Document Woodburn_doc_6f999ee5dc

Statutory Life YOUR BENEFIT PLAN WOODBURN All Eligible Police Officers ---PAGE BREAK--- ---PAGE BREAK--- Questions or Complaints about Your Coverage In the event You have questions or complaints regarding any aspect of Your coverage, You should contact Your Employee Benefits Manager or You may write to us at: The Hartford Group Benefits Division, Customer Service P.O. Box 2999 Hartford, CT 06104-2999 Or call Us at: 1-[PHONE REDACTED] When calling, please give Us the following information: 1) the policy number; and 2) the name of the policyholder (employer or organization), as shown in Your Certificate of Insurance. Or You may contact Our Sales Office: Hartford Life and Accident Insurance Company Group Sales Department 520 Pike Street Suite 905 Seattle, WA 98101 TOLL FREE: [PHONE REDACTED] FAX: [PHONE REDACTED] If you have a complaint, and contacts between you and the insurer or an agent or other representative of the insurer have failed to produce a satisfactory solution to the problem, the following states require we provide you with additional contact information: For residents of: Write Telephone Arkansas Arkansas Insurance Department 1(800) 852-5494 Consumer Services Division 1(501) 371-2640 (in the Little Rock area) 1200 West Third Street Little Rock, AR 72201-1904 California State of California Insurance Department 1(800) 927-HELP Consumer Communications Bureau 300 South Spring Street, South Tower Los Angeles, CA 90013 Idaho Idaho Department of Insurance 1-[PHONE REDACTED] or www.DOI.Idaho.gov Consumer Affairs 700 W State Street, 3rd Floor PO Box 83720 Boise, ID 83720-0043 Illinois Illinois Department of Insurance Consumer Assistance: 1(866) 445-5364 Consumer Services Station Officer of Consumer Health Insurance: Springfield, Illinois 62767 1(877) 527-9431 Indiana Public Information/Market Conduct Consumer Hotline: 1(800) 622-4461 Indiana Department of Insurance 1(317) 232-2395 (in the Indianapolis Area) 311 W. Washington St. Suite 300 Indianapolis, IN 46204-2787 Virginia Life and Health Division 1(804) 371-9741 (inside Virginia) Bureau of Insurance 1(800) 552-7945 (outside Virginia) P.O. Box 1157 Richmond, VA 23209 Wisconsin Office of the Commissioner of Insurance 1(800) 236-8517 (outside of Madison) Complaints Department 1(608) 266-0103 (in Madison) P.O. Box 7873 to request a complaint form. ---PAGE BREAK--- Madison, WI 53707-7873 The following states require that We provide these notices to You about Your coverage: For residents of: Arizona This certificate of insurance may not provide all benefits and protections provided by law in Arizona. Please read This certificate carefully. Florida The benefits of the policy providing you coverage are governed primarily by the law of a state other than Florida. STATE OF DELAWARE The Civil Union and Equality Act of 2011 Effective January 1, 2012 In accordance with Delaware law, insurers are required to provide the following notice to applicants of insurance policies issued in Delaware. The Civil Union and Equality Act of 2011 (“the Act”) creates a legal relationship between two persons of the same sex who form a civil union. The Act provides that the parties to a civil union are entitled to the same legal obligations, responsibilities, protections and benefits that are afforded or recognized by the laws of Delaware to spouses in a legal marriage. The law further provides that a party to a civil union shall be included in any definition or use of the terms “spouse,” “family,” “immediate family,” “dependent,” “next of kin,” and other terms descriptive of spousal relationships as those terms are used throughout Delaware law. This includes the terms “marriage” or “married,” or variations thereon. Insurance policies are required to provide identical benefits and protections to both civil unions and marriages. If policies of insurance provide coverage for children, the children of civil unions must also be provided coverage. The Act also requires recognition of same sex civil unions or marriages legally entered into in other jurisdictions. For more information regarding the Act, refer to Chapter 2 of Title 13 of the Delaware Code or the State of Delaware website at www.delaware.gov/CivilUnions. Georgia The laws of the state of Georgia prohibit insurers from unfairly discriminating against any person based upon his or her status as a victim of family abuse. STATE OF ILLINOIS The Religious Freedom Protection and Civil Union Act Effective June 1, 2011 In accordance with Illinois law, insurers are required to provide the following notice to applicants of insurance policies issued in Illinois. The Religious Freedom Protection and Civil Union Act (“the Act”) creates a legal relationship between two persons of the same or opposite sex who form a civil union. The Act provides that the parties to a civil union are entitled to the same legal obligations, responsibilities, protections and benefits that are afforded or recognized by the laws of Illinois to spouses. The law further provides that a party to a civil union shall be included in any definition or use of the terms “spouse,” “family,” “immediate family,” “dependent,” “next of kin,” and other terms descriptive of spousal relationships as those terms are used throughout Illinois law. This includes the terms “marriage” or “married,” or variations thereon. Insurance policies are required to provide identical benefits and protections to both civil unions and marriages. If policies of insurance provide coverage for children, the children of civil unions must also be provided coverage. The Act also requires recognition of civil unions or same sex civil unions or marriages legally entered into in other jurisdictions. ---PAGE BREAK--- For more information regarding the Act, refer to 750 ILCS 75/1 et seq. Examples of the interaction between the Act and existing law can be found in the Illinois Insurance Facts, Civil Unions and Insurance Benefits document available on the Illinois Department of Insurance’s website at www.insurance.illinois.gov. Maine The laws of the State of Maine require notification of the right to designate a third party to receive notice of cancellation, to change the designation and, policy reinstatement if the insured suffers from organic brain disease and the ground for cancellation was the insured's nonpayment of premium or other lapse or default on the part of the insured. Within 10 days after a request by an insured, a Third Party Notice Request Form shall be mailed or personally delivered to the insured. Maryland The group insurance policy providing coverage under this certificate was issued in a jurisdiction other than Maryland and may not provide all of the benefits required by Maryland law. Massachusetts As of January 1, 2009, the Massachusetts Health Care Reform Law requires that Massachusetts residents, eighteen (18) years of age and older, must have health coverage that meets the Minimum Creditable Coverage standards set by the Commonwealth Health Insurance Connector, unless waived from the health insurance requirement based on affordability or individual hardship. For more information call the Connector at 1-877-MA- ENROLL or visit the Connector