Loading...
HomeMy WebLinkAboutexhibit ContractMINNESOTA LIFE GROUP TERM LIFE INSURANCE POLICY Minnesota Life Insurance Company • 400 Robert Street North • St. Paul, Minnesota 55101-2098 • 1-866-293-6047. Read Your Policy Carefully This policy was issued to the policyholder on the effective date shown on the specifications page attached to this policy. We promise to pay the benefits provided by this policy, subject to its conditions, limitations, and exceptions. We make this promise and issue this policy in consideration of the application for this policy and the payment of the premiums. Minnesota Life Insurance Company is a subsidiary of Minnesota Mutual Companies, Inc., a mutual insurance holding company. The policyholder is a member of Minnesota Mutual Companies, Inc., which holds its annual meetings on the first Tuesday in March of each year at 3 p.m. local time. The meetings are held at 400 Robert Street North, St. Paul, Minnesota 55101-2098. Right to Cancel It is important to us that you are satisfied with this policy after it is issued. If you are not satisfied with this policy, you may cancel it by delivering or mailing a written notice or sending a telegram to Minnesota Life Insurance Company (Minnesota Life), 400 Robert Street North, St. Paul, Minnesota 55101-2098 and returning the policy before midnight of the 30th day after you received this Policy Notice given by mail and retum of the policy by mail are effective on being postmarked, properly addressed, and postage prepaid. If you retum this policy, you will receive, within 10 days of the date we receive a notice of cancellation, a full refund of any premiums you paid. Upon cancellation of this policy, it will be void as if it had never been issued. Signed for Minnesota Life Insurance Company at St. Paul, Minnesota on the effective date. Secretary President Notice to Policyholders If you have any questions regarding this group policy, or if you need assistance in resolving a complaint, you can contact us at: Minnesota Life Insurance Company, 400 Robert Street North, St. Paul, MN 55101-2098. Toll Free Telephone Number: 1-800-843-8358. TABLE OF CONTENTS Definitions 2 Termination 5 General Information 2 Conversion Right 6 Premiums 4 Additional Information 6 Death Benefit 4 GROUP TERM LIFE INSURANCE POLICY • NONPARTICIPATING MHC-96-13180.9 Minnesota life 1 Ed. F. mom 10-2004 &y7-)-rde)' GROUP POLICY SPECIFICATIONS PAGE GENERAL INFORMATION POLICYHOLDER: ASSOCIATED EMPLOYERS: POLICY EFFECTIVE DATE: POLICY ANNIVERSARY DATE: PREMIUM DUE DATE(S): GROUP: ENROLLMENT PERIOD: WAITING PERIOD: MINIMUM HOURS PER WEEK REQUIRED: City of Miami None. January 1, 2005 January 1 of each year beginning January 1, 2006. The first day of each month. POLICY NO.: 33050-G The group is composed of eligible retirees and regular working at the employer's normal place of business. Not applicable for noncontributory insurance; 31 days for contributory insurance. For employees in an eligible class on January 1, 2005: None For all other employees: 90 days 40 hours per week. full-time employees actively from the first day of eligibility PLAN OF INSURANCE EMPLOYEE TERM LIFE INSURANCE: Basic Insurance Class Eligible Class 1 Elected officials, directors, and assistant directors 2 3 4 5 EMPLOYEE BENEFIT SCHEDULE Managerial/confidential employees or non -union firefighters Retirees under age 65 Retirees age 65 or over Closed group of grandfathered retirees Amount of Insurance Two times basic annual earnings rounded to the next higher $1,000, subject to a maximum of $500,000. One times basic annual earnings rounded to the next higher $1,000, subject to a maximum of $250,000. The lesser of $25,000 or the amount of basic life insurance inforce immediately prior to retirement. The lesser of $25,000 or the amount of basic life insurance inforce immediately prior to retirement. The amount reported to Minnesota Life as detailed in Addendum 1. Supplemental Insurance An employee of class 1 or class 2 may choose among the following amounts of supplemental insurance: Eligible Class All employees Amount of Insurance One to five times basic annual earnings rounded to the next higher $1,000, subject to a maximum of $1,000,000 of combined basic and supplemental life insurance. F.MHC-50062 A EMPLOYEE ACCIDENTAL DEATH AND DISMEMBERMENT (AD&D) INSURANCE: Basic and Supplemental Insurance Eliaible Class Amount of Insurance Class 5 The amount reported to Minnesota Life as detailed in Addendum 1. All employees except An amount equal to the amount of basic and supplemental life insurance for employees of class 5 which the employee is insured under the group policy. GENERAL PROVISIONS FOR EMPLOYEE INSURANCE AGE REDUCTIONS: The amount of life and AD&D insurance on an employee age 65 or older shall be a percentage of the amount otherwise provided by the plan of insurance applicable to such employee in accordance with the following table: RETIREMENT REDUCTIONS: CONTRIBUTORY/NONCONTRIBUTORY: GUARANTEED ISSUE AMOUNT: EVIDENCE OF INSURABILITY: EFFECTIVE DATE OF INCREASES AND DECREASES DUE TO CHANGE IN ELIGIBLE CLASS OR EARNINGS: Age of Employee 61 62 63 64 65 Amount of Insurance 90% 80% 70% 60% 50% Age reductions will apply the first day of the month following an insured employee's attainment of the specified age. All insurance terminates upon retirement except as provided in the Schedule of Benefits. Basic insurance is noncontributory insurance; supplemental insurance is contributory insurance; retiree insurance is noncontributory insurance. Guaranteed issue is the amount of insurance an employee can receive without evidence of insurability when first eligible under the plan provided enrollment is made within the enrollment period. The amounts are as follows: For basic insurance: All basic insurance is guaranteed issue. For supplemental insurance: The lesser of two times salary or $500,000. Evidence of insurability is required as stated in the policy and for an amount of insurance greater than the guaranteed issue amount. Increases and decreases as a result of a change in earnings or eligible class will become effective the date of change. All increases are subject to the actively at work requirement. DEPENDENTS BENEFIT SCHEDULE DEPENDENTS TERM LIFE INSURANCE: Anolies to emolovees of classes 1 and 2 only Supplemental Spouse Term Life Insurance: Eiisiible Class Spouse Amount of Life Insurance If elected by the employee, an amount equal to 50 percent of the employee's amount of basic and supplemental insurance combined. F.MHC-50062 B AGE REQUIREMENTS: Supplemental Spouse AD&D Insurance Eligible Class, Spouse Amount of AD&D Insurance An amount equal to the amount of supplemental life insurance for which the spouse is insured under the group policy. Child Term life Insurance (does not include AD&D) Children $5,000 or $10,000 as elected by the employee.* The amount of supplemental spouse life insurance cannot exceed 50% of the employee's amount of basic and supplemental insurance combined *The amount of insurance on a child from live birth to attainment of six months of age is limited to 10% of the option chosen. GENERAL PROVISIONS FOR DEPENDENTS INSURANCE Children are eligible from live birth until attainment of age 19, or age 25 if a full-time student in an accredited educational institution. CONTRIBUTORY/NONCONTRIBUTORY: Dependents insurance is contributory insurance. GENERAL PROVISIONS FOR DEPENDENTS INSURANCE GUARANTEED ISSUE AMOUNT: SPOUSE GUARANTEED ISSUE REQUIREMENT: EVIDENCE OF INSURABILITY: EFFECT OF EMPLOYEE'S RETIREMENT: Guaranteed issue is the amount of insurance an eligible dependent can receive without evidence of insurability when first eligible under the plan provided enrollment is made within the enrollment period. The amounts are as follows: For employees with eligible dependents immediately prior to the effective date of this group policy, the guaranteed issue amount is equal to the amount of dependents insurance for which they were insured under the prior group policy. For all other employees, the guaranteed issue amount is as follows: For spouse insurance: $20,000 For child insurance: All child coverage is guaranteed issue. To be eligible for the guaranteed issue amount a spouse cannot be: (1) receiving or be entitled to receive any sick pay or disability benefits due to sickness or injury; or (2) confined at home or in a care facility under the care of a physician for sickness or injury; or in a chemotherapy, radiation therapy or dialysis treatment program. Evidence of insurability is required as stated in the policy and for an amount of insurance greater than the guaranteed issue amount. All dependents insurance terminates upon the employee's retirement. ADDITIONAL INFORMATION SUICIDE EXCLUSION FOR LIFE INSURANCE: WAIVER OF PREMIUM APPLICATION: RIDER(S) TO THE GROUP POLICY Accidental Death and Dismemberment, Dependents Term Life, Waiver of Premium, Accelerated Benefits F.MHC-50062 Applies only to employee and spouse supplemental life insurance under this policy. Exclusions for accidental death and dismemberment are listed on the applicable rider. Applies to contributory and noncontributory employee insurance. Addendum 1 Closed Group of Grandfathered Retirees Volume of Insurance Last Name First Name Life A D&D Bow Mary $5,000 $10,000 Guinn Lindon 5,000 10,000 Wright Thomas 5,000 10,000 Bow Louis 5,000 