insurance and Basic Accidental Death and Dismemberment Insurance. Employer Group means a county, municipality, political subdivision, the Washington health benefit exchange, tribal government, or employee organizations representing state civil service employees obtaining employee benefits through a contractual agreement with the Policyholder to participate in benefit plans. Employing Agency means a division, department, or separate agency of state government, including an institution of higher education; a county, municipality, or other political subdivision; and a tribal government covered by state statute. It also includes Washington health benefit exchange and employee organizations representing state civil service employees. Hospital means a facility which is licensed as such in the jurisdiction in which it is located and: provides a broad range of medical and surgical services on a 24 hour a day basis for injured and sick persons by or under the supervision of a staff of Physicians; and provides a broad range of nursing care on a 24 hour a day basis by or under the direction of a registered professional nurse. Hospitalized means: admission for inpatient care in a Hospital; receipt of care in the following: a hospice facility; an intermediate care facility; or a long term care facility; or receipt of the following treatment, wherever performed: chemotherapy; GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 42
DEFINITIONS (continued) radiation therapy; or dialysis. Physician means: a person licensed to practice medicine in the jurisdiction where such services are performed; or any other person whose services, according to applicable law, must be treated as Physician’s services for purposes of the Group Policy. Each such person must be licensed in the jurisdiction where they perform the service and must act within the scope of that license. They must also be certified and/or registered if required by such jurisdiction. The term does not include: You; Your Spouse or State-Registered Domestic Partner; or any member of Your immediate family including Your and/or Your Spouse or State-Registered Domestic Partner’s: parents; Child(ren); siblings; grandparents; or grandchildren. Policyholder means WA State Health Care Authority PEBB. Proof means Written evidence satisfactory to Us that a person has satisfied the conditions and requirements for any benefit described in this certificate. When a claim is made for any benefit described in this certificate, Proof must establish: the nature and extent of the loss or condition; Our obligation to pay the claim; and the claimant’s right to receive payment. Proof must be provided at the claimant's expense. Signed means any symbol or method executed or adopted by a person with the present intention to authenticate a record, which is on or transmitted by paper or electronic media which is acceptable to Us and consistent with applicable law. Spouse means Your legal spouse. State-Registered Domestic Partner as defined in state statue and substantially equivalent legal unions from jurisdictions as defined in Washington state statute. We, Us and Our mean MetLife. Written or Writing means a record which is on or transmitted by paper or electronic media which is acceptable to Us and consistent with applicable law. You and Your mean a Certificateholder who is insured under the Group Policy for the insurance described in this certificate. GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 43
ELIGIBILITY PROVISIONS: INSURANCE FOR YOU ELIGIBLE FOR PEBB BENEFITS All Actively at Work employees of an Employing Agency, except for employees of an Employer Group that do not contract with the Policyholder for the insurance benefits described in this certificate. Totally Disabled Patrolmen, Disability Leave Patrolmen and Disability Status Patrolmen deemed disabled in the line of duty by the Chief of Washington State Patrol (WSP); Actively at Work requirements do not apply to Totally Disabled Patrolmen, Disability Leave Patrolmen and Disability Status Patrolmen. DATE YOU ARE ELIGIBLE FOR INSURANCE You may only become eligible for the insurance available for Your eligible class as shown in the SCHEDULE OF BENEFITS. If You are eligible for PEBB benefits on January 1, 2024, You will be eligible for the insurance described in this certificate on that date. If You become eligible for PEBB benefits after January 1, 2024, You will be eligible for the insurance described in this certificate on the date You become eligible for PEBB benefits. Previous Employment With The Employing Agency If You were employed by an Employing Agency and insured by Us under a policy of group life insurance when Your employment ended, You will not be eligible for life insurance under this Group Policy if You are re-hired by the Employing Agency within 2 years after such employment ended, unless You surrender: any individual policy of life insurance to which You converted when Your employment ended; and any certificate of insurance continued as ported insurance when such employment ended. The cash value, if any, of such surrendered insurance will be paid to You. ENROLLMENT PROCESS You are automatically enrolled for Employer-Paid Insurance if You become eligible for PEBB benefits. If You are eligible for Employee-Paid Life Insurance, You may enroll by completing the required form. In addition, You must give evidence of Your Insurability satisfactory to Us at Your expense if You are required to do so under the section entitled EVIDENCE OF INSURABILITY. DATE YOUR INSURANCE TAKES EFFECT Requirements for Employer-Paid Insurance: Basic Life Insurance and Basic Accidental Death and Dismemberment Insurance Employer-Paid Insurance will take effect on the first day of the month following the date You become eligible for PEBB benefits. If You become eligible for PEBB benefits on the first working day of the month, Employer- Paid Insurance will take effect on that date. Employer-Paid Insurance for Faculty hired on a quarter/semester to quarter/semester basis will take effect the first day of the month following the beginning of the second consecutive quarter/semester of half-time or more employment. If the first day of the second consecutive quarter/semester is the first working day of the month, Employer-Paid Insurance will take effect at the beginning of the second consecutive quarter/semester. GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 44
ELIGIBILITY PROVISIONS: INSURANCE FOR YOU (continued) Employer-Paid Insurance for an employee who regains eligibility, including following a period of leave or after being between periods of leave will take effect on the first day of the month in which the employee is in pay status 8 or more hours, or on the first day of the month in which the quarter or semester begins for faculty who regain eligibility within 12 months. When an employee who is called to active duty in the uniformed services under Uniformed Services Employment and Reemployment Rights Act (USERRA) loses eligibility for the employer contribution toward PEBB benefits, they regain eligibility for the employer-contribution toward PEBB benefits the day they return from active duty. Employer-Paid insurance will take effect the first day of the month in which You return from active duty. You must be Actively at Work on that date. If You are not Actively at Work on the date the Employer-Paid Insurance would otherwise take effect, insurance will take effect on the first day of the month following the date You resume Active Work. Requirements for Employee-Paid Insurance: Plan 1 Supplemental Life Insurance and Supplemental Accidental Death and Dismemberment Insurance If You request Employee-Paid Insurance before the date You become eligible for such insurance, such insurance will take effect as follows: if You are not required to give evidence of Your insurability, such insurance will take effect on the first day of the month following the date We receive Your completed enrollment form, provided that You are eligible on that date. You must be Actively at Work on that date. if You are required to give evidence of Your insurability and We determine that You are insurable, such insurance will take effect on the first day of the month following the date We approve Your evidence of insurability, provided that You are eligible on that date. You must be Actively at Work on that date. If You are not Actively at Work on the date insurance would otherwise take effect, insurance will take effect on the first day of the month following the day You resume Active Work. If You request Employee-Paid Insurance no later than 31 days after You become newly eligible or regain eligibility for PEBB benefits, life insurance will take effect as follows: if You are not required to give evidence of Your insurability, such insurance will take effect on the first day of the month following the date We receive Your completed enrollment form. You must be Actively at Work on that date. Except, if You self-paid Employee-Paid Insurance during a period of leave, such insurance will be continue upon Your return. if You are required to give evidence of Your insurability and We determine that You are insurable, such insurance will take effect on the first day of the month following the date We approve Your evidence of insurability. You must be Actively at Work on that date. If You are not Actively at Work on the date insurance would otherwise take effect, insurance will take effect on the first day of the month following the day You resume Active Work. If You request Employee-Paid Insurance more than 31 days after the date You become eligible for such insurance, You must give evidence of Your insurability satisfactory to us. You must give such evidence at Your expense. If We determine that You are insurable, such insurance will take effect on the first day of the month following the date We approve Your evidence of insurability. Accidental Death and Dismemberment Insurance does not require evidence of Your Insurability. You must be Actively at Work on that date. If You are not Actively at Work on the date insurance would otherwise take effect, insurance will take effect on the first day of the month following the day You resume Active Work. Transfer in Coverage due to a Qualifying Event Qualifying Event means employment of Your Spouse or State-Registered Domestic Partner, who is covered in the PEBB insurance plan, ends due to termination or retirement from an Employing Agency. GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 45
ELIGIBILITY PROVISIONS: INSURANCE FOR YOU (continued) If You have a Qualifying Event, You will have 31 days from the date of that change to make a request to transfer Dependent Life Insurance and Dependent Accidental Death and Dismemberment Insurance that Your Spouse or State-Registered Domestic Partner had prior to the date their employment ends, to Your Supplemental Life Insurance and Supplemental Accidental Death and Dismemberment Insurance. The transfer in coverage amounts are limited to the maximum benefit amounts as shown in the SCHEDULE OF BENEFITS. There is no Evidence of Insurability required. We will require the following prior to the transfer of coverage: Your completed request form; and Proof of Your marriage or State-Registered Domestic Partnership. The transfer in coverage made as a result of a Qualifying Event, will take effect on the first day of the month following the date We receive Your completed request form and proof of Your marriage or State-Registered Domestic Partnership. You must be Actively at Work on that date. If You are not Actively at Work on the date insurance would otherwise take effect, transfer of coverage will take effect on the first day of the month following the day You resume Active Work. Requirements for Employee-Paid Insurance: Plan 2 Supplemental Life Insurance and Supplemental Accidental Death and Dismemberment Insurance Your Employee-Paid insurance will become effective on the date You become eligible for such insurance. Transfer in Coverage due to a Qualifying Event Qualifying Event means employment of Your Spouse or State-Registered Domestic Partner, who is covered in the PEBB insurance plan, ends due to termination or retirement from an Employing Agency. If You have a Qualifying Event, You will have 31 days from the date of that change to make a request to transfer Dependent Life Insurance and Dependent Accidental Death and Dismemberment Insurance that Your Spouse or State-Registered Domestic Partner had prior to the date their employment ends, to Your Supplemental Life Insurance and Supplemental Accidental Death and Dismemberment Insurance. The transfer in coverage amounts are limited to the maximum benefit amounts as shown in the SCHEDULE OF BENEFITS. There is no Evidence of Insurability required. We will require the following prior to the transfer of coverage: Your completed request form; and Proof of Your marriage or State-Registered Domestic Partnership. The transfer in coverage made as a result of a Qualifying Event, will take effect on the first day of the month following the date We receive Your completed request form and proof of Your marriage or State-Registered Domestic Partnership. You must be Actively at Work on that date. If You are not Actively at Work on the date insurance would otherwise take effect, transfer of coverage will take effect on the first day of the month following the day You resume Active Work. Employee-Paid Insurance-Supplemental Life Insurance Increase in Insurance If You make a Written request to increase Your insurance, You are required to give evidence of Your insurability satisfactory to Us. If We approve Your evidence of insurability, the increase will take effect on the first day of the month following the date We approve Your evidence of insurability. If We do not approve Your evidence of insurability, or You do not submit evidence of insurability, the increase in insurance will not take effect. GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 46
