GREAT-WEST LIFE
CONTRACTS
CALIFORNIA GUARANTY ASSOCIATION ACT - SUMMARY
CALIFORNIA LIFE AND HEALTH INSURANCE GUARANTY ASSOCIATION ACT SUMMARY
DOCUMENT AND DISCLAIMER
Residents of California who purchase life and health insurance and annuities
should know that the insurance companies licensed in this state to write this
type of insurance are members of the California Life and Health Insurance
Guaranty Association (CLHIGA). The purpose of this Association is to assure that
policyholders will be protected, within limits, in the unlikely event that a
member insurer becomes financially unable to meet its obligations. If this
should happen, the Guaranty Association will assess its other member insurance
companies for the money to pay the claims of insured persons who live in this
state and, in some cases, to keep coverage in force. The valuable extra
protection provided by these insurers through the Guaranty Association is not
unlimited, however, as noted below, and is not a substitute for consumers' care
in selecting insurers.
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The California Life and Health Insurance Guaranty Association may not provide
coverage for this policy. If coverage is provided, it may be subject to
substantial limitations or exclusions, and require continued residency in
California. You should not rely on coverage by the California Health Insurance
Guaranty Association in selecting an insurance company or in selecting an
insurance policy.
Coverage is NOT provided for your policy or any portion of it that is not
guaranteed by the insurer or for which you have assumed the risk, such as a
variable contract sold by prospectus.
Insurance companies or their agents are required by law to give or send you this
notice. However, insurance companies and their agents are prohibited by law from
using the existence of the Guaranty Association to induce you to purchase any
kind of insurance policy.
Policyholders with additional questions should first contact their insurer or
agent, and may then contact:
Executive Director
California Life and Health Insurance Guaranty Association
P.O. Box 70069
Los Angeles, CA 90070
Allegra Willison, Staff Counsel
California Department of Insurance
45 Fremont Street, 24th Floor
San Francisco, California 94105
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Page 1
CALIFORNIA GUARANTY ASSOCIATION ACT - SUMMARY (Continued)
The state law that provides for this safety-net coverage is called the
California Life and Health Insurance Guaranty Association Act. Below is a brief
summary of this law's coverages, exclusions and limits. This summary does not
cover all provisions of the law; nor does it in any way change anyone's rights
or obligations under the act or the right or obligations of the Association.
COVERAGE
Generall, individuals will be protected by the California Life and Health
Insurance Guaranty Association if they live in this state and hold a life or
health insurance contract, or an annuity, or if they are insured under a group
insurance contract, issued by a member insurer. The beneficiaries, payees or
assignees of insured persons are protected as well, even if they live in another
state.
EXCLUSIONS FROM COVERAGE
However, persons holding such policies are not protected by this Guaranty
Association if:
* Their insurer was not authorized to do business in this state when it
issued the policy or contract.
* Their policy was issued by a health care service plan (HMO, Blue
Cross, Blue Shield), a charitable organization, a fraternal benefit
society, a mandatory state pooling plan, a mutual assessment company,
an insurance exchange, or a grants and annuities society.
* They are eligible for protection under the laws of another state. This
may occur when the insolvent insurer was incorporated in another state
whose guaranty association protects insureds who live outside that
state.
The Guaranty Association also does not provide coverage for:
* Unallocated annuity contracts; that is, contracts which are not issued
to and owned by an individual and which guarantee rights to group
contract holders, not individuals.
* Employer and association plans, to the extent they are self-funded or
uninsured.
* Any policy or portion of a policy which is not guaranteed by the
insurer or for which the individual has assumed the risk, such as a
variable contract sold by prospectus.
* Any policy of reinsurance unless an assumption certificate was issued.
* Interest rate yields that exceed an average rate.
* Any portion of a contract that provides dividends or experience rating
credits.
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CALIFORNIA GUARANTY ASSOCIATION ACT - SUMMARY (Continued)
LIMITS ON AMOUNTS OF COVERAGE
The Act limits the Association to pay benefits as follows:
* for Life and Annuity Benefits:
-- 80% of what the life insurance company would owe under a life
policy or annuity contract up to:
* $100,000 in cash surrender values;
* $100,000 in present value of annuities; or
* $250,000 in life insurance death benefits.
-- a maximum of $250,000 for any one insured life no matter how many
policies and contracts there were with the same company, even if the
policies provided different types of coverages.
* for Health Benefits, a maximum of $200,000 of the contractual
obligations that the health insurance company would owe were it not
insolvent. the maximum may increase or decrease annually based upon
changes in the health care cost component of the consumer price index.
PREMIUM SURCHARGE
Member insurers are required to recoup assessments paid to the Association by
way of a surcharge on premiums charged for insurance policies to which the Act
applies.
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CALIFORNIA GUARANTY ASSOCIATION ACT - NOTICE OF NON-COVERAGE
any benefits self-funded by an Employer are NOT covered by
the California Life and Health Insurance Guaranty Association.
The following are not covered by the California Life and Health Insurance
Guaranty Association:
* Unallocated annuity contracts; that is, contracts which are not issued
to and owned by an individual and which guarantee rights to group
contract holders, not individuals.
* Employer and association plans, to the extent they are self-funded or
uninsured.
* Any policy or portion of a policy which is not guaranteed by the
insurer or for which the insured has assumed the risk, such as a
variable contract sold by prospectus.
* Any policy of reinsurance unless an assumption certificate was issued.
* Interest rate yields that exceed an average rate.
* Any portion of a contract that provides dividends or experience rating
credits.
A determination as to whether an insurance contract is covered under the
Guaranty Association or whether an annuity contract is allocated or unallocated
must be initially made by the insurer based on its knowledge of the specific
contract offered.
Also, you are not protected by this Association if:
* The insurer was not authorized to do business in this state when it
issued the policy or contract.
* The policy is issued by a health care service plan (HMO, Blue Cross,
Blue Shield), a charitable organization, a fraternal benefit society,
a mandatory state pooling plan, a mutual assessment company, an
insurance exchange, or a grants and annuities society.
* You are eligible for protection under the laws of another state. this
may occur when the insolvent insurer was incorporated in another state
whose guaranty association protects insureds who live outside that
state.
Insurance companies or their agents are required by law to give or send you this
notice. however, insurance companies and their agents are prohibited by law from
using the existence of the Guaranty Association to induce you to purchase any
kind of insurance policy.