10,000 Edmonds May 5,000 10,000 McCann O.M 5,000 10,000 Rice J.R. 5,000 10,000 Trexler L. 5,000 10,000 Wishart B.G. 5,000 10,000 Anderson Helen 5,000 10,000 Baker L.J. 5,000 10,000 Bratizi Irene 5,000 10,000 10,000 Brazinsky Ida 5,000 10,000 Bennett Cecilia 5,000 Berry Rennie 5,000 10,000 Boddington Gordon 5,000 10,000 Cotton Ralph 5,000 10,000 Cromer Lewis 5,000 10,000 Daniels Leroy 5,000 10,000 Davis Emily 5,000 10,000 Dorsett Helen 5,000 10,000 Finkelstein D. 5,000 10,000 Fort Ernest A. 5,000 10,000 Frazier Edith 5,000 10,000 Clyde 5,000 10,000 Ganzos Fry � Theodore 5,000 10,000 ' Gold Harry 5,000 10,000 Herman M.L. 5,000 10,000 Ingalls Louise 5,000 10,000 Jacobs P.E. 5,000 10,000 Klug H. 5,000 10,000 Malone Dorothy 5,000 10,000 Matthews M. 5,000 10,000 Mond Earl 5,000 10,000 Morrison M.M. 5,000 10,000 Oster L. 5,000 10,000 Pettigrew William 5,000 10,000 Rhoades Ronald 5,000 10,000 Roe T.J. 5,000 10,000 F.MHC-50062 D Volume of Insurance Last Name First Name Life AD&D Schallern Ellen 5,000 10,000 Vasil Emmanuel 5,000 10,000 Allen Sara 5,000 10,000 Barbara Anne 5,000 10,000 Bell J. 5,000 10,000 Bergere M.L. 5,000 10,000 10,000 Bradfield Ruth 5,000 10,000 Curwood William 5,000 Elliott Alex 5,000 10,000 Gooch Wilton 5,000 10,000 Hawkins Grover 5,000 10,000 Hayes Emmie 5,000 10,000 Kern Margaret 5,000 10,000 Lovie J.L. 5,000 10,000 Lubinsky Sanford 5,000 10,000 Malmet Sophie 5,000 10,000 Matthews J.L. 5,000 10,000 Michael Helen 5,000 10,000 Morrow Loy 5,000 10,000 F.P.5,000 10,000 Mullady5,000 10,000 Owlett O.E. Pechstein Arnold 5,000 10,000 Romes Affia 5,000 10,000 Shaughnessy Eli 5,000 10,000 Estes Leon 5,000 10,000 Barr Irma 5,000 10,000 Garey Sara 5,000 10,000 Palmer ; Elliot 5,000 10,000 Adler / Belle 3,500 2,500 Nolan P.M. 6,000 0 F.MHC-50062 Definitions age Attained age as of most recent birthday. associated company Any company which is a subsidiary or affiliate of the policyholder which is designated by the policyholder and agreed to by us to participate under this policy. certificate effective date The date the insured's coverage under this policy becomes effective. certificate holder An employee who is eligible for and becomes insured according to the terms of this policy. contributory insurance Insurance for which an employee is required to make premium contributions. earnings An employee's basic rate of compensation not induding commissions, overtime or premium pay, bonuses, or any other additional compensation. employee An individual who is employed by the policyholder or by an associated company. A sole proprietor will be considered the employee of the proprietorship. A partner in a partnership will be considered an employee so long as the partner's principal work is the conduct of the partnership's business. The term employee does not indude temporary employees nor corporate directors who are not otherwise employees. employer The policyholder or any designated associated companies. evidence of insurability Evidence satisfactory to us of the good health of the prospective insured and any other underwriting information we require. insured A person who is eligible for and becomes insured according to the terms of this policy. non work day A day on which the employee is not regularly scheduled to work, including scheduled time off for vacations, personal MHC-96-13180.9 holidays, weekends and holidays, and approved leaves of absence for non -medical reasons. Non -work day does not include time off for medical leave of absence, temporary layoff, employer suspension of operations in total or in part, strike, and any time off due to sickness or injury including sick days, short-term disability, or long-term disability. noncontributory insurance Insurance for which an employee is not required to make premium contributions. policy anniversary The policy anniversary date shown on the specifications page attached to this policy. policy effective date The date this policy was issued as shown on the specifications page attached to this policy. policyholder The owner of the group policy as shown on the specifications page attached to the group policy. specifications page The outline which summarizes the policyholder's plan of insurance. waiting period The period, if any, of continuous employment with the employer required prior to becoming eligible for coverage under this policy. The waiting period is shown on the specifications page attached to this policy. we, our, us Minnesota Life Insurance Company. you, your The policyholder named on the specifications page attached to this policy. General Information What is your agreement with us? This policy and your application contain the entire contract between you and us. Any statements you make will, in the absence of fraud, be considered representations and not warranties. Also, any statement that you make will not be used to void this policy, nor will it be used in our defense if we refuse to pay a claim, unless the statement is contained in your application. No change or waiver of any provisions of this policy, or any certificate issued under it, will be valid unless made in writing by us and signed by our president, a vice- Mlnnesda Life 2 Ed. F.l0000c 10-2004 president, our secretary, or an assistant secretary. No agent or other person has the authority to change or waive any provisions of this policy, or of any certificate issued under it. Are employees of associated companies eligible for insurance under this policy? Yes. Employees of associated companies may be eligible for insurance under this policy. Associated companies are shown on the specifications page attached to this policy. You represent any associated company in all transactions pertaining to this policy. Your acts or omissions and every notice given by us to you shall be binding on every associated company. Can this policy be amended? Yes. The insured's consent is not required to amend this policy or any certificates issued under it. Any amendment will be without prejudice to any daim for benefits incurred prior to the effective date of the amendment. Who Is eligible for insurance? An employee is eligible if he or she: (1) is a member of the group and of an eligible class as shown on the specifications page attached to this policy; and (2) works for the employer for at least the number of hours per week shown as the minimum hours per week requirement on the specifications page attached to this policy; and (3) has satisfied the waiting period as shown on the specifications page attached to this policy; and (4) meets the actively at work requirement as shown in the section entitled "What is the actively at work requirement?'. Are retired employees eligible for insurance? If the policyholder's plan of insurance, as reflected in the specifications page attached to this policy, does not specifically provide insurance for retired employees, a retired employee shad not be eligible to become insured, nor have his or herinsurance continued. If the policyholder's plan of insurance specifically provides insurance for retired employees, the minimum hours per week and actively at work requirements will not apply to such persons. What is the actively at work requirement? To be eligible to become insured or to receive an increase in the amount of insurance, an employee must be actively at work performing his or her customary duties at the employer's normal place of business, or at other places the employer's business requires him or her to travel. If the employee is not actively at work on the date coverage would otherwise begin, or on the date an increase in his or her amount of insurance would otherwise be effective, he or she will not be eligible for the coverage or increase until he or she returns to active MHG96.13180.9 When will we require evidence of insurability? Evidence of insurability will be required if: (1) the specifications page attached to this policy states that evidence of insurability is required; or (2) the insurance is contributory and the employee does not enroll within the enrollment period shown on the specifications page attached to this policy; or the insurance is noncontributory and the employee does not become insured, due to nonpayment of premium, within the three-month period beginning on the date he or she is first eligible for coverage. This will not apply if it is shown that it was due to derical error only, in which case premiums will be due retroactive to the date the employee was first eligible for coverage; or (4) the insurance for which the employee previously enrolled did not go into effect or was terminated because the employee failed to make a required premium contribution; or during a previous period of eligibility, the employee failed to submit required evidence of insurability or that which was submitted was not satisfactory to us; or (6) the employee is insured by an individual policy issued under the terms of the conversion right section. work. However, if the absence is on a non -work day, coverage will not be delayed provided the employee was actively at work on the work day immediately preceding the non -work day. Except as otherwise provided for in this policy, an employee is eligible to continue to be insured only while he or she remains actively at work. (3) (6) When does insurance become effective? Insurance becomes effective on the date that all of the following