ELIGIBILITY PROVISIONS: INSURANCE FOR YOU (continued) If You are not Actively at Work on the date insurance would otherwise take effect, the increase in insurance will take effect on the first day of the month following the date You resume Active Work. Decrease in Insurance If You make a Written request to decrease Your insurance, that decrease will take effect on the first day of the month following the date We receive Your Written request. Employee-Paid Insurance- Supplemental Accidental Death and Dismemberment Insurance Increase in Insurance If You make a Written request to increase Your insurance, You are not required to give Your evidence of insurability to Us. The increase will take effect on the first day of the month following the date We receive Your Written request. If You are not Actively at Work on the date insurance would otherwise take effect, the increase in insurance will take effect on the first day of the month following the date You resume Active Work. Decrease in Insurance If You make a Written request to decrease Your insurance, that decrease will take effect on the first day of the month following the date We receive Your Written request. DATE YOUR INSURANCE ENDS Your insurance will end on the earliest of: 1. the date the Group Policy ends; or 2. the last day of the calendar month insurance ends for Your class; or 3. the date You die; or 4. the last day of the calendar month for which the last premium has been paid for You; or 5. the last day of the calendar month in which You cease to be eligible for PEBB benefits; or 6. the last day of the calendar month in which Your employment ends; Your life insurance will end if You cease to be Actively at Work, except as stated in the section entitled CONTINUATION OF INSURANCE WITH PREMIUM PAYMENT; or 7. the last day of the calendar month in which You retire in accordance with Your applicable retirement plan; or 8. the date Your Employer Group ceases to participate in the Group Policy. Please refer to the section entitled ELIGIBILITY FOR CONTINUATION OF CERTAIN INSURANCE WHILE YOU ARE TOTALLY DISABLED for information concerning continuation of Your Life Insurance if insurance ends while You are Totally Disabled. Please refer to the section entitled LIFE INSURANCE: CONVERSION OPTION FOR YOU for information concerning the option to convert to an individual policy of life insurance if Your Life Insurance ends. In certain cases insurance may be continued as stated in the section entitled CONTINUATION OF INSURANCE WITH PREMIUM PAYMENT. GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 47
ELIGIBILITY PROVISIONS: DEPENDENT LIFE AND DEPENDENT AD&D INSURANCE ELIGIBLE FOR PEBB BENEFITS: DEPENDENT INSURANCE All Actively at Work employees of an Employing Agency, except for employees of an Employer Group that do not contract with the Policyholder for the insurance benefits described in this certificate. Totally Disabled Patrolmen, Disability Leave Patrolmen and Disability Status Patrolmen deemed disabled in the line of duty by the Chief of Washington State Patrol (WSP); Actively at Work requirements do not apply to Totally Disabled Patrolmen, Disability Leave Patrolmen and Disability Status Patrolmen. DATE YOU ARE ELIGIBLE FOR DEPENDENT LIFE AND DEPENDENT AD&D INSURANCE You may only become eligible for the Dependent insurance available for Your eligible class as shown in the SCHEDULE OF BENEFITS. If You are eligible for PEBB benefits on January 1, 2024, You will be eligible to enroll or to elect Dependent insurance on the later of: 1. January 1, 2024; or 2. the date You obtain a Dependent. If You become eligible for PEBB benefits after January 1, 2024, You will be eligible for Dependent insurance on the later of: 1. the date You become eligible for PEBB benefits; or 2. the date You obtain a Dependent. ENROLLMENT PROCESS In order to enroll for Life Insurance for Your Dependents, You must either (a) already be enrolled for Supplemental Life Insurance for You or (b) enroll at the same time for Supplemental Life Insurance for You. If You become eligible for Dependent insurance, You may enroll for such insurance by providing Us with the information We require for each Dependent to be insured. In addition, each of Your Dependents must give evidence of insurability satisfactory to Us at Your expense if required to do so under the section entitled EVIDENCE OF INSURABILITY. Once You have enrolled one Child for a Dependent insurance benefit, each succeeding Child will automatically be covered for such insurance on the date that Child becomes eligible as defined in this certificate. GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 48
ELIGIBILITY PROVISIONS: INSURANCE FOR YOUR DEPENDENTS (continued) DATE INSURANCE TAKES EFFECT FOR YOUR DEPENDENTS Requirements for Spouse or State-Registered Domestic Partner Dependent Life Insurance: Plan 1 and Child Dependent Life Insurance Dependents You Want to Enroll When You Become Eligible For Dependent Insurance If You request Dependent Life Insurance no later than 31 days after the date You become eligible for such insurance, such insurance will take effect as follows: if the Dependent is not required to give evidence of insurability, the insurance for those Dependents will take effect on the first day of the month following the date We receive Your completed enrollment form. You must be Actively at Work on that date and the Dependent must satisfy the Additional Requirement stated below; or if the Dependent is required to give evidence of insurability and We determine that the Dependent is insurable, such insurance will take effect on the first day of the month following the date We approve the Dependent’s evidence of insurability. You must be Actively at Work on that date and the Dependent must satisfy the Additional Requirement stated below. If You request Dependent Life Insurance more than 31 days after the date You become eligible for such insurance, the Dependent must give evidence of insurability satisfactory to us. You must give such evidence at Your expense. If We determine that the Dependent is insurable, such insurance will take effect on the first day of the month following the date We approve the Dependent’s evidence of insurability. Accidental Death and Dismemberment Insurance does not require evidence of insurability. You must be Actively at Work on that date and the Dependent must satisfy the Additional Requirement stated below. Once You have enrolled one Child for a Dependent Insurance benefit, each succeeding Child will automatically be covered for such insurance on the date that Child qualifies as a Dependent. If You are not Actively at Work on the date the Dependent Life Insurance would otherwise take effect, the insurance will take effect on the first day of the month following the date You resume Active Work and the Additional Requirement stated below is satisfied. For Dependents You Acquire After You Become Eligible For Dependent Life Insurance If You acquire a Dependent after You become eligible for Dependent Life Insurance, You may enroll the Dependent for such insurance no later than 60 days after the date the Dependent becomes an eligible Dependent as defined in this certificate. The Dependent must give evidence of insurability satisfactory to Us at Your expense if required to do so under the section entitled Evidence of Insurability. The Dependent insurance for the Dependent will take effect as follows: if the Dependent is not required to give evidence of insurability, the insurance for those Dependents will take effect on the first day of the month following the date We receive Your completed enrollment form. You must be Actively at Work on that date and the Dependent must satisfy the Additional Requirement stated below; or if the Dependent is required to give evidence of insurability and We determine that the Dependent is insurable, the insurance will take effect on the first day of the month following the date We approve the Dependent’s evidence of insurability. You must be Actively at Work on that date and the Dependent must satisfy the Additional Requirement stated below. If You complete the enrollment process for any Dependent more than 60 days after the date the Dependent qualifies as a Dependent, the Dependent must give evidence of insurability satisfactory to Us at Your expense. If We determine that the Dependent is insurable, the insurance will take effect on the first day of the month following the date We approve the Dependent’s evidence of insurability. Accidental Death and Dismemberment Insurance does not require evidence of insurability. You must be Actively at Work on that date and the Dependent must satisfy the Additional Requirement stated below. GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 49
ELIGIBILITY PROVISIONS: INSURANCE FOR YOUR DEPENDENTS (continued) Once You have enrolled one Child for a Dependent insurance benefit, each succeeding Child will automatically be covered for such insurance on the date that Child qualifies as a Dependent. If You are not Actively at Work on the date the Dependent Life Insurance would otherwise take effect, the insurance will take effect on the first day of the month following the date You resume Active Work and the Additional Requirement stated below is satisfied. Transfer in Coverage due to a Qualifying Event Qualifying Event means employment of Your Spouse or State-Registered Domestic Partner, who is covered in the PEBB insurance plan, ends due to termination or retirement from an Employing Agency. You will have 31 days from the date of that change to make a request to transfer Supplemental Life Insurance and Supplemental Accidental Death and Dismemberment Insurance that Your Spouse or State-Registered Domestic Partner had prior to the date their employment ends, to Your Dependent Life Insurance and Dependent Accidental Death and Dismemberment Insurance. The transfer in coverage amounts are limited to the maximum benefit amounts as shown in the SCHEDULE OF BENEFITS. There is no Evidence of Insurability required. We will require the following prior to the transfer of coverage: Your completed request form; and Proof of Your marriage or State-Registered Domestic Partnership. The transfer in coverage made as a result of a Qualifying Event, will take effect on the first day of the month following the date We receive Your completed request form and proof of Your marriage or State- Registered Domestic Partnership. You must be Actively at Work on that date. If You are not Actively at Work on the date insurance would otherwise take effect, transfer of coverage will take effect on the first day of the month following the day You resume Active Work. Requirements for Spouse or State-Registered Domestic Partner Dependent Life Insurance: Plan 2 Your Employee-Paid insurance for Your Spouse or State-Registered Domestic Partner will become effective on the date You become eligible for such insurance. Transfer in Coverage due to a Qualifying Event Qualifying Event means employment of Your Spouse or State-Registered Domestic Partner, who is covered in the PEBB insurance plan, ends due to termination or retirement from an Employing Agency. You will have 31 days from the date of that change to make a request to transfer Supplemental Life Insurance and Supplemental Accidental Death and Dismemberment Insurance that Your Spouse or State-Registered Domestic Partner had prior to the date their employment ends, to Your Dependent Life Insurance and Dependent Accidental Death and Dismemberment Insurance. The transfer in coverage amounts are limited to the maximum benefit amounts as shown in the SCHEDULE OF BENEFITS. There is no Evidence of Insurability required. We will require the following prior to the transfer of coverage: Your completed request form; and Proof of Your marriage or State-Registered Domestic Partnership. The transfer in coverage made as a result of a Qualifying Event, will take effect on the first day of the month following the date We receive Your completed request form and proof of Your marriage or State- Registered Domestic Partnership. You must be Actively at Work on that date. GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 50
ELIGIBILITY PROVISIONS: INSURANCE FOR YOUR DEPENDENTS (continued) If You are not Actively at Work on the date insurance would otherwise take effect, transfer of coverage will take effect on the first day of the month following the day You resume Active Work. Additional Requirement On the date the Dependent insurance is scheduled to take effect, the Dependent must not be: confined at home under a Physician's care; receiving or applying to receive disability benefits from any source; or Hospitalized. If the Dependent does not meet this requirement on such date, insurance for the Dependent will take effect on the date the Dependent is no longer: confined; receiving or applying to receive disability benefits from any source; or Hospitalized. The Additional Requirement will not apply to a Child with a developmental or physical disability who has been continuously disabled since a date before the Child reached the limiting age under this certificate and for whom satisfactory Proof of such disability and dependency has been provided as specified under FOR DEVELOPMENTALLY OR PHYSICALLY DISABLED CHILDREN. Dependent Life Insurance Increase in Insurance for Your Dependents If You make a Written request to increase insurance for Your Spouse or State-Registered Domestic Partner, Your Spouse or State-Registered Domestic Partner is required to give evidence of insurability to Us. You must give such evidence at Your expense. If We approve the Spouse or State-Registered Domestic Partner’s evidence of insurability, the increase will take effect on the first day of the month following the date We approve the Spouse or State-Registered Domestic Partner’s evidence of insurability. If We do not approve the evidence of insurability, or You do not submit evidence of insurability for Your Spouse or State-Registered Domestic Partner, the increase in insurance for Your Spouse of State-Registered Domestic Partner will not take effect. If You make a Written request to increase insurance for Your Children, that increase will take effect on the first day of the month following the date We receive Your Written request. You must be Actively at Work on that date. If You are not Actively at Work on the date the increase would otherwise take effect, the increase will take effect on the first day of the month following the date You resume Active Work. Decrease in Insurance for Your Dependents If You make a Written request to decrease insurance for Your Dependents, that decrease will take effect on the first day of the month following the date We receive Your Written request. Dependent Accidental Death and Dismemberment Insurance Increase in Insurance for Your Dependents If You make a Written request to increase insurance for Your Dependents, that increase will take effect on the first day of the month following the date We receive Your Written request. You must be Actively at Work on that date. If You are not Actively at Work on the date the increase would otherwise take effect, the increase will take effect on the first day of the month following the date You resume Active Work. GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 51
