G.O. # 806
Satellite # 719
THE PAUL REVERE LIFE INSURANCE COMPANY
Worcester, Massachusetts 01608
Amendment No. PD8-1
Group Policy Number: G-42326
Policyholder: GRACO INC.
Effective Date of Revision: April 1, 1995
It is hereby understood and agreed upon that the above group policy or policies
issued by the Paul Revere Life Insurance Company shall be amended as follows:
Said group policy with any of its amendments is deleted and the attached group
policy is substituted therefore.
This amendment is hereby incorporated into and made a part of the said group
policy or policies.
THE PAUL REVERE LIFE INSURANCE COMPANY
January 23, 1996
- ----------------
Date of Issue
/s/John H. Budd /s/Charles E. Soula
- --------------- -------------------
Secretary President
AMD 94-3
The Paul Revere Life
Insurance Company
Group Policy Number: 42326
Policyholder: GRACO INC.
Effective Date: March 1, 1993
State of Issue: Minnesota
Revision Date: April 1, 1995
THE PAUL REVERE LIFE INSURANCE COMPANY agrees to pay the Group Insurance
Benefits set forth in this Policy. This Policy provides long term disability
insurance benefits for the replacement of income loss due to Disability.
Benefits are paid to or on behalf of all Employees of the policyholder who
become insured according to the provisions of this Policy. This Policy is based
upon yearly renewable term products. The duration of this Policy, subject to
Termination and all other Policy provisions, is shown in the Duration Rider.
The premium for the benefits provided by this Policy shall be paid by the
policyholder. All premiums are computed according to the provisions of this
Policy. The first premium is due on the date this Policy begins. All other
premiums due while this Policy is in force are to be paid in advance monthly on
the premium due date.
The provisions on the following pages are part of this Policy.
Signed by the officers of The Paul Revere Life Insurance Company at Worcester,
Massachusetts.
/s/John H. Budd /s/Charles E. Soula
--------------- -------------------
Secretary President
GROUP INSURANCE POLICY
NON-PARTICIPATING
PD8FACE 93-6
POLICYHOLDER SUBSIDIARIES AND AFFILIATES APPROVED FOR COVERAGE
Application to add an affiliate or subsidiary must be made in writing on an
approved application form. All agreements made between the policyholder and Us
are binding on all Employers. The list of approved affiliates and/or
subsidiaries is shown below.
The policyholder acts for and on behalf of all accepted Employers. All
agreements made between the policyholder and Us are binding on all Employers. No
other Employer may discontinue, modify, reduce or terminate this Policy.
PD8-A/S 93-8
TABLE OF CONTENTS
SCHEDULE OF BENEFITS .........................................................SB
GENERAL PROVISIONS ............................................................1
Definitions/Employees Eligible/Waiting Period/Effective Dates/Changes in
Amounts of Insurance/Policyholder Requests for Plan Changes/Termination of
Employee Insurance/Leave of Absence/Recurrent Disability
LONG TERM DISABILITY INCOME BENEFIT ...........................................2
Benefit/Rehabilitation Benefit/Period of Time Before Benefits Begin to
Accrue/Calculation/Maximum Benefit Period/Return to Work Benefit/Residual
Benefit/Family Survivor Income Benefit/Adjustable Cost of Living
Benefit/Conversion Privilege
BENEFIT REDUCTIONS ............................................................3
Integration Method/Income Sources That Will Reduce Our Benefit/Estimated
Social Security Benefits/Workers' Compensation Benefits
EXCLUSIONS AND LIMITATIONS ....................................................4
Exclusions/Pre-Existing Condition Limitation/Exception to Pre-Existing
Condition Limitation/PECL for Revisions/Other Limitations
PREMIUMS ......................................................................5
Payment of Premiums/The Grace Period/Amount of Premiums/Waiver of
Premium/Charges for Changes/Premium Credits/Simplified Accounting/
Inaccurate Census and Premium/Schedule of Premium Rates
CLAIMS ........................................................................6
Notice of Claim/Forms/Proof of Loss/Time Limits/Exams/Proof of Financial
Loss/How We Pay Benefits/Choice of Doctor/Legal Actions and Limitations
TERMINATION OF POLICY .........................................................7
MISCELLANEOUS PROVISIONS ......................................................8
Entire Contract/Time Limits for Certain Defenses/Agency/Misstatement/
Misrepresentation/Rescission/Certificates of Insurance/Insurance
Information/Changes in This Policy/Clerical Errors or Delays/Assignment
of Benefits/Workers' Compensation
DURATION AND RATE RIDER ...................................................RIDER
Duration of the Policy/Rate Guarantee
PD8TOC 93-8
SCHEDULE OF BENEFITS
Classification of Eligible Employees:
Class 1 - Corporate Officers and Executive Officers earning a minimum base
salary of $105,000; Sales Directors whose base salary and on-plan bonus
together total $105,000 or more; and, other Managing Directors earning
a minimum base salary of $105,000.
Amount of Disability Income Benefit:
- ------------------------------------
33.33% of the first $12,000.00 of Monthly Earnings and
67% of the remaining Monthly Earnings:
Maximum Benefit: $17,500.00 per month.
Minimum Benefit: 15% of basic monthly earnings,
up to a maximum of $100.00
Non-Evidence Limit: $16,000.00 Maximum Monthly Benefit
- ------------------
Maximum Benefit Period:
- -----------------------
Insured's Age When
Disability Begins Maximum Benefit Period
- ----------------- ----------------------
Less than Age 60 To Age 65
Age 60 5 Years
Age 61 4 Years
Age 62 42 Months
Age 63 36 Months
Age 64 30 Months
Age 65 24 Months
Age 66 21 Months
Age 67 18 Months
Age 68 15 Months
Age 69 and over 12 Months
Elimination Period: 180 Days
- ------------------
PD8-SOB SB 93-8
GENERAL PROVISIONS
DEFINITIONS
Here are some of the terms used in this Policy. Other terms are defined where
used in this Policy. All defined terms are important in describing rights under
this Policy. Please refer back to these meanings as you read. Defined terms are
presented with capital letters to help identify them as such. Masculine pronouns
used in this Policy apply to both sexes.
ACTIVELY AT WORK or ACTIVE WORK means that an Employee
1. is present at the Employer's place of business or a work site other than
the Employee's home, as designated by the Employer; and
2. is performing the duties of his job; and
3. is producing the work product required by his job.
DISABLED OR DISABILITY -- these terms mean either Total Disability or Residual
Disability. The definitions of these terms are presented in the Long Term
Disability Benefit (Section 2). One or more may apply to the Employee.
DOCTOR means a person, other than the insured, who is licensed to practice the
healing arts and who is practicing within the scope of his license. The term
covers only a licensed medical practitioner whose services are required to be
covered by the law of the jurisdiction where the treatment is rendered. See the
CLAIMS section for the provision on CHOICE OF DOCTOR.
DOCTOR'S CARE means the regular and personal care of a Doctor that, under
prevailing medical standards, is appropriate for the condition causing the
Disability.
EARNINGS (SALES DIRECTORS) means, for purposes of determining an Employee's
total disability benefit, the Employee's basic annual, monthly or weekly pay
based on a Work week of not more than 40 hours, prior to becoming disabled and
as last reported to Us in writing by the Employer and verified by Us. It
includes earnings from Incentive Bonuses, but not overtime or other special pay.
Incentive Bonuses are averaged for the lesser of the 24 month period immediately
prior to the date disability begins or the period of employment. Earnings from
sources other than the Employer are not included in determining total disability
benefits.
PD81000 SECTION 1 93-8
GENERAL PROVISIONS
DEFINITIONS
EARNINGS (ALL OTHER EMPLOYEES) means, for purposes of determining an Employee's
total disability benefit, the Employee's basic annual, monthly or weekly pay
based on a work week of not more than 40 hours, prior to becoming disabled and
as last reported to Us in writing by the Employer and verified by Us.
Commissions, bonuses, overtime or other special pay is not included. Earnings
from sources other than the Employer are not included in determining total
disability benefits.