website (www.mahealthconnector.org ) . This plan is not intended to provide comprehensive health care coverage and does not meet Minimum Creditable Coverage standards, even if it does include services that are not available in the insured’s other health plans. If you have questions about this notice, you may contact the Division of Insurance by calling (617) 521-7794 or visiting its website at www.mass.gov/doi. Montana Conformity with Montana statutes: The provisions of this certificate conform to the minimum requirements of Montana law and control over any conflicting statutes of any state in which the insured resides on or after the effective date of this certificate. North Carolina UNDER NORTH CAROLINA GENERAL STATUTE SECTION 58-50-40, NO PERSON, EMPLOYER, FINANCIAL AGENT, TRUSTEE, OR THIRD PARTY ADMINISTRATOR, WHO IS RESPONSIBLE FOR THE PAYMENT OF GROUP LIFE INSURANCE, GROUP HEALTH OR GROUP HEALTH PLAN PREMIUMS, SHALL: 1) CAUSE THE CANCELLATION OR NONRENEWAL OF GROUP LIFE INSURANCE, GROUP HEALTH INSURANCE, HOSPITAL, MEDICAL, OR DENTAL SERVICE CORPORATION PLAN, MULTIPLE EMPLOYER WELFARE ARRANGEMENT, OR GROUP HEALTH PLAN COVERAGES AND THE CONSEQUENTIAL LOSS OF THE COVERAGES OF THE PERSON INSURED, BY WILLFULLY FAILING TO PAY THOSE PREMIUMS IN ACCORDANCE WITH THE TERMS OF THE INSURANCE OR PLAN CONTRACT; AND 2) WILLFULLY FAIL TO DELIVER, AT LEAST 45 DAYS BEFORE THE TERMINATION OF THOSE COVERAGES, TO ALL PERSONS COVERED BY THE GROUP POLICY WRITTEN NOTICE OF THE PERSON'S INTENTION TO STOP PAYMENT OF PREMIUMS. VIOLATION OF THIS LAW IS A FELONY. ANY PERSON VIOLATING THIS LAW IS ALSO SUBJECT TO A COURT ORDER REQUIRING THE PERSON TO COMPENSATE PERSONS INSURED FOR EXPENSES OR LOSSES INCURRED AS A RESULT OF THE TERMINATION OF THE INSURANCE. IMPORTANT TERMINATION INFORMATION ---PAGE BREAK--- YOUR INSURANCE MAY BE CANCELLED BY THE COMPANY. PLEASE READ THE TERMINATION PROVISION IN THIS CERTIFICATE. THIS CERTIFICATE OF INSURANCE PROVIDES COVERAGE UNDER A GROUP MASTER POLICY. THIS CERTIFICATE PROVIDES ALL OF THE BENEFITS MANDATED BY THE NORTH CAROLINA INSURANCE CODE, BUT YOU MAY NOT RECEIVE ALL OF THE PROTECTIONS PROVIDED BY A POLICY ISSUED IN NORTH CAROLINA AND GOVERNED BY ALL OF THE LAWS OF NORTH CAROLINA. Texas IMPORTANT NOTICE AVISO IMPORTANTE To obtain information or make a complaint: Para obtener informacion o para someter una queja: You may call The Hartford's toll-free telephone number for information or to make a complaint at: Usted puede llamar al numero de telefono gratis de The Hartford para informacion o para someter una queja al: 1-[PHONE REDACTED] 1-[PHONE REDACTED] You may also write to The Hartford at: Usted tambien puede escribir a The Hartford: P.O. Box 2999 P.O. Box 2999 Hartford, CT 06104-2999 Hartford, CT 06104-2999 You may contact the Texas Department of Insurance to obtain information on companies, coverages, rights or complaints at: Puede comunicarse con el Departamento de Seguros de Texas para obtener informacion acerca de companias, coberturas, derechos o quejas al: 1-[PHONE REDACTED] 1-[PHONE REDACTED] You may write the Texas Department of Insurance at: Puede escribir al Departamento de Seguros de Texas: P.O. Box 149104 P.O. Box 149104 Austin, TX 78714-9410 Austin, TX 78714-9410 Fax # (512) 475-1771 Web: http://www.tdi.state.tx.us E-mail: [EMAIL REDACTED] Fax # (512) 475-1771 Web: http://www.tdi.state.tx.us E-mail: [EMAIL REDACTED] PREMIUM OR CLAIM DISPUTES: DISPUTAS SOBRE PRIMAS O RECLAMOS: Should you have a dispute concerning your premium or about a claim you should contact the agent or The Hartford first. If the dispute is not resolved, you may contact the Texas Department of Insurance. Si tiene una disputa concerniente a su prima o a un reclamo, debe comunicarse con el agente o The Hartford primero. Si no se resuelve la disputa, puede entonces comunicarse con el departamento (TDI). ATTACH THIS NOTICE TO YOUR POLICY: UNA ESTE AVISO A SU POLIZA: This notice is for information only and does not become a part or condition of the attached document. Este aviso es solo para proposito de informacion y no se convierte en parte o condicion del documento adjunto. ---PAGE BREAK--- Form GBD-1100 ODB (10/08) (398260) (398257) 8.1 Group Term Life Insurance HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY 200 Hopmeadow Street Simsbury, Connecticut 06089 (A stock insurance company) CERTIFICATE OF INSURANCE Policyholder: THE TRUSTEES OF THE CIS TRUST Policy Number: GL-398260 Participating Employer: WOODBURN Policy Effective Date: August 1, 2009 Account Number: 398257 Policy Anniversary Date: January 1, 2013 Participating Employer Effective Date: August 1, 2009 Participating Employer Anniversary Date: January 1, 2013 We have issued The Policy to the Policyholder to extend coverage to eligible Employees of each Participating Employer. Our name, the Policyholder's name, the Participating Employer's name, the Policy Number and the Account Number are shown above. The provisions of The Policy, which are important to You, are summarized in this certificate consisting of this form and any additional forms which have been made a part of this certificate. This certificate replaces any other certificate We may have given to You earlier under The Policy. The Policy alone is the only contract under which payment will be made. Any difference between The Policy and this certificate will be settled according to the provisions of The Policy on file with Us at Our home office. The Policy may be inspected at the office of the Policyholder. Signed for the Company Terence Shields, Secretary Ronald R. Gendreau, President A note on capitalization in this Certificate: Capitalization of a term, not normally capitalized according to the rules of standard punctuation, indicates a word or phrase that is a defined term in The Policy or refers to a specific provision contained herein. ---PAGE BREAK--- 8 TABLE OF CONTENTS SCHEDULE OF Cost of Coverage Eligible Class(es) for Eligibility Waiting Period for Coverage Benefit ELIGIBILITY AND ENROLLMENT Eligible Persons Eligibility for PERIOD OF Effective Life Insurance Conversion GENERAL AMENDATORY ---PAGE BREAK--- 9 SCHEDULE OF INSURANCE The benefits described herein are those in effect as of August 10, 2012. Cost of Coverage: Non-Contributory Coverage: Life Insurance Eligible Class(es) For Coverage: All Active Employees who are police officers and are citizens or legal residents of the United States, its territories and protectorates; excluding temporary, leased or seasonal employees. Eligibility Waiting Period for Coverage: None Life Insurance Benefit Amount of Life Insurance: Amount of Life Insurance Maximum Amount $10,000 Reduction in Amount of Life Insurance We will reduce the Amount of Life Insurance for You by any Amount of Life Insurance in force, paid or payable: 1) in accordance with the Conversion Right; or 2) under the Prior Policy. ELIGIBILITY AND ENROLLMENT Eligible Persons: Who is eligible for coverage? All persons in the class or classes shown in the Schedule of Insurance will be considered Eligible Persons. Eligibility for Coverage: When will I become eligible? You will become eligible for coverage on the latest of: 1) the Policy Effective Date; 2) the