conditions have been met: an employee meets all eligibility requirements; and if required, the employee applies for the insurance on forms which are approved by us; and we are satisfied with the employee's evidence of insurability, if we require evidence; and we receive the required premium. Can an insured employee's coverage be continued during sickness, injury, leave of absence or temporary layoff? Yes. Insurance may be continued on an insured employee who is not actively at work due to sickness, injury, leave of absence or temporary layoff. Insurance will be deemed to continue until terminated by discontinuance of premium payments or written request. Insurance continued for non -medical leave of absence or temporary layoff may not be continued beyond twelve Minnesota Ufa 3 Ed. F. 000a 10-2004 months from the last day the insured employee was premiums are due. The premium may also be computed actively at work. by any other method on which you and we agree. Insurance continued for sickness, injury or medical leave of absence may be continued as follows: (1) if retirees are not an eligible class of insureds according to the policyholder's plan of insurance as provided for by this policy, continuation for medical leave of absence cannot be continued beyond the insureds retirement date. (2) if retirees are an eligible class of insureds according to the policyholder's plan of insurance as provided for by this policy, continuation for medical leave of absence can be continued indefinitely. However, any reductions in the amount of insurance or any other change in policy provisions which apply at retirement will apply to the insured at his or her retirement date. For purposes of this provision, an insured's retirement date shall be the earlier of: (1) the date he or she actually retires; or (2) his or her presumed normal retirement date as established by the employer's applicable retirement plan. If no such date has been established, the insured's retirement date shall be age 65. Continuation of insurance must be in accordance with a plan that predudes individual selection. Coverage during a leave of absence and upon return from a leave of absence shall meet all state and federal requirements. The above limits will be expanded if necessary in order to meet such requirements. Premiums When and how often are premiums due? Unless we have agreed to some other premium payment procedure, premiums for this policy are remitted to us monthly. Premiums are due on the premium due date as shown on the specifications page attached to this policy. We apply premiums consecutively to keep the insurance in force. You may pay premiums before they are due for any period up to the next policy anniversary. Premiums paid in advance should be calculated at the rate of the monthly premium currently due. Premium contributions for contributory insurance are to be paid to you. The premium contributions by insureds for contributory insurance should be remitted to us as due along with the premiums payable for noncontributory insurance. How is the premium determined? The premium will be the premium rate multiplied by the number of $1,000 units of insurance in force on the date MHG98.13180.9 We may change the premium rate: (1) (2) on any premium due date after the expiration of the rate guarantee period; or anytime, if the policy terms are amended or the total amount of insurance in force changes by 10% or more. Can a premium be paid after the date it is due? Yes. This policy has a 31-day grace period. If a premium is not paid on or before the date it is due, that premium may be paid during the 31-day period following the due date. The insurance under this policy will remain in effect during the 31-day grace period. This grace period does not apply to the first premium payment. Can the premium be adjusted? Yes. We will adjust the premium on each due date for insurance which was effective or terminated before the most recent due date, but not reflected in prior premium payments. We will charge you for any additional premium, and will refund any overpayment, exduding any overpayment made more than 12 months before the adjustment. Death Benefit What is the amount of the death benefit? The amount of the death benefit is the amount of insurance shown on the specifications page attached to this group policy. Can an insured request a change in the amount of his or her contributory insurance? Yes. If the policyholder's plan of insurance, as reflected in the specifications page attached to this policy, allows for a choice of amounts of insurance for the insured's class, an insured can request an increase or a decrease in the amount of his or her contributory insurance within the limitations of the policyholder's plan of insurance, including any limitations on when and how often such requests may be made. All requests must be made in writing. If an insured requests an increase in the amount of his or her oontrbutory insurance, we will require evidence of insurabThty. If an insured requests a decrease in the amount of his or her contributory insurance, we will grant the request. When will changes in an insured's coverage amount be effective? Requested increases in the amount of an insured's contributory insurance, if approved, are effective on the date we approve the increase. Requested decreases in the amount of an insured's contributory insurance are Minnesota life 4 Ed. F. looms 10-2004 effective on the first day of the month following our receipt of the insured% request for a decrease. Increases and decreases in insurance amounts which result from a change in the insureds eligible class or eamings will be effective as shown on the specifications page attached to this policy. All increases in the amount of insurance are subject to the actively at work requirement. When will the death benefit be payable? We will pay the death benefit upon receipt at our home office of written proof satisfactory to us that an individual died while insured under this policy. AN payments by us are payable from our home office. The death benefit will be paid in a single sum or by any other method agreeable to us and the beneficiary. We will pay interest on the death benefit from the date of the insured's death until the date of payment. Interest will be at an annual rate determined by us, but never less than 4% per year compounded annually, or the minimum required by state law, whichever is greater. Payment of the death benefit will extinguish our liability under the certificate for which the death benefit has been Paid - To whom will we pay the death benefit? We will pay the death benefit to the beneficiary or beneficiaries. A beneficiary is named by an insured to receive the death benefit to be paid at the insured% death. The insured may name one or more beneficiaries. The insured cannot name you or an associated company as a beneficiary. The insured may also choose to name a beneficiary that the insured cannot change without the beneficiary's consent. This is called an irrevocable beneficiary. If there is more than one beneficiary, each will receive an equal share, unless the insured has requested another method in writing. Tgeceive the death benefit, a beneficiary must be living on the date of the insured's death. In the event a beneficiary is not living on the date of the insured's death, that beneficiary's portion of the death benefit shall be equally distributed to the remaining surviving beneficiaries. In the event of the simultaneous deaths of the insured and a beneficiary, the death benefit will be paid as if the insured survived the beneficiary. If there is no eligible beneficiary, or if the insured does not name one, we will pay the death benefit to: (1) (2) (3) (4) the insured's lawful spouse if living, otherwise; the insured's natural or legally adopted child (children) in equal shares, if living, otherwise; the insured's parents in equal shares, tf living, otherwise; the personal representative of the insured's estate. MHG98-13180.9 Can an insured add or change beneficiaries? Yes. An insured can add or change beneficiaries if all of the following are true: (1) the insured's coverage is in force; and (2) we have written consent of all irrevocable beneficiaries; and (3) the insured has not assigned the ownership of his or her insurance. A request to add or change a beneficiary must be made in writing. All requests are subject to our approval. A change will take effect as of the date it is signed, but will not affect any payment we make or action we take before receiving an insured's notice. Termination When does an insured's coverage terminate? The insured's coverage ends on the earliest of the following: the date this policy ends; or the date the employee no longer meets the eligibility requirements; or the date the policy is amended so the employee is no longer eligible; or 31 days (the grace period) after the due date of any premium contribution which is not paid; or the last day for which premium contributions have been paid following an employee's written request to cease participation under this policy. If an insured's coverage under this policy terminates due to non-payment of premiums, his or her coverage may be reinstated if all premiums due are paid and received by us within 31 days of the date of termination and during the insured's lifetime. Can insurance on