PD81000 SECTION 1 93-8
GENERAL PROVISIONS
DEFINITIONS
EMPLOYEE means any person who works Full-time for the Employer. An Employee must
be paid by the Employer for work done at the Employer's usual place of business
or some other location that is usual for the Employee's particular duties.
For the purposes of this long term disability benefit, the term Employee does
not include any person performing services for the Employer
o pursuant to a contractual relationship with the Employer;
o subject to the terms of a leasing agreement between the Employer and a leasing
organization; or
o who receives income which is reported by the Employer on IRS Form 1099.
EMPLOYER means the policyholder or a branch or a division of the policyholder,
and any company legally affiliated with or subsidiary to the policyholder that
has been approved by Us.
A SUBSIDIARY is an entity with controlling stock ownership (51 % or more) held
by the Employer who is the policyholder.
An AFFILIATE is a company whose business is controlled by the policyholder
through stock ownership, contract, common officers or otherwise.
EVIDENCE OF INSURABILITY means written proof given to Us that an Employee is
insurable. This proof must be based on medical and financial information and
must be acceptable to Us.
FULL-TIME means, for an Employee, his Employer's normal work week of at least 30
hours. For Employees whose work weeks vary above and below this number, We will
determine eligibility by averaging the hours worked during weeks in the month.
IMPORTANT DUTIES means, with respect to an Employee's occupation, the material
and substantial duties of that occupation.
INCURRED DATE OF DISABILITY means the first date the Employee satisfies the
required definition of Disability. This date is determined by Us.
INJURY means accidental bodily loss or harm incurred while insured under this
Policy.
MONTHLY EARNINGS means the Employee's annualized Earnings divided by twelve
(12).
NON-EVIDENCE LIMIT means the greatest amount of insurance an Employee may have
without providing Evidence of Insurability.
1. The Employee may be eligible for more than this amount initially; or
2. the amount of existing insurance may be increased to an amount in excess of
any NonEvidence Limit; or
3. the amount of insurance currently in excess of the Non-Evidence Limit may be
further increased.
In any of these situations, the Employee must send Us Evidence of Insurability.
If We do not approve the Evidence of Insurability, the Employee's insurance is
limited, but in no event will the Employee's insurance be less than the lowest
amount shown in the Non-Evidence Limit provision of the Schedule of Benefits.
PERIOD OF DISABILITY means a continuous period of time during which an Employee
is Disabled as the result of Injury or Sickness whether from one or more causes.
PD81100-MN SECTION 1 93-8
GENERAL PROVISIONS
DEFINITIONS
PRIOR PLAN means the Employer's group long term disability insurance program in
effect the day before the effective date of this Policy. This Policy replaces
that plan or a portion of it.
RETIREMENT PLAN means, for the purpose of determining benefit reductions, a plan
that provides retirement benefits to employees. It also includes any retirement
plan for which the insured is eligible as a result of his job with the Employer,
including any plan that is part of any federal, state, county, municipal or
association retirement system.
The term does not include:
1. Profit Sharing Plans as defined in 401 (a);
2. Thrift plans (e.g., 401 (k)s);
3. Individual Retirement Accounts (IRAs);
4. Tax Sheltered Annuities (TSAs); or
5. Stock Ownership Plans as defined in Internal Revenue Code section 4975.
When used in this Policy, the term "Retirement Benefits" means the following
benefits payable from a Retirement Plan:
1. retirement benefits payable from the Employer's Retirement Plan upon early
or normal retirement; or
2. disability benefits payable from the Employer's Retirement Plan.
SICKNESS means an illness or disease. It also includes pregnancy.
WE, US or OUR means The Paul Revere Life Insurance Company.
PD81200 SECTION 1 93-8
GENERAL PROVISIONS
BECOMING ELIGIBLE FOR EMPLOYEE INSURANCE
An Employee is eligible for insurance if he is a member of an eligible class
listed in the Schedule of Benefits and is not excluded in the list shown below.
No Employee is eligible
1. who is scheduled to work less than six months in any twelve month period;
or
2. who works less than the required number of hours as defined in the
definition of "Full-time;" or
3. who is employed as an airline pilot, co-pilot or crew member unless
specifically mentioned in the Classification of Eligible Employees found on
the Schedule of Benefits.
An Employee who is not a citizen of the United States must be a permanent
resident of the United States, Canada or Puerto Rico in order to be an eligible
Employee. An Employee who is not a citizen is considered not eligible for
insurance if he leaves the United States, Canada or Puerto Rico for 180 or more
consecutive days.
SERVICE WAITING PERIOD
The service waiting period is a period of active Full-time employment the
Employee must complete before becoming eligible for insurance.
An Employee is eligible for insurance on the later of the Effective Date of this
Policy or the date the Employee begins work for the Employer on an active
Full-time basis.
CHANGING CLASSES
An Employee becomes eligible for insurance when he transfers from an ineligible
class to an eligible class. For the purposes of this provision, he is considered
to be a new Employee at that time. We use all past periods of Full-time work for
the Employer to determine the Employee's eligibility date. Any period of
part-time work does not count. An Employee cannot become eligible for insurance
before moving into an eligible class.
RE-HIRED EMPLOYEES
A re-hired Employee is treated as a new Employee and must satisfy a new service
waiting period. However, if an Employee is re-hired within one year from the
date of ineligibility for insurance, We use all past periods of Full-time work
for the Employer to determine the date the Employee satisfies the waiting
period. If an Employee is re-hired after one year, any past periods of work will
not count when We determine the date the Employee satisfies the waiting period.
An Employee cannot become eligible for insurance before the last date re-hired.
REINSTATEMENT
If an Employee requests Us to reinstate insurance that terminated while he was
still eligible to be insured by this Policy, We must first approve Evidence of
Insurability. Evidence must be given at the Employee's expense. The Employee's
insurance does not begin until the date We specify after approving the evidence.
PD81300 SECTION 1 93-8
GENERAL PROVISIONS
EFFECTIVE DATE OF EMPLOYEE INSURANCE
The Employee must be Actively At Work on the date his insurance goes into
effect. If the effective date occurs on a vacation, holiday or weekend, the
Employee must have been Actively At Work on the last scheduled working day. If
an Employee is absent from work for any other reason, including absence due to
Injury, Sickness or leave of absence, insurance does not become effective until
return to Full-time work.
NON-CONTRIBUTORY INSURANCE means that the Employer pays all of the cost of the
insurance. All eligible Employees must be enrolled unless they were eligible for
insurance but not covered under the Prior Plan. Insurance will become effective
on the date the Employee is eligible for insurance and Actively At Work.
If the amount of insurance exceeds the Non-Evidence Limit, the amount of an
Employee's insurance in excess of the Non-Evidence Limit will become effective
when:
1. the Employee becomes eligible for insurance; and
2. We approve the Employee's Evidence of Insurability. Evidence for amounts
over the Non-Evidence Limit is submitted at Our expense.
OTHER PROVISIONS
Application to add an affiliate or subsidiary must be made in writing. All
agreements made between the Policyholder and Us are binding on all Employers.
The list of approved affiliates and/or subsidiaries is shown on the policy page
before the Table of Contents.
If an Employer is a partnership or a sole proprietorship, a partner or
proprietor must also qualify as an Employee to be eligible for insurance.
Earnings definitions for owners of such entities will be applied.
PD81400 SECTION 1 93-8
GENERAL PROVISIONS
CHANGE IN AMOUNTS OF INSURANCE FOR INDIVIDUAL EMPLOYEES
The amount of insurance for which an Employee is eligible is shown in the
Schedule of Benefits. The benefits offered and the amounts of those benefits may
vary by class.
Benefits may increase or decrease due to a change in class or Earnings. The
Employer must notify Us in writing of any change in class or Earnings. This
notification must be received before the Employee ceases active, Full-time
employment.
Any change in an Employee's amount of insurance becomes effective on the date
the Employee is eligible for the change.
Any amount of the change that exceeds the Non-Evidence Limit will become
effective on the later of the date We approve the Employee's Evidence of
Insurability or the date the Employee becomes eligible for the increase.