ELIGIBILITY PROVISIONS: INSURANCE FOR YOUR DEPENDENTS (continued) Decrease in Insurance for Your Dependents If You make a Written request to decrease insurance for Your Dependents, that decrease will take effect on the first day of the month following the date We receive Your Written request. DATE YOUR INSURANCE FOR YOUR DEPENDENTS ENDS A Dependent's insurance will end on the earliest of: 1. for Dependent Life Insurance, the date all of the Life Insurance under the Group Policy ends; or 2. for Dependent Accidental Death and Dismemberment Insurance, the last day of the calendar month all of Your Accidental Death and Dismemberment Insurance under the Group Policy ends; or 3. the date You die; or 4. the date the Group Policy ends; or 5. the last day of the calendar month Your Employee Life Insurance under the Group Policy ends; or 6. the last day of the calendar month insurance for Your Dependents ends under the Group Policy; or 7. the last day of the calendar month in which insurance for Your Dependents ends for Your class; or 8. the last day of the calendar month the Dependent meets eligibility criteria; or 9. the last day of the calendar month in which Your employment ends; Dependent insurance will end if You cease to be Actively at Work in any eligible class, except as stated in the section entitled CONTINUATION OF INSURANCE WITH PREMIUM PAYMENT; or 10. the last day of the calendar month in which You retire in accordance with the Employing Agency’s retirement plan; or 11. the last day of the calendar month in which the last premium has been paid for the Dependent; or 12. the date Your Employer Group ceases to participate in the Group Policy. Please refer to the section entitled ELIGIBILITY FOR CONTINUATION OF CERTAIN INSURANCE WHILE YOU ARE TOTALLY DISABLED for information concerning continuation of Life Insurance for your Dependents if insurance ends while You are Totally Disabled. Please refer to the section entitled LIFE INSURANCE: CONVERSION OPTION FOR YOUR DEPENDENTS for information concerning the option to convert to an individual policy of life insurance if Life Insurance for a Dependent ends. In certain cases insurance may be continued as stated in the section entitled CONTINUATION OF INSURANCE WITH PREMIUM PAYMENT. GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 52
SPECIAL REQUIREMENTS FOR GROUPS PREVIOUSLY COVERED UNDER OTHER GROUP LIFE AND AD&D INSURANCE The following requirements will apply if the Life and AD&D Insurance under this Group Policy replaces other group Life and AD&D insurance provided to You by the Policyholder. Prior Plan means the group life and AD&D insurance underwritten by another insurer and provided to You by the Policyholder on the day before the Replacement Date. Replacement Date means the effective date of the Life and AD&D Insurance under this Group Policy. Requirements if You and Your Spouse were Covered Under the Prior Plan on the Day Before the Replacement Date: 1. Actively at Work on the Replacement Date - If You and Your Spouse were covered under the Prior Plan on the day before the Replacement Date and You are Actively at Work in an eligible class on the Replacement Date, You will be insured under this Group Policy for an amount of Basic Life, Supplemental Life, Supplemental Accidental Death and Dismemberment Insurance, and Dependent Life Insurance for Your Spouse or State-Registered Domestic Partner, referred to as Active Employee Coverage. The amount of the Active Employee Coverage on the Replacement Date will be the amount of Life Insurance described in the SCHEDULE OF BENEFITS. 2. Not Actively at Work on the Replacement Date - If You and Your Dependent(s) were covered under the Prior Plan on the day before the Replacement Date and You are not Actively at Work on the Replacement Date, but You would otherwise be a member of an eligible class if You were Actively at Work on the Replacement Date, You will be insured under this Group Policy for an amount of Life and AD&D Insurance referred to as Transition Coverage. The amount of the Transition Coverage on the Replacement Date will be the lesser of: the amount of group life and AD&D insurance in effect under the Prior Plan, and the amount of Life and AD&D Insurance available under this Group Policy for the eligible class to which You belong. While Transition Coverage is in effect, the amount of coverage will continue to be determined in accordance with the provisions of the plan used to determine the amount of Transition Coverage on the Replacement Date. If You are not Actively at Work on the Replacement Date due to a disability, Transition Coverage will remain in effect on and after the Replacement Date until the earliest of: the date You return to Active Work as a member of an eligible class, at which time Active Employee Coverage will supersede the Transition Coverage; the date Life and AD&D Insurance would otherwise end in accordance with the terms and conditions of this certificate; the date on which Your life and AD&D insurance under the Prior Plan would have ended for any reason other than the Prior Plan ending; the date You are approved for extension of life and AD&D insurance without premium payment under the terms of Prior Plan; and if the Prior Plan provided for extension of life and AD&D insurance without premium payment during a period of disability, the last day of the 12-month period following the Replacement Date. GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 53
SPECIAL REQUIREMENTS FOR GROUPS PREVIOUSLY COVERED UNDER OTHER GROUP LIFE AND AD&D INSURANCE (continued) In any other case where You are not Actively at Work on the Replacement Date, Transition Coverage will remain in effect on and after the Replacement Date until the earliest of: the date You return to Active Work as a member of an eligible class, at which time Active Employee Coverage will supersede the Transition Coverage; and the date Life and AD&D Insurance would otherwise end in accordance with the terms and conditions of this certificate. Requirements if You and Your Dependents were NOT Covered Under the Prior Plan on the Day Before the Replacement Date: 1. You will be eligible for the Life and AD&D Insurance under this Group Policy when You meet the eligibility requirements for such insurance as described in ELIGIBILITY PROVISIONS: INSURANCE FOR YOU and ELIGIBILITY PROVISIONS: INSURANCE FOR YOUR DEPENDENTS; and 2. We will credit any time accumulated toward any eligibility waiting period under the Prior Plan to the satisfaction of any eligibility waiting period required to be met under this Life and AD&D Insurance. GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 54
CONTINUATION OF INSURANCE WITH PREMIUM PAYMENT FOR DEVELOPMENTALLY OR PHYSICALLY DISABLED CHILDREN Insurance for a Child may be continued past the age of twenty-six if the child is incapable of self- sustaining employment and chiefly dependent upon the Certificateholder for support and maintenance because of a developmental or physical disability as defined by applicable law, provided the condition occurred before age twenty-six. Proof of such disability must be provided to the Policyholder within 60 days of the Child’s attainment of age twenty-six and will periodically be verified after such date, but not more frequently than once a year after the two-year period following the child’s twenty-sixth birthday, which may require renewed proof from the Certificateholder. Subject to the DATE YOUR INSURANCE FOR YOUR DEPENDENTS ENDS subsection of the section entitled ELIGIBILITY PROVISIONS: INSURANCE FOR YOUR DEPENDENTS, insurance will continue while such Child: remains incapable of self-sustaining employment and chiefly dependent upon the Certificateholder for support and maintenance because of a developmental or physical disability; and continues to qualify as a Child, except for the age limit. FOR FAMILY AND MEDICAL LEAVE Certain leaves of absence may qualify for continuation of insurance under the federal Family and Medical Leave Act of 1993 (FMLA), Washington state Paid Family and Medical Leave Program, or other legally mandated leave of absence or similar laws. Please contact the Policyholder for information regarding such legally mandated leave of absence laws. AT YOUR OPTION: PORTABILITY For Life Insurance If Your Portability Eligible Insurance or Portability Eligible Dependent Insurance ends for any of the reasons stated below, You have the option to continue that insurance under another group policy in accordance with the conditions and requirements of this section. This is referred to as Porting. Evidence of Your insurability will not be required. For purposes of this subsection the term "Portability Eligible Insurance" refers to Your Life Insurance benefits for which the Portability Eligible Insurance is shown as available in the SCHEDULE OF BENEFITS. If Insurance for Your Dependents is in effect, the term "Portability Eligible Dependent Insurance" refers to Your Life Insurance for Your Dependents for which the Portability Eligible Dependent Insurance is shown as available in the SCHEDULE OF BENEFITS. When Porting is an Option Porting may only be exercised by a request in Writing during the Request Period specified below. If You choose not to Port, Life Insurance benefits may be converted in accordance with the section entitled LIFE INSURANCE: CONVERSION OPTION FOR YOU or the section entitled LIFE INSURANCE: CONVERSION OPTION FOR YOUR DEPENDENTS. 1. You may choose to Port if Portability Eligible Insurance and/or Portability Eligible Dependent Insurance ends because: You become retired from active service with the Employing Agency; or Your employment ends, due to a reason other than retirement; or You cease to be in a class that is eligible for such insurance; or the Policy is amended to end the Portability Eligible Insurance or Portability Eligible Dependent Insurance, unless such insurance is replaced by similar insurance under another group insurance policy issued to the Policyholder or its successor; or GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 55
CONTINUATION OF INSURANCE WITH PREMIUM PAYMENT (continued) this Policy has ended, unless such insurance is replaced by similar insurance under another group insurance policy issued to the Policyholder or its successor. 2. You may choose to Port the reduced amount of insurance if Your Portability Eligible Insurance is reduced due to: an amendment to the Plan which affects the amount of insurance for Your class. 3. Your former Spouse or State-Registered Domestic Partner may choose to Port if their Portability Eligible Dependent Insurance on their own life ends because: You die; or Your marriage ends in divorce, annulment, or dissolution; or Your State-Registered Domestic Partnership, or Legal Union ends provided that former Spouse or State-Registered Domestic Partner satisfies the Additional Requirement subsection of the ELIGIBILITY PROVISIONS; INSURANCE FOR YOUR DEPENDENTS. 4. Your former Spouse or State-Registered Domestic Partner may also Port Portability Eligible Dependent Insurance on Your Child if Your former Spouse or State-Registered Domestic Partner Ports insurance on their own life. If Your former Spouse or State-Registered Domestic Partner Ports that insurance on that Child, that Porting will have no effect on the insurance You may have on that Child. 5. Your former Child may request to Port Portability Eligible Dependent Insurance on their own life if that insurance ends because Your former Child no longer meets the definition of Child. If a request is made under this subsection, We will issue a new certificate of insurance which will explain the new insurance benefits. The insurance benefits under the new certificate may not be the same as those that ended under this Policy. A request under this subsection may be made, if on the date the Portability Eligible Insurance or Portability Eligible Dependent Insurance ended, the following requirements are met: the Group Policy is in effect; with respect to any amount of Portability Eligible Life Insurance or Portability Eligible Dependent Life Insurance that is to be Ported, no application has been made to convert that amount of insurance to an individual policy of life insurance as provided in the section entitled LIFE INSURANCE: CONVERSION OPTION FOR YOU or the section entitled LIFE INSURANCE: CONVERSION OPTION FOR YOUR DEPENDENTS; and the person making the request resides in a jurisdiction that permits this Portability feature. Request Period For You or a former Dependent to Port, We must receive a completed request form within the Request Period as described below. If written notice of the option to Port is given within 15 days before or after the date such insurance ends, the Request Period: begins on the date the insurance ends, and expires 60 days after the date. If written notice of the option to Port is given more than 15 days after but within 91 days of the date such insurance ends, the Request Period: begins on the date the insurance ends, and expires 45 days after the date of the notice. GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 56
CONTINUATION OF INSURANCE WITH PREMIUM PAYMENT (continued) If written notice of the option to Port is not given within 91 days of the date such insurance ends, the Request Period: begins on the date the insurance ends, and expires at the end of such 91 day period. Amount of the New Certificate The amount of Ported Insurance for You and for Your Dependents that may be continued is shown in the SCHEDULE OF BENEFITS. However, at the time of Porting You may change the amount of Portability Eligible Insurance in the following circumstances: Your Increase in Amount For Portability Eligible Life Insurance At the time of Porting, You may increase the amount of Your Portability Eligible Life Insurance. This may be done in increments of $25,000, up to a maximum ported amount of $2,000,000. To be eligible for this increased amount, You must provide evidence of Your insurability satisfactory to us, at Your expense. If We approve the increase, it will take effect on the date We state in Writing. Spouse or State-Registered Domestic Partner Increase in Amount For Portability Eligible Dependent Life Insurance At the time of Porting, the amount of Your Spouse or State-Registered Domestic Partner’s (or Your former Spouse or State-Registered Domestic Partner’s) Portability Eligible Dependent Life Insurance may be increased. This may be done in increments of $25,000, up to a maximum ported amount of $250,000. To be eligible for this increased amount, Your Spouse or State- Registered Domestic Partner (or Your former Spouse or State-Registered Domestic Partner) must provide evidence of insurability satisfactory to us, at Your Spouse or State-Registered Domestic Partner’s (or Your former Spouse or State-Registered Domestic Partner’s) expense. If We approve the increase, it will take effect on the date We state in Writing. Child Increase in Amount For Portability Eligible Dependent Life Insurance At the time of Porting, if Your former Child is making the request to continue Portability Eligible Dependent Life Insurance because they no longer meet the definition of a Child, that former Child is eligible to increase coverage by $25,000. To be eligible for this increased amount, Your former Child must give evidence of insurability satisfactory to Us at Your former Child’s expense. If we approve the increase, it will take effect on the date We state in Writing. You and/or Your Dependent(s) Decrease in Amount If We receive a request to decrease an amount of insurance, any such decrease will take place on the date We state in Writing. Premiums for the New Certificate All premium payments for ported insurance must be made directly to Us. When We issue the new certificate, We will also provide a schedule of premiums and payment instructions. You are not required to provide evidence of insurability to Port Your existing amount of Portability Eligible Life Insurance. However, to qualify for a lower premium rate, You may give us, at Your expense, evidence of Your insurability satisfactory to Us. If We determine that the evidence satisfies Us, We will notify You that the lower premium rates will apply to You. GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 57