date You become a member of an Eligible Class; or 3) the date You complete the Eligibility Waiting Period for Coverage shown in the Schedule of Insurance, if applicable. Enrollment: How do I enroll for coverage? For Non-Contributory Coverage, Your Employer will automatically enroll You for coverage. However, You will be required to complete a beneficiary designation form. PERIOD OF COVERAGE Effective Date: When does my coverage start? Coverage will start on the date You become eligible. Termination: When will my coverage end? Your coverage will end on the earliest of the following: 1) the date The Policy terminates; 2) the date You are no longer in a class eligible for coverage, or the class is cancelled; ---PAGE BREAK--- 10 3) the date the premium payment is due but not paid; 4) the date Your Employer terminates Your employment; 5) the date Your Employer ceases to be a Participating Employer; or 6) the date You are no longer Actively at Work. BENEFITS Life Insurance Benefit: When is the Life Insurance Benefit payable? If You suffer a Loss of life as the result of a Covered Occupational Death, We will pay an Occupational Death Benefit if Your Death: 1) occurred within 365 days after the date You were last Actively at Work; and 2) occurred while You were covered under The Policy. Covered Occupational Death means a death caused by or resulting from: 1) an Injury sustained during working hours as an Employee of the Employer, or in the case of a required period of work not coinciding with regular work hours, while in transit to or from work; 2) any disease or infection which arises out of the scope of active employment as an Employee and to which You are not ordinarily exposed, if Your death occurs within 365 days after the date You were subjected or exposed to the disease or infection; 3) Silicosis and You were treated by a Physician within 90 days after You were last Actively at Work; 4) cardiovascular or hypertension disease if You were Actively at Work for 31 days or more and: a) death occurs within 365 days after You were last Actively at Work; and b) were treated by a Physician within 90 days after Your were last Actively at Work; 5) any disease of the lungs or respiratory tract or renal disease, if: a) You were Actively at Work for 31 days or more; and b) death occurs within 365 days after You were last Actively at Work; and c) Your death occurs within 365 days after You were first treated by a Physician for the disease. Injury means bodily injury resulting: 1) directly from an accident; and 2) independently of all other causes; which occurs while You are covered under The Policy. Loss resulting from: 1) sickness or disease, except a pus-forming infection which occurs through an accidental wound; or 2) medical or surgical treatment of a sickness or disease; is not considered as resulting from Injury. Silicosis means a disease of the lungs caused by breathing silica dust producing fibrous nodules, distributed through the lungs and demonstrated by x-ray or autopsy. No benefit will be payable for any death for which benefits are payable under any individual insurance policy obtained by exercising Your Conversion Right. The specific amounts for this Benefit are shown in the Schedule of Insurance. Conversion Right: If coverage under The Policy ends, do I have a right to convert? If Life Insurance coverage or any portion of it under The Policy ends for any reason, You have the right to convert the coverage that terminated to an individual conversion policy without providing Evidence of Insurability. Conversion is not available for any Amount of Life Insurance for which You were not eligible and covered under The Policy. If coverage under The Policy ends because: 1) The Policy is terminated; or, 2) coverage for an Eligible Class is terminated; or 3) Your Employer is no longer a Participating Employer; then You must have been insured under The Policy for 5 years or more, in order to be eligible to convert coverage. The amount which may be converted under these circumstances is limited to the lesser of: 1) $10,000; or ---PAGE BREAK--- 11 2) the Life Insurance Benefit under The Policy less any Amount of Life Insurance for which You may become eligible under any group life insurance policy issued or reinstated within 31 days of termination of group life coverage. If coverage under The Policy ends for any other reason, the full amount of coverage which ended may be converted. Conversion: How do I convert my coverage? To convert Your coverage You must: 1) complete a Notice of Conversion Right form; and 2) have Your Employer sign the form. The Insurer must receive this within: 1) 31 days after Life Insurance terminates; or 2) 15 days from the date Your Employer signs the form; whichever is later. However, We will not accept requests for Conversion if they are received more than 91 days after Life Insurance terminates. After the Insurer verifies eligibility for coverage, the Insurer will send You a Conversion Policy proposal. You must: 1) complete and return the request form in the proposal; and 2) pay the required premium for coverage; within the time period specified in the proposal. Any individual policy issued to You under the Conversion Right: 1) will be effective as of the 32nd day after the date coverage ends; and 2) will be in lieu of coverage for this amount under The Policy. Conversion Policy Provisions: What are the Conversion Policy provisions? The Conversion Policy will: 1) be issued on any one of the Life Insurance policy forms the Insurer is issuing for this purpose at the time of conversion; and 2) base premiums on the Insurer's rates in effect for new applicants of Your class and age at the time of conversion. The Conversion Policy will not provide: 1) the same terms and conditions of coverage as The Policy; and 2) term insurance. Death within the Conversion Period: What if I die before coverage is converted? We will pay the Amount of Life Insurance You would have had the right to apply for under this provision if: 1) coverage under The Policy terminates; and 2) You die within 31 days of the date coverage terminates; and 3) We receive Proof of Loss. If the Conversion Policy has already taken effect, no Life Insurance Benefit will be payable under The Policy for the amount converted. GENERAL PROVISIONS Notice of Claim: When should I notify the Company of a claim? You, or the person who has the right to claim benefits, must give Us, written notice of a claim within 30 days after the date of death. If notice cannot be given within that time, it must be given as soon as reasonably possible after that. Such notice must include the claimant’s name, address, account number, and the Policy Number. Claim Forms: Are special forms required to file a claim? Within days of receiving a Notice of Claim, We will send forms to the claimant to provide Proof of Loss. If We do not send the forms within 15 days, any other written proof which fully describes the nature and extent of the claim may be submitted. Proof of Loss: What is Proof of Loss? Proof of Loss may include, but is not limited to, the following: ---PAGE BREAK--- 12 1) a completed claim form; 2) a certified copy of the death certificate (if