The Employee must be Actively At Work on the date a change in the amount of
insurance becomes effective. If the effective date of the change occurs on a
vacation, holiday or weekend, the Employee must have been Actively At Work on
the last scheduled working day. If an Employee is absent from work for any other
reason, including absence due to Injury, Sickness or leave of absence, a change
does not become effective until return to Full-time work.
POLICYHOLDER REQUESTS FOR PLAN CHANGES
Any revisions to:
1. change benefits;
2. add affiliated or subsidiary employers;
3. change contribution basis; or
4. make other plan changes
must be requested in writing by the Policyholder and will not be effective
before the later of:
1. the applicant's signature date; or
2. the date The Paul Revere approves the change(s).
If this Policy is revised to increase or decrease benefits after its effective
date, an eligible Employee becomes insured for the revised benefits on the
effective date of the revision, subject to the Actively At Work requirement and
to the applicable pre-existing condition limitation.
PD81500 SECTION 1 93-8
GENERAL PROVISIONS
TERMINATION OF EMPLOYEE INSURANCE
An Employee's insurance terminates on the earliest of:
1. the date this Policy terminates;.
2. the first day for which the Employee fails or refuses to make any required
premium payment;
3. the first day for which premium on behalf of the Employee is not made;
4. the date the Employee no longer works in an eligible class; or
5. the date the Employee no longer works for the Employer.
Termination of insurance will not affect any claim incurred before the date of
termination.
LEAVE OF ABSENCE
Coverage may be continued when an Employee is on an unpaid leave under the
Federal Family and Medical Leave Act (FMLA) for any of the following reasons:
1. to provide care after the birth or adoption of a son or daughter; or
2. to provide care after the placement of a foster child; or
3. to provide care to a spouse, son, daughter, or parent due to serious
illness.
Upon approval by the Employer of an Employee's leave of absence for the above
reasons, coverage will be continued, subject to premium payments, for up to
three (3) months from the date the leave of absence began or, if sooner, until
Employee termination. If an Employee becomes Disabled while on leave, benefits
will be based upon Earnings as last reported to Us immediately prior to the
beginning of the leave.
PD81600 SECTION 1 93-8
GENERAL PROVISIONS
RECURRENT DISABILITY -- SAME INJURY OR SICKNESS
If, after the end of a Disability, the Employee becomes Disabled from the same
or related causes, We will deem it a separate Disability subject to a new
Elimination Period and a new Maximum Benefit Period. However, if such recurrence
occurs within 6 months of the end of the prior period, We will deem it a
continuation of the prior Disability. However, no benefit is payable for any day
the Employee is not Disabled, and no benefit period is extended by time not
Disabled. The gross amount payable prior to any adjustments as outlined in this
Policy would be the amount determined at the original date of Disability. A
recurrent Disability ends on the first to occur of the following dates:
1. the last day of 6 consecutive months during which the Employee was not
Disabled by the same Sickness or Injury.
2. the first day the Employee ceases to be disabled by the same Injury or
Sickness, even if immediately disabled by a different Injury or Sickness,
3. the date the last benefit for the Injury or Sickness becomes due.
The recurrent Disability provision applies only to Disabilities that began under
this Policy. If the Employee becomes eligible for coverage under any other group
long term disability policy, this recurrent disability section will cease to
apply to him.
CONCURRENT DISABILITY
If a Disability is caused by more than one Injury or Sickness, or from both, We
will pay benefits as if the Disability were caused by only one Injury or
Sickness. We will not pay more than one Disability benefit for the same period.
We will pay the larger benefit.
PD81700 SECTION 1 93-8
LONG TERM DISABILITY INCOME BENEFIT
WHAT WE PAY
We pay monthly disability benefits to an Employee who satisfies the following
definitions. The maximum amount We pay is shown in the Schedule of Benefits.
Benefit payments may be reduced if the Employee receives income from other
sources. When and how this occurs is described in the provision entitled Benefit
Reductions.
Own Occupation Benefit with Residual Disability
- -----------------------------------------------
TOTAL DISABILITY or TOTALLY DISABLED FROM THE EMPLOYEE'S OWN OCCUPATION means
that until he reaches the end of his Maximum Benefit Period, the Employee:
1. is unable to perform the important duties of his own occupation on a
Full-time or part-time basis because of an Injury or Sickness that started
while insured under this Policy; and
2. does not work at all; and
3. is under Doctor's Care.
If the Employee is employed and is earning wages or a salary, he will be
considered Residually Disabled as defined below.
RESIDUAL DISABILITY or RESIDUALLY DISABLED means, as a result of Injury or
Sickness, the Employee is unable to perform the important duties of his own
occupation on a Full-time basis, but:
1. he is able to perform one or more of the important duties of his own
occupation, or any other occupation, on a Full-time or part-time basis; and
2. he is earning less than 80% of his Prior Earnings.
To qualify for the Own Occupation Benefit with Residual Disability, the
Employee:
1. must satisfy the Elimination Period with the required number of days of
Total and/or Residual Disability as defined in this Policy; and
2. must be receiving Doctor's Care. We will waive the Doctor's Care
requirement if We receive written proof acceptable to Us that further
Doctor's Care would be of no benefit to the Employee.
PD82000 SECTION 2 93-8
LONG TERM DISABILITY INCOME BENEFIT
SPECIAL PROVISIONS RELATING TO DISABILITY
The loss of a professional or occupational license for any reason does not, in
itself, constitute Disability.
An Employee's Disability is determined relative to his ability or inability to
work. It is not determined by the availability of a suitable position with his
Employer.
WHEN WE PAY BENEFITS
Benefits begin to accrue on the first day after the Employee completes the
Elimination Period shown in the Schedule of Benefits. Benefits are paid monthly
while the Employee is Disabled,
PARTIAL MONTH PAYMENT
For any day a Disability benefit is payable in a period of less than a whole
month, We pay one thirtieth of the applicable monthly benefit.
RECOVERY OF OVERPAYMENTS
If the monthly benefit for any month is overpaid, We have the right to recover
the amount overpaid. We may deduct the amount overpaid from any future payments.
REHABILITATION BENEFIT
We will pay for the cost of services incurred in connection with a program of
vocational rehabilitation if:
1. We enter into a written agreement with the Employee on both the program and
the services; and
2. the cost of the services is not covered by another plan or program.
Participating in such a program will not affect the Employee's eligibility for
benefits under this Policy.
PD82100 SECTION 2 93-8
LONG TERM DISABILITY INCOME BENEFIT
PERIOD OF TIME BEFORE BENEFITS BEGIN TO ACCRUE
Before benefits begin to accrue, the Employee must be Totally or Residually
Disabled for a certain number of days.
ELIMINATION PERIOD means the length of time that the Employee must be Totally or
Residually Disabled before benefits begin. The length of the Employee's
Elimination Period is shown in the Schedule of Benefits. The Employee must
satisfy the Elimination Period before the Accumulation Period ends.
ACCUMULATION PERIOD means the period of time from the Incurred Date of
Disability during which the Employee must satisfy the Elimination Period. The
Elimination Period is shown on the Schedule of Benefits. The Accumulation Period
is equal to two times the Elimination Period. If the Employee does not satisfy
the Elimination Period within the Accumulation Period, or if the Employee
returns to work for 180 consecutive days, a new Period of Disability begins.
For purposes of the Elimination Period provision, INCURRED DATE OF DISABILITY
means the first date the Employee satisfies the definition of Total or Residual
Disability. This date is determined by Us.
BENEFIT CALCULATION FOR TOTAL DISABILITY
The amount of an Employee's Total Disability benefit is the least of:
1. the Employee's Monthly Earnings multiplied by the benefit percent less all
other income benefits as shown in the provision entitled Benefit
Reductions; or
2. the maximum monthly benefit; or
3. the Non-Evidence Limit, if Evidence of Insurability has not been approved
by Us for a higher maximum.
The benefit percent, the maximum monthly benefit and the Non-Evidence Limit are
shown on the Schedule of Benefits.