the life of an insured be reinstated after termination? Yes. When an insured's coverage terminates because he or she is no longer eligble, and the insured becomes eligible again within three months after the date his or her coverage terminated, the insured's coverage under this policy may be reinstated. Provided the insured is not then covered by an individual policy issued under the terms of the conversion right section, his or her coverage under this group policy shall be reinstated automatically, without evidence of insurability or satisfaction of any waiting period. The amount of insurance will be that which applies to the classification to which he or she then belongs, on the date he or she again becomes eligible. If the policyholder's plan of insurance provides for contributory insurance under this policy, an insured's amount of contributory insurance will be limited to that for which he or she was insured immediately prior to the loss of coverage. Minnesota life 5 Ed. F. rooms 10-2004 When does this group policy terminate? You may terminate this group policy by giving us 31 days prior written notice. We reserve the right to terminate this policy on the earliest of the following to occur: (1) (2) (3) 31 days (the grace period) after the due date of any premiums which are not paid; or on any subsequent policy anniversary after the date the number of employees insured is less than any minimum established by us or as required by applicable state law; or 31 days after we provide you with notice of our intent to terminate this policy. Can this policy be reinstated? No. We will not reinstate this policy after it terminates. You must submit a new application for a new policy after this policy has terminated. Conversion Right What is the conversion right? An insured can convert this insurance to a new individual life insurance policy if all or part of the insured's life insurance under this policy terminates. The insured may convert up to the full amount of terminated insurance if termination occurs because he or she moves from one existing eligible class to another, or he or she is no longer in an eligible dass. What is the limited conversion right? Limited conversion is available if, after the insured has been insured for at least five years, insurance is terminated because: (1) the policy is terminated; or (2) the policy is changed to reduce or terminate the insurance for that individual. The insured may convert/Up to the full amount of terminated insurance, but not more than the maximum. The maximum is the Lesser of: (a) $10,000; and (b) the amount of life insurance which terminated minus any amount of group life insurance for which the insured becomes eligible under any group policy issued or reinstated by us or any other carrier within 31 days of the date the insurance terminated under this policy. Neither the conversion right nor the limited conversion right is available if the insured's coverage under this policy terminates due to failure to make, when due, required premium contributions. Under both the conversion right and the limited conversion right, the insured may convert his or her insurance to any type of individual policy of life insurance then customarily MHG98-13180.9 issued by us for purposes of conversion, except term insurance. The individual policy will not indude any supplemental benefits, including, but not limited to, any disability benefits, accidental death and dismemberment benefits, or accelerated benefits. How does an insured convert his or her insurance? An insured converts his or her insurance by applying for an individual policy and paying the first premium within 31 days after the group insurance terminates. No evidence of insurability will be required. How is the premium for the individual policy determined? We base the premium for the individual policy on the plan of insurance, the insured's age, and the class of risk to which the insured belongs on the date of the conversion. When Is the individual policy effective? The individual policy takes effect 31 days after the group insurance provided under this policy terminates. What happens if the insured dies during the 31-day period allowed for conversion? If the insured dies during the 31-day period allowed for conversion, we will pay a death benefit regardless of whether or not an application for coverage under an individual policy has been submitted. The death benefit will be the amount of insurance the insured would have been eligible to convert under the terms of the conversion right section. We will retum any premium the insured paid for an individual policy to the insured's beneficiary named under this group policy. In no event will we be liable under both this group policy and the individual policy. Additional Information What if an insured's age has been misstated? If an insured's age has been misstated, the death benefit payable will be that amount to which the insured is entitled based on his or her correct age. A premium adjustment will be made to the premium you pay for the insured's noncontributory insurance and to the premium an insured pays for contributory insurance, if any, so that the actual premium required at the insured's correct age is paid. Is there a suicide exclusion? The specifications page attached to this policy indicates what insurance, if any, is subject to the suicide exclusion outlined below. When applicable, this suicide exdusion limits our liability to an amount equal to the premiums paid for an insured, if that insured, whether sane or insane, dies by suicide Minnesota Life 8 Ed. F.moots 10-2004 within two years of the effective date of his or her insurance. If there has been an increase in the insured's amount of insurance for which he or she was required to apply or for which we required evidence of insurability, and if the insured dies by suicide within two years of the effective date of the increase, our liability with respect to that increase will be limited to the premiums paid and attributable to such increase. When does an insured's insurance become incontestable? Except for the non-payment of premiums, after the insured's insurance has been in force during his or her lifetime for two years from the effective date of his or her coverage, we cannot contest the insured's coverage. However, if there has been an increase in the amount of insurance for which the insured was required to apply or for which we required evidence of insurability, then, to the extent of the increase, any loss which occurs within two years of the effective date of the increase will be contestable. Any statements the insured makes in his or her application will, in the absence of fraud, be considered representations and not warranties. Also, any statement an insured makes will not be used to void his or her insurance, nor defend against a claim, unless the statement is contained in the application and any evidence of insurability application attached to the insured's certificate. Can an insured's insurance be assigned? Yes. However, we will not be bound by an assignment of the certificate or of any interest in it unless it is made as a written instrument, the insured files the original instrument or a certified copy with us at our home office, and we send the insured an acknowledged copy. We are not responsible for the validity of any assignment. An insured is responsible for ensuring that the assignment is legal in his or her stateand that it accomplishes his or her intended goals. !fa claim is based on an assignment, we may require proof of interest of the claimant. A valid assignment will take precedence over any claim of a beneficiary. MHC-96-13180.9 Are you required to maintain records? Yes. You are required to maintain adequate records of any information necessary for us to administer this policy. We own the records relating to the insurance provided by this policy, and can obtain them from you at any reasonable time. If a clerical error is made in keeping records on the insurance under this policy, it will not affect otherwise valid insurance. A clerical error does not continue insurance which is otherwise stopped. If an error causes a change in premium payment, we will make a fair adjustment. Will a certificate of Insurance be provided for each certificate holder? Yes. We will provide you with a certificate of insurance for delivery to each certificate holder. The certificate will include information regarding the principal provisions of his or her coverage. Will this policy receive experience credits? Each year we will determine if this policy will receive an experience credit. Are you our agent? No. For all purposes of this policy, neither you, an associated company, nor any administrator you appoint is our agent. We will not be liable for any of your acts or omissions or those of an associated company or administrator. Will the provisions of this policy conform with state law? Yes. If any provision in this policy, or in the certificates issued under this policy, is in conflict with the laws of the state governing the policy or the certificates, the provision will be deemed to be amended to conform to such laws. Minnesota Lire 7 Ed. F. moos 10-2004 MINNESOTA LIFE ACCIDENTAL DEATH AND DISMEMBERMENT POLICY RIDER Minnesota Life Insurance Company • 400 Robert Street North • St. Paul, Minnesota 55101-2098 General