applicable); 3) Your Enrollment form; 4) Your Beneficiary Designation (if applicable); 5) documentation of: a) the date Your disability began; b) the cause of Your disability; and c) the prognosis of Your disability; 6) any and all medical information, including x-ray films and photocopies of medical records, including histories, physical, mental or diagnostic examinations and treatment notes; 7) the names and addresses of all: a) Physicians or other qualified medical professionals You have consulted; b) hospitals or other medical facilities in which You have been treated; and c) pharmacies which have filled Your prescriptions within the past three years; 8) Your signed authorization for Us to obtain and release medical, employment and financial information (if applicable); or 9) any additional information required by Us to adjudicate the claim. All proof submitted must be satisfactory to Us. Sending Proof of Loss: When must Proof of Loss be given? Written Proof of Loss should be sent to Us within 90 day(s) after the loss. However, all claims should be submitted to Us within 90 day(s) of the date coverage ends. If proof is not given by the time it is due, it will not affect the claim if: 1) it was not reasonably possible to give proof within the required time; and 2) proof is given as soon as reasonably possible; but 3) not later than 1 year after it is due unless You, or the person who has the right to claim benefits, are not legally competent. Physical Examination and Autopsy: Can We have a claimant examined or request an autopsy? While a claim is pending We have the right at Our expense: 1) to have the person who has a loss examined by a Physician when and as often as We reasonably require; and 2) to have an autopsy performed in case of death where it is not forbidden by law. Claim Payment: When are benefit payments issued? When We determine that benefits are payable, We will pay the benefits in accordance with the Claims to be Paid provision, but not more than 30 days after such Proof of Loss is received. Benefits may be subject to interest payments as required by applicable law. Claims to be Paid: To whom will benefits for my claim be paid? Life Insurance Benefits will be paid in accordance with the life insurance Beneficiary Designation provided it does not contradict the Claim Payment provision. If no beneficiary is named, or if no named beneficiary survives You, We may, at Our option, pay: 1) the executors or administrators of Your estate; 2) all to Your surviving spouse; 3) if Your spouse does not survive You, in equal shares to Your surviving children; or 4) if no child survives You, in equal shares to Your surviving parents. In addition, We may, at Our option, pay a portion of Your Life Insurance Benefit up to $500 to any person equitably entitled to payment by reason of having incurred expenses on Your behalf or because of expenses from Your burial. Payment to any person, as shown above, will release Us from liability for the amount paid. If any beneficiary is a minor, We may pay his or her share, until a legal guardian of the minor’s estate is appointed, to a person who at Our option and in Our opinion is providing financial support and maintenance for the minor. We will pay: 1) $200 at Your death; and 2) installments of not more than $200. Payment to any person as shown above will release Us from all further liability for the amount paid. ---PAGE BREAK--- 13 If benefits are payable and meet Our guidelines, then Your Beneficiary, may elect to receive benefits in a lump sum payment or may elect to receive benefits through a draft book account. The draft book account will be owned by Your beneficiary, in the event of Your death. However, an account will not be established for a benefit payable to Your estate. Beneficiary Designation: How do I designate or change my beneficiary? You may designate or change a beneficiary by doing so in writing on a form satisfactory to Us and filing the form with the Employer. Only satisfactory forms sent to the Employer prior to Your death will be accepted. Beneficiary designations will become effective as of the date You signed and dated the form, even if You have since died. We will not be liable for any amounts paid before receiving notice of a beneficiary change from the Employer. In no event may a beneficiary be changed by a power of attorney. Claim Denial: What notification will my beneficiary receive if a claim is denied? If a claim for benefits is wholly or partly denied, Your beneficiary will be furnished with written notification of the decision. This written notification will: 1) give the specific reason(s) for the denial; 2) make specific reference to the provisions upon which the denial is based; 3) provide a description of any additional information necessary to perfect a claim and an explanation of why it is necessary; and 4) provide an explanation of the review procedure. Claim Appeal: What recourse does my beneficiary have if a claim is denied? On any claim, the claimant or his or her representative may appeal to Us for a full and fair review. To do so, he or she: 1) must request a review upon written application within: a) 180 days of receipt of claim denial if the claim requires Us to make a determination of disability; or b) 60 days of receipt of claim denial if the claim does not require Us to make a determination of disability; and 2) may request copies of all documents, records, and other information relevant to the claim; and 3) may submit written comments, documents, records and other information relating to the claim. We will respond in writing with Our final decision on the claim. Eligibility Determination: How will We determine Your eligibility for benefits? We, and not Your Employer or plan administrator, have the responsibility to fairly, thoroughly, objectively and timely investigate, evaluate and determine Your eligibility for benefits for any claim You or Your beneficiaries make on The Policy. We will: 1) obtain with Your or Your beneficiaries’ cooperation and authorization if required by law, only such information that is necessary to evaluate Your or Your beneficiaries’ claim and decide whether to accept or deny Your or Your beneficiaries’ claim for benefits. We may obtain this information from Your or Your beneficiaries’ Notice of Claim, submitted proofs of loss, statements, or other materials provided by You or others on Your behalf; or, at Our expense We may obtain necessary information, or have You physically examined when and as often as We may reasonably require while the claim is pending. In addition, and at Your or Your beneficiaries’ option and at Your or Your beneficiaries’ expense, You or Your beneficiaries may provide Us and We will consider any other information, including but not limited to, reports from a Physician or other expert of Your or Your beneficiaries’ choice. You or Your beneficiaries should provide Us with all information that You or Your beneficiaries want Us to consider regarding Your or Your beneficiaries’ claim; 2) consider and interpret The Policy and all information obtained by Us and submitted by You or Your beneficiaries that relates to Your or Your beneficiaries’ claim for benefits