MAXIMUM BENEFIT PERIOD FOR TOTAL DISABILITY
The maximum benefit period is shown in the Schedule of Benefits. It is the
maximum length of time for which We pay benefits. It applies to all Periods of
Disability whether from one or more causes. In no case do We pay benefits after
the earliest of:
1. the date the Employee is no longer Totally Disabled; or
2. the end of the Maximum Benefit Period shown in the Schedule of Benefits; or
3. the date the Employee dies; or
4. the date benefits would cease according to any exclusion or limitation
contained in this Policy; or
5. the date benefits equaling or exceeding the long term disability benefit
become payable to the Employee under the Employer's Retirement Plan.
If the maximum benefit period is limited to a certain number of years or months
rather than age, the full benefit period may be restored after the Employee has
worked Full-time for six consecutive months.
PD82200 SECTION 2 93-6
LONG TERM DISABILITY INCOME BENEFIT
RETURN TO WORK ADJUSTMENT BENEFIT FOR RESIDUAL DISABILITY
When an Employee returns to work from any continuous Period of Disability
immediately following completion of the Employee's Elimination Period but before
the end of the benefit period, We pay the Employee a monthly benefit for each
whole month following return to work.
WHAT WE PAY
During the first 24 months that an Employee returns to work for any employer
during any continuous Period of Disability and while continuing to meet the
applicable definitions pertaining to Residual Disability:
1. We will not apply the requirement that the Employee's Loss of Earnings must
exceed 20% for Residual Disability benefits; and
2. in lieu of the Disability benefit, We will pay a special Return to Work
Adjustment Benefit.
The amount of the Return to Work Adjustment Benefit will be the amount of the
Total Disability benefit otherwise payable after reduction for other income
sources. The Return to Work Adjustment Benefit will be further reduced to the
extent that the sum of the benefit plus the Employee's earnings from any
employer plus other income sources (as defined in the Benefit Reduction section)
would exceed 100% of the Employee's Prior Earnings.
INDEXATION OF PRIOR EARNINGS
After 12 monthly Disability benefits have been paid, the amount of Prior
Earnings used to calculate the Employee's Return to Work Adjustment Benefit will
be increased by 7%. The initial Prior Earnings amount will, be increased on each
anniversary of the Employee's completing the Elimination Period.
MAXIMUM BENEFIT PERIOD
The Return to Work Adjustment Benefits are not paid beyond the first to occur
of:
1. the date the 24th monthly Return to Work Adjustment Benefit is paid during
any continuous Period of Disability; or
2. the date the Employee is no longer Residually Disabled; or
3. the end of the Maximum Benefit Period shown in the Schedule of Benefits; or
4. the date the Employee dies; or
5. the date benefits would cease according to any exclusion or limitation
contained in this Policy; or
6. the date benefits become payable under any other employer's group long term
disability insurance plan; or
7. the date benefits equaling or exceeding the long term disability benefit
become payable to the Employee under the Employer's Retirement Plan.
PD82300 SECTION 2 93-6
LONG TERM DISABILITY INCOME BENEFIT
BENEFIT CALCULATION FOR RESIDUAL DISABILITY
DEFINITIONS
The following are terms used within the Residual Disability Benefit and the
Return to Work Adjustment Benefit.
INITIAL TOTAL DISABILITY BENEFIT means the benefit that would have been payable
immediately following the completion of the Elimination Period after integration
with Social Security and/or other income sources.
LOSS OF EARNINGS means the Employee's Prior Earnings minus the Employee's Actual
Monthly Residual Earnings for the month the benefit is due. The difference must
be due to the Injury or Sickness causing the Residual Disability.
ACTUAL MONTHLY RESIDUAL EARNINGS means the Employee's salary, wages,
commissions, bonuses, fees, and income earned for services performed. If the
Employee owns any portion of a business or profession, it means the following:
Sole Proprietor earnings means the net profit of the business for federal income
- ---------------
tax purposes. Net profit is defined as gross business revenues less deductible
operating expenses.
Partner earnings means the partner's proportionate share of the partnership net
- -------
profit as reported for federal income tax purposes. The partnership's net
profit is defined as gross partnership revenues less deductible operating
expenses.
Employee/Shareholder earnings means the total gross salary, pension/profit
- --------------------
sharing plan contributions made on behalf of the individual, and the
proportionate share of the current year corporate net profit.
PRIOR EARNINGS means the greater of:
1. the Employee's average monthly earnings from all employment for the 12
whole calendar months immediately preceding his last regular day of active
Full-time work; or
2. the Employee's highest average monthly earnings from all employment for any
period of 2 successive years during the 5 year period immediately preceding
his last regular day of active Full-time work.
PD82400 SECTION 2 93-6
LONG TERM DISABILITY INCOME BENEFIT
BENEFIT CALCULATION FOR RESIDUAL DISABILITY (Continued)
In any continuous Period of Disability, immediately following completion of the
Employee's Elimination Period but before the end of the benefit period, We pay
the Employee a monthly Residual Disability benefit for each whole month while
the Employee is Residually Disabled, as defined.
During the first 24 months, We will pay a monthly benefit according to the
Return to Work Adjustment Benefit provisions. After the first 24 months of
Residual Disability and for the remainder of any continuous Period of
Disability, the Employee's Residual Disability benefit is proportionate to his
Total Disability benefit. The proportion depends on the actual amount of
earnings the Employee earns from work. To determine the monthly Residual
Disability benefit, We use the following formula:
Loss of Earnings X The Initial Total = The Employee's Residual
- ---------------- Disability Benefit Disability Benefit
Prior Earnings
If the Loss of Earnings for any month is 80% or more of Prior Earnings, We will
pay the Total Disability benefit. However, if the Loss of Earnings is less than
20% of Prior Earnings, then no Residual Disability benefit is payable.
INDEXATION OF PRIOR EARNINGS
After 12 monthly Disability benefits have been paid, the amount of Prior
Earnings used to calculate the Employee's Residual Disability benefit will be
increased by 7%. The initial Prior Earnings amount will be increased on each
anniversary of the Employee's completing the Elimination Period.
MAXIMUM BENEFIT PERIOD FOR RESIDUAL DISABILITY
Residual Disability benefits are not paid beyond the first to occur of the
following:
1. The date the Employee is no longer Residually Disabled; or
2. The end of the Maximum Benefit Period shown in the Schedule of Benefits; or
3. The date the Employee dies; or
4. The date benefits become payable under any employer's long term disability
insurance plan; or
5. The date the Employee is earning more than 80% of his indexed Prior
Earnings; or
6. The date benefits would cease according to any exclusion or limitation
contained in this Policy; or
7. The date benefits equaling or exceeding the long term disability benefit
become payable to the Employee under the Employer's Retirement Plan.
PD82500 SECTION 2 93-6
LONG TERM DISABILITY INCOME BENEFIT
FAMILY SURVIVOR INCOME BENEFIT
WHAT WE PAY
We pay a Family Survivor Income Benefit when We receive proof that all the
following conditions have been satisfied:
1. the Employee becomes Totally Disabled while insured for this benefit;
2. Disability benefits have been payable to the Employee; and
3. the Employee dies while Disabled and while in the maximum benefit period.
WHOM WE PAY
Benefits are payable to the Employee's lawful spouse, if living and mentally
competent. If the spouse is not living at the time benefits are payable, they
are paid in equal shares to each Child. If the spouse is not mentally competent,
We will pay according to applicable state law.
We decide to whom Payments are made. After We make payment, We have no further
liability,
CHILD means the Employee's natural born, step-child, adopted Child, and any
Child for whom the Employee is the legal guardian. Each Child must be unmarried
and under the age of twenty-one in order to be eligible to receive this benefit.
Unmarried children under the age of twenty-five are also eligible if they are
enrolled in a school as full-time students. Students who, by reason of illness,
injury, or physical or mental disability as documented by a Doctor, are unable
to carry a full-time course load will be covered, provided that the course load
is at least 60% of what is considered to be full-time.
HOW WE PAY
We pay a single lump sum benefit equal to three times the Disability benefit
payable to the Employee, after benefit reduction, for the last full calendar
month before the Employee's death. If the Employee dies before a full calendar
month's benefit has been paid, the survivor benefit will be based on the
Disability benefit that would have been paid at the end of the first month after
satisfying the Elimination Period.