CONTINUATION OF INSURANCE WITH PREMIUM PAYMENT (continued) Your former Dependents are not required to provide evidence of insurability to Port their existing amount of Portability Eligible Dependent Life Insurance. However, to qualify for a lower premium rate, they may give us, at their expense, evidence of their insurability satisfactory to Us. If We determine that the evidence satisfies Us, We will notify them that the lower premium rates will apply to them. Right to Convert Life Insurance Amounts Not Ported Any amount of Life Insurance not Ported under this subsection may be converted under the section entitled LIFE INSURANCE: CONVERSION OPTION FOR YOU or the section entitled LIFE INSURANCE: CONVERSION OPTION FOR YOUR DEPENDENTS. If You Die Within 60 Days of the Date Portability Eligible Life Insurance Ends If You die within 60 days of the date Portability Eligible Life Insurance ends and an application to Port is not received by Us during such period, We will determine whether Your life insurance qualifies for payment. This determination will be made in accordance with the section entitled LIFE INSURANCE: CONVERSION OPTION FOR YOU. If a former Dependent Dies Within 60 Days of the Date Portability Eligible Dependent Life Insurance Ends If a former Dependent dies within 60 days of the date Portability Eligible Dependent Life Insurance ends and an application for a new certificate is not received by Us during such period, We will determine whether Your life insurance qualifies for payment. This determination will be made in accordance with the section entitled LIFE INSURANCE: CONVERSION OPTION FOR YOUR DEPENDENTS. If You are Totally Disabled on the Date Your Employment Ends If You are Totally Disabled on the date Your employment ends and You elect to Port as provided in this subsection, You may at a later date become approved for the continuation of insurance under the section entitled ELIGIBILITY FOR CONTINUATION OF CERTAIN INSURANCE WHILE YOU ARE TOTALLY DISABLED. If You are so approved, all Ported insurance continued under this Portability subsection will end, including Life Insurance and Dependent Life Insurance. AT YOUR OPTION: CONTINUATION OF YOUR LIFE INSURANCE DURING A LABOR DISPUTE You may elect to continue Life Insurance for You, Accidental Death and Dismemberment Insurance for You, Life Insurance for Your Dependents and Accidental Death and Dismemberment Insurance for Your Dependents if You cease to be Actively at Work as the result of a strike, lockout or other labor dispute. Life Insurance for You, Accidental Death and Dismemberment Insurance for You, Life Insurance for Your Dependents and Accidental Death and Dismemberment Insurance for Your Dependents may be continued for up to 6 months if You make the required premium payments for such insurance. If continued under this subsection, Life Insurance for You, Accidental Death and Dismemberment Insurance for You, Life Insurance for Your Dependents and Accidental Death and Dismemberment Insurance for Your Dependents will end if: a premium payment is required and You fail to pay premiums for such insurance; or You cease to be eligible to continue insurance under this subsection and You do not immediately resume Active Work in a class that is eligible for such insurance. If Life Insurance for You or Life Insurance for Your Dependents ends, You may have the right to convert to a policy of individual life insurance. We urge You to read the section entitled LIFE INSURANCE: CONVERSION OPTION FOR YOU or the section entitled LIFE INSURANCE: CONVERSION OPTION FOR YOUR DEPENDENTS. GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 58
CONTINUATION OF INSURANCE WITH PREMIUM PAYMENT (continued) AT THE EMPLOYING AGENCY’S OPTION The Employing Agency has elected to continue insurance by paying premiums for employees who cease Active Work in an eligible class for any of the reasons specified below; 1. if You cease Active Work due to injury or sickness, for a period in accordance with the Employing Agency's general practice; 2. if You cease Active Work due to layoff, for a period in accordance with the Employing Agency's general practice; 3. if You die, Your surviving Spouse or State-Registered Domestic Partner may continue Dependent Life Insurance for up to five months or the date such Spouse or State-Registered Domestic Partner remarries if earlier, and Your surviving Child may continue insurance for up to five months or the date such Child ceases to be a Dependent due to reaching the maximum age if earlier; 4. if You cease Active Work due to military leave, for a period in accordance with the Employing Agency’s general practice for an employee in Your job class. The Employing Agency’s general practice for employees in a job class determines which employees with the above types of absences are to be considered as still insured and for how long among persons in like situations. At the end of any of the continuation periods listed above, Your insurance will be affected as follows: if You resume Active Work in an eligible class at this time, You will continue to be insured under the Group Policy; if You do not resume Active Work in an eligible class at this time, Your employment will be considered to end and Your insurance will end in accordance with the DATE YOUR INSURANCE ENDS subsection of the section entitled ELIGIBILITY PROVISIONS: INSURANCE FOR YOU. If Your insurance ends, Your Dependents’ insurance will also end in accordance with the DATE YOUR INSURANCE FOR YOUR DEPENDENTS ENDS subsection of the section entitled ELIGIBILITY PROVISIONS: INSURANCE FOR YOUR DEPENDENTS. GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 59
EVIDENCE OF INSURABILITY We require evidence of insurability satisfactory to Us as follows: Plan 1: 1. in order to become covered for an amount of Supplemental Life Insurance greater than the Maximum Amount Allowed Without Evidence of Insurability as shown in the SCHEDULE OF BENEFITS. If You do not give Us evidence of Your insurability, or if such evidence of insurability is not accepted by Us as satisfactory, the amount of Your Supplemental Life Insurance will be limited to the Maximum Amount Allowed Without Evidence of Insurability as shown in the SCHEDULE OF BENEFITS. 2. if You make a late request for Supplemental Life Insurance. A late request is one made more than 31 days after You become eligible. If You do not give Us evidence of insurability or the evidence of insurability is not accepted by Us as satisfactory, You will not be covered for Supplemental Life Insurance. 3. if You make a request to increase the amount of Your Supplemental Life Insurance. If You do not give Us evidence of insurability or the evidence of insurability is not accepted by Us as satisfactory, the amount of your Supplemental Life Insurance will not be increased. 4. in order to become covered for an amount of Life Insurance for Your Spouse or State-Registered Domestic Partner greater than the Maximum Amount Allowed Without Evidence of Insurability for Your Spouse or State-Registered Domestic Partner as shown in the SCHEDULE OF BENEFITS. If You do not give Us evidence of the insurability of Your Spouse or State-Registered Domestic Partner, or if such evidence of insurability is not accepted by Us as satisfactory, the amount of Life Insurance for Your Spouse or State-Registered Domestic Partner will be limited to the Maximum Amount Allowed Without Evidence of Insurability for Your Spouse or State-Registered Domestic Partner . 5. For a Spouse or State-Registered Domestic Partner You Want to Enroll When You Become Eligible for Dependent Life Insurance if You make a late request for Life Insurance for Your Spouse or State-Registered Domestic Partner. A late request is one made more than 31 days after You become eligible for Life Insurance for Your Spouse or State-Registered Domestic Partner. If You do not give Us evidence of insurability or the evidence of insurability is not accepted by Us as satisfactory, Your Spouse or State-Registered Domestic Partner will not be covered for Life Insurance. 6. For a Spouse or State-Registered Domestic Partner You Acquire After You Become Eligible for Dependent Life Insurance if You make a late request for Life Insurance for Your Spouse or State-Registered Domestic Partner. A late request is one made more than 60 days after You become eligible for Life Insurance for Your Spouse or State-Registered Domestic Partner. If You do not give Us evidence of insurability or the evidence of insurability is not accepted by Us as satisfactory, Your Spouse or State-Registered Domestic Partner will not be covered for Life Insurance. 7. if You make a request to increase the amount of Life Insurance for Your Spouse or State-Registered Domestic Partner. If You do not give Us evidence of insurability or the evidence of insurability is not accepted by Us as satisfactory, the amount of Life Insurance for Your Spouse or State-Registered Domestic Partner will not be increased. The evidence of insurability is to be given at Your expense. GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 60
LIFE INSURANCE: FOR YOU If You die, Proof of Your death must be sent to Us. When We receive such Proof with the claim, We will review the claim and, if We approve it, will pay the Beneficiary the Life Insurance in effect on the date of Your death. PAYMENT OPTIONS We will pay the Life Insurance in one sum. Other modes of payment may be available upon request. For details, call Our toll free number shown on the Certificate Face Page. GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 61
LIFE INSURANCE: FOR YOUR DEPENDENTS If a Dependent dies, Proof of the Dependent’s death must be sent to Us. When We receive such Proof with the claim, We will review the claim and, if We approve it, will pay the Beneficiary the Life Insurance in effect on the life of such Dependent on the date of death. PAYMENT OPTIONS We will pay the Life Insurance in one sum. Other modes of payment may be available upon request. For details, call Our toll free number shown on the Certificate Face Page. GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 62
LIFE INSURANCE: ACCELERATED BENEFIT OPTION (ABO) FOR YOU For purposes of this section, the term “ABO Eligible Life Insurance” refers to each of Your Life Insurance benefits for which the Accelerated Benefit Option is shown as available in the SCHEDULE OF BENEFITS. If You become Terminally Ill, You or Your legal representative have the option to request Us to pay ABO Eligible Life Insurance before Your death. This is called an accelerated benefit. The request must be made while ABO Eligible Life Insurance is in effect. Terminally Ill or Terminal Illness means that due to injury or sickness, You are expected to die within 24 months. Requirements For Payment of an Accelerated Benefit Subject to the conditions and requirements of this section, We will pay an accelerated benefit to You or Your legal representative if: the amount of each ABO Eligible Life Insurance benefit to be accelerated equals or exceeds $10,000; and the ABO Eligible Life Insurance to be accelerated has not been assigned; and We have received Proof that You are Terminally Ill. We will only pay an accelerated benefit for each ABO Eligible Life Insurance benefit once. Proof of Your Terminal Illness We will require the following Proof of Your Terminal Illness: a completed accelerated benefit claim form; a signed Physician’s certification that You are Terminally Ill; and an examination by a Physician of Our choice, at Our expense, if We request it. In determining whether You are Terminally Ill, the certification provided by Your Physician and the opinion of the Physician We chose to examine You may not agree. If this happens, You are not required to accept the opinion of the Physician We chose to examine You. We will try to resolve the issue of whether You are Terminally Ill promptly and amicably. If We cannot, You may ask to have the issue mediated by, or submitted to binding arbitration with, a disinterested third party who has no ongoing relationship with either party. As part of any final decision, the arbitrator or mediator will determine who will pay the cost of the arbitration or mediation or may divide the costs equally or otherwise. You or Your legal representative should contact Us to obtain a claim form and information regarding the accelerated benefit. Upon Our receipt of Your request to accelerate benefits, We will send You a letter with information about the accelerated benefit payment You requested. Our letter will describe the amount of the accelerated benefits We will pay and the amount of Life Insurance remaining after the accelerated benefit is paid. Accelerated Benefit Amount We will pay an accelerated benefit up to the percentage shown in the SCHEDULE OF BENEFITS for each ABO Eligible Life Insurance benefit in effect for You, subject to the following: Maximum Accelerated Benefit Amount. The maximum amount We will pay for each ABO Eligible Life Insurance benefit is shown in the SCHEDULE OF BENEFITS. GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 63