Information This rider is issued in consideration of the required premium and amends the group policy to which it is attached. This rider is subject to every term, condition, exclusion, limitation, and provision of the group policy unless otherwise expressly provided for herein. Coverage under this rider will not be included in any insurance issued under the conversion right section of the group policy. What does this rider provide? This rider provides a benefit for an insured employee or an insured spouse's accidental death or dismemberment which occurs as a result of an accidental injury. Accidental Death and Dismemberment Benefit What does accidental death or dismemberment by accidental injury mean? Accidental death or dismemberment by accidental injury as used in this rider means that the insured's death or dismemberment results, directly and independently of all other causes, from an accidental injury which is unintended, unexpected, and unforeseen. The injury must occur while the insured's coverage under this rider is in force. The insured's death or dismemberment must occur within 180 days after the date of the injury and while his or her coverage under this rider is in force. If by reason of a covered accident an insured is unavoidably exposed to the elements and, as the result of such exposure and within one year, the insured suffers a loss that is included in the list of covered losses, such loss will be covered under the terms of this rider. If an insured's body has not been found after one year from the date the vehicle in which he or she was traveling disappeared, exploded, sank, became stranded, made a forced landing or was wrecked, it shall be presumed, subject to all other terms of the policy, that the insured has died resulting from an accidental injury which was unintended, unexpected and unforeseen. In no event will we pay the accidental death or dismemberment benefit where the insured's death or dismemberment results from or is caused directly or indirectly by any of the following: (1) suicide or attempted suicide, whether sane or insane; or (2) the insured's participation in or attempt to commit an assault or a felony; or MHC-98-13182 (3) bodily or mental infirmity, illness or disease; or (4) drugs, poisons, gases or fumes, voluntarily taken, administered, absorbed, inhaled, ingested or injected; or (5) bacterial infection, other than infection occurring simultaneously with, and as a result of, the accidental injury; or (6) travel or flight in or on, or descent from or with, any type of military aircraft; or (7) war or any act of war, whether declared or undeclared. What is the amount of the accidental death and dismemberment benefit? FOR LOSS OF AMOUNT OF BENEFIT Life Full Amount of Insurance Both Hands or Both Feet Full Amount of Insurance Sight of Both Eyes Full Amount of Insurance Speech and Hearing Full Amount of Insurance One Hand and One Foot FuN Amount of Insurance One Foot and Sight of One Eye Full Amount of Insurance One Hand and Sight of One Eye FuN Amount of Insurance Sight of One Eye 50% of Amount of Insurance The amount of insurance is shown on the specifications page attached to the group policy. Loss of hands or feet means complete severance at or above the wrist or ankle joints. Loss of sight means the entire and irrecoverable Toss of sight which cannot be corrected by medical or surgical treatment or by artificial means. Benefits may be paid for more than one accidental injury but the total amount of insurance payable under this rider for any one accident will never exceed the full amount of insurance shown on the specifications page attached to the group policy. When will the accidental death and dismemberment benefit be payable? We will pay the accidental death and dismemberment benefit upon receipt at our home office of written proof satisfactory to us that the insured died or suffered dismemberment as a result of an accidental injury. All payments by us are payable from our home office. The benefit will be paid in a single sum. We will pay interest on the benefit from the date of the insured's death or dismemberment until the date of payment. Interest will be at an annual rate determined by us, but never less than 4% per year compounded annually or the minimum required by state law, whichever is greater. To whom do we pay the benefit? Minnesota Ufe 1 Ed. F. xxxxx 10-2004 We pay the death benefit to the person or persons entitled to receive them under the terms of the group policy. The benefit for other losses is paid to the certificate holder. Additional Benefits Repatriation Benefit What Is the repatriation benefit? We will pay an additional accidental death benefit equal to the actual expenses incurred, subject to a maximum of $5,000, for the preparation and transportation of the insured's body to a mortuary if, as the result of a covered accident, the insured dies at least 75 miles from his or her principal place of residence. Seatbelt Benefit What is the seatbelt benefit? We will pay an additional accidental death benefit equal to 10% of the death benefit, subject to a maximum of $10,000, if the insured dies as a result of a covered accident which occurs while he or she is driving or riding in a private passenger car, provided: (1) the private passenger car is equipped with seatbelts; and (2) a seatbelt was in proper use by the insured at the time of the accident as certified in the official accident report or by the investigating officer, and (3) at the time of the accident, the driver of the private passenger car was a licensed driver and was not intoxicated, impaired, or under the influence of alcohol or drugs. Seatbelt means a properly installed seatbelt, lap and shoulder restraint, or other restraint approved by the National Highway Traffic Safety Administration or any successor govemmental agency. Air Bag Benefit What is the air bag benefit? We will pay an additional accidental death benefit equal to 5% of the death benefit, subject to a maximum of $5,000, if the insured dies as a result of a covered accident which occurs while he or she is driving or riding in a private passenger car, provided: (1) the seat in which the insured was seated was equipped with a properly installed air bag at the time of the accident; and (2) the private passenger car is equipped with seatbelts; and (3) a seatbelt was in proper use by the insured at the time of the accident as certified in the official accident report or by the investigating officer, and (4) at the time of the accident, the driver of the private passenger car was a licensed driver and was not intoxicated, impaired, or under the influence of alcohol or drugs. MHG98-13182 Termination When does an insured's coverage under this rider terminate? An insured's coverage ends on the earliest of: (1) the date the insured is no longer covered for life insurance under the group policy; or (2) the insured's 70th birthday; or (3) 31 days (the grace period) after the due date of any premium contribution which is not paid; or When does this rider terminate? This rider will terminate on the earlier of: (1) the date we receive a written request to cancel this rider, or (2) the date the group policy is terminated. Additional Information Do we have the right to obtain independent medical verification? Yes. We retain the right to have the certificate holder medically examined at our expense whenever a claim is pending and, where not forbidden by law, we reserve the right to have an autopsy performed in case of death. E. Secretary President Minnesota Life 2 Ed. F. xxxxx 10-2004 MINNESOTA LIFE DEPENDENTS TERM LIFE INSURANCE POLICY RIDER Minnesota life Insurance Company • 400 Robert Street North • St. Paul, Minnesota 55101-2098 General Information This rider is issued in consideration of the required premium and amends the group policy to which it is attached. The rider is subject to every term, condition, exclusion, limitation, and provision of the group policy unless otherwise expressly provided for herein. What does this rider provide? This rider provides insurance on the lives of the insured employee's eligible dependents. What members of the insured employee's family are eligible for insurance under this rider? The following members of the insured employee's family are eligible for insurance under this rider. (1) the insured employee's lawful spouse who is not legally separated from the insured, who is not eligible for insurance as an employee under the policy to which this rider is attached, and who meets any age requirements as shown on the specifications page attached to the group policy; and (2) the insured employee's children, stepchildren, and legally adopted children, who are unmarried, dependent on the insured for financial support, and who meet the age requirements as shown on the specifications page attached to the group policy. If both parents of a child qualify as eligible employees under the group policy, the child shall be considered a dependent of only one parent for purposes of this rider. If any child qualifies as an eligible employee under the group policy, he or she isnot eligible to be insured as a dependent child. Any dependent who, subsequent to the effective date of the insured employee's certificate supplement for Dependents Term Life Insurance, meets the requirements of this provision will become insured on the