If you have questions concerning this Notice, you may contact:
EXECUTIVE DIRECTOR
CALIFORNIA LIFE AND HEALTH INSURANCE GUARANTY ASSOCIATION
P. 0. BOX 70069
LOS ANGELES, CA 90070
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CALIFORNIA GUARANTY ASSOCIATION ACT - NOTICE OF NON-COVERAGE
(Continued)
Allegra Willison, Staff Counsel
California Department of Insurance
45 Fremont Street, 24th Floor
San Francisco, California 94105
Questions as to specific policies or annuities should be directed to the
insurance company offering the product.
Page 5
Attached to and forming part of the Services Contract between
GREAT-WEST LIFE & ANNUITY INSURANCE COMPANY
and
PACIFIC CAPITAL BANCORP
The Services Contract which was effective on JANUARY 1,1995 and is dated JANUARY
30, 1995 is hereby terminated as of DECEMBER 31, 1994 and replaced by the
attached Services Contract which is effective JANUARY 1, 1995.
Dated at Englewood, Colorado this 13th day of April, 1995.
GREAT-WEST LIFE & ANNUITY INSURANCE COMPANY
/s/ D.C. Lennox /s/ William McCallum
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Senior Vice-President, General President
Counsel and Secretary
/s/ Debe Hickman
------------------------
For the Actuary
The terms of this Contract are accepted by PACIFIC CAPITAL BANCORP this
day of , 19 .
BY /s/ Naomi Walling
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TITLE VP Human Resources
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Page 1
SERVICES CONTRACT
This CONTRACT entered into on JANUARY 1, 1995 (hereinafter referred to as the
Effective Date)
Between
GREAT-WEST LIFE & ANNUITY INSURANCE COMPANY,
hereinafter referred to as "Great-West"
-and-
PACIFIC CAPITAL BANCORP
hereinafter referred to as "the Contractholder."
The Contractholder has established a Health Care Payment Plan or Health Care
Payment Plan and Trust for the benefit of its Employees and Dependents
(hereinafter referred to as the "Plan").
The Plan is an Employee benefit plan within the meaning of the Employee
Retirement Income Security Act of 1974 and the undersigned fiduciary
(hereinafter referred to as the "Fiduciary") of the Plan hereby retains
Great-West to provide services for the Plan in accordance with the following
terms and conditions contained herein.
Page 1
ARTICLE 1 - DEFINITIONS
In this contract unless otherwise specifically provided:
(1) "Dependent" and "Employee" mean Dependent and Employee as defined by the
Plan;
(2) "Anniversary Date", "Contract Months" and "Contract Years" will be
calculated from JANUARY 1, 1995; JANUARY 1 of any year will be known as the
Anniversary Date;
(3) "Contract Year" means that period of 12 consecutive months which begins on
the ANNIVERSARY DATE.
(4) "Coverages" provided under the Plan and covered by this contract are:
Medical Coverage
Dentalcare Coverage
Visioncare Coverage
Prescription Drug Coverage
ARTICLE 2- ADMINISTRATIVE SERVICES AND FEES
Great-West agrees to perform such services involving the performance of
non-discretionary duties as are specified in the Schedule of Services marked
Schedule "A", which is attached hereto and forms part of this contract in
accordance with the terms and conditions of this contract.
To facilitate the performance of such duties:
(1) the Contractholder has advised its bank that Great-West is authorized to
demand moneys payable by the Contractholder for checks issued for benefit
payments made by Great-West under the Plan.
(2) Great-West will initiate transfers from the Contractholder's designated
bank account with the Transfer Frequency shown in Schedule C. The
Contractholder agrees to maintain funds in such account both before and
after termination of this Services Contract which are adequate to cover
checks issued for benefit payments made by Great-West under the Plan and
the Deficit Recoveries defined in the Article entitled Deficit Recovery of
the Stop-Loss Contract, if any, issued to the Contractholder by Great-West.
Page 2
ARTICLE 2 - ADMINISTRATIVE SERVICES AND FEES (Continued)
The Contractholder and Fiduciary agree to pay Great-West the fees specified in
the Schedule of Fees marked Schedule "B" which is attached hereto and forms part
of this contract as reasonable compensation for services necessary for the
Plan's operation. The Contractholder and Fiduciary will be jointly and severally
liable for the payment of such fees. Such fees will be paid as described in the
attached Schedule B. A grace period of 31 days will be granted for each payment
of fees falling due after the first payment during which period this contract
will remain in force. If any payment is not made within the days of grace, this
contract will automatically terminate at the end of the grace period. No written
notice of such automatic termination is required. If this contract terminates
for any reason, the Contractholder and Fiduciary will be liable for all payments
due and unpaid, including a pro-rata payment for any time this contract is in
force during the grace period.
TERMINAL FEE
Subject to all provisions of this Article 2, a Terminal Fee is due and payable
on the date of termination of this contract. The method of determining this
Terminal Fee is shown in the attached Schedule B, SCHEDULE OF FEES.
ARTICLE 3- FURNISHING OF INFORMATION; ACCESS TO RECORDS
The Contractholder and Fiduciary will furnish Great-West, on request, with
correct and complete information required by Great-West to provide the services
which Great-West has agreed to perform under this contract, including, but not
limited to, a copy of the Plan `and any amendments thereto. The information will
be furnished at the times and in such manner as Great-West may request.
Great-West will assume that all such information is complete and accurate and
will be under no duty to question the accuracy of such information. Great-West,
at its discretion, may charge additional fees for its services where information
is not furnished, is incomplete or inaccurate or is not furnished at the time or
in the manner as requested. The Contractholder agrees to give Great-West the
right to inspect and copy the records of the Contractholder which are pertinent
to the operation of the Plan. Such right will continue for the 5 years
immediately following termination of this contract.
All communications sent to the Contractholder or Fiduciary from Great-West will
be transmitted to the Contractholder at the address appearing below or to such
other person and address as may from time to time be designated by the
Contractholder in writing. Notice transmitted to the Contractholder as aforesaid
will be considered received by the Contractholder and Fiduciary. Notice sent to
Great-West will be directed to the address shown below or to such other address
as Great-West may designate in writing from time to time.