ASSIGNMENT
This benefit may not be assigned, attached or applied to the debts of the
survivor unless required by law.
PD82600-1-MN SECTION 2 93-6
LONG TERM DISABILITY INCOME BENEFIT
ADJUSTABLE COST OF LIVING BENEFIT
If we pay the employee total or residual disability benefits for 12 months in
any continuous period of disability, and if further benefits are payable in the
continuous period of disability for months after the 12th month, we will
increase further these total or residual disability benefits by a cost of living
factor annually to the end of the Maximum Benefit Period in which benefits are
payable under this Adjustable Cost of Living Benefit. We First Calculated the
employee's adjusted monthly benefit, considering all benefits from other
sources, other income and any benefit adjustments other than prior cost of
living adjustments. We then increase the employee's adjusted monthly total or
residual disability benefit payment by the applicable cost of living factor
according to the CPl on each Review Data as follows:
LET:
A = the CPI for the most recent Index Month;
B = the CPI for the First Index Month;
THEN:
A - B = Cost of Living Factor
-----
B
The cost of living adjustment factor uses to determine the Adjusted Monthly
Benefit payment will be a minimum of four percent, and a maximum of ten percent.
CPI means the Consumer Price Index for All Urban Consumers. It is published by
the United States Department of Labor. If this index is discontinued or if the
method for computing it is materially changed, We may choose another index. We
will choose an index which in out opinion most accurately reflects the rate of
change in the cost of living in the United States. CPI would then mean the index
we choose.
INDEX MONTH means the calendar month four months prior to the calendar month in
which a Review Date occurs. However, the first Index Month will be the calendar
month four months prior to the month in which Disability payments began.
REVIEW DATE means the date that occurs after each twelve month Period of
Disability in which benefits are payable.
DL8PLR042326
PD8COLA-1 SECTION 2 93-6
LONG TERM DISABILITY INCOME BENEFIT
CONVERSION PRIVILEGE
An insured Employee whose insurance terminates because employment with the
Employer terminates may be eligible to convert all or some of his Group Long
Term Disability Insurance. To be eligible for conversion, the Employee:
1. must have been insured for Long Term Disability (LTD) benefits under the
plan for at least 12 consecutive months; and
2. must submit a completed conversion application and the first premium to The
Paul Revere within 31 days of the date his employment terminates.
The Employee will not be eligible for conversion if:
1. employment terminates coincident with termination of this Policy; or
2. the Employee is eligible to receive Total or Residual Disability benefits
under this Policy; or
3. the Employee is in an Elimination Period for Total or Residual Disability
benefits under this Policy; or
4. the Employee is not receiving benefits but is in a Period of Disability; or
5. the Employee is no longer in a class of Employees eligible for conversion;
or
6. the Employee becomes insured for other group long term disability benefits
within 31 days of the date of termination; or
7. the Employee retires or ceases to be actively employed; or
8. the coverage would, in our opinion, result in over insurance.
If the Employee is eligible for conversion and applies and pays the first
premium within 31 days of the date his employment terminates, We will issue him
a certificate of insurance. The certificate:
1. will be effective on the day after the day his Group LTD Insurance would
otherwise terminate; and
2. will be on one of the standard certificate forms then being offered by The
Paul Revere for the class of risk to which the Employee will belong after
his employment with the Employer terminates.
The certificate will be issued without medical Evidence of Insurability.
The premium will be determined by:
1. the certificate form issued;
2. the amount of insurance;
3. the class of risk to which the Employee will belong after his current
employment terminates; and
4. the Employee's age.
PD8CONV SECTION 2 93-6
LONG TERM DISABILITY INCOME BENEFIT
BENEFIT REDUCTIONS
While an Employee is Disabled, he may be eligible for benefits from other
sources. If so, We reduce our benefit by the amount of such other benefits paid
or payable.
Listed below are other income sources that will reduce our benefit.
1. Social Security benefits, including: Primary Social Security and Family
Social Security benefits received by an Employee or an Employee's
dependents because of the Employee's Disability or retirement. If an
Employee fails to apply for Social Security benefits, We determine the
amount he was eligible to receive, and, for the purposes of this insurance,
he will be considered to receive that amount.
Any general cost of living adjustment received from the Federal Social
Security Act, the Railroad Retirement Act, any Veteran's Disability
Compensation and Survivor Benefits Act, Workers Compensation or any similar
federal or state law which takes effect after long term disability benefits
become payable to an Employee is not used to reduce the Employee's benefit.
2. Other disability benefits from:
a. Statutory Disability ("Cash Sickness") Plans, where applicable;
b. Canadian Federal or Provincial Disability Benefits;
c. Railroad Retirement Act Disability Benefits;
d. Disability benefits with which We are required by law to
integrate.
3. Workers' Compensation benefits;
4. That portion of any sick pay or other salary continuation (other than
vacation pay) paid to the Employee by the Employer which, when added to the
amount of the Employee's benefit, exceeds 100% of the Employee's Earnings
as reported prior to Disability and as verified by Us;
5. Total, residual, or partial disability benefits from another group
disability plan provided by the Employer;
6. Group disability benefits from the following plans, but only if the plan is
Employer-sponsored:
a. Association Plans;
b. Fraternal Benefit Plans; or
c. Union Plans.
Employer-sponsored means a plan that is endorsed, promoted, or facilitated
by the Employer. For example, if the Employer made payroll deductions for
the plan, or permitted solicitation or enrollment of the plan on company
premises and/or company time, We would consider the plan to be
Employer-sponsored, even if the Employee pays the entire premium.
7. No fault disability benefits; or
8. Loss of Time awards or settlements involving liability insurance or court
actions; or
9. Disability benefits which are part of the Employer's Retirement Plan.
10. Retirement benefits attributable to Employer contributions. For benefits
that are paid or payable under an Employer's Retirement Plan, We will end
benefits under this Policy if retirement benefits are equal to or greater
than our long term disability benefit.
If the Employee's retirement benefit is a lump sum instead of a monthly benefit,
We will use the monthly benefit calculated for a lifetime annuity of that lump
sum amount. If the Plan requires the Employee to take the lump sum distribution
instead of leaving it in the Retirement Plan and he elects to roll the sum into
a Qualified vehicle such as an IRA, We will defer the integration until monthly
benefits can be received by the Employee without tax penalties.
If any of these benefits, except a retirement benefit, is paid in other than a
monthly sum, We divide the amount paid into equal monthly amounts in order to
reduce the monthly benefit. The number of monthly amounts depends on the length
of time the benefit award covers. If no length of time is stated in the benefit
award, We divide the amount paid into sixty equal payments. If any of these
benefits is paid on a retroactive basis, We may adjust our monthly payments in
order to offset any overpayment which results.
PD83000-MN,PD83100-MN SECTION 3 93-6
LONG TERM DISABILITY INCOME BENEFIT
BENEFIT REDUCTIONS (Continued)
Listed below are other income sources that will not reduce our benefit.
1. Individual disability insurance;
2. General Cost of Living increases from federal or state disability or
retirement programs that become effective after benefits become payable to
the Employee.
3. Non-Qualified Deferred Compensation plans;
4. Whether individually purchased or provided or sponsored by the Employer,
savings and investment accounts such as:
a. Individual Retirement Accounts (IRAs);
b. Internal Revenue Code Section 4975 Employee Stock Option Plans;
c. Thrift Plans (401 k)
d. 401 (a) Profit Sharing Plans; or
e. Tax Sheltered Annuities.
5. Disability benefits from the following plans, (including Franchise Plans),
purchased as individual coverage:
a. Association Plans;
b. Fraternal Benefit Plans; or
c. Union Plans.
6. Government or military pensions; or
7. Disabled veterans' benefits; or
8. Retirement benefits attributable to the Employee's contributions.
PD83000-MN,PD83100-MN SECTION 3 93-6
LONG TERM DISABILITY INCOME BENEFIT
ESTIMATED SOCIAL SECURITY BENEFITS
For the purpose of this section, the term Social Security benefits means
unreduced disability or retirement benefits that the Employee, his spouse or any
of his dependents are entitled to receive because of his disability under:
1. the United States Social Security Act;
2. the Canada Pension Plan;
3. the Quebec Pension Plan; or
4. any similar law, plan or act.