and make Our determination of Your eligibility for benefits based on that information and in accordance with The Policy and applicable law; 3) if We approve Your claim, We will review Our decision to approve Your or Your beneficiaries claim for benefits as often as is reasonably necessary to determine Your continued eligibility for benefits; 4) if We deny Your or Your beneficiaries’ claim, We will explain in writing to You or Your beneficiaries the basis for an adverse determination in accordance with The Policy as described in the provision entitled Claim Denial. In the event We deny Your or Your beneficiaries’ claim for benefits, in whole or in part, You or Your beneficiaries can appeal the decision to Us. If You or Your beneficiaries choose to appeal Our decision, the process You or Your beneficiaries must follow is set forth in The Policy provision entitled Claim Appeal. If You or Your beneficiaries do not appeal the decision to Us, then the decision will be Our final decision. ---PAGE BREAK--- 14 Incontestability: When can the Life Insurance Benefit of The Policy be contested? Except for non-payment of premiums, Your Life Insurance Benefit cannot be contested after two years from its effective date. In the absence of fraud, no statement made by You relating to Your insurability will be used to contest Your insurance for which the statement was made after Your insurance has been in force for two years. In order to be used, the statement must be in writing and signed by You. All statements made by the Policyholder, the Employer or You under The Policy will be deemed representations and not warranties. No statement made to affect this insurance will be used in any contest unless it is in writing and a copy of it is given to the person who made it, or to his or her beneficiary or Your representative. Assignment: Are there any rights of assignment? You have the right to absolutely assign all of Your rights and interest under The Policy including, but not limited to the following: 1) the right to make any contributions required to keep the insurance in force; 2) the right to convert; and 3) the right to name and change a beneficiary. We will recognize any absolute assignment made by You under The Policy, provided: 1) it is duly executed; and 2) a copy is acknowledged and on file with Us. We and the Policyholder assume no responsibility: 1) for the validity or effect of any assignment; or 2) to provide any assignee with notices which We may be obligated to provide to You. You do not have the right to collaterally assign Your rights and interest under The Policy. Legal Actions: When can legal action be taken against Us? Legal action cannot be taken against Us: 1) sooner than 60 days after the date written Proof of Loss is furnished; or 2) more than 3 years after the date Proof of Loss is required to be furnished according to the terms of The Policy. Workers' Compensation: How does The Policy affect Workers' Compensation coverage? The Policy does not replace Workers' Compensation or affect any requirement for Workers' Compensation coverage. Insurance Fraud: How does the Company deal with fraud? Insurance fraud occurs when You, and/or the Participating Employer provide Us with false information or file a claim for benefits that contains any false, incomplete or misleading information with the intent to injure, defraud or deceive Us. It may be a crime if You, and/or the Employer commit insurance fraud. We will use all means available to Us to detect, investigate, deter and prosecute those who commit insurance fraud. We will pursue all available legal remedies if You and/or the Employer perpetrate insurance fraud. Misstatements: What happens if facts are misstated? If material facts about You were not stated accurately: 1) the premium may be adjusted; and 2) the true facts will be used to determine if, and for what amount, coverage should have been in force. DEFINITIONS Active Employee means a public safety employee while in the line of duty and in accordance with ORS 243.005 who works for the Employer. Actively at Work means performing Your regular duties as a public safety employee for the Employer. Employer means the Participating Employer. ---PAGE BREAK--- 15 Participating Employer means an Employer who agrees to participate in the Trust, pays the required contribution and is a participant in accordance with the provisions of The Policy. Physician means a person who is: 1) a doctor of medicine, Osteopathy, or other legally qualified practitioner of a healing art that We recognize or are required by law to recognize; 2) licensed to practice in the jurisdiction where care is being given; 3) practicing within the scope of that license; and 4) not You or Related to You by blood or marriage. Prior Policy means the group life insurance policy carried by the Employer on the day before the Participating Employer Policy Effective Date and will only include the coverage which is transferred to Us. Related means Your Spouse, or someone in a similar relationship in law to You, or other adult living with You, or Your sibling, parent, step-parent, grandparent, aunt, uncle, niece, nephew, son, daughter, or grandchild. The Policy means the Policy which We issued to the Policyholder under the Policy Number shown on the face page. Trust means the Policyholder stated on the face page of The Policy. We, Us, or Our means the insurance company named on the face page of the certificate. You or Your means the person to whom this Certificate of Insurance is issued. ---PAGE BREAK--- Form PA-9394 ODB (10/08) (398260) 16 (398257) 8.1 Amendatory Rider HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY 200 Hopmeadow Street Simsbury, Connecticut 06089 (A stock insurance company) This rider is attached to a certificate given in connection with The Policy. This rider becomes effective on the certificate effective date. This rider is intended to amend Your certificate, as indicated below, to comply with the laws of Your state of residence. Only those references to benefits, provisions or terms actually included in Your certificate will affect Your coverage. In addition, any reference made herein to Dependent coverage will only apply if Dependent coverage is provided in Your certificate. For California residents: 1) The following is added to the definition of Spouse: Spouse will also include an individual who is in a registered domestic partnership with You in accordance with California law. References to Your marriage or divorce will include Your registered domestic partnership or dissolution of Your registered domestic partnership. 2) The following is added to the definition of Dependent Child(ren): Dependent Child(ren) will also include child(ren) of Your California registered domestic partner. For Colorado residents, the Suicide provision will only exclude amounts of life insurance in effect within the first year of coverage or within the first year following an increase in coverage. For Connecticut residents: 1) The definition of Dependent Child(ren) is amended to include relationships due to domestic partnership. 