This schedule shows the benefits, amounts of insurance, waiting periods and maximum amounts which apply
to coverages for which you are insured under the Group Plan. The subsequent pages of this Certificate
describe the benefits and general provisions of your plan of insurance.
PART I-Employee Basic Term Life
200% of the employee's annual earnings, rounded to the next higher $1,000.00, if not already a multiple thereof, to a maximum of $250,000.00 .
Insurance amounts on employees age 70 or higher, will be limited as explained below. The limited amount is in place of the amount which otherwise applies to the employee's class. But, in no event will any employee's insurance be limited under this provision to less than $1,000.00.
For employees whose insurance starts on the plan effective date:
(a) If an employee is less than age 70 when his insurance starts, the amount will be cutback on his 70th birthday by 50% of the amount that otherwise applies to his class; and
(b) If an employee is age 70 or higher when his insurance starts, then his initial amount will be cutback by 50% of the amount which otherwise applies to his class.
For employees whose insurance starts after the plan effective date:
(a) If an employee is less than age 70 when his insurance starts, the amount will be cutback on his 70th birthday by 50 % of the amount that otherwise applies to his class; and
(b) If an employee is age 70 or higher when his insurance starts, then we limit the amount of insurance available, as explained below:
If the employee provides us with evidence of insurability, and we approve it in writing, the amount of his insurance will be 50% of the amount of insurance usually applicable to the class of employees to which he belongs.
If the employee does not provide us with evidence of insurability which is satisfactory to us, his amount of insurance will be limited to $1,000.00.
If an employee's insurance continues during disability (whether or not under the extended life benefit provisions of this plan), or during leave of absence or temporary lay-off, his insurance amount is the amount he was insured for on his last day of active work. But such insurance amount is still subject to any age limitation described above,
The amount of an employee's insurance shall be redetermined as of each change in earnings, to an amount determined in accordance with the table shown above, on the basis of the employee's then current annual earnings, provided the employee is actively at work on full-time on that date. Otherwise, such insurance shall be redetermined on the date he returns to active work on full-time. However, any employee whose benefits were previously reduced because of an age limitation will be retained at the reduced benefits.
Earnings, with respect to life coverages, means an employee's earnings exclusive of bonus, overtime pay or other special forms of remuneration. In the case of weekly earnings, it refers only to those earnings for a normal work week not exceeding forty hours.
CGP-3-SI
PART 2-Dependent Term Life
Spouse $5,000.00
Dependent Child - Age at Death
In no event shall a dependent's term life amount exceed 50% of the employee's term life amount.
PART 3-Employee Long Term Disability Income Insurance
Gross Monthly Benefit
70% of an employee's prior monthly
earnings, rounded to the nearest $1.00, if not already a multiple thereof, to a maximum of $10,000.00 .
We integrate an employee's Gross Monthly Benefit with certain other income he may receive. Read all of the terms of this plan to see what income we integrate with, and how.
Benefit Waiting Period:
For disability due to injury - 60 days
For disability due to sickness - 60 days
Maximum Payment Period:
For a disability starting before the employee reaches age 60, the maximum payment period will last until the Social Security Normal Retirement Age as shown in the following table:
| Employee's year of Birth | Social Security Normal Retirement Age |
| Before 1938 | 65 |
| 1938 | 65 and 2 months |
| 1939 | 65 and 4 months |
| 1940 | 65 and 6 months |
| 1941 | 65 and 8 months |
| 1942 | 65 and 10 months |
| 1943-1954 | 66 |
| 1955 | 66 and 2 months |
| 1956 | 66 and 4 months |
| 1957 | 66 and 6 months |
| 1958 | 66 and 8 months |
| 1959 | 66 and 10 months |
| After 1959 | 67 |
| Age When Disability Starts | Maximun Payment Period |
| Age 60 | 5 years |
| Age 61 | 4 years |
| Age 62 | 3 1/2 years |
| Age 63 | 3 years |
| Age 64 | 2 1/2 years |
| Age 65 | 2 years |
| Age 66 | 1 3/4 years |
| Age 67 | 1 1/2 years |
| Age 68 | 1 1/4 years |
| Age 69 or Older | 1 year |
But if an employee whose disability starts after age 60 reaches the end of the maximum payment from this table before he reaches the Social Security Normal Retirement Age, we will extend his maximum payment period until he reaches Social Security Normal Retirement Age.
Survivor's Benefit -3 times the deceased employee's last computed Gross Monthly Benefit.
Maximum number of indexing
factor adjustments -Unlimited
For Long Term Disability Income Insurance, monthly earnings means an employee's rate of monthly earnings. Bonuses, commissions, expense accounts, overtime pay and any other extra compensation are excluded. But, any employee compensation which is deposited into a cash or deferred compensation plan, or a salary reduction plan, qualified under IRC Section 401 (k) is included.
Subject to any proof of insurability requirements set forth above, as of the date of each change in an employee's earnings, we use the employee's then current monthly earnings to set rates and to project the employee's gross monthly benefit for billing purposes. But, the employee must be actively at work on a full-time basis on that date. If he is not, we do this on the date he returns to active full-time work.
PART 4-Employee and Dependent Prescription Drug Expense Insurance
Any increase or decrease in the amount of insurance on any individual shall become effective on the effective date of a change in the Employee's classification, except that any increase in the amount of insurance on an Employee or a Qualified Dependent eligible for benefits under an established benefit period shall become effective:
In no event shall the insurance of an Eligible Dependent of an Employee who is not actively at work on a full-time basis be increased or decreased prior to the date such Employee returns to active work on a full-time basis.
If an insured Employee's classification changes, the Employee's insurance shall be adjusted automatically to conform to the new classification on the first day on which he is actively at work on full-time and makes a contribution, if required, applicable to the new classification; provided that if thirty-one days elapse after a change to a classification for which a larger amount of insurance is provided, and the Employee fails to make a contribution, if required, applicable to the new classification by the first day thereafter on which he is actively at work on full-time, no increase shall be allowed as a result of such change or any subsequent change unless the Employee furnishes evidence of insurability satisfactory to the Insurance Company. However, any Employee whose benefits were previously reduced because of an age limitation will be retained at the reduced benefits.
All coverages terminate at retirement.
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