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ARTICLE 4 - AUTHORITY TO CONTROL AND MANAGE THE PLAN
The Contractholder and Fiduciary acknowledge that they have authority to control
and manage the operation of the Plan. It is expressly agreed that under no
circumstances will Great-West be designated as plan administrator or a fiduciary
of the Plan. Nothing herein will be deemed to constitute Great-West a party to
the Plan or to confer upon Great-West any authority or control respecting
management of the Plan, authority or responsibility in connection with
administration of the Plan or responsibility for the terms or validity of the
Plan. Great-West will not be responsible for any tax liability which may be
imposed upon the Contractholder, any fiduciary or any Employee or Dependent
under the Plan. The Contractholder and Fiduciary further agree that nothing
herein will be deemed to impose upon Great-West any obligation to any Employee
or Dependent under the Plan.
ARTICLE 5 - INDEMNIFICATION AND LIMITATION OF LIABILITY
The Contractholder and Fiduciary will indemnify, protect and hold Great-West
harmless from any loss, liability, claim or expense (including attorneys' fees,
court costs and expenses of litigation) arising out of any act or omission of
the Contractholder or Fiduciary in connection with the Plan. The Contractholder
and Fiduciary agree to indemnify Great-West and hold Great-West harmless against
any tax relating to this contract, including any accrued interest and penalties
levied on such tax, but excluding any tax based upon Great-West's net income.
The terms of this provision will survive the termination of this contract.
Great-West will not be liable for any act or failure to act, in the exercise of
its powers and performance of its duties hereunder, which act or failure to act
is performed by Great-West in good faith.
Great-West agrees to indemnify the Contractholder and hold the Contractholder
harmless against any and all loss, damage, and expense with respect to this
contract resulting from or arising out of the dishonest, fraudulent or criminal
acts of Great-West's employees, acting alone or in collusion with others.
ARTICLE 6 - CONTRACT TERMINATION
This contract may be terminated at any time by either the Contractholder and
Fiduciary or Great-West, provided written notice of such termination is given at
least 31 days in advance. In addition, this contract:
(1) may terminate immediately upon termination of the Stop-Loss Contract, if
any, between Great-West and the Contractholder, or
(2) may terminate upon amendment of the Plan in a manner deemed unsatisfactory
by Great-West, provided that Great-West gives 31 days written notice of
such termination to the Contractholder; or
Page 4
ARTICLE 6 - CONTRACT TERMINATION (Continued)
(3) will terminate immediately upon failure of the Contractholder to comply
with any term or condition of this contract, such as but not limited to
failure to:
(A) pay the Administrative Fees as specified in the Article of this
contract entitled Administrative Services and Fees; or
(B) fund the bank account(s) (referred to in the Article of this
contract entitled Administrative Services and Fees) established to
handle payment of the benefits provided under the Plan.
If prior to the date of termination of this contract, the Contractholder had
elected Terminal Protection under the Stop-Loss Contract issued to the
Contractholder by Great-West and such Terminal Protection is in effect on the
date this contract terminates, then Great-West will continue to process claims
after the date of termination of this contract.
ARTICLE 7 - AMENDMENT OF SCHEDULE OF FEES
Unless otherwise indicated in the Schedule of Fees, the fees shown are for the
first Contract Year.
Great-West has the right to revise the Schedule of Fees:
(1) when the Contractholder's Plan is amended; and
(2) on or after the first anniversary of the Effective Date of this contract
but not more than once in any 12 month period, except as provided in (4)
below; and
(3) when the services described in the Schedule of Services are changed; and
(4) at any time during the first or subsequent Contract Years:
(A) if the Coverages under the Contractholder's Plan are changed;
(B) if the provisions of the Contractholder's Plan have to be changed
because of a change in law; or
(C) if there is a change in the number of Employees and/or Dependents
covered under the Contractholder's Plan for any Coverages provided
under the Contractholder's Plan which equals or exceeds:
(a) 10% in any Contract Month when compared to the prior Contract
Month; or
(b) 20% at any time within a Contract Year. In this case, the change
in the number of Employees and/or Dependents covered will be
determined by comparing the number of Employees and/or
Dependents covered for any Coverages under the Contractholders
Plan at the beginning of the first Contract Month of the
Contract Year in question with the number of Employees and/or
Dependents covered for any Coverages under the Contractholder's
Plan at the beginning of any subsequent Contract Month. The
Contractholder agrees to make available to Great-West all
information necessary to determine such change. If the change in
Page 5
ARTICLE 7 - AMENDMENT OF SCHEDULE OF FEES (Continued)
the number of Employees and/or Dependents covered under the Plan
is such that a change in fees results, then Great-West will
advise the Contractholder of its intention to change the fees.
(D) upon addition or deletion of coverage for subsidiary or
affiliated companies or corporate divisions.
The effective date of the change in fees will be the effective date of the event
in (A), (B), (C) or (D) above that causes such change.
ARTICLE 8 - MISCELLANEOUS
(1) An Employee or Dependent under age 65 whose Medical Coverage under the Plan
ends due to:
(A) termination of employment;
(B) termination of employment in an eligible class;
(C) change in marital status (in the case of a Dependent);
(D) attainment of the limiting age specified in the Plan (in the case of
a Dependent child); or
(E) death of the Employee (in the case of a Dependent); OR
(F) termination of the Plan but only if the Plan is not replaced by
similar group medical coverage within 30 days and such Employee or
Dependent had been covered under the Plan for at least the 90 day
period prior to the date the Plan terminated;
will be entitled to purchase medical insurance from Great-West. This
medical insurance is referred to as Health Conversion Coverage. If such
Employee has Dependents who are also covered under the Plan, the Health
Conversion Coverage may also cover such Dependents.
NOTE: Employees and/or their eligible Dependents who are eligible for
the COBRA health continuation coverage provided under the Plan, will
only be able to apply for Health Conversion Coverage at the end of the
applicable 18 month or 36 month maximum period of continuation allowed
under COBRA. This will be the case unless:
(A) the Plan terminates in its entirety and isn't replaced by similar
group medical coverage within 30 days; or
(B) the Employee becomes ineligible for disability benefits under the
Social Security Act after 18 months but before the end of the 29
month maximum period of continuation allowed under COBRA if the
Employee is eligible for disability benefits under the Social
Security Act.