As part of an Employee's proof of loss, We require that the Employee furnish Us
evidence that he has duly applied for all other income sources for which he is
or may become eligible. In the case of Social Security benefits, this includes:
1. making due application for such benefits; and
2. if the Employee's initial application is denied, and if We so recommend,
making any and all available appeals.
Until the Employee has given Us written proof that all available appeals have
been exhausted, We may:
1. estimate the Employee's monthly Social Security benefit; and
2. reduce our monthly benefit to the Employee by that amount.
If We reduce the Employee's benefits on this basis, and if all of his appeals
are denied, We restore the reduced amounts to the Employee in one payment.
If the Employee signs our Social Security Reimbursement Agreement, We agree not
to reduce his benefits by estimated Social Security benefits while the
Employee's appeals are pending. In the Social Security Reimbursement Agreement,
the Employee promises to pay Us back for any overpayment of his long term
disability claim that results from a retroactive award of Social Security
benefits. If the Employee does not pay Us back, We have the right to recover our
overpayment from any future benefits that may be due him.
With proper authorization from the Employee and his Doctor, We will give the
Employee or his legal representative information from our claim file to assist
in any appeal of denied Social Security benefits.
PD83200 SECTION 3 93-6
LONG TERM DISABILITY INCOME BENEFIT
WORKERS' COMPENSATION BENEFITS
If an Employee is disabled due to an employment-related Injury, he should file
for workers' compensation benefits. Receipt of workers' compensation benefits
will reduce Disability benefits under this Policy.
As part of an Employee's proof of loss, We require that the Employee furnish Us
evidence that he has duly applied for all other income sources for which he is
or may become eligible. In the case of workers' compensation benefits, this
includes:
1. making due application for such benefits; and
2. if the Employee's initial application is denied, and if We so recommend,
making any and all available appeals.
We must receive written proof that all available appeals have been exhausted.
PD83300-MN SECTION 3 93-6
LONG TERM DISABILITY INCOME BENEFIT
EXCLUSIONS
WHAT WE DO NOT PAY
We do not pay benefits for any disabilities that result from:
1. war, whether declared or not, or any act or accident of war, or armed or
unarmed military or paramilitary conflict;
2. active participation in a riot;
3. the Employee's commission or attempt to commit a felony; or
4. an intentionally self-inflicted injury.
We do not pay benefits during any period in which an Employee is incarcerated.
PD84000 SECTION 4 93-6
LONG TERM DISABILITY INCOME BENEFIT
LIMITATIONS
PRE-EXISTING CONDITIONS LIMITATION
This Policy will not cover any Disability:
1. caused by, or contributed to by a Pre-Existing Condition; or
2. resulting from a Pre-Existing Condition.
PRE-EXISTING CONDITION means any Injury or Sickness that causes the Employee,
during the three (3) months just before becoming insured under this Policy, to:
1. consult a doctor;
2. seek diagnosis or medical advice or receive medical care or treatment;
3. undergo hospital admission or doctor's visits for testing or for
diagnostic studies; or
4. obtain services, supplies, prescription drugs or medicines.
However, this Policy will cover that Disability if it begins after the insured
Employee has performed the important duties of his own occupation:
1. on a Full-time basis;
2. for at least twelve (12) months.
In no event will this limitation be applied to loss incurred or disabilities
commencing after the Employee has been insured for twenty-four consecutive
months, notwithstanding any other eligibility provisions to the contrary.
PD84100-MN SECTION 4 93-6
LONG TERM DISABILITY INCOME BENEFIT
LIMITATIONS
EXCEPTION TO PRE-EXISTING CONDITIONS LIMITATION
An Employee insured under the prior group policy on the day before the effective
date of this Policy is eligible for coverage under this Policy on its effective
date regardless of Actively At Work conditions.
Benefits for a Disability caused by a Pre-Existing Condition
- ------------------------------------------------------------
Benefits for a Disability classified as due to a Pre-Existing Condition may be
payable to the insured Employee provided:
1. the condition would have been covered under the prior group policy had that
policy remained in force; or
2. on the Incurred Date of Disability the Employee has been insured and
working Full-time for twelve (12) months under any combination of this
Policy and the prior group policy.
If the above conditions are met, the benefit We pay will be the lesser of:
1. the monthly benefit payable under this Policy; or
2. the monthly benefit which would have been paid under the prior group
policy, taking into consideration all provisions of the prior group policy.
Any payment We make is reduced by any payments made for the same Disability
under the prior group policy.
In no event will We make payment beyond the first to occur of:
1. the date benefits cease under this Policy; or
2. the date benefits would have ceased under the prior group policy.
PD84200-D&R SECTION 4 93-6
LONG TERM DISABILITY INCOME BENEFIT
EXCEPTION TO PRE-EXISTING CONDITIONS LIMITATION DOES NOT APPLY TO INCREASED
BENEFITS
The exception to the pre-existing conditions limitation will not apply for the
amount of benefits in excess of the benefit provided by the prior group policy
on the day before this Policy became effective. The portion equal to the
increased amount of benefit will be subject to the preexisting conditions
limitation.
PD84200-D&R SECTION 4 93-6
LONG TERM DISABILITY INCOME BENEFIT
LIMITATIONS
PRE-EXISTING CONDITIONS LIMITATION APPLIES TO REVISED BENEFITS
After its effective date, this Policy may be revised to increase the amount or
duration of the long term disability benefit payable, to decrease the
Elimination Period, or to otherwise increase the terms under which benefits are
paid. In that event, benefits for a Disability due to a pre-existing condition
will be paid according to the policy terms in effect prior to the effective date
of the revision.
For the purposes of this provision, PRE-EXISTING CONDITION means any Injury or
Sickness that causes the Employee, during the three (3) months just before the
revision effective date, to:
1. consult a doctor;
2. seek diagnosis or medical advice or receive medical care or treatment;
3. undergo hospital admission or doctor's visits for testing or for
diagnostic studies; or
4. obtain services, supplies, prescription drugs or medicines.
This limitation does not apply to Disabilities that begin after the Employee has
been insured while working Full-time for twelve (12) months after the revision
effective date.
In no event will this limitation be applied to loss incurred or disabilities
commencing after the Employee has been insured for twenty-four (24) consecutive
months, notwithstanding any other eligibility provisions to the contrary.
PD84300-MN SECTION 4 93-8
PREMIUMS
PAYMENT OF PREMIUMS
All premiums are to be paid monthly in advance. The payment is due on or before
the premium due date. Make premium payment to The Paul Revere Life Insurance
Company and send it to the address requested by Us.
THE GRACE PERIOD
After the initial premium payment, a grace period of thirty-one days is allowed
for all late premiums. This Policy automatically terminates if premium payments
have not been made at the end of the grace period. Insurance is in force during
this grace period, and premiums are charged.
AMOUNT OF PREMIUMS
The premium due each month is the total of the current rates for all insured
Employees. The initial premium rates are shown in the Schedule of Premium Rates.
We have the right to charge new rates effective on any premium due date, unless
a Rate Guarantee Rider is in force. Before We can make a change, We must give
written notice at least thirty-one days before the new rates take effect.
WAIVER OF PREMIUM
After the Employee becomes insured, premium is due for that Employee while he is
Actively At Work and during his Elimination Period. Premium for the Employee is
waived while benefits are payable to him during any continuous Period of
Disability. Provided this Policy is in force when the Employee's continuous
Period of Disability ends, the Employee will remain insured if he returns to
active Full-time work in an eligible class and premium payments for the Employee
resume.
PREMIUM CHARGES FOR POLICY PLAN OR BENEFIT CHANGES
When premium rates are changed because of a change in plan or benefits on other
than a premium due date, the new premiums are charged on a pro-rata basis from
the effective date of the change to the next monthly premium due date. Full
monthly premiums are charged thereafter.
PREMIUM CREDITS
If We receive notice of an Employee's termination or decrease in amount of
insurance, We allow a full premium credit for that Employee from the effective
date of the change.