LIFE INSURANCE: ACCELERATED BENEFIT OPTION (ABO) FOR YOU (continued) Scheduled Reduction of an ABO Eligible Life Insurance Benefit. If an ABO Eligible Life Insurance benefit is scheduled to reduce within the 24 month period after the date You or Your legal representative request an accelerated benefit, We will calculate the accelerated benefit using the amount of such ABO Eligible Life Insurance that will be in effect immediately after the reduction(s) scheduled for such period. Scheduled End of an ABO Eligible Life Insurance Benefit. If an ABO Eligible Life Insurance benefit is scheduled to end due to Your age within 24 months after the date You or Your legal representative request an accelerated benefit, We will not pay an accelerated benefit for such ABO Eligible Life Insurance benefit. Previous Conversion of an ABO Eligible Life Insurance Benefit. We will not pay an accelerated benefit for any amount of ABO Eligible Life Insurance which You previously converted under the section entitled LIFE INSURANCE: CONVERSION OPTION FOR YOU. We will pay the accelerated benefit in one sum unless You or Your legal representative select another payment mode. Effect of Payment of an Accelerated Benefit On premium for Your Insurance. After We pay the accelerated benefit, any future premium will be waived for Basic Life Insurance, Supplemental Life Insurance, Basic Accidental Death and Dismemberment Insurance, Supplemental Accidental Death and Dismemberment Insurance, Dependent Life Insurance, and Dependent Accidental Death and Dismemberment Insurance. On Your Life Insurance at Your death. The amount of Life Insurance that We will pay at Your death will be decreased by the amount of the accelerated benefit paid by Us. On Your Life Insurance at conversion. The amount to which You are entitled to convert under the section entitled LIFE INSURANCE: CONVERSION OPTION FOR YOU will be decreased by the amount of the accelerated benefit paid by Us. On Your Accidental Death and Dismemberment Insurance. Payment of an accelerated benefit will not affect Your Accidental Death and Dismemberment Insurance. Date Your Option to Accelerate Benefits Ends The accelerated benefit option will end on the earliest of: the date the ABO Eligible Life Insurance ends; the date You or Your legal representative assign all ABO Eligible Life Insurance; or the date You or Your legal representative have accelerated all ABO Eligible Life Insurance benefits. GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 64
LIFE INSURANCE: ACCELERATED BENEFIT OPTION (ABO) FOR YOUR SPOUSE OR STATE-REGISTERED DOMESTIC PARTNER If Your Spouse or State-Registered Domestic Partner becomes Terminally Ill, You or Your legal representative have the option to request Us to pay Life Insurance for Your Spouse or State-Registered Domestic Partner before Your Spouse or State-Registered Domestic Partner's death. This is called an accelerated benefit. The request must be made while Life Insurance for Your Spouse or State-Registered Domestic Partner is in effect. Terminally Ill or Terminal Illness means that due to injury or sickness, Your Spouse or State-Registered Domestic Partner is expected to die within 24 months. Requirements For Payment of an Accelerated Benefit Subject to the conditions and requirements of this section, We will pay an accelerated benefit to You or Your legal representative if: the amount of Life Insurance for the Terminally Ill Spouse or State-Registered Domestic Partner equals or exceeds $10,000; and the ABO Eligible Life Insurance to be accelerated has not been assigned; and We have received Proof that Your Spouse or State-Registered Domestic Partner is Terminally Ill. We will only pay an accelerated benefit for Life Insurance for Your Spouse or State-Registered Domestic Partner once. Proof of Your Spouse or State-Registered Domestic Partner’s Terminal Illness We will require the following Proof of Your Spouse or State-Registered Domestic Partner’s Terminal Illness: a completed accelerated benefit claim form; a signed Physician’s certification that Your Spouse or State-Registered Domestic Partner is Terminally Ill; and an examination by a Physician of Our choice, at Our expense, if We request it. In determining whether Your Spouse or State-Registered Domestic Partner is Terminally Ill, the certification provided by Your Physician and the opinion of the Physician We chose to examine Your Spouse or State-Registered Domestic Partner may not agree. If this happens, You are not required to accept the opinion of the Physician We chose to examine Your Spouse or State-Registered Domestic Partner. We will try to resolve the issue of whether Your Spouse or State-Registered Domestic Partner is Terminally Ill promptly and amicably. If We cannot, You may ask to have the issue mediated by, or submitted to binding arbitration with, a disinterested third party who has no ongoing relationship with either party. As part of any final decision, the arbitrator or mediator will determine who will pay the cost of the arbitration or mediation or may divide the costs equally or otherwise. You or Your legal representative should contact the Us to obtain a claim form and information regarding the accelerated benefit. Upon Our receipt of Your request to accelerate benefits, We will send You a letter with information about the accelerated benefit payment You requested. Our letter will describe the amount of the accelerated benefits We will pay and the amount of Life Insurance remaining after the accelerated benefit is paid. GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 65
LIFE INSURANCE: ACCELERATE BENEFIT OPTION (ABO) FOR YOUR SPOUSE OR STATE-REGISTERED DOMESTIC PARTNER (continued) Accelerated Benefit Amount We will pay an accelerated benefit up to the percentage shown in the SCHEDULE OF BENEFITS for the amount of Life Insurance in effect for a Terminally Ill Spouse or State-Registered Domestic Partner, subject to the following: Maximum Accelerated Benefit Amount. The maximum amount We will pay is shown in the SCHEDULE OF BENEFITS. Scheduled Reduction of Life Insurance for a Terminally Ill Spouse or State-Registered Domestic Partner. If the Life Insurance in effect for a Terminally Ill Spouse or State-Registered Domestic Partner is scheduled to reduce within the 24 month period after the date You or Your legal representative request an accelerated benefit, We will calculate the accelerated benefit using the amount of Life Insurance that will be in effect for Your Spouse or State-Registered Domestic Partner immediately after the reduction(s) scheduled for such period. Scheduled end of Life Insurance for a Terminally Ill Spouse or State-Registered Domestic Partner . If the Life Insurance in effect for a Terminally Ill Spouse or State-Registered Domestic Partner is scheduled to end due to Your age, Your Spouse or State-Registered Domestic Partner 's age within 24 months after the date You or Your legal representative request an accelerated benefit, We will not pay an accelerated benefit. We will pay the accelerated benefit in one sum unless You or Your legal representative select another payment mode. Effect of Payment of an Accelerated Benefit On Premiums for Life Insurance. After We pay the accelerated benefit, any future premiums for Dependent Life Insurance You are required to pay for Life Insurance for Your Spouse or State- Registered Domestic Partner will be waived. On Payment of Life Insurance at Your Spouse or State-Registered Domestic Partner’s death. The amount of Life Insurance that We will pay at death of Your Spouse or State-Registered Domestic Partner for whom We paid an accelerated benefit will be decreased by the amount of the accelerated death benefit paid by Us for Your Spouse or State-Registered Domestic Partner . On Life Insurance at conversion. The amount to which Your Spouse or State-Registered Domestic Partner for whom We paid an accelerated benefit is entitled to convert under the section entitled LIFE INSURANCE: CONVERSION OPTION FOR YOUR DEPENDENTS provision will be decreased by the amount of the accelerated benefit paid by Us for Your Spouse or State-Registered Domestic Partner . On Your Spouse or State-Registered Domestic Partner's Accidental Death and Dismemberment Insurance. Payment of an accelerated benefit will not affect Your Spouse or State-Registered Domestic Partner's Accidental Death and Dismemberment Insurance. Date Your Option to Accelerate Benefits Ends The accelerated benefit option for Your Spouse or State-Registered Domestic Partner will end on the earliest of: the date Life Insurance for Your Spouse or State-Registered Domestic Partner ends; the date Your rights in Life Insurance for Your Spouse or State-Registered Domestic Partner are assigned; or the date You or Your legal representative have accelerated all Dependent Life Insurance benefits. GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 66
LIFE INSURANCE: CONVERSION OPTION FOR YOU If Your life insurance ends or is reduced for any of the reasons stated below, You have the option to buy an individual policy of life insurance (“new policy”) from Us during the Application Period in accordance with the conditions and requirements of this section. This is referred to as the “option to convert”. Evidence of Your insurability will not be required. When You Will Have the Option to Convert You will have the option to convert when: A. Your life insurance ends because: You cease to be in an eligible class; Your employment ends; this Group Policy ends, provided You have been insured for life insurance for at least 5 continuous years; or this Group Policy is amended to end all life insurance for an eligible class of which You are a member, provided You have been insured for at least 5 continuous years; or B. Your life insurance is reduced due to an amendment of this Group Policy. If You opt not to convert a reduction in the amount of Your life insurance as described above, You will not have the option to convert that amount at a later date. A reduction in the amount of Your life insurance as a result of the payment of an accelerated benefit will not give rise to a right to convert under this section. Application Period If You opt to convert Your Life Insurance for any of the reasons stated above, We must receive a completed conversion application form from You within 60 days after the date Your Life Insurance ends or is reduced. Option Conditions The option to convert is subject to the following: A. Our receipt within the Application Period of: Your Written application for the new policy; and the premium due for such new policy; B. the premium rates for the new policy will be based on: Our rates then in use; the form and amount of insurance for which you apply; Your class of risk; and Your age; C. the new policy may be on any form then customarily offered by Us excluding term insurance; D. the new policy will be issued without an accidental death and dismemberment benefit, an accelerated benefit option, a waiver of premium benefit or any other rider or additional benefit; and nd E. the new policy will take effect on the 32 day after the date Your life insurance ends or is reduced; this will be the case regardless of the duration of the Application Period. GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 67
LIFE INSURANCE: CONVERSION OPTION FOR YOU (continued) Maximum Amount of the New Policy If Your Life Insurance ends due to the end of this Group Policy or the amendment of this Group Policy to end all life insurance for an eligible class of which You are a member, the maximum amount of insurance that You may elect for the new policy is the lesser of: the amount of Your life insurance that ends under this Group Policy less the amount of life insurance for which You become eligible under any group policy within 31 days after the date insurance ends under this Group Policy; or $10,000. If Your life insurance ends or is reduced due to the Policyholder’s or Employing Agency’s organizational restructuring, the maximum amount of insurance that You may elect for the new policy is the amount of Your life insurance that ends under this Group Policy less the amount of life insurance for which You become eligible under any other group policy within 31 days after the date insurance ends under this Group Policy. If Your life insurance ends or is reduced for any other reason, the maximum amount of insurance that You may elect for the new policy is the amount of Your life insurance which ends under this Group Policy. ADDITIONAL PROVISIONS IF YOU DIE OR BECOME DISABLED UNDER CERTAIN CONDITIONS If You Die Within 60 Days After Your Life Insurance Ends Or Is Reduced If You die within 60 days after Your life insurance ends or is reduced by an amount You are entitled to convert, Proof of Your death must be sent to Us. When We receive such Proof with the claim, We will review the claim and if We approve it, We will pay the Beneficiary. The amount We will pay is the amount You were entitled to convert. The amount You were entitled to convert will not be paid as insurance under both a new individual conversion policy and the Group Policy. If You Become Eligible To Have Insurance Continued Due To Your Total Disability If You obtain a new individual conversion policy because Your life insurance ends or is reduced and You later become eligible to have insurance continued under the section entitled ELIGIBILITY FOR CONTINUATION OF CERTAIN INSURANCE WHILE YOU ARE TOTALLY DISABLED, We will only continue Your life insurance under such section if the conversion policy is returned to Us. If the conversion policy is returned to Us, We will refund the premium paid for such policy without interest, less any debt incurred under such policy. We will not pay a benefit for insurance under both the Group Policy and the new individual conversion policy. GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 68
LIFE INSURANCE: CONVERSION OPTION FOR YOUR DEPENDENTS If life insurance for a Dependent ends or is reduced for any of the reasons stated below, You or that Dependent will have the option to buy from Us an individual policy of life insurance on the life of the Dependent (“new policy”) during the Application Period in accordance with the conditions and requirements of this section. This is referred to as “the option to convert”. Evidence of the Dependent’s insurability will not be required. When You or a Dependent Will Have the Option to Convert You will have the option to convert life insurance for a Dependent when: A. life insurance for the Dependent ends because: You cease to be eligible for PEBB benefits; Your employment ends; this Group Policy ends, provided You have been insured for life insurance for the Dependent for at least 5 continuous years; or this Group Policy is amended to end all life insurance for Dependents for an eligible class of which You are a member, provided You have been insured for life insurance for the Dependent for at least 5 continuous years; or B. life insurance for the Dependent is reduced due to an amendment of this Group Policy. A Dependent will have the option to convert when: life insurance for such Dependent ends because that Dependent ceases to qualify as a Dependent as defined in this certificate, or You die. If You opt not to convert a reduction in the amount of life insurance for a Dependent, You will not have the option to convert that amount at a later date. A reduction in the amount of life insurance for a Dependent as a result of the payment of an accelerated benefit will not give rise to a right to convert under this section. You must notify Us in the event that a Dependent ceases to qualify as a Dependent as defined in this certificate. Application Period If You or a Dependent opt to convert as stated above, We must receive a completed conversion application form within 60 days of the date Life Insurance for the Dependent ends or is reduced. Option Conditions The option to convert is subject to the following: A. Our receipt within the Application Period of: a Written application for the new policy for the Dependent; and the premium due for such new policy; B. the premium rates for the new policy will be based on: Our rates then in use; the form and amount of insurance which is applied for; the Dependent’s class of risk; and GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 69