Issuance of the Health Conversion Coverage will be subject to all of the
following conditions:
Page 6
ARTICLE 8 - MISCELLANEOUS (Continued)
(A) No evidence of insurability is required.
(B) The Employee or Dependent is not eligible for Medicare.
(C) The Employee or Dependent is not covered by or eligible for similar
benefits, as a result of termination of his Medical Coverage. Under
any policy, contract, or other arrangement for group insurance
benefits or services.
(D) Written application and the first premium for the Health Conversion
Coverage must be delivered or mailed to Great-West at its Executive
Offices in Englewood, Colorado within 31 days after the date on
which the covered Employee or Dependent's Medical Coverage under the
Plan terminates.
(E) The Health Conversion Coverage provides coverage customarily issued
by Great-West at the then current rates. Benefits provided under the
Health Conversion Coverage may not be the same as those provided by
the Plan.
(F) The Health Conversion Coverage is effective on the next day after
the date on which coverage under the Plan ceases.
(2) Great-West will have the sole right to make claims under the Subrogation and
Right of Recovery Provision contained in the Plan. In its sole discretion
Great-West may litigate, negotiate, settle, compromise, release or waive any
such claim. The Contractholder hereby assigns to Great-West all of its
rights to make, litigate, negotiate, settle, compromise, release or waive
any such claim.
All money recovered by Great-West under the Subrogation and Right of
Recovery Provision will be distributed as follows:
(A) first, to Great-West to be applied to reduce Great-West payment of
Specific Stop-Loss Benefits pursuant to the Article entitled
Specific Stop Loss Benefit, if any, of the Stop-Loss Contract, if
any, issued by Great-West to the Contractholder with regard to any
Employee or Dependent against whom the Subrogation and Right of
Recovery Provision is enforced; and
(B) secondly, to Great-West to be applied to reduce Great-West's payment
of Aggregate Stop-Loss Benefits pursuant to the Article entitled
Aggregate Stop Loss Benefit, if any, of the Stop-Loss Contract, if
any, issued by Great-West to the Contractholder; and
(C) thirdly, to the Contractholder.
All money recovered will be applied to the accounting for the Contract Year in
which the claim giving rise to subrogation or Right of Recovery was paid. If
claim expenses were paid in more than one Contract Year, the money will be
applied on a pro rata basis in accordance with the amount of claim expenses paid
in each of the Contract Years.
Action taken under the Subrogation and Right of Recovery Provision contained in
the Plan may result in the incurral of legal expenses. Such legal expenses will
be borne by Great-West and the Contractholder in the same proportion as any
money recovered under the Subrogation and Right of Recovery Provision is
distributed between Great-West and the Contractholder. If no money is recovered,
the legal expenses will be borne by Great-West and the Contractholder in the
same proportion that each party's share of claim payments bears to the total
amount of claim payments. Legal expenses will not be used when calculating the
Specific Stop-Loss Benefit pursuant to the Article entitled Specific Stop Loss
Benefit, if any, or the aggregate Stop-Loss Benefit pursuant to the Article
entitled Aggregate Stop Loss Benefit, if any, of the Stop-Loss Contract, if any,
issued by Great-West to the Contractholder.
Page 7
ARTICLE 9 - ENTIRE CONTRACT
This contract contains the entire agreement between the parties and sets forth
in full the services to be rendered by Great-West. It may only be modified or
amended by written agreement of the parties hereto and any representation or
statement not expressly set forth hereunder will not be binding on any party
hereto in any respect.
PACIFIC CAPITAL BANCORP
By /s/ Naomi Walling VP Human Resources 4/13/95
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Signature Title Date
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Fiduciary Signature Title Date
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Mailing Address of Fiduciary
GREAT-WEST LIFE & ANNUITY INSURANCE COMPANY
By /s/ Debe Hickman Asst. Acct. Manager 4/13/95
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Signature Title Date
Tower 1, Great-West Life Center
8505 E. Orchard Road
Englewood, CO 80111
Page 8
SERVICES CONTRACT
SCHEDULE A - SCHEDULE OF SERVICES
The following services will be provided for the administration of the
Contractholder's Plan:
Drafting Assistance Benefit determination in accordance with the
- - Booklet Plan
- - Booklet Amendments Benefit payments in accordance with the Plan
Standard Allowance for Booklet printing Monthly Individual Claims Listing
I.D. Card Preparation Issued Check Listing
Standard Allowance for I.D. Card printing Preparation of Physician payment reports
Preparation of enrollment procedures Actuarial cost estimates:
Assistance in plan enrollment - Open and Unreported claims liabilities
Late applicant underwriting - Review of Past Experience
Claim form preparation - Projection of future cost
Standard Allowance for Claim form printing - Legislated changes in benefits
Check preparation - Plan modifications
Standard Allowance for Check printing
Expenses incurred by Great-West for services not covered or for covered services
beyond standard allowances will be charged as incurred.
Page 1
SERVICES CONTRACT
SCHEDULE B - SCHEDULE OF FEES
The Fees for the Services provided under the terms of this contract will be as
set forth in the following paragraph.
The Contractholder will pay to Great-West an amount equal to the sum of the
items listed below:
(1) on the first day of each Contract Month, for each Employee covered under
the Plan during the Contract Month in question, an amount equal to
(A) for Medical Coverage, $24.74.
(B) for Dentalcare Coverage, $2.14.
(2) on the first day of each Contract Month, for one Dependent covered under
the Plan during the Contract Month in question an amount equal to
(A) for Medical and PCS Coverage, $23.72.
(B) for Dentalcare Coverage, $1.91.
(3) on the first day of each Contract Month, for two or more Dependents covered
under the Plan during the Contract Month in question an amount equal to
(A)for Medical and PCS Coverage, $32.12.
(B) for Dentalcare Coverage, $3.27.
(4) an amount equal to $500.00 for each Employee or Dependent who purchases the
Health Conversion Coverage referred to in Article 8 of this contract
during the Contract Month in question.
TERMINAL FEE
On the Date of termination of this contract, the Contractholder will pay to
Great-West,
(1) for each Employee covered under the Plan at the beginning of the Contract
Month immediately prior to the date of termination of this contract, an
amount equal to
(A) for Medical Coverage, $19.26.
(B) for Dentalcare Coverage, $3.14.
(2) for one Dependent covered under the Plan at the beginning of the Contract
Month immediately prior to the date of termination of this contract an
amount equal to
(A) for Medical Coverage, $22.32.