PD85000 SECTION 5 93-8
PREMIUMS
SIMPLIFIED ACCOUNTING FOR INDIVIDUAL EMPLOYEE CHANGES
When insurance for an Employee is added on other than a premium due date, his
premium is charged beginning from the next monthly due date.
When insurance for an Employee is terminated on other than a premium due date,
his premium is charged up to the next monthly premium due date. This method of
charging premiums is for accounting purposes only and will not extend insurance
coverage beyond the date of termination as described in the provision entitled
Termination of Employee Insurance.
When an Employee's insurance changes on other than a premium due date, the
premium is charged beginning from the next monthly premium due date.
INACCURATE CENSUS AND PREMIUM
Enrollment before the effective date could result inadvertently in premium being
paid for a person enrolled but not Actively At Work since before the policy
effective date. If this should occur, premium will be refunded as soon as We are
notified of the situation.
SCHEDULE OF PREMIUM RATES
The initial premium rates are:
Class 1 - 0.770% of the first $31,857 of Basic Monthly Earnings.
PD851 00 SECTION 5 93-8
CLAIMS
WE MUST BE NOTIFIED OF INTENT TO FILE A CLAIM
Written notice of a claim for Disability must be given to Us by the Employer or
claimant. The notice must be in writing and must be filed at Our Home Office in
Worcester, Massachusetts. Any claim will be based on the written notice. The
notice must be received by Us within thirty days after the end of the
Elimination Period. If We do not receive notice within thirty days, the claim
may be reduced or invalidated. If it can be shown that it was not reasonably
possible to submit notice within the thirty day period and it is shown that
notice was given as soon as possible, the claim will not be reduced or
invalidated.
WE FURNISH PROOF OF LOSS FORMS
After We receive written notice of claim, We provide a proof of loss form. This
form should be furnished within fifteen days after We receive written notice. If
We fail to furnish this form within fifteen days, the claimant can meet the time
period shown below by submitting written proof that explains the reason for the
claim. Written proof should establish facts about the claim such as occurrence,
nature and extent of the Disability involved. A supply of forms is included in
the Employer's administration kit.
WHEN TO FILE PROOF OF LOSS
The claimant must file written proof of the loss within ninety days of the end
of the Elimination Period. We have the right to require additional written proof
to verify the continuance of any Disability. We may request this additional
proof as often as We feel is necessary, within reason.
If proof of loss is not submitted and received by Us within the required time
period, the claim may be reduced or invalidated. If it can be shown that it was
not reasonably possible to submit proof within the time period and it is shown
that the proof was filed as soon as possible, the claim will not be reduced or
invalidated. However, proof of loss may not be submitted more than one year
after the time proof is otherwise required.
WE MAY EXTEND TIME LIMITS
If the time limit that We allow for giving notice of claim or for submitting
proof of loss is less than the law permits in the state where the claimant
lives, We extend Our time limit to agree with the minimum period specified by
law. The law must exist at the time this Policy is issued.
OUR RIGHT TO REQUIRE EXAMS
We have the right to require an exam of any claimant as often as it may be
required reasonably. The examination may be performed by a physician or
vocational expert of Our choice. Any such exam will be at Our own expense.
PD86000 SECTION 6 93-8
CLAIMS
OUR RIGHT TO REQUIRE PROOF OF FINANCIAL LOSS
We have the right to require written proof of financial loss. This includes, but
is not limited to:
1. statements of pre-disability income;
2. statements of income received from all sources while disabled;
3. evidence that due application has been made for all other available
benefits;
4. tax returns, tax statements, and accountants' statements; and
5. any other proof We reasonably may require.
We may perform financial audits at Our own expense as often as We reasonably may
require. Payment of benefits may be contingent upon the proof of financial loss
being satisfactory to Us.
HOW WE PAY BENEFITS
Any accrued benefits payable are subject to Our receiving proof of loss. Any
unpaid balance at the end of Our period of liability is paid within a reasonable
length of time after Our receiving proof of loss.
TO WHOM WE PAY BENEFITS
In the case of death, any unpaid accrued benefits are paid, at Our option, to
the Employee's estate or to one or more of the Employee's surviving relatives
based on Our selection.
All other benefits payable under this Policy are paid to the Employee. After We
have made payment, Our obligation with respect to the amount paid ends.
CHOICE OF DOCTOR
For treatment purposes, the Employee is free to select any Doctor. For purposes
of Disability certification, the Employee must select a Doctor who is not
related by blood or marriage and who is not an Employee of the policyholder.
LEGAL ACTIONS AND LIMITATIONS
No action at law or in equity may be brought to recover under this Policy unless
proof of loss has been filed according to the terms of this Policy. In addition,
the claimant must wait sixty days after filing proof of loss before taking
action. If any action is to be taken, it must be taken within three years from
the end of the sixty day time period. If any time limit in this Policy is less
than the law specifies in the state where the claimant lives at the time this
Policy is issued, We extend the time limit to agree with the minimum period
specified by such law.
PD86100 SECTION 6 93-8
TERMINATION
This Policy automatically terminates at the end of the 31 day grace period if
premium payments have not been made.
We have the right to terminate this Policy if:
1. less than one hundred percent (100%) of Employees eligible are insured for
any noncontributory benefit; or
2. less than seventy-five percent (75%) of the eligible Employees are insured
for any contributory benefit; or
3. fewer than ten (10) Employees are insured; or
4. the policyholder does not report all Employees who are eligible for
insurance under this Policy; or
5. the policyholder fails, at any time:
a. to furnish promptly any information We reasonably may require; or
b. to perform any other obligations pertaining to this Policy.
We may specify in advance written notice to the policyholder a date of
termination. We must give the policyholder notice of termination at least thirty
(30) days before the termination. It is not our responsibility to notify the
Employees.
The Duration Rider includes the date this Policy terminates without renewal. If
mutual agreement of renewal conditions cannot be reached, We will provide to the
policyholder thirty (30) days advance written notice.
The policyholder may terminate the entire contract or may terminate certain
affiliates and/or subsidiaries and their Employees at any time. In either case,
the policyholder must send Us written notice and include the date the insurance
will end. However, no termination of this Policy may take place during a period
for which the premiums have been paid. The termination takes effect on the later
of:
1. the date given in the notice; or
2. the date We receive the notice.
The policyholder must send Us any unpaid premiums for any insurance We provide
while this Policy was in force, even if notice of termination had been given to
Us. We determine the portion of premium to be paid for any period between the
premium due date and the date of termination.
PD87000 SECTION 7 93-8
MISCELLANEOUS PROVISIONS
ENTIRE CONTRACT
The entire contract is made up of this Policy, the application of the
policyholder, applications of the Participating Employers, and application by
each Employee. A copy of the policyholder's application is attached to this
Policy; each Employee retains a copy of his own application.
STATEMENTS
In the absence of fraud, all application statements made by the policyholder or
by an Employee are considered representations not warranties. This means that
the statements are made in good faith. No statement voids this Policy, reduces
the benefits We provide or is used as defense to a claim unless it is contained
in a written application and a copy is furnished to the Employee.
TIME LIMIT FOR CERTAIN DEFENSES
After two years from the effective date of this Policy, no misstatement made by
the Policyholder, except a fraudulent misstatement made in the application, may
be used to void this Policy. After two years from the effective date of the
Employer's participation in this Policy, no misstatement made by the Employer,
except a fraudulent misstatement made in the application, may be used to void
the Employer's participation in this Policy. After two years, no misstatement or
omission made by the Employee, except a fraudulent misstatement made in an
application, may be used to deny a claim for any Disability that begins after
the end of the two year period.
If any time limit in this Policy is other than that specified by the law of the
state where the claimant lives, We amend the time limit to agree with the period
specified by such law.
MISREPRESENTATION/RESCISSION
Certain amounts of insurance or increases in insurance may be subject to
Evidence of Insurability.
1. If an Employee makes a representation on his application for such an
amount; and
2. if such representation or omission was material to Our approval of his
application; and
3. if We discover within two (2) years of the effective date of the insurance
or the increase that the material fact or omission was a misrepresentation,
then We may, at Our option, rescind that amount or increase. This means that the
amount or increase will never have been in effect. All premium paid for
insurance that is rescinded will be refunded.