date he or she so qualifies. When will we require evidence of insurability? Evidence of insurability will be required if: (1) the specifications page attached to the group policy states that evidence of insurability is required; or MHC-96-13188 (2) the insurance is contributory and the employee does not enroll for coverage under this rider within the enrollment period shown on the specifications page attached to the group policy; or dependents insurance for which the employee previously enrolled did not go into effect or was terminated because the employee failed to make a required premium contribution; or (4) during a previous period of eligibility, the employee failed to submit evidence of insurability that was required for a dependent or that which was submitted was not satisfactory to us; or the dependent is insured by an individual policy issued under the terms of the conversion right of this rider. (3) (5) When does insurance on a dependent become effective? Insurance on a dependent becomes effective on the date when aN of the foNowing conditions have been met: (1) the dependent meets all eligibility requirements; and (2) if required, the insured employee applies for dependents coverage on forms which are approved by us; and (3) we are satisfied with the dependent's evidence of insurability, if we require evidence; and (4) we receive the required premium. If a dependent is hospitalized or confined because of illness or disease on the date his or her insurance would otherwise become effective, his or her effective date shall be delayed until he or she is released from such hospitalization or confinement. However, in no event will insurance on a dependent be effective before the insured employee's insurance under the group policy is effective. Death Benefit What is the amount of life Insurance on each Insured dependent? The amount of life insurance on each insured dependent is shown on the specifications page attached to the group policy. To whom will we pay the death benefit? The death benefit payable under this rider will be paid to the insured employee if living, otherwise to his or her estate. Minnesota Life 1 Ed. F. )3000t 10-2004 Termination When does an insured dependent's coverage under this rider terminate? An insured dependent's coverage ends on the earliest of the following: (1) the date the dependent no longer meets the eligibility requirements; or (2) 31 days (the grace period) after the due date of any premium contribution which is not paid; or (3) the last day for which premium contributions have been made following an employee's written request that insurance on his or her eligible dependents be terminated; or (4) the date the employee is no longer covered under the group policy. The employee must notify us or the employer when a dependent is no longer eligible for coverage under this rider so that premiums may be discontinued. All premiums paid for dependents who are no longer eligible for coverage under this rider will be refunded without any payment of claim. When does this rider terminate? This rider will terminate on the earlier of: (1) the date we receive a written request to cancel this rider, or (2) the date the group policy is terminated. Additional Information What Is the conversion right under this rider? If an insured dependent's coverage under this rider terminates because he or she is no longer eligible, or because of the death of the insured employee, or because of termination or amendment of this rider, the insurance may be converted to a policy of individual insurance with Minnesota Life. MHC-96-13188 Conversion may be requested by the insured employee, an insured dependent of legal capacity, or the insured dependent's guardian, if applicable. AN other conditions and provisions of the conversion right section of the group policy to which this rider is attached will apply. Do any Waiver of Premium, Extended Benefits, or Total and Permanent Disability riders to the group policy apply to Insured dependents? Any Waiver of Premium, Extended Benefits, or Total and Permanent Disability rider to the group policy will not apply to dependents covered under this rider except as provided for herein. If, due to the insured employee's disability, his or her insurance is continued in force without further payment of premiums due to any Waiver of Premium, Extended Benefits, or Total and Permanent Disability rider to the group policy, any dependents insurance provided by this rider shall also continue in force without further payment of premiums until the dependent's eligibility terminates or until the insured employee's insurance is no longer continued in force due to any such rider to the group policy. This provision is not applicable if the dependent's insurance has been converted under the conversion right section of this rider, unless the converted policy is surrendered without claim except for refund of premiums. �... £. Cr,,►,te� Secretary President MInnesom Lire 2 Ed. F. xxxxx 10-2004 MIFINESOTA LIFE TERM LIFE WAIVER OF PREMIUM POLICY RIDER Minnesota Life Insurance Company • 400 Robed Street North • St. Paul, Minnesota 55101-2098 General Information This rider is issued in consideration of the required premium and amends the group policy to which it is attached. The specifications page attached to the group policy indicates whether this rider applies to contributory insurance or noncontributory insurance. This rider is subject to every term, condition, exclusion, limitation, and provision of the group policy unless otherwise expressly provided for herein. Coverage under this rider will not be included in any insurance issued under the conversion right section of the group policy. What does this rider provide? This rider provides for waiver of premium for certificate holders who become totally and permanently disabled, as defined herein, while under age 60. Upon approval of proof of such disability, a certificate holder's insurance, induding all riders applicable to such certificate holder which are in force on the date of the onset of the certificate holder's disability, will be continued in force without payment of premiums during the uninterrupted continuance of the total and permanent disability. What is total disability? Total disability is a disability which occurs while a certificate holder's insurance is in force and which results from an accidental injury or an illness that continuously prevents the certificate holder from engaging in any occupation for which he or she is reasonably suited by education, training, or experience. The certificate holder must be under the care of a licensed physician. The licensed physician cannot be the certificate holder or a member of the certificate holder's immediate family. For purposes of this rider, the certificate holder's immediate family consists of his or her spouse, children, parents, grandparents, grandchildren, brothers and sisters and their spouses. What is permanent disability? Permanent disability is a total disability which has existed continuously for at least nine months. Are there any limitations? Yes. Insurance will not be continued if a certificate holder's disability results from intentionally self -infected injury, participation in or any attempt to commit a felony, or war or any act of war, whether declared or undedared. What if a certificate holder recovers and again becomes totally disabled? For purposes of this rider, if a certificate holder recovers, retums to work for the employer, and due to the same MHC-96-13208 accidental injury or illness again becomes totally disabled within six months while insured under this rider, the two periods of total disability will be considered as one period of total disability and the certificate holder will not be required to satisfy a new nine month waiting period before the waiver of premium resumes. However, premiums will not be waived during any such recovery period. Do premiums have to be paid for a certificate holder after he or she becomes disabled? Yes. Premiums have to be paid after a certificate holder becomes disabled, but only until we approve his or her total and permanent disability daim. Continued payment prevents the possible loss of the certificate holder's coverage and eligibility if the daim is not approved. What if a certificate holder converts his or her group life insurance to a policy of individual insurance prior to the approval of his or her disability claim? If a certificate holder's coverage has been converted in accordance with the conversion right section of the group policy, benefits under this rider will apply only if the converted policy is surrendered without claim, except for refund of premiums. What will be considered due proof of total and permanent disability? A certificate holder must fumish evidence satisfactory to us that his or her disability: (1) commenced while his or her insurance under the group policy was in force; and (2) meets the definition of total disability; and (3) commenced before his or her 60th birthday; and (4) was continuous for nine months or more. We will, from time to time, also require additional proof satisfactory to us that the certificate holder continues to be totally and permanently disabled. We may also require that the certificate holder submit to one or more medical examinations at our expense. If a certificate holder