(B) for Dentalcare Coverage, $3.63.
Page 1
SERVICES CONTRACT
SCHEDULE B SCHEDULE OF FEES (Continued)
(3) for two or more Dependents covered under the Plan at the beginning of the
Contract Month immediately prior to the date of termination of this
contract an amount equal to
(A) for Medical Coverage, $30.81.
(B) for Dentalcare Coverage, $5.01.
Page 2
SERVICES CONTRACT SCHEDULE C
Transfer Frequency Weekly with one
week delay
Page 1
Attached to and forming part of Group Contract No. 256374GSL
issued by
GREAT-WEST LIFE & ANNUITY INSURANCE COMPANY
TO
PACIFIC CAPITAL BANCORP
The contract (the Deleted Contract) which was effective on January 1,1995 is
hereby deleted as of December 31, 1994 and replaced by the attached contract
(the Replacement Contract) which is effective January 1, 1995.
Notwithstanding anything to the contrary in the Replacement Contract,
(1) the terms "Contract Months" and "Contract Year" will be calculated from the
effective date of the Deleted Contract.
(2) any deficit which has accrued under the terms of the Deleted Contract prior
to January 1, 1995 will be carried toward and become a part of the
Experience Deficit under the Replacement Contract.
Dated at Englewood, Colorado this 13th day of April, 1995
GREAT-WEST LIFE & ANNUITY INSURANCE COMPANY
/s/ D.C. Lennox /s/ William McCallum
- ------------------------------ -------------------------------
Senior Vice-President, General President
Counsel and Secretary
/s/ Debe Hickman
------------------------
For the Actuary
Accepted and attached to the Contract by PACIFIC CAPITAL BANCORP
this day of , 19 .
BY /s/ Naomi Walling
-----------------------------------
TITLE VP Human Resources
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Page 1
GREAT-WEST LIFE & ANNUITY INSURANCE COMPANY
EXECUTIVE OFFICES - ENGLEWOOD, COLORADO
APPLICATION FOR GROUP CONTRACT
PACIFIC CAPITAL BANCORP
(the Applicant) hereby applies to Great-West Life & Annuity Insurance Company
for Group Contract No. 256374GSL in the form attached hereto. This Group
Contract has been approved and its terms accepted by the Applicant.
Dated at Salinas this 9th day of May, 1995
PACIFIC CAPITAL BANCORP
/s/ Naomi Walling /s/ Naomi Walling
- ------------------------------ -----------------------------
Witness BY
/s/ Jackson Booth VP Human Resources
- ----------------------------- -----------------------------
Licensed Resident Agent Title
Page 1
STOP-LOSS CONTRACT
GREAT-WEST LIFE & ANNUITY INSURANCE COMPANY (herein called Great-West) in
consideration of the application of
PACIFIC CAPITAL BANCORP
(herein called the Contractholder)
and in consideration of the payment of premiums as herein provided, hereby
agrees to pay to the Contractholder the benefits as provided herein.
This contract will be effective from JANUARY 1, 1995 (herein called the
Effective Date).
This contract is not in lieu of and does not affect any requirement for coverage
by Workers' Compensation insurance.
All provisions set forth on the following pages form a part of this contract as
fully as it the same were stated over the signatures hereto.
IN WITNESS WHEREOF Great-West has caused this contract to be executed at its
Executive Offices.
/s/ D.C. Lennox /s William McCallum
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Senior Vice-President, General President
Counsel and Secretary
/s/ Debe Hickman
------------------------
For the Actuary
Group Health Insurance
GSL-M2
Contract Form No. GSL-190 Group Contract No.
256374GSL
GSLl90
Page 1
ARTICLE 1 - DEFINITIONS
(1) "Aggregate Limitation Factor" is as shown in Schedule "A".
(2) "Bank Account" means the bank account(s) established by the Contractholder
from which Great-West is authorized to demand moneys payable by the
Contractholder for Benefit Payments made under the Plan.
(3) "Benefit Payments" for a Contract Month means the sum of checks issued for
Claim Payments made for the Contract Month under the provisions of the
Plan, less payments made by Great-West under the Article of this contract
entitled Specific Stop-Loss Benefit.
(4) "Claim Payments" for a Contract Month means payments made by Great-West for
a Contract Month for benefits provided under the terms of the Plan, less
any benefit credits under the plan, such as but not limited to refunds and
voided checks. In no event will the amounts paid for investigation of or
defense against claims be included in determining Claim Payments for any
Contract Month.
If Great-West determines that a claim for benefits under the Plan for an
Employee or one of his eligible dependents:
(A) is not payable in whole or in part; but
(B) the Contractholder instructs Great-West to pay an amount greater than
that determined by Great-West;
then only the amount determined by Great-West will be considered as a claim
payment when Great-West calculates:
(A) the Specific Stop Loss Benefit for the Employee or Dependent pursuant
to the Article of this contract entitled Specific Stop-Loss Benefit;
(B) the Aggregate Stop Loss Benefit pursuant to the Article of this
contract entitled Aggregate Stop-Loss Benefit.
(5) "Contract Months" are consecutive periods of one month within a Contract
Year, except that the last Contract Month terminates at the end of the last
Contract Year. The first Contract Month begins on the Effective Date.
(6) "Contract Year" is any period of 12 months beginning on an anniversary of
the Effective Date, except that the last Contract Year will end upon
termination of this contract.
(7) "Coverages" provided under the Plan and covered by this Contract are:
Medical Coverage
Page 2
ARTICLE 1 - DEFINITIONS (Continued)
Dentalcare Coverage
Visioncare Coverage
Prescription Drug Coverage
(8) "Cumulative Attachment Level" for a Contract Month in a Contract Year is
the sum of the Monthly Attachment Level for the Contract Month and the
Monthly Attachment Levels for all previous Contract Months in the Contract
Year.
(9) "Cumulative Benefit Payments" for a Contract Month in a Contract Year means
the sum of Benefit Payments for the Contract Month and the Benefit Payments
for all previous Contract Months in the Contract Year.
(10) "Dependent" and "Employee" and "Employee Class" are as defined in the Plan.