LIFE INSURANCE: CONVERSION OPTION FOR YOUR DEPENDENTS (continued) the Dependent's age; C. the new policy may be on any form then customarily offered by Us excluding term insurance; D. the new policy will be issued without an accidental death and dismemberment benefit, an accelerated benefit option, waiver of premium benefit or any other rider or additional benefit; and nd E. the new policy will take effect on the 32 day after the date Life Insurance for the Dependent ends or is reduced; this will be the case regardless of the duration of the Application Period. Maximum Amount of the New Policy If Life Insurance for a Dependent ends due to the end of this Group Policy or the amendment of this Group Policy to end all life insurance for Dependents for an eligible class of which You are a member, the maximum amount of insurance that may be elected for the new policy is the lesser of: the amount of Life Insurance for the Dependent that ends under this Group Policy less the amount of life insurance for Dependents for which You become eligible under any group policy within 31 days after the date insurance ends under this Group Policy; or $10,000. If life insurance for a Dependent ends or is reduced due to the Policyholder’s or Employing Agency’s organizational restructuring, the maximum amount of insurance that may be elected for the new policy is the amount of life insurance for the Dependent that ends under this Group Policy less the amount of life insurance for dependents for which You become eligible under any other group policy within 31 days after the date insurance ends under this Group Policy. If Your life insurance for a Dependent ends or is reduced for any other reason, the maximum amount of insurance that You may elect for the new policy is the amount of Your life insurance for a Dependent that ends under this Group Policy. ADDITIONAL PROVISIONS IF A DEPENDENT DIES If a Dependent Dies Within the 60 Days After Life Insurance for a Dependent Ends Or Is Reduced If a Dependent dies within 60 days after the date life insurance for the Dependent ends or is reduced by an amount eligible to convert, Proof of the Dependent’s death must be sent to Us. When We receive such Proof with the claim, We will review the claim and if We approve it, will pay the Beneficiary. The amount We will pay is the amount that could have been converted. The amount that could have been converted will not be paid as insurance under both a new individual conversion policy and the Group Policy. GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 70
ELIGIBILITY FOR CONTINUATION OF CERTAIN INSURANCE WHILE YOU ARE TOTALLY DISABLED If You become Totally Disabled while You are insured for Continuation Eligible Insurance under this policy, You may qualify to continue certain insurance under this section. If continued, premium payment will not be required. We will determine if You qualify for this continuation after We receive Proof that You have satisfied the conditions of this section. Total Disability must start before You attain age 60 and while You are insured for Continuation Eligible Insurance. Your Total Disability must continue without interruption from the date You became Totally Disabled through the end of the Continuation Waiting Period. DEFINITIONS For the purpose of this section, "Continuation Eligible Insurance" means Basic Life Insurance (except for Totally Disabled Patrolmen, Disability Leave Patrolmen and Disability Status Patrolmen deemed disabled in the line of duty by the Chief of Washington State Patrol (WSP); and Supplemental Life Insurance; Dependent Life Insurance if You continue Supplemental Life Insurance; to the extent that such insurance was in effect for You on the date Your Total Disability began. Continuation Eligible Insurance does not include: Life Insurance amounts accelerated under the section entitled LIFE INSURANCE: ACCELERATED BENEFIT OPTION FOR YOU. Continuation Waiting Period means the period which starts on the date You become Totally Disabled and ends 6 consecutive months later. Total Disability or Totally Disabled means, for purposes of this section, that due to an injury or sickness: You are unable to perform the material duties of Your regular job; and You are unable to perform any other job for which You are fit by education, training or experience. TOTAL DISABILITY AND PROOF REQUIREMENTS If You become disabled You should contact Us as soon as reasonably possible. After the Continuation Waiting Period ends, You must send Us Proof that You were Totally Disabled with no interruption throughout the Continuation Waiting Period. You must do this within the time frame specified in the section entitled FILING A CLAIM. As part of such Proof, We may choose a Physician to examine You to verify that You are Totally Disabled. We will pay for the exam. After We receive and review Your Proof, We will determine if You qualify. We will notify You in writing of Our decision. To verify that You continue to be Totally Disabled without interruption, We may require from time to time that You send Us Proof that You continue to be Totally Disabled. We will not ask for Proof more than once each year. IF YOU OR YOUR DEPENDENT DIE DURING CONTINUATION If You or Your Dependent die during the continuation, Proof of the death must be sent to Us. In addition to the Proof which is otherwise required for the insurance, the Proof must show that Your Total Disability continued with no interruption from the date We informed You that the continuation was approved until the date of the death. GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 71
ELIGIBILITY FOR CONTINUATION OF CERTAIN INSURANCE WHILE YOU ARE TOTALLY DISABLED (continued) When We receive such Proof with the claim, We will review the claim and if We approve it, will pay any benefit payable under the insurance continued under this section. EFFECT OF PREVIOUS CONVERSION If You converted any portion of Your Continuation Eligible Life Insurance to an individual policy, We will only pay the life insurance under this section if the individual policy is returned to Us. If it is returned to Us, We will refund to Your estate the premiums paid for such policy without interest, less any debt incurred under such policy. If such individual policy is not returned to Us, We will pay the life insurance in effect under the individual policy. We will not pay insurance under both the Group Policy and the individual policy. EFFECT OF PREVIOUS ELECTION TO PORT COVERAGE If You ported any portion of Your Continuation Eligible Insurance to a certificate under another policy, We will only pay insurance under this section if the other policy’s certificate is surrendered to Us. If it is returned to Us, We will refund to Your estate the premiums paid under such policy without interest. If that certificate is not returned to Us, We will pay any insurance which applies under the other policy’s certificate. We will not pay insurance under both this Group Policy and the other policy. DATE CONTINUATION ENDS The Continuation Eligible Insurance continued under this section may be continued in a reduced amount on account of Your age or the payment of accelerated benefits and will end at the earliest of: 1. the date You die; 2. the date Your Total Disability ends; 3. the date You do not give Us Proof of Total Disability, as required; 4. the date You refuse to be examined by Our Physician, as required; or 5. with respect to Dependent Life Insurance, the date You no longer have any Dependents. Option To Convert Your Continuation Eligible Life Insurance When a continuation under this section ends, You may buy an individual policy of life insurance from Us. The details of this option are described in the section entitled LIFE INSURANCE: CONVERSION OPTION FOR YOU and LIFE INSURANCE: CONVERSION OPTION FOR YOUR DEPENDENTS. For the purpose of that section, the end of this continuation will be considered the end of Your employment. You may not use the conversion option described in those sections if before the end of the Application Period for conversion You return to Active Work in an eligible class and become insured under the Group Policy. You will not be able to convert any of Your Continuation Eligible Life Insurance which You have already converted to an individual policy. Option To Port Your Continuation Eligible Insurance When a continuation under this section ends, You may elect to port to a different policy the insurance which has been continued under this section. The details of this option are described in the At Your Option: Portability subsection of the CONTINUATION OF INSURANCE WITH PREMIUM PAYMENT section. For the purpose of that section, the end of this continuation will be considered the end of Your employment. You may not use the portability option described in that section if before the end of the Portability Request Period, You return to Active Work in an eligible class and become insured under the Group Policy. You will not be able to port any of Your Continuation Eligible Insurance which You have already converted to an individual policy. GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 72
ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE If You or a Dependent sustain an accidental injury that is the Direct and Sole Cause of a Covered Loss described in the SCHEDULE OF BENEFITS, Proof of the accidental injury and Covered Loss must be sent to Us. When We receive such Proof We will review the claim and, if We approve it, will pay the insurance in effect on the date of the injury. Direct and Sole Cause means that the Covered Loss occurs within 12 months of the date of the accidental injury and was a direct result of the accidental injury, independent of other causes. We will deem a loss to be the direct result of an accidental injury if it results from unavoidable exposure to the elements and such exposure was a direct result of an accident. PRESUMPTION OF DEATH You and/or a Dependent will be presumed to have died as a result of an accidental injury if: the aircraft or other vehicle in which You and/or a Dependent were traveling disappears, sinks, or is wrecked; and the body of the person who has disappeared is not found within 1 year of: the date the aircraft or other vehicle was scheduled to have arrived at its destination, if traveling in an aircraft or other vehicle operated by a Common Carrier; or the date the person is reported missing to the authorities, if traveling in any other aircraft or other vehicle. EXCLUSIONS We will not pay benefits under this section for any loss caused or contributed to by: 1. physical or mental illness or infirmity, or the diagnosis or treatment of such illness or infirmity; 2. infection, other than infection occurring in an external accidental wound or from food poisoning; 3. suicide or attempted suicide; 4. intentionally self-inflicted injury; 5. service in the armed forces of any country or international authority. However, service in reserve forces does not constitute service in the armed forces, unless in connection with such reserve service an individual is on active military duty as determined by the applicable military authority other than weekend or summer training. For purposes of this provision reserve forces are defined as reserve forces of any branch of the military of the United States or of any other country or international authority, including but not limited to the National Guard of the United States or the national guard of any other country; 6. any incident related to: travel in an aircraft as a pilot, crew member, flight student or while acting in any capacity other than as a passenger; travel in an aircraft for the purpose of parachuting or otherwise exiting from such aircraft while it is in flight; parachuting or otherwise exiting from an aircraft while such aircraft is in flight, except for self- preservation; travel in an aircraft or device used: for testing or experimental purposes; by or for any military authority; or for travel or designed for travel beyond the earth’s atmosphere; 7. committing or attempting to commit a felony; GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 73
ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE (continued) 8. the voluntary intake or use by any means of: any drug, medication or sedative, unless it is: taken or used as prescribed by a Physician; or an "over the counter" drug, medication or sedative taken as directed; alcohol in combination with any drug, medication, or sedative; or poison, gas, or fumes; or 9. war, whether declared or undeclared; or act of war, insurrection, rebellion or active participation in a riot. Exclusion for Intoxication We will not pay benefits under this section for any loss if the injured party is intoxicated at the time of the incident and is the operator of a vehicle or other device involved in the incident. Intoxicated means that the injured person’s blood alcohol level met or exceeded the level that creates a legal presumption of intoxication under the laws of the jurisdiction in which the incident occurred. BENEFIT PAYMENT For loss of Your life, We will pay benefits to Your Beneficiary. For any other loss sustained by You, or for any loss sustained by a Dependent, We will pay benefits to You. If You or a Dependent sustain more than one Covered Loss due to an accidental injury, the amount We will pay, on behalf of any such injured person, will not exceed the Full Amount. We will pay benefits in one sum. Other modes of payment may be available upon request. For details call Our toll free number shown on the Certificate Face Page. If You and any Dependent die within a 24 hour period, We will pay the Dependent’s Accidental Death and Dismemberment Insurance to the Beneficiary receiving payment of Your Accidental Death and Dismemberment Insurance including payment of any Additional Benefits, or We may pay Your estate. If a Beneficiary is a minor or is incompetent to receive payment, We will pay that person’s guardian. APPLICABILITY OF PROVISIONS The provisions set forth in this ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE section apply to all Accidental Death and Dismemberment Insurance – Additional Benefit sections included in this certificate except as may otherwise be provided in such Additional Benefit sections. GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 74
ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE (continued) ADDITIONAL BENEFIT: SEAT BELT USE If You or a Dependent die as a result of an accidental injury, We will pay this additional Seat Belt Use benefit if: 1. We pay a benefit for loss of life under the ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE section; 2. this benefit is in effect on the date of the injury; and 3. We receive Proof that the deceased person: was in an accident while driving or riding as a passenger in a Passenger Car; was wearing a Seat Belt which was properly fastened at the time of the accident; and died as a result of injuries sustained in the accident. A police officer investigating the accident must certify that the Seat Belt was properly fastened. A copy of such certification must be submitted to Us with the claim for benefits. Passenger Car means any validly registered four-wheel private passenger car, four-wheel drive vehicle, sports-utility vehicle, pick-up truck or mini-van. It does not include any commercially licensed car, any private car being used for commercial purposes, or any vehicle used for recreational or professional racing. Seat Belt means any restraint device that: meets published United States Government safety standards; is properly installed by the car manufacturer; and is not altered after the installation. The term includes any child restraint device that meets the requirements of state law. BENEFIT AMOUNT The Seat Belt Use benefit is an additional benefit equal to 10% of the Full Amount shown in the SCHEDULE OF BENEFITS. However, the amount We will pay for this benefit will not be less than $1,000 or more than $25,000. If it is unclear whether the Seat Belt was properly fastened, the Seat Belt Use benefit is $1,000. BENEFIT PAYMENT For loss of Your life, We will pay benefits to Your Beneficiary. For loss of a Dependent’s life, We will pay benefits to You. GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 75
ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE (continued) ADDITIONAL BENEFIT: AIR BAG USE If You or a Dependent die as a result of an accidental injury, We will pay this additional benefit if: 1. We pay a benefit for loss of life under the ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE section; 2. this benefit is in effect on the date of the injury; and 3. We receive Proof that the deceased person: was in an accident while driving or riding as a passenger in a Passenger Car equipped with an Air Bag(s); was riding in a seat protected by an Air Bag; was wearing a Seat Belt which was properly fastened at the time of the accident; and died as a result of injuries sustained in the accident. A police officer investigating the accident must certify that the Seat Belt was properly fastened and that the Passenger Car in which the deceased was traveling was equipped with Air Bags. A copy of such certification must be submitted to Us with the claim for benefits. Passenger Car means any validly registered four-wheel private passenger car, four-wheel drive vehicle, sports-utility vehicle, pick-up truck or mini-van. It does not include any commercially licensed car, any private car being used for commercial purposes, or any vehicle used for recreational or professional racing. Seat Belt means any restraint device that: meets published United States government safety standards; is properly installed by the car manufacturer; and is not altered after the installation. The term includes any child restraint device that meets the requirements of state law. Air Bag means an inflatable restraint device that: meets published United States government safety standards; is properly installed by the car manufacturer; and is not altered after the installation. BENEFIT AMOUNT The Air Bag Use Benefit is an additional benefit equal to 5% of the Full Amount shown in the SCHEDULE OF BENEFITS. However, the amount We will pay for this benefit will not be less than $1,000 or more than $10,000. If it is unclear whether the Seat Belt was properly fastened or that the seat in which the deceased was traveling was protected by Air Bags, the Air Bag Use benefit is $1,000. BENEFIT PAYMENT For loss of Your life, We will pay benefits to Your Beneficiary. For a loss of a Dependent's life, We will pay benefits to You. GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 76
ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE (continued) ADDITIONAL BENEFIT: CHILD CARE If You die as a result of an accidental injury, We will pay this additional Child Care benefit if: 1. We pay a benefit for loss of Your life under the ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE section; 2. this benefit is in effect on the date of the injury; and 3. We receive Proof that: on the date of death a Child was enrolled in a Child Care Center; or within 12 months after the date of death a Child was enrolled in a Child Care Center. Child Care Center means a facility that: is operated and licensed according to the law of the jurisdiction where it is located; and provides care and supervision for children in a group setting on a regularly scheduled and daily basis. BENEFIT AMOUNT For each Child who qualifies for this benefit, We will pay an amount equal to the Child Care Center charges incurred for a period of up to 4 consecutive years, not to exceed: an annual maximum of $5,000; and an overall maximum of 12% of the Full Amount shown in the SCHEDULE OF BENEFITS. We will not pay for Child Care Center charges incurred after the date a Child attains age 12. We may require Proof of the Child’s continued enrollment in a Child Care Center during the period for which a benefit is claimed. BENEFIT PAYMENT We will pay this benefit quarterly when We receive Proof that Child Care Center charges have been paid. Payment will be made to the person who pays such charges on behalf of the Child. If this benefit is in effect on the date You die and there is no Child who could qualify for it, We will pay $1,000 to Your Beneficiary in one sum. GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 77
ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE (continued) ADDITIONAL BENEFIT: CHILD EDUCATION If You die as a result of an accidental injury, We will pay this additional Child Education benefit if: 1. We pay a benefit for loss of life under the ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE section; 2. this benefit is in effect on the date of the injury; and 3. We receive Proof that on the date of death a Child was: enrolled as a full-time student in an accredited college, university or vocational school above the 12th grade level; or at the 12th grade level and, within one year after the date of death, enrolls as a full-time student in an accredited college, university or vocational school. BENEFIT AMOUNT For each Child who qualifies for this benefit, We will pay an amount equal to the tuition charges incurred for a period of up to 4 consecutive academic years, not to exceed: an academic year maximum of $10,000; and an overall maximum of 20% of the Full Amount shown in the SCHEDULE OF BENEFITS. We may require Proof of the Child’s continued enrollment as a full-time student during the period for which a benefit is claimed. BENEFIT PAYMENT We will pay this benefit semi-annually when We receive Proof that tuition charges have been paid. Payment will be made to the person who pays such charges on behalf of the Child. If this benefit is in effect on the date of death and there is no Child who could qualify for it, We will pay $1,000 to Your Beneficiary in one sum. GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 78
ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE (continued) ADDITIONAL BENEFIT: SPOUSE OR STATE-REGISTERED DOMESTIC PARTNER EDUCATION If You die as a result of an accidental injury, We will pay this additional Spouse or State-Registered Domestic Partner Education benefit if: 1. We pay a benefit for loss of life under the ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE section; 2. this benefit is in effect on the date of the injury; and 3. We receive Proof that: on the date of Your death, Your Spouse or State-Registered Domestic Partner was enrolled as a full- time student in an accredited school; or within 12 months after the date of Your death, Your Spouse or State-Registered Domestic Partner enrolls as a full-time student in an accredited school. BENEFIT AMOUNT We will pay an amount equal to the tuition charges incurred for a period of up to 1 academic year, not to exceed: an academic year maximum of $5,000; and an overall maximum of 5% of the Full Amount shown in the SCHEDULE OF BENEFITS. We may require Proof of the Spouse or State-Registered Domestic Partner’s continued enrollment as a full- time student during the period for which a benefit is claimed. BENEFIT PAYMENT We will pay this benefit semi-annually when We receive Proof that tuition charges have been paid. Payment will be made to the Spouse or State-Registered Domestic Partner. If this benefit is in effect on the date You die and there is no Spouse or State-Registered Domestic Partner who could qualify for it, We will pay $1,000 to Your Beneficiary in one sum. GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 79
ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE (continued) ADDITIONAL BENEFIT: HOSPITAL CONFINEMENT Subject to the provisions of the ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE, We will pay this additional benefit if: 1. We receive Proof that You or a Dependent are confined in a Hospital as a result of an accidental injury which is the direct cause of such confinement independent of other causes; and 2. this benefit is in effect on the date of the injury. BENEFIT AMOUNT We will pay an amount for each full month of Hospital Confinement equal to the lesser of: 1% of the Full Amount shown in the SCHEDULE OF BENEFITS; and $2,500. We will pay this benefit on a monthly basis beginning on the 5th day of confinement, for up to 12 months of continuous confinement. This benefit will be paid on a pro-rata basis for any partial month of confinement. We will only pay benefits for one period of continuous confinement for any accidental injury. That period will be the first period of confinement that qualifies for payment. BENEFIT PAYMENT Benefit payments will be made monthly. Payment will be made to You. GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 80
ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE (continued) ADDITIONAL BENEFIT: COMMON CARRIER If You or a Dependent die as a result of an accidental injury, We will pay this additional benefit if: 1. We pay a benefit for loss of life under the ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE section; 2. this benefit is in effect on the date of the injury; and 3. We receive Proof that the injury resulting in the deceased’s death occurred while traveling in a Common Carrier. BENEFIT AMOUNT The Common Carrier Benefit is shown in the SCHEDULE OF BENEFITS. BENEFIT PAYMENT For loss of Your life, We will pay benefits to Your Beneficiary. For a loss of a Dependent's life, We will pay benefits to You. GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 81
FILING A CLAIM CLAIMS FOR LIFE INSURANCE BENEFITS When there has been the death of an insured person, notify Us by calling 1-866-548-7139. This notice should be given to Us as soon as is reasonably possible after the death. The claim form will be sent to the beneficiary or beneficiaries of record. The beneficiary or beneficiaries should complete the claim form and send it and Proof of the death to Us as instructed on the claim form. When We receive the claim form and Proof, We will review the claim and, if We approve it, We will pay benefits subject to the terms and provisions of this certificate and the Group Policy. The benefit amount may be reduced by the amount of any due and unpaid premiums outstanding at the time We make payment. When a claimant files a claim to continue Life Insurance on account of Total Disability, notice and Proof should be sent to Us as soon as reasonably possible, but in any event must be received by Us within 12 months of the date the claimant became Totally Disabled, except in the case of legal incapacity of the claimant. GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 82
FILING A CLAIM CLAIMS FOR ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS When there has been a Covered Loss, notify Us by calling 1-866-548-7139. This notice should be given to Us as soon as is reasonably possible but in any case within 20 days of the Covered Loss. The claim form will be sent to You or the beneficiary or beneficiaries of record. The claim form should be completed and sent along with Proof of the Covered Loss to Us as instructed on the claim form. If You or the beneficiary have not received a claim form within 15 days of giving notice of the claim, Proof may be sent using any form sufficient to provide Us with the required Proof. The claimant must give us Proof no later than 90 days after the date of the Covered Loss. If notice of claim or Proof is not given within the time limits described in this section, the delay will not cause a claim to be denied or reduced if such notice or Proof are given as soon as is reasonably possible. When We receive the claim form and Proof, We will review the claim and, if We approve it, We will immediately pay benefits subject to the terms and provisions of this certificate and the Group Policy. The benefit amount may be reduced by the amount of any due and unpaid premiums outstanding at the time We make payment. Time Limit on Legal Actions. A legal action on a claim may only be brought against Us during a certain period. This period begins 60 days after the date Proof is filed and ends 3 years after the date such Proof is required. GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 83