MISSTATEMENT OF FACT
If any important facts about an individual in relation to his insurance are
found to be misstated, We adjust Our premium to the correct amount. If the
misstatement affects the amount of insurance, the true facts are used to
determine the correct amount of insurance. Delay in reporting changes is not
considered a misstatement.
PD88000 SECTION 8 93-8
MISCELLANEOUS PROVISIONS
AGENCY
The Employer acts on his own behalf or as an agent of the Employees. The
Employer is not an agent of The Paul Revere.
WE PROVIDE CERTIFICATES OF INSURANCE
We issue certificates of insurance for each insured Employee. These are
delivered to the Employer to be given to the Employee. The certificate states
what the insurance coverage is and to whom We pay benefits. If the terms of this
Policy and the Employee's certificate differ, this Policy governs.
INSURANCE INFORMATION
The Employer will provide Us with the information We need to administer this
insurance contract and compute the premium.
This information will include:
1. that relative to Employees:
a. who newly qualify;
b. whose class changes;
c. whose Earnings amount changes;
d. whose insurance terminates;
e. who are on leaves of absence;
f. full census data as requested; and
2. any other information about this Policy that reasonably may be requested.
We have the right to verify this information. Employer records that may be
relevant, in Our opinion, will be open for inspection by Us at any reasonable
time.
CHANGES IN THIS POLICY
We may change the terms of this Policy if We receive a written request from the
policyholder. All changes that are made are stated in riders or amendments to
this Policy. These documents must be signed by Our President and Secretary. The
Employee's consent is not needed to make a policy change.
We may change this Policy if there is a change in the Federal Social Security
Act that affects Our liability. The change will take effect as of the date the
Federal Social Security Act changes. We may make other changes mandated by state
or Federal law.
CLERICAL ERRORS OR DELAYS
Clerical errors or omissions do not result in the denial of insurance. If there
is any delay in posting the date of any termination of insurance, the delay does
not extend any insurance provided by this Policy.
PD88100 SECTION 8 93-8
MISCELLANEOUS PROVISIONS
ASSIGNMENT OF BENEFITS
The Employee may not assign the right, title or interest of this long term
disability benefit to a third party.
WORKERS' COMPENSATION
This Policy does not affect or take the place of Workers' Compensation
insurance.
PD88200 SECTION 8 93-8
THE PAUL REVERE LIFE INSURANCE COMPANY
Worcester, Massachusetts 01608
DURATION AND RATE GUARANTEE RIDER
This Rider is attached to and forms a part of Group Policy G-42326
Effective Date of this Rider: April 1, 1995
DURATION OF THE ATTACHED GROUP POLICY
Subject to the conditions set forth in the TERMINATION OF THIS POLICY provision
of the attached Group Policy, the Group Policy and this Rider are in effect from
April 1, 1995, through February 28, 1996. Shortly before the expiration date,
the group will be reviewed for renewal. Mutual acceptance of renewal conditions
will result in our issuing an updated Duration and Rate Guarantee Rider.
If We decide not to renew this Policy, We will provide to the policyholder 30
days advance written notice.
RATE GUARANTEE
The Amount of Premiums provision of the Group Policy to which this Rider is
attached is amended as follows:
Premium rates in effect on the effective date of this Rider will not be changed
until the earliest of the following dates:
1. the date this Rider expires; or
2. the date the Group Policy is amended to change eligibility provisions or
benefits or to add or drop insurance on any affiliated or subsidiary
Employer; or
3. the date the total number of insured Employees changes by more than
twenty-five percent from the number of Employees insured on the effective
date of this Rider.
If any of the events described in 1, 2, or 3 above occur, the Rate Guarantee
portion of this Rider ceases to operate. Any subsequent changes in premium rates
under the Group Policy are made in accordance with the section of the Group
Policy entitled Premiums.
THE PAUL REVERE LIFE INSURANCE COMPANY
/s/John H. Budd /s/Charles E. Soula
Secretary President
PD8-R&D RIDER 93-8
NOTICE CONCERNING POLICYHOLDER RIGHTS IN AN
INSOLVENCY UNDER THE MINNESOTA LIFE AND HEALTH
INSURANCE GUARANTY ASSOCIATION LAW
If the insurer that issued your life, annuity, or health insurance policy
becomes impaired or insolvent, you are entitled to compensation for your policy
from the assets of that insurer. The amount you recover will depend on the
financial condition of the insurer.
In addition, residents of Minnesota who purchase life insurance, annuities, or
health insurance from insurance companies authorized to do business in Minnesota
are protected, SUBJECT TO LIMITS AND EXCLUSIONS, in the event the insurer
becomes financially impaired or insolvent. This protection is provided by the
Minnesota Life and Health Insurance Guaranty Association.
Minnesota Life & Health Insurance Guaranty Association
750 Norwest Center
55 East 5th Street
St. Paul, Minnesota 55101
(612) 222-2799
The maximum amount the guaranty association will pay for all policies issued on
one life by the same insurer is limited to $300,000. Subject to this $300,000
limit, the Guaranty Association will pay up to $300,000 in life insurance death
benefits, $100,000 in net cash surrender and net cash withdrawal values for life
insurance, $300,000 in health insurance benefits, including any net cash
surrender and net cash withdrawal values, $100,000 in annuity net cash surrender
and net cash withdrawal values, $300,000 in present value of annuity benefits
for annuities which are part of a structured settlement or for annuities in
regard to which periodic annuity benefits, for a period of not less than the
annuitant's lifetime or for a period certain of not less than ten years, have
begun to be paid on or before the date of impairment or insolvency, or if no
coverage limit has been specified for a covered policy or benefit, the coverage
limit shall be $300,000 in present value. Unallocated annuity contracts issued
to retirement plans, other than defined benefit plans, established under section
401, 403(b), or 457 of the Internal Revenue Code of 1986, as amended through
December 31, 1992, are covered up to $100,000 in net cash surrender and net cash
withdrawal values, for Minnesota residents covered by the plan provided,
however, that the association shall not be responsible for more than $7,500,000
in claims from all Minnesota residents covered by the plan. If total claims
exceed $7,500,000, the $7,500,000 shall be prorated among all claimants. These
are the maximum claim amounts.
Coverage by the Guaranty Association is also subject to other substantial
limitations and exclusions and requires continued residency in Minnesota. If
your claim exceeds the Guaranty Association's limits, you may still recover a
part or all of that amount from the proceeds of the liquidation of the insolvent
insurer, if any exist. Funds to pay claims may not be immediately available. The
Guaranty Association assesses insurers licensed to sell life and health
insurance in Minnesota after the insolvency occurs. Claims are paid from this
assessment.
PD8GAA-MN-1
NOTICE CONCERNING POLICYHOLDER RIGHTS IN AN
INSOLVENCY UNDER THE MINNESOTA LIFE AND HEALTH
INSURANCE GUARANTY ASSOCIATION LAW
THE COVERAGE PROVIDED BY THE GUARANTY ASSOCIATION IS NOT A SUBSTITUTE FOR USING
CARE IN SELECTING INSURANCE COMPANIES THAT ARE WELL MANAGED AND FINANCIALLY
STABLE. IN SELECTING AN INSURANCE COMPANY OR POLICY, YOU SHOULD NOT RELY ON
COVERAGE BY THE GUARANTY ASSOCIATION.
THIS NOTICE IS REQUIRED BY MINNESOTA STATE LAW TO ADVISE POLICYHOLDERS OF LIFE,
ANNUITY OR HEALTH INSURANCE POLICIES OF THEIR RIGHTS IN THE EVENT THEIR
INSURANCE CARRIER BECOMES FINANCIALLY INSOLVENT. THIS NOTICE IN NO WAY IMPLIES
THAT THE COMPANY CURRENTLY HAS ANY TYPE OF FINANCIAL PROBLEMS. ALL LIFE, ANNUITY
AND HEALTH INSURANCE POLICIES ARE REQUIRED TO PROVIDE THIS NOTICE.
PD8GAA-MN-2