(11) "Experience Deficit" for the first Contract Month means any aggregate stop
loss benefits paid by Great-West for the first Contract Month pursuant to
the Article of this contract entitled aggregate Stop-Loss Benefit. For any
succeeding Contract Month, "Experience Deficit" means the excess of the sum
of (A) and (B) over (C) where:
(A) is the Experience Deficit for the Previous Contract Month;
(B) is any aggregate stop loss benefits paid by Great-West for the Contract
Month pursuant to the Article of this contract entitled Aggregate Stop
Loss Benefit;
and
(C) is any reimbursement made by the Contractholder to Great-West for the
Contract Month pursuant to the Article of this contract entitled
Deficit Recovery;
except that in no event will the Experience Deficit for the last Contract Month
in any Contract Year prior to the Contract Year in which this Contract
terminates exceed the sum of (D) and (E) where:
(D) is the Experience Deficit for the last Contract Month of the previous
Contract Year; and
(E) is the product of the Aggregate Limitation Factor and the Cumulative
Attachment Level for the Contract Year.
(12) "Exposure" for a Coverage and Contract Month and Employee Class is the
number of Employees in that Employee Class having that Coverage under the
Plan at the beginning of the second prior Contract Month. For the first
three Contract Months of the first Contract Year, exposure for a Coverage
and Employee Class is the number of Employees in that Employee Class having
that Coverage under the Plan at the beginning of the first Contract Month.
NOTE: The term "Employees" as used in this definition will include
Employees and/or eligible Dependents whose coverage under the Plan is being
continued under the COBRA HEALTH CONTINUATION provision which forms a part
of the Plan.
Page 3
ARTICLE 1 - DEFINITIONS (Continued)
(13) "Monthly Attachment Factor" is as shown in Schedule "A".
(14) "Monthly Attachment Level" for a Contract Month before termination of this
contract, means the sum for all Coverages and Employee Classes of the
product of the Monthly Attachment Factor multiplied by the exposure.
(15) "Plan" means that part of the Contractholder's Employee benefit plan which
is:
(A) administered by Great-West; and
(B) listed in the definition of "Coverages"; and
(C) in effect on the Effective Date of this contract.
Any amendments accepted BY Great-West which are made to the Plan from time
to time while this contract is in effect are also included, provided they
are administered by Great-West and apply to the "Coverages" listed in the
definition of "Coverages" in this Article of the Contract.
(16) "Premium Factor" is as shown in Schedule "A".
(17) "Specific Stop-Loss Level" is as shown in Schedule "A."
(18) "Terminal Attachment Factor" is as shown in Schedule "A".
ARTICLE 2 - CONTRACT PAYMENTS
The Contractholder will make funds available in its Bank Account(s) which are
sufficient to honor all of the Contractholder's obligations under the Plan and
under this contract while it is in force and FOR 15 months after this contract's
termination.
ARTICLE 3 - SPECIFIC STOP-LOSS BENEFIT
On and after the date within any Contract Year prior to termination of this
contract that the Claim Payments made for all Contract Months in such Contract
Year for Medical Coverage provided under the Plan for each Employee or Dependent
reach the Specific Stop-Loss Level, Great-West will reimburse the Contractholder
for the remainder of that Contract Year for Claim Payments made on behalf of
that Employee or Dependent which are in excess of the Specific Stop-Loss Level.
Page 4
ARTICLE 3 - SPECIFIC STOP-LOSS BENEFIT (Continued)
Only Claim Payments made for expenses incurred after the Effective Date of this
contract will be used when determining the Specific Stop-Loss Benefit for an
Employee or Dependent. Specific Stop Loss protection does not apply to
Dentalcare, Visioncare and Prescription Drug Coverage(s).
No Specific Stop-Loss Benefit reimbursements will BE made by Great-West for
Claim Payments made after the date of termination of this contract, regardless
of when the claim was incurred.
ARTICLE 4 - AGGREGATE STOP-LOSS BENEFIT
For each Contract Month, Great-West will reimburse the Contractholder in an
amount equal to the positive excess, if any, of the sum of (1) and (2) over the
sum of (3) and (4) where:
(1) is the Cumulative Benefit Payments for the Contract Month;
(2) is the sum of any reimbursements made by the Contractholder to Great-West
for any prior Contract Months in the Contract Year pursuant to the Article
of this contract entitled Deficit Recovery;
(3) is the Cumulative Attachment level for the Contract Month;
(4) is the sum of any Aggregate Stop-Loss Benefits paid by Great-West pursuant
to this Article for any prior Contract Months in the Contract Year.
ARTICLE 5 - DEFICIT RECOVERY
At the end of every Contract Month in a Contract Year, the Contractholder will
reimburse Great-West for the lesser of:
(1) the Experience Deficit for the previous Contract Month; and
(2) the excess, if any, of:
(A) the Monthly Attachment Level for the Contract Month; and
(B) the Benefit Payments for the Contract Month.
Page 5
ARTICLE 6 - PREMIUMS
The premium for each Contract Month is equal to the sum for all Coverages and
Employee Classes under the Plan of the product of the Premium Factor shown in
Schedule "A", multiplied by the number of Employees covered during that Contract
Month.
The Contractholder will pay the premiums on or before the first day of Each
Contract Month. A grace period of 31 days will be granted for the payment of
each premium falling due after the first premium, during which period this
contract will remain in force. If:
(1) any premium is not paid by the Contractholder to Great-West within the
grace period, this contract will automatically terminate at the end of thE
grace period. no written notice of such automatic termination is required.
If this contract terminates for any reason, the Contractholder will be
liable FOR all premiums due and unpaid, including a pro rata premium for
any time this contract is in force during the grace period.
(2) a check in payment of the premium due is returned to Great-West because
there were not sufficient funds (NSF) in the Contractholder's Bank Account
to cover the check, then this contract will automatically terminate on the
date on which the grace period for such premium ends. No written notice of
such automatic termination is required. This will be the case even if the
check presented for payment by Great-West is found to be NSF after the end
of the grace period.
ARTICLE 7 - SUBSIDIARIES AND AFFILIATES
Great-West may approve the inclusion of Employees of subsidiary and affiliated
companies and their Dependents under this contract. The Contractholder will be
liable for the payment of all amounts due to Great-West and for the adequate
funding of the Contractholder's Bank Account(s) with regard to employees and
Dependents of subsidiary and affiliated companies.