GENERAL PROVISIONS Assignment You may assign Your Life Insurance rights and benefits under the Group Policy as a gift or as a viatical assignment. You may also assign Your Accidental Death and Dismemberment Insurance rights and benefits under the Group Policy as a gift. We will recognize the assignee(s) under such assignment as owner(s) of Your right, title and interest in the Group Policy if: 1. a Written form satisfactory to Us, affirming this assignment, has been completed; 2. the Written form has been Signed by You and the assignee(s); 3. the Policyholder acknowledges that Your Life Insurance and Accidental Death and Dismemberment Insurance being assigned is in force on the life of the assignor; and 4. the Written form is delivered to Us for recording. All other insurance under the Group Policy may not be assigned prior to a claim for benefits, except as required by law. We are not responsible for the validity of an assignment. Beneficiary You may designate a Beneficiary in Your application or enrollment form. You may change Your Beneficiary at any time. To do so, You must send a Signed and dated, Written request to Us using a form satisfactory to Us. Your Written request to change the Beneficiary must be sent to Us within 30 days of the date You Sign such request. You do not need the Beneficiary’s consent to make a change. When We receive the change, it will take effect as of the date You Signed it. The change will not apply to any payment made in good faith by Us before the change request was recorded. If two or more Beneficiaries are designated and their shares are not specified, they will share the insurance equally. If there is no Beneficiary designated or no surviving designated Beneficiary at Your death, We may determine the Beneficiary to be one or more of the following who survive You: Your Spouse or State-Registered Domestic Partner; Your biological child(ren), legally adopted child(ren), and stepchildren, including children of Your State- Registered Domestic Partner; Your natural or adopted parent(s); or Your sibling(s). Instead of making payment to any of the above, We may pay Your estate. Any payment made in good faith will discharge our liability to the extent of such payment. If a Beneficiary or a payee is a minor or incompetent to receive payment, We will pay that person's guardian. If an insured employee who is a member of an eligible class dies and a surviving Spouse elects to continue Dependent Insurance in effect on the date of the insured employee’s death, such surviving Spouse will be deemed the Certificateholder thereafter for purposes of determining payment of benefits and designating a Beneficiary. Only Dependents covered on the date of the insured employee’s death are eligible for continued coverage. For Your Life Insurance for Your Dependents, We will pay You as the Beneficiary if alive. If you are not alive, We may determine the Beneficiary to be one or more of the following who survive You: Your Spouse or State-Registered Domestic Partner; Your biological child(ren), legally adopted child(ren), and stepchildren, including children of Your State- Registered Domestic Partner; GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 84
GENERAL PROVISIONS (continued) Your natural or adopted parent(s); or Your sibling(s). Instead of making payment to any of the above, We may pay Your estate. Any payment made in good faith will discharge our liability to the extent of such payment. If You and any Dependent die within a 24 hour period, We will pay the Dependent's Life Insurance to the Beneficiary receiving payment of your Life Insurance or We may pay Your estate. If a Beneficiary or a payee is a minor or incompetent to receive payment, We will pay that person's guardian. Entire Contract Your insurance is provided under a contract of group insurance with the Policyholder. The entire contract with the Policyholder is made up of the following: 1. the Group Policy and its Exhibits, which include the certificate(s); 2. the Policyholder's application; and 3. any amendments and/or endorsements to the Group Policy. Incontestability: Statements Made by You Any statement made by You will be considered a representation and not a warranty. We will not use such statement to avoid insurance, reduce benefits or defend a claim unless the following requirements are met: 1. the statement is in a Written application or enrollment form; 2. You have Signed the application or enrollment form; and 3. a copy of the application or enrollment form has been given to You or Your Beneficiary. For Life Insurance We will not use Your statements which relate to insurability to contest life insurance after it has been in force for 2 years during Your life. In addition, We will not use such statements to contest an increase or benefit addition to such insurance after the increase or benefit has been in force for 2 years during Your life. For Accidental Death and Dismemberment Insurance We will not use Your statements which relate to insurability to contest Accidental Death and Dismemberment Insurance after it has been in force for 2 years during Your life, unless the statement is fraudulent. In addition, We will not use such statements to contest an increase or benefit addition to such insurance after the increase or benefit has been in force for 2 years during Your life, unless the statement is fraudulent. Misstatement of Age If Your or Your Dependent's age is misstated, the correct age will be used to determine if insurance is in effect and, as appropriate, We will adjust the benefits and/or premiums to the amount of premium that would have been charged, or benefit that would have been provided, in the absence of the misstatement. Conformity with Law If the terms and provisions of this certificate do not conform to any applicable law, this certificate shall be interpreted to so conform. GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 85
GENERAL PROVISIONS (continued) Physical Exams If a claim is submitted for insurance benefits other than life insurance benefits, We have the right to ask the insured to be examined by a Physician(s) of Our choice as often as is reasonably necessary to process the claim. We will pay the cost of such exam. Autopsy We have the right to make a reasonable request for an autopsy where permitted by law. Any such request will set forth the reasons We are requesting the autopsy. GCERT2024-WSHCA-WA-LIFE-EMPLOYEE1 86
THE PRECEDING PAGE IS THE END OF THE CERTIFICATE. THE FOLLOWING IS ADDITIONAL INFORMATION.
If you disagree with a decision about your eligibility or enrollment for life insurance, visit www.hca.wa.gov/pebb-appeals for guidance on filing an appeal. If you disagree with any other decision concerning life insurance, contact MetLife at 1-866-548-7139.
Delaware American Life Insurance Company Metropolitan Life Insurance Company MetLife Health Plans, Inc. Metropolitan Tower Life Insurance Company MetLife Legal Plans, Inc. SafeGuard Health Plans, Inc. MetLife Legal Plans of Florida, Inc. SafeHealth Life Insurance Company Metropolitan General Insurance Company Our Privacy Notice We know that you buy our products and services because you trust us. This notice explains how we protect your privacy and treat your personal information. It applies to current and former customers. “Personal information” as used here means anything we know about you personally. SECTION 1: Plan Sponsors and Group Insurance Contract Holders This privacy notice is for individuals who apply for or obtain our products and services under an employee benefit plan, group insurance or annuity contract, or as an executive benefit. In this notice, “you” refers to these individuals. SECTION 2: Protecting Your Information We take important steps to protect your personal information. We treat it as confidential. We tell our employees to take care in handling it. We limit access to those who need it to perform their jobs. Our outside service providers must also protect it, and use it only to meet our business needs. We also take steps to protect our systems from unauthorized access. We comply with all laws that apply to us. SECTION 3: Collecting Your Information We typically collect your name, address, age, and other relevant information. We may also collect information about any business you have with us, our affiliates, or other companies. Our affiliates include life, car, and home insurers. They also include a legal plans company, and a securities broker-dealer. In the future, we may also have affiliates in other businesses. SECTION 4: How We Get Your Information We get your personal information mostly from you. We may also use outside sources to help ensure our records are correct and complete. These sources may include consumer reporting agencies, employers, other financial institutions, adult relatives, and others. These sources may give us reports or share what they know with others. We don’t control the accuracy of information outside sources give us. If you want to make any changes to information we receive from others about you, you must contact those sources. We may ask for medical information. The Authorization that you sign when you request insurance permits these sources to tell us about you. We may also, at our expense: Ask for a medical exam Ask for blood and urine tests Ask health care providers to give us health data, including information about alcohol or drug abuse We may also ask a consumer reporting agency for a “consumer report” about you (or anyone else to be insured). Consumer reports may tell us about a lot of things, including information about: Reputation Driving record Finances Work and work history Hobbies and dangerous activities The information may be kept by the consumer reporting agency and later given to others as permitted by law. The agency will give you a copy of the report it provides to us, if you ask the agency and can provide adequate identification. If you write to us and we have asked for a consumer report about you, we will tell you so and give you the name, address and phone number of the consumer reporting agency. CPN–Initial Enr/SOH and SBR (08/21) Page 1
Another source of information is MIB, Inc. (“MIB”). It is a not-for-profit membership organization of insurance companies which operates an information exchange on behalf of its Members. We, or our reinsurers, may make a brief report to MIB. If you apply to another MIB Member company for life or health insurance coverage, or a claim for benefits is submitted, MIB, upon request, will supply such company with the information in its file. Upon receipt of a request from you MIB will arrange disclosure of any information it may have in your file. Please contact MIB at 866-692-6901. If you question the accuracy of information in MIB’s file, you may contact MIB and seek a correction in accordance with the procedures set forth in the federal Fair Credit Reporting Act. You may do so by writing to MIB, Inc., 50 Braintree Hill, Suite 400, Braintree, MA 02184- 8734 or go to MIB website at www.mib.com. SECTION 5: Using Your Information We collect your personal information to help us decide if you’re eligible for our products or services. We may also need it to verify identities to help deter fraud, money laundering, or other crimes. How we use this information depends on what products and services you have or want from us. It also depends on what laws apply to those products and services. For example, we may also use your information to: administer your products and services process claims and other transactions perform business research confirm or correct your information market new products to you help us run our business comply with applicable laws SECTION 6: Sharing Your Information With Others We may share your personal information with others with your consent, by agreement, or as permitted or required by law. We may share your personal information without your consent if permitted or required by law. For example, we may share your information with businesses hired to carry out services for us. We may also share it with our affiliated or unaffiliated business partners through joint marketing agreements. In those situations, we share your information to jointly offer you products and services or have others offer you products and services we endorse or sponsor. Before sharing your information with any affiliate or joint marketing partner for their own marketing purposes, however, we will first notify you and give you an opportunity to opt out. Other reasons we may share your information include: doing what a court, law enforcement, or government agency requires us to do (for example, complying with search warrants or subpoenas) telling another company what we know about you if we are selling or merging any part of our business giving information to a governmental agency so it can decide if you are eligible for public benefits giving your information to someone with a legal interest in your assets (for example, a creditor with a lien on your account) giving your information to your health care provider having a peer review organization evaluate your information, if you have health coverage with us those listed in our “Using Your Information” section above SECTION 7: HIPAA We will not share your health information with any other company – even one of our affiliates – for their own marketing purposes. The Health Insurance Portability and Accountability Act (“HIPAA”) protects your information if you request or purchase dental, vision, long-term care and/or medical insurance from us. HIPAA limits our ability to use and disclose the information that we obtain as a result of your request or purchase of insurance. Information about your rights under HIPAA will be provided to you with any dental, vision, long- term care or medical coverage issued to you. You may obtain a copy of our HIPAA Privacy Notice by visiting our website at www.MetLife.com. For additional information about your rights under HIPAA; or to have a HIPAA Privacy Notice mailed to you, contact us at [email protected], or call us at telephone number (212) 578-0299. SECTION 8: Accessing and Correcting Your Information CPN–Initial Enr/SOH and SBR (08/21) Page 2
You may ask us for a copy of the personal information we have about you. We will provide it as long as it is reasonably locatable and retrievable. You must make your request in writing listing the account or policy numbers with the information you want to access. For legal reasons, we may not show you privileged information relating to a claim or lawsuit, unless required by law. If you tell us that what we know about you is incorrect, we will review it. If we agree, we will update our records. Otherwise, you may dispute our findings in writing, and we will include your statement whenever we give your disputed information to anyone outside MetLife. SECTION 9: Questions We want you to understand how we protect your privacy. If you have any questions or want more information about this notice, please contact us. A detailed notice shall be furnished to you upon request. When you write, include your name, address, and policy or account number. Send privacy questions to: MetLife Privacy Office P. O. Box 489 Warwick, RI 02887-9954 [email protected] We may revise this privacy notice. If we make any material changes, we will notify you as required by law. We provide this privacy notice to you on behalf of the MetLife companies listed at the top of the first page. CPN–Initial Enr/SOH and SBR (08/21) Page 3