2) The following is added to the definition of Spouse: Spouse will include Your domestic partner, provided You have executed a domestic partner affidavit satisfactory to Us, establishing that You and Your partner are domestic partners for the purposes of The Policy. You will continue to be considered domestic partners provided You continue to meet the requirements described in the domestic partner affidavit. For Louisiana residents: 1) The age limit stated in the Continuation for Dependent Child(ren) with Disabilities provision is increased to 21, if less than 21. 2) The following provision is added to the PERIOD OF COVERAGE provisions: Reinstatement after Military Service: Can coverage be reinstated after return from active military service? If Your or Your Dependents' coverage ends because You or Your Dependents enter active military service, coverage may be reinstated, provided You request such reinstatement upon Your or Your Dependents' release from active military service. The reinstated coverage will: 1) be the same coverage amounts in force on the date coverage ended; 2) not be subject to any Eligibility Waiting Period for Coverage or Evidence of Insurability; and 3) be subject to all the terms and provisions of The Policy. For Maryland residents: 1) The definition of Dependent Child(ren) is amended to include relationships due to domestic partnership. 2) The following is added to the definition of Spouse: ---PAGE BREAK--- 17 Spouse will include Your domestic partner, provided You have executed a domestic partner affidavit satisfactory to Us, establishing that You and Your partner are domestic partners for the purposes of The Policy. You will continue to be considered domestic partners provided You continue to meet the requirements described in the domestic partner affidavit. For Massachusetts residents, the definition of Terminal Illness or Terminally Ill in the Accelerated Benefit cannot exceed 24 months. For Minnesota residents: 1) The term "granted military leave of absence" in the Military Leave of Absence portion of the Continuation Provisions section, is amended to "documented military leave of absence." 2) The following applies to You if there are more than 25 residents of Minnesota who are covered under The Policy and those 25 residents constitute 25% or more of the total number of people covered under The Policy: The provision titled "Lay Off" is deleted from the Continuation Provisions and is replaced by the following: Lay Off: If You are voluntarily or involuntarily terminated or Laid Off, You may elect to continue Your coverage by making premium payments to the Employer for the cost of continued coverage. You must elect this continued coverage within 60 days from: 1) the date Your coverage would otherwise terminate; or 2) the date You receive a written notice of Your right to continue coverage; whichever is later. The amount of premium charged may not exceed 102% of the premium paid, either by You or the Employer, for life insurance coverage for an Active Employee. The Employer will inform You of: 1) Your right to continue coverage; 2) the amount of premium; and 3) how, where and by when payment must be made. Upon request, the Employer will provide You Our written verification of the cost of coverage. Coverage will continue until the first to occur of: 1) the date You are covered under another group policy; or 2) the last day of the 18th month following the date of termination or layoff. At the end of such 18 month period, You may exercise the Conversion Right if You do so within the time limits described in such provision. However, in lieu of conversion coverage You may accept a policy providing reduced benefits at a reduced premium rate. Minnesota law requires that if Your coverage ends because the Employer fails: 1) to notify You of Your right to continue coverage; or 2) to pay the premium after timely receipt; the Employer will be liable for benefit payments to the extent We would have been liable had You still been covered. Laid Off means that there is a reduction in the number of hours You work for the Employer so that You are no longer eligible for coverage. The term termination does not include discharge for gross misconduct but does include retirement. 3) the 9th paragraph of the Accelerated Benefit provision is deleted. 4) the 2nd, 3rd and 4th paragraphs of the Conversion Right provision are deleted. 5) The first sentence of the 5th paragraph of the Claims to be Paid provision is amended as follows: If benefits are payable and are greater than $15,000, then You or Your beneficiary may request that We pay benefits into a draft book account (checking account) which will be owned by: 1) You, if living; or 2) Your beneficiary, in the event of Your death. For Missouri residents: 1) The time periods stated in the Conditions for Qualification and the Benefit Payable before Approval of Waiver of Premium provisions are changed to 180 days, if greater than180 days. 2) The following language is added to the When Premiums are Waived provision: If Waiver of Premium is approved, it will be retroactive to the date the disability began. Premiums will be waived retrospectively once You have completed the 180 day waiting period. 3) The Suicide provision is replaced by the following: Suicide: What benefit is payable if death is a result of suicide? If You or Your Dependent commit suicide, whether sane or insane, We will not pay any Supplemental Amount of Life Insurance or Supplemental Amount of Dependent Life Insurance for the deceased person which was elected within the 1 year period immediately prior to the date of death. This applies to initial coverage and elected increases in coverage. It does not apply to benefit increases that resulted solely due to an increase in Earnings. If You or Your Dependent die as a result of suicide, whether sane or insane, within 1 year of the Policy effective date, all premiums paid for coverage will be refunded. ---PAGE BREAK--- 18 This 1 year period includes the time group life insurance coverage was in force under the Prior Policy. For Montana residents: 1) The time period stated in the Conversion Right provision is changed to 3 years, if greater than 3 years. 2) The dollar amount stated in the Conversion Right provision is changed to $10,000, if less than $10,000. 3) The 2nd paragraph of the Conversion Policy Provisions is deleted. 4) The dollar amount stated in the second paragraph of the Claims to be Paid provision is changed to $500, if not $500. 5) The following provision is added to the Claims to be Paid provision. Payable Interest: Is interest payable on death claims? Claims payable for loss of life will be paid within 60 days of the date due proof is received. If the claim is paid more than 30 days after the date due proof is received, the amount payable will include interest. Interest will be paid at the discount rate, on 90-day commercial paper, in effect at the Federal Reserve Bank in the Ninth Federal Reserve District on the date due proof is received. For New Hampshire residents: 1) The Waiver of Premium and Disability Extension provision or the Disability Extension provision is deleted 2) The following is added to the end of the first paragraph of the Conversion provision: The Notice of Conversion Right form will be mailed to You within 15 days after the Policy ceases. If notice is given more than 15 days after the Policy ceases, the time You have to convert will be extended for 15 days from the date notice was given. 