ARTICLE 8 - ADMINISTRATION OF THE PLAN, ACCESS TO INFORMATION
The Contractholder or his agent will furnish monthly to Great-West and warrant
the accuracy of the number of Employees in each Employee Class and the types of
Coverage(s) they have under the Plan for such Contract Month.
Great-West will have the right to inspect and copy the records of the
Contractholder and its agent which are pertinent to the operation of the Plan
and this contract. Such right will continue for 5 years immediately following
termination of this contract.
Page 6
ARTICLE 9 - AMENDMENTS AND ALTERATIONS
(1) Unless otherwise indicated, the factors shown in Schedule "A" are for the
first Contract Year.
(2) Great-West will have the right to modify the Specific Stop-Loss Level and
the factors shown in Schedule "A" on any premium due date, but not more
frequently than once in each Contract Year except as provided in (3) below.
(3) A change in factors shown in Schedule A can be made at any time during the
first or subsequent Contract Years:
(A) if the Coverages provided under the Contractholder's Plan are changed;
or
(B) if the provisions of the Contractholder's Plan have to be changed
because of a change in law; or
(C) if there is a change in the number of Employees and/or Dependents
covered for any of the Coverages provided under the Contractholder's
Plan which equals or exceeds:
(a) 10% in any Contract Month when compared to the prior Contract Month;
or
(b) 20% at any time within a Contract Year. In this case, the change in
the number of Employees and/or Dependents covered will be determined
by comparing the number of Employees and/or Dependents covered for
any Coverages under the Contractholder's Plan AT the beginning of
the first Contract Month OF the Contract Year in question with the
number of Employees and/or Dependents covered for any Coverages
under the Contractholder's Plan at the beginning OF any subsequent
Contract Month. The Contractholder agrees TO MAKE available to
Great-West all information necessary to determine such change.
(D) upon addition or deletion of coverage for subsidiary or affiliated
companies or corporate divisions.
The effective date of the change in factors will be the effective date of
the event in (A), (B), (C) or (D) above that causes such change.
ARTICLE 10 - CONTRACT TERMINATION
This contract may be terminated by either the Contractholder or Great-West by
providing 31 days written advance notice to the other party.
In addition, this contract will terminate:
(1) immediately upon termination of the Services Contract between Great-West
and the Contractholder; or
(2) upon amendment of the plan in a manner deemed unsatisfactory by Great-West,
provided Great-West gives 31 days written notice of such termination to the
Contractholder. Great-West will not be liable under this contract for any
Benefit Payments, Specific Stop-Loss Benefit reimbursements, Aggregate
Stop-Loss Benefit reimbursements or any other payment attributable to such
amendment.
(3) immediately upon failure of the Contractholder to comply with any term or
condition of this contract, such as but not limited to failure to:
Page 7
ARTICLE 10 - CONTRACT TERMINATION (Continued)
(A) pay the premiums as specified in this contract; or
(B) fund the Bank Account(s) established to handle Benefit Payments under
the Plan.
If the contract terminates due to the failure of the Contractholder to comply
with (3)(A) or (3)(B) above, the Contractholder will be solely liable for all
unpaid Employee and Dependent claims, regardless of when incurred.
If any state or other jurisdiction enacts or amends a law or regulation which,
in the opinion of Great-West prohibits the continuance of this contract, the
contract will terminate in respect of that jurisdiction. Termination of the
contract will take place by the effective date of the law, regulation oR
amendment as determined by Great-West.
ARTICLE 11 - TERMINAL PROTECTION
The Contractholder may elect the Terminal Protection described below on:
(1) the Effective Date of this contract. If this is the case, the Terminal
Protection becomes effective on the Effective Date of this contract.
(2) any subsequent anniversary of the Effective Date. If this is the case, the
Terminal Protection will not become effective until 12 months after such
anniversary.
The Contractholder may request deletion of the Terminal Protection by sending a
request in writing to Great-West to delete the Terminal Protection. If he does
so, the deletion of the Terminal Protection will not become effective until the
date which is 12 months after the end of the Contract Year in which the request
To Delete the Terminal Protection was received by Great-West.
If the Terminal Attachment Factor shown in Schedule A is applicable on the date
of termination of this contract, then:
(1) the following modifications are hereby made to the terms listed below which
are defined in Article 1 - Definitions:
(A) the last Contract Year will also include any months after termination
of this contract in which any Claim Payments are made by Great-West.
(B) the monthly attachment level for each of the first two Contract Months
after termination of this contract is the Terminal Attachment Level
defined in (2) below.
(C) the Cumulative Attachment Level will be calculated as follows:
Page 8
ARTICLE 11 - TERMINAL PROTECTION (Continued)
(a) for the first Contract month following termination of this contract,
it will be the sum of the Cumulative Attachment Level for the last
Contract Month before such termination and the Terminal Attachment
Level for the first Contract Month following termination of this
contract.
(b) for any other Contract Month following termination of this contract,
it will be the sum of the Cumulative Attachment Level for the
previous contract month and the Terminal Attachment Level for the
current Contract Month.
(D) Benefit payments will include the sum of all checks issued for claim
payments made after termination of this contract. The Contractholder
agrees to keep his Bank Account(s) open to facilitate the handling of
Claim Payments made after termination of this contract.
(2) the following definition is hereby added to this contract:
"Terminal Attachment Level" means:
(A) for each of the first two months just after termination of this
contract, the product of (a) and (b) below, where:
(a) is the Terminal Attachment Factor; and
(b) is the Exposure for the month.
(B) for each month after that, NIL.
(3) the Contractholder understands and agrees that:
(A) The Article of this contract entitled Deficit Recovery is applicable to
each Contract Month following termination of this contract.
(B) the Terminal Protection described in this Article is applicable to this
contract on its termination, even if there is a succeeding carrier or
claims administrator and the succeeding carrier or claims administrator
agrees to pay claims for expenses incurred by Employees and dependents
prior to the termination of this contract.
ARTICLE 12 - PARTIES TO THE CONTRACT
The parties to the contract will be the Contractholder and Great-West. This
contract will not create any rights or obligations whatsoever on the part of
Great-West with respect to the persons covered under the Plan, or their
beneficiaries.
ARTICLE 13 - MISCELLANEOUS
The Contractholder agrees to indemnify Great-West and hold Great-West harmless
against any tax relating to this contract, including any accrued interest and
penalties levied on such tax, but excluding any tax based upon Great-West net
income. The terms of this provision will survive the termination of this
contract.