dies within one year of the date of onset of his or her disability, the certificate holder's beneficiary may claim benefits under this rider even if the certificate holder's premium payments were discontinued and he or she had not submitted due proof satisfactory to us of his or her total disability or was continuously disabled for less than nine months. The certificate holder's beneficiary must submit due proof satisfactory to us that the certificate holder's total disability, which began before the certificate holder's premium payments were discontinued and before his or her 60th birthday, continued without interruption until his or her death. Mlnnescta Ufa 1 Ed. F. X0XXX 10-2004 When must we be notified of a certificate holder's disability or death? We must receive written notice at our home office of a certificate holder's total disability within one year of the date of onset of such disability. However, failure to give notice within the time provided will not invalidate the claim if it is shown that notice was given as soon as reasonably possible. We must receive written notice at our home office within one year of death that a certificate holder died during a period of continuance provided by this rider. Proof must be furnished that he or she continued to be totally disabled during the entire period of continuance until death. If such notice and proof are not provided within the required time frame, there shall be no liability for any payment under this rider. What Is the amount of Insurance to be continued without payment of premium under this rider? The amount of a certificate holder's insurance continued at any given time shall be the amount of insurance then available under the group policy for a certificate holder of his or her age and eligible class or, if Tess, the amount for which he or she was insured under the group policy when the last premium contribution was made on his or her behalf. The amount of insurance for any other individual insured under the certificate holder's certificate will be the amount of insurance then available under the group policy for such insured or, if less, the amount for which he or she was insured under the group policy when the last premium contribution was made on his or her behalf. If the group policy provides for reductions in amounts of insurance based on age, such reductions shall apply to the insurance of the disabled certificate holder. If the group policy provides for reductions in amounts of insurance at retirement, the retirement date for an insured employee whose insurance is being continued by the terms of this rider shall be the earlier of: (1) the date he or -she actually retires; or (2) his or her presumed normal retirement date as established by the employer's applicable retirement plan. If no such date has been established, the insured employee's presumed retirement date shall be age 65. How long will insurance be continued without payment of premium? If a certificate holder becomes totally and permanently disabled, insurance will be continued, without payment of premium, until the earliest of: (1) the certificate holder's 65th birthday; or (2) the date the certificate holder recovers so that he or she is no longer totally and permanently disabled; or MHC-98-13208 (3) the date the certificate holder fails to fumish proof of continued disability when requested or refuses to submit to a required medical examination. However, if the group policy provides for termination of insurance at retirement, insurance provided under this rider will also terminate when the insured employee retires, including normal or early retirement. The retirement date for an employee whose insurance is being continued by the terms of this rider shall be the earlier of: (1) the date he or she actually retires; or (2) his or her presumed normal retirement date as established by the employer's applicable retirement plan. If no such date has been established, the insured employee's presumed retirement date shall be age 65. What happens to a certificate hotder's insurance when the waiver of premium benefit ends? When the benefits under this rider end according to the provisions of the section entitled "How long will insurance be continued without payment of premium?," the following will apply: (1) If the certificate holder is then eligible for coverage under the group policy, his or her insurance may be continued under the group policy provided that premiums are paid. The first such premium payment must be made within 31 days of the date the waiver of premium benefit ends. (2) If the certificate holder is no longer eligible for coverage under the group policy, he or she may convert coverage to an individual policy, as provided for under the conversion right section of the group policy. Insurance will end for a certificate holder unless, within 31 days of the date benefits under this rider end, premium payment is resumed or the insured applies to convert his or her coverage. When does this rider terminate? This rider will terminate on the earlier of: (1) the date we receive a written request to terminate this rider, or (2) the date the group policy is terminated. Insurance being continued without further payment of premiums in accordance with the provisions of this rider will not end due solely to the termination of this rider or of the group policy. C74r y „tLAgae.. Secretary President Minnesota Lire 2 Ed. F. x)000( 10-2004 MINNESO►TA LIFE ACCELERATED BENEFITS POLICY RIDER Minnesota Ltfe Insurance Company • 400 Robert Street North • St. Paul, Minnesota 55101-2098 • 1-866-293-6047 Benefits received under this Accelerated Benefits Policy Rider may be taxable. Certificate holders should seek assistance from a personal tax advisor prior to requesting an accelerated payment of death benefits. General Information This rider amends the group policy to which it is attached and is subject to every term, condition, exclusion, limitation, and provision of the group policy unless otherwise expressly provided for herein. What does this rider provide? This rider provides for the accelerated payment of either the full or a partial amount of an insureds death benefit provided under the group policy. If the insured has a terminal condition as defined in this rider, an accelerated payment of the death benefit may be requested. Definitions accelerated benefit The amount of the death benefit we will pay if the insured is eligible under this rider. death benefit The amount of the insured's life insurance as shown on the specifications page attached to the certificate holder's certificate. immediate family The certificate holder's spouse, children, parents, grandparents, grandchildren, brothers and sisters, and their spouses. insured For purposes of this rider, an insured employee, an insured spouse, or an insured dependent child. physician An individual who is licensed to practice medicine or treat illness in the state in which treatment is received. This does not include the certificate holder, or a member of the certificate holder's immediate family. Terminal Condition What Is a terminal condition? A terminal condition is a condition caused by sickness or accident which directly results in a life expectancy of twelve months or less. MHC-96-13184.9 What evidence do we require of the insured's terminal condition? We must be given evidence that satisfies us that the insured's life expectancy, because of sickness or accident, is twelve months or Tess. That evidence must include certification by a physician. Do we have the right to obtain independent medical verification? Yes. We retain the right to have the insured medically examined at our own expense to verify the insureds medical condition. We may do this as often as reasonably required while accelerated benefits are being considered or paid. Payment of Accelerated Benefit How do we calculate the accelerated benefit? We will multiply the death benefit by the accelerated benefit factor to determine the accelerated benefit available. How do we calculate the accelerated benefit factor? The accelerated benefit factor will be stated as a percentage of the insured's death benefit. When we calculate this factor, we will consider the insured's age and gender. We will also base our calculation on certain assumptions, which we may change from time to time, including but not limited to assumptions about: (1) expected future premiums; and (2) the insured's life expectancy. What are the conditions for the payment of an accelerated benefit? We will consider the payment of an accelerated benefit, subject to all of the following conditions: (1) coverage must be in force and all premiums due must be fully paid; and (2) application must be made in writing and in a form which is satisfactory to us. We will tell a certificate holder what form is required; and (3) the certificate holder must be the sole owner of the certificate; and (4) the insured's insurance must not have an irrevocable beneficiary. Minnesota Life 1 Ed. F. X)000C 10-2004 Who may request an accelerated payment of the death benefit? A certificate holder may request an accelerated payment of the insurance on his or her life or on the life of a spouse or dependent child insured under his or her certificate. Is the request for an accelerated benefit voluntary? Yes. An accelerated benefit will be made available