3) The last sentence of the second paragraph of the Conversion provision is replaced by the following: However, unless you did not have notice, We will not accept requests for Conversion if they are received more than 91 days after Life Insurance terminates. 4) Item #3 in the second paragraph of the Sending Proof of Loss provision is deleted. 5) The dollar amount stated in the third paragraph of the Claims to be Paid provision is changed to $250, if less than $250. 6) The following is added to the Period of Coverage if Spouse Accidental Death and Dismemberment is included in the contract: Spouse Continuation: Can coverage be continued for a divorced Spouse? If You are legally separated or divorced from Your Spouse, coverage for Your former Spouse may continue under The Policy until the earliest of: 1) the last day of the third year following the anniversary of a final divorce or legal separation; 2) the date You remarry; 3) the date Your former Spouse remarries; 4) a date specified in the final divorce decree; 5) the date Your former Spouse fails to pay any premiums that may be due; or 6) the date You die. For North Dakota residents, the Suicide provision will only exclude amounts of life insurance in effect within the first year of coverage or within the first year following an increase in coverage. For South Carolina residents: 1) The dollar amount stated in the third paragraph of the Claims to be Paid provision is changed to $2,000, if greater than $2,000. 2) The lead-in of the second half of the first paragraph of the Continuity from a Prior Policy for Disability Extension provision is amended to read “Your Amount of Insurance will be the greater of the amount of life insurance and accidental death and dismemberment principal sum:” 3) Item 3) The Policy terminates or Your Employer ceases to be a Participating Employer;” of the second paragraph of the Waiver Ceases provision is deleted. 4) Items 1) and 2) of the first paragraph of the Disability Extension Ceases provision are deleted. 5) Item 3) The Policy terminates or Your Employer ceases to be a Participating Employer;” of the Disability Extension Ceases provision is deleted. 6) The following paragraph is added between the first and second paragraphs of the Disability Extension Ceases provision: In the event of Policy termination or Your Employer ceases to be a Participating Employer Your coverage will continue for a period of 12 months from the date of Policy termination as long as premiums are paid when due. This period will be subject to the terms and conditions of this provision. 7) The following paragraph is added between the second and third paragraphs of the Disability Extension Ceases ---PAGE BREAK--- 19 provision: In the event of Policy termination or Your Employer ceases to be a Participating Employer Dependent coverage will continue for a period of 12 months from the date of Policy termination as long as premiums are paid when due. This period will be subject to the terms and conditions of this provision. 8) The following paragraph is added at the end of the Disability Extension Ceases provision: When the 12 month extension period ceases after The Policy terminates, coverage will end and You may be eligible to exercise the Conversion Right for You and Your Dependents if You do so within the time limits described in such provision. The Amount of Life Insurance that may be converted will be subject to the terms and conditions of the Conversion Right. Portability will not be available. 9) Item 1) of the last paragraph of the Effect of Policy Termination provision is amended to read: “Your Dependent coverage will continue for a period of 12 months from the date of Policy Termination and will be subject to the terms and conditions of this provision; and” For South Dakota residents: The definition of Physician is deleted and replaced by the following: Physician means a person who is: 1) a doctor of medicine, osteopathy, or other legally qualified practitioner of a healing art that We recognize or are required by law to recognize; 2) licensed to practice in the jurisdiction where care is being given; 3) practicing within the scope of that license; and 4) not You or Your Spouse or Related to You or Your Spouse by blood or marriage, unless such physician is the only one in the area and is acting within the scope of their normal employment. For Utah residents: 1) The time period stated in the Claim Forms provision is changed to 15 days. 2) Item 3 of the second paragraph of the Sending Proof of Loss provision is deleted. 3) The time period stated in the Claim Payment provision is changed to 45 days if more than 45 days. 4) The provision titled Policy Interpretation is replaced in its entirety as follows: Policy Interpretation: Who interprets the terms and conditions of the Policy? Benefits under this plan will be paid only if We decide in Our discretion that You or Your Dependents are entitled to them. We also have discretion to determine eligibility for benefits and to interpret the terms and conditions of the benefit plan. Determinations made by Us pursuant to this reservation of discretion do not prohibit or prevent You or Your Dependents from seeking judicial review in federal court of Our determinations. The reservation of discretion made under this provision only establishes the scope of review that a federal court will apply when You or Your Dependents seek judicial review of Our determination of eligibility for benefits, the payment of benefits, or interpretation of the terms and conditions applicable to the benefit plan. We are an insurance company that provides insurance to this benefit plan and the federal court will determine the level of discretion that it will accord to Our determinations. 5) The phrase "In the absence of fraud" is deleted from the second paragraph of the Incontestability provision. 6) The following “Sickness or Injury” continuation, will apply if the continuation included is for less than 6 months, or is added to the Continuation Provisions if not already included: Sickness or Injury: If You are not Actively at Work due to sickness or injury, all of Your coverages (including Dependent Life coverage) may be continued: 1) for a period of 6 consecutive months from the date You were last Actively at Work; or 2) if such absence results in a leave of absence in accordance with state or federal family and medical leave laws, then the combined continuation period will not exceed 6 consecutive months. For Vermont residents: The following Endorsement applies: Purpose: This endorsement is intended to provide benefits for parties to a civil union. Vermont law requires that insurance contracts and policies offered to married persons and their families be made available to parties to a ---PAGE BREAK--- 20 civil union and their families. In order to receive benefits in accordance with this endorsement, the civil union must have been established in the state of Vermont according to Vermont law. General Definitions, Terms, Conditions and Provisions: The general definitions, terms, conditions or any other provisions of the policy, contract, certificate and/or riders and endorsements to which this mandatory endorsement is attached are hereby amended and superseded as follows: 1) Terms that mean or refer to a marital relationship or that may be construed to mean or refer to a marital relationship: such as "marriage", "spouse", "husband", "wife", "dependent", "next of kin", "relative", "beneficiary", "survivor", "immediate family" and any other such terms include the relationship created by a civil union. 2) Terms that mean or refer to a family relationship arising from a marriage such as "family", "immediate family", "dependent", "children", "next of kin", "relative", "beneficiary", "survivor" and any other such terms include the family relationship created by a civil union. 3) Terms that mean or refer to the inception or dissolution of a marriage, such as "date of marriage", "divorce decree", "termination of marriage" and any other such terms include the inception or dissolution of a civil union. 4) "Dependent" means a spouse, a party to a civil union, and/or a child or children (natural, stepchild, legally adopted or a minor who is dependent on the insured for support and maintenance) who is born to or brought to a marriage or to a civil union. 5) "Child or covered child" means a child (natural, step-child, legally adopted or a minor who is dependent on the insured for support and maintenance) who is born to or brought to a marriage or to a civil union. Cautionary Disclosure: THIS RIDER IS ISSUED TO MEET THE REQUIREMENTS OF VERMONT LAW AS EXPLAINED IN THE "PURPOSE" PARAGRAPH OF THE RIDER. THE FEDERAL GOVERNMENT OR ANOTHER STATE GOVERNMENT MAY NOT RECOGNIZE THE BENEFITS GRANTED UNDER THIS RIDER. YOU ARE ADVISED TO SEEK EXPERT ADVICE TO DETERMINE YOUR RIGHTS UNDER THIS CONTRACT. For Virginia residents, any and all references to Domestic Partners are hereby deleted. For Washington residents: 1) The provision titled Disputed Diagnosis is added as follows: Disputed Diagnosis: What happens if a dispute occurs over whether I am Terminally Ill or my Dependent is Terminally Ill? If Your or Your Dependent's attending Physician, and a Physician appointed by Us, disagree on whether You or Your Dependent are Terminally Ill, Our Physician’s opinion will not be binding upon You or Your Dependent. The two parties shall attempt to resolve the matter and amicably. If the disagreement is not resolved, You or Your Dependent have the right to mediation or binding arbitration conducted by a disinterested third party who has no ongoing relationship with either You or Your Dependent or Us. Any such arbitration shall be conducted in accordance with the laws of the State of Washington. As part of the final decision, the arbitrator or mediator shall award the costs of the arbitrator to one party or the other, or may divide the costs equally or otherwise. 2) The Labor Dispute continuation provision is replaced with the following: Labor Dispute: If You are not Actively at Work as the result of a labor dispute, all of Your coverages (including Dependent Life coverage) may be continued during such dispute for a period not exceeding 6 months. If the labor dispute ends, this continuation will cease immediately. 3) The provision titled Policy Interpretation is deleted in its entirety. 4) The following provision is added to the General Provisions section of Your certificate: Eligibility Determination: How will We determine Your or Your Dependent’s eligibility for benefits? We, and not Your Employer or plan administrator, have the responsibility to fairly, thoroughly, objectively and timely investigate, evaluate and determine Your or Your Dependent’s eligibility for benefits for any claim You or Your beneficiaries make on The Policy. We will: 1) obtain with Your or Your beneficiaries’ cooperation and authorization if required by law, only such information that is necessary to evaluate Your or Your beneficiaries’ claim and decide whether to accept or deny Your or Your beneficiaries’ claim for benefits. We may obtain this information from Your or Your beneficiaries’ Notice of Claim, submitted proofs of loss, statements, or other materials provided by You or others on Your behalf; or, at Our expense We may obtain necessary information, or have You or Your Dependent’s physically examined when and as often as We may reasonably require while the claim is pending. In addition, and at Your or Your beneficiaries’ option and at Your or Your beneficiaries’ expense, You or Your beneficiaries may provide Us and We will consider any other information, including but not limited to, reports from a Physician or other expert of Your or Your beneficiaries’ choice. You or Your beneficiaries should provide Us with all information that You or Your beneficiaries want Us to consider regarding Your or Your beneficiaries’ claim; ---PAGE BREAK--- 21 2) consider and interpret The Policy and all information obtained by Us and submitted by You or Your beneficiaries that relates to Your or Your beneficiaries’ claim for benefits and make Our determination of Your or Your Dependent’s eligibility for benefits based on that information and in accordance with The Policy and applicable law; 3) if We approve Your claim, We will review Our decision to approve Your or Your beneficiaries claim for benefits as often as is reasonably necessary to determine Your or Your Dependent’s continued eligibility for benefits; 4) if We deny Your or Your beneficiaries’ claim, We will explain in writing to You or Your beneficiaries the basis for an adverse determination in accordance with The Policy as described in the provision entitled Claim Denial. In the event We deny Your or Your beneficiaries’ claim for benefits, in whole or in part, You or Your beneficiaries can appeal the decision to Us. If You or Your beneficiaries choose to appeal Our decision, the process You or Your beneficiaries must follow is set forth in The Policy provision entitled Claim Appeal. If You or Your beneficiaries do not appeal the decision to Us, then the decision will be Our final decision. 5) The definition of Dependent Child(ren) is amended to include relationships due to domestic partnership. 6) The following is added to the definition of Spouse: Spouse will include Your domestic partner, provided You have executed a domestic partner affidavit satisfactory to Us, establishing that You and Your partner are domestic partners for the purposes of The Policy. You will continue to be considered domestic partners provided You continue to meet the requirements described in the domestic partner affidavit. 7) The provision titled Suicide is deleted in it’s entirety and any suicide restrictions appearing in Continuity from a Prior Policy, Reinstatement and/or Occupational Death Benefit will not apply. In all other respects the certificate remains the same. Signed for Hartford Life and Accident Insurance Company Terence Shields, Secretary Ronald R. Gendreau, President ---PAGE BREAK--- The Plan Described in this Booklet is Insured by the Hartford Life and Accident Insurance Company Simsbury, Connecticut Member of The Hartford Insurance Group