on a voluntary basis only. An accelerated benefit under this rider is not intended to cause an involuntary reduction of the death benefit ultimately payable to the named beneficiary. Therefore, payment of the death benefit cannot be accelerated under this rider if the insured: (1) is required by law to use this option to meet the claims of creditors, whether in bankruptcy or otherwise; or (2) is required by a govemment agency to use this option in order to apply for, obtain, or keep a govemment benefit or entitlement. Is there a minimum or maximum death benefit eligible for an accelerated benefit? Yes. The minimum death benefit to be eligible for an accelerated benefit under this rider is $10,000. The maximum death benefit to be eligible for an accelerated benefit is the lesser of $1,000,000. Does a certificate holder have to take the entire accelerated benefit? No. The certificate holder may choose to receive a partial accelerated benefit. If he or she does so, the insured's remaining coverage will stay in force. If a certificate holder elects to receive only a partial accelerated benefit amount available under this rider, the remaining death benefit under the certificate must be at least $25,000. The certificate holder may reapply for the payment of the remaining amount of insurance at any time. However, we may ask for further satisfactory evidence that the insured meets all requirements for the accelerated benefit. MHC-96-13184.9 What is the effect on an insured's coverage of the receipt of an accelerated benefit? If a certificate holder elects to accelerate the full amount of an insured's death benefit, the insured's coverage and all other benefits under the certificate and any certificate supplements which apply to that insured will end. If the insured is a certificate holder, any other individual insured under his or her certificate will be allowed to convert any such insurance to a policy of individual life insurance according to the conversion right section of the group policy to which this rider is attached. If a partial accelerated benefit is chosen, coverage will remain in force and premiums will be reduced accordingly. The remaining amount of insurance under the certificate will be the full amount of insurance minus the amount of insurance that was accelerated. How will we pay the accelerated benefit? We will pay the accelerated benefit in one lump sum or in any other mutually agreeable manner. To whom will we pay accelerated benefits? All accelerated benefits will be paid to the certificate holder who requested the accelerated payment unless the certificate holder validly assigns them otherwise. If such certificate holder dies before all payments have been made, we will pay the remainder to the insured's beneficiary named under the certificate. Payment will be made in one lump sum which will be the present value of the payments that remain, using the interest rate we use to determine the payments. Termination When does an insured's coverage under this rider terminate? An insured's coverage ends on the date the insured is no longer covered for life insurance under the group policy. When does this rider terminate? This rider will terminate on the earlier of: (1) the date we receive a written request to cancel this rider; or (2) the date the group policy is terminated. Otis....:. Cris cy 44,YASis Secretary President Minnesota Lire 2 Ed. F. X)000( 10-2004 MINNESOTA LIFE 400 Robert Street North • St. Paul, Minnesota 55101-2098 GROUP TERM LIFE INSURANCE POUCY • NONPARTICIPATING Agreement The purpose of this Agreement is to confirm and summarize in a single document the agreement between Minnesota Life Insurance Company ("Minnesota Life") and The City of Miami ("The City") with respect to: (1) underwriting by Minnesota Life of basic and optional life and AD&D insurance for certain eligible employees and retirees of The City's employee group life insurance benefit plan; and (2) the provision by Minnesota Life of certain administrative services to the Plan relating to such basic and optional life and AD&D insurance. Section 1. Entire Agreement. This Agreement together with the following documents, which are too voluminous to attach but which are available as public records from The City, or from Minnesota Life's Home Office in St. Paul, Minnesota, represents the entire and integrated agreement between the parties and supersedes all prior negotiations, representations or agreements, written or oral: (1) Group Term Life Insurance Policy number 33050-G, effective January 1, 2005, providing basic and optional group term life and accidental death and dismemberment (AD&D) insurance, as amended from time to time (hereinafter referred to as the "Policy"); and (2) City of Miami RFP number 03-04-078, dated September 20, 2004, as modified by any addendums, for Life and AD&D insurance coverage (hereinafter referred to as the "RFP"); and (3) Minnesota Life's formal response to the RFP, dated September 17, 2004 (hereinafter referred to as the "Minnesota Life Proposal"). Section 2. Basic and Optional Life and AD&D Insurance. The parties agree that Minnesota Life will provide basic and optional life and AD&D insurance benefits to certain eligible participants of The City in accordance with the terms and provisions of the Policy as modified and clarified in the RFP, the Minnesota Life Proposal and this Agreement beginning January 1, 2005 until such time as the Policy is terminated. Section 3. Administrative Service to be Rendered. The parties mutually agree to administer the Policy in accordance with the terms and provisions of the Policy, the RFP, the Minnesota Life Proposal, and this Agreement, beginning January 1, 2005 until such time as the Policy is terminated. i Section 4. Independent Contractor. Minnesota Life and its employees and agents are independent contractors and not agents or employees of The City, and shall not attain any rights, benefits or stipends afford employees of The City. Section 5. Financial Basis. The insurance coverages are provided to The City by Minnesota Life on a nonparticipating, fully -insured basis. Under this basis, premiums are collected at stated rates and Minnesota Life retains the full insurance risk for the insurance coverages. The insurance coverages are not eligible for experience credits. Any annual surpluses or deficits are absorbed by Minnesota Life. The initial premium rates to which The City and Minnesota Life have agreed are shown in Exhibit A attached to this Agreement. These initial rates are guaranteed for three years, starting from the effective date of the plan (January 1, 2005) and continuing through December 31, 2007. These rates may be extended by Minnesota Life for an additional two year period if the plan financial experience is as expected as documented in the\ Minnesota Life Proposal. Section 6. Discontinuance of Agreement. The term of this Agreement shall be for three years, commencing on January 1, 2005 and ending on December 31, 2007. The City Manager may administratively renew this Agreement for two additional terms of two years each by affording written notice to Minnesota Life of such election more than thirty days prior to the expiration of the then current term. Section 7. Third Party Beneficiaries. The parties agree that there are no third party beneficiaries to this Agreement and that no third party shall be entitled to assert a claim against either of them based on this Agreement. Section 8. Applicable Law and Venue. This Agreement shall be governed by the laws, cases and statutes of the State of Florida and any civil actions between the parties shall be in a court of competent jurisdiction in Miami -Dade County, Florida. Section 9. Amendments. No changes, modifications, or amendments in the terms and conditions of this Agreement shall be effective unless reduced to writing, numbered and signed by a duly authorized representative of Minnesota Life and The City. Section 10. Anti -Discrimination. Minnesota Life represents and warrants that there shall be no unlawful discrimination as provided by federal, state or local law, in connection with its performance of this Agreement. IN WITNESS WHEREOF, the parties hereto have caused this instrument to be executed by their respective officials thereunto duly authorized, this the day and year above written. "Provider" ATTEST: Minnesota Life Insurance Company A State of Minnesota Corporation Corporate Secretary (affix corporate seal) "City" ATTEST: Priscilla A. Thompson, City Clerk APPROVED AS TO FORM AND CORRECTNESS: Jorge I. Fernandez City Attorney Title CITY OF MIAMI, a municipal corporation By: Joe Arriola, City Manager APPROVED AS TO INSURANCE REQUIREMENTS: Dania Carrillo, Risk Management Administrator Exhibit A Initial Premium Rates COVERAGE / CLASS* MONTHLY RATE PER $1,000 OF COVERAGE Basic Life — Class 1 $ .43 Basic Life — Class 2 $ .85 Basic Life — Class 3 $1.75 Basic Life — Class 4 $2.28 Basic Life — Class 5 $2. 28 Basic AD&D — Class 1 and 2 $.025 Basic AD&D — Class 3 and 4 $ .06 Basic AD&D — Class 5 $ .06 Supplemental Employee / Spouse Age Rate/$1,000 Life and Matching AD&D Under 30 $ .12 Classes 1 and 2 30 — 34 .13 35 — 39 .15 40 — 44 .19 45 — 49 .25 50 — 54 .35 55 — 59 .64 60 — 65 .97 65 — 69 1.47 70 + 2.98 Dependent Child — Life only $.75 per $5,000 Class 1 and 2 only *Classes as defined in the Policy.