Page 9
ARTICLE 14 - ENTIRE CONTRACT
This contract contains the entire agreement between the parties and sets forth
in full the services to be rendered by Great-West. It may only be modified or
amended by written agreement of the parties hereto and any representation or
statement not expressly set forth hereunder will not be binding on any party
hereto in any respect.
Page 10
STOP-LOSS CONTRACT
SCHEDULE A
The Level and Factor shown below apply to all Employees in all Employee Classes:
Specific Stop-Loss Level $35,000.00
Aggregate Limitation Factor 10.00%
The Coverages and Factors applicable to each Employee Class are shown below:
Employee Class Coverages Factors
GREAT-WEST CARE
- - For Employee Coverage
Monthly Attachment Factor for:
- Medical Coverage $103.63
- Dentalcare Coverage $16.87
Terminal Attachment Factor for:
- Medical Coverage $224.30
- Dentalcare Coverage $36.51
Premium Factor for:
- Medical Coverage $19.85
- Dentalcare Coverage $0.44
- - For One Dependent Coverage
Monthly Attachment Factor for:
- Medical Coverage $110.57
- Dentalcare Coverage $18.00
Terminal Attachment Factor for:
- Medical Coverage $259.64
- Dentalcare Coverage $42.27
Premium Factor for:
- Medical Coverage $34.75
Page 1
STOP-LOSS CONTRACT
SCHEDULE A (Continued)
- Dentalcare Coverage $0.47
- - For Two or More Dependents
Coverage
Monthly Attachment Factor for:
- Medical Coverage $152.65
- Dentalcare Coverage $24.85
Terminal Attachment Factor for:
- Medical Coverage $358.47
- Dentalcare Coverage $58.36
Premium FACTOR FOR:
- Medical Coverage $47.99
- Dentalcare Coverage $0.65
NOTE: The amount applicable for an Employee covered for himself and his
Dependent(s) is the sum of the amount shown above for Employee Coverage and the
amount shown above for the applicable Dependent Coverage.
The following overrides anything to the contrary expressed or implied in this
contract.
Action taken under the Subrogation and Right of Recovery Provision contained in
the Plan may result in the incurral of legal expenses. Such legal expenses will
be borne by Great-West and the contractholder in the same proportion as any
money recovered under the Subrogation and Right of Recovery Provision is
distributed between Great-West and the Contractholder. If no money is recovered,
the legal expenses will be borne by Great-West and the Contractholder in the
same proportion that each party's share of Claim Payments bears to the total
amount of Claim Payments. Legal expenses will not be used when calculating the
Specific Stop-Loss Benefit pursuant to the Article of this contract entitled
Specific Stop-Loss Benefit or the Aggregate Stop-Loss Benefit pursuant to the
Article of this contract entitled Aggregate Stop-Loss Benefit.
All money recovered by Great-West under the Subrogation and Right of Recovery
Provision of the Plan will be distributed as follows:
(1) first, to Great-West to be applied to reduce Great-West's payment of
Specific Stop-Loss Benefits pursuant to the Article of this contract
entitled Specific Stop-Loss Benefit with regard to the Employee or
Dependent against whom the Subrogation and Right of Recovery Provision is
enforced; and
(2) secondly, to Great-West to be applied to reduce Great-West's payment of
Aggregate Stop-Loss Benefits pursuant to the Article of this contract
entitled Aggregate Stop-Loss Benefit; and
Page 2
STOP-LOSS CONTRACT
SCHEDULE A (Continued)
(3) thirdly, to the Contractholder.
ALL money recovered will be applied to the accounting for the Contract Year in
which the claim giving rise to subrogation or right of recovery was paid. If
claim expenses were paid in more than one Contract Year, the money will be
applied on a pro rata basis in accordance with the amount of claim expenses paid
in each of the Contract Years.
Page 3
GREAT-WEST LIFE & ANNUITY INSURANCE COMPANY
EXECUTIVE OFFICES - ENGLEWOOD, COLORADO
APPLICATION FOR GROUP POLICY
PACIFIC CAPITAL BANCORP
(the Applicant) hereby applies to Great-West Life & Annuity Insurance Company
for Group Policy No. 256374GL in the attached form. The Applicant has approved
this Group Policy and has accepted its terms.
Dated at Salinas this 9th day of May 1995
PACIFIC CAPITAL BANCORP
/s/ Naomi Walling /s/ Naomi Walling
- ------------------------------- ----------------------------------
Witness BY
/s/ Jackson Booth VP Human Resources
- ------------------------------- -------------------------------------
Licensed Resident Agent Title
Page 1
GREAT-WEST LIFE & ANNUITY INSURANCE COMPANY
EXECUTIVE OFFICES - ENGLEWOOD, COLORADO
(the Company)
AGREES, under the application of
PACIFIC CAPITAL BANCORP
(the Group Policyholder)
to insure the lives of Employees (Insured Persons) according to the terms of
this policy.
This policy is issued in consideration of the payment of the required premiums.
The Life Insurance and Accidental Death, Dismemberment and Loss of Sight (AD&D)
benefits to which an Insured Person is entitled are described in the
Booklet/Certificate which is attached to and forms a part of this policy.
Group Policy Effective Date:
This policy will take effect on JANUARY 1, 1995 at 12:01 a.m., standard time at
the Group Policyholder's address.
Currency:
All money payable under this policy is payable in the lawful money of the United
States of America.
All provisions:
(1) on the following pages of this policy; and
(2) in the sections of the Booklet/Certificate that apply to Life Insurance and
AD&D Benefits;
form a part of this policy as fully as IF THEY were stated over the signatures
below and are referred to herein as the Group Policy.
This policy has been executed by the Company at its Executive Offices.
/s/ D.C. Lennox /s/ William McCallum
- ------------------------------ ------------------------------
Senior Vice-President, General President
Counsel and Secretary
/s/ Debe Hickman
------------------------
For the Actuary
Group Term Life Insurance
- - Contributory
- - Non-Participating
Policy Format No. GL 193 Group Policy No. 256374GL BPL1
Page 1
MISCELLANEOUS PROVISIONS
(1) Insurance months and years start from the Group Policy Effective Date.
(2) The Group Policyholder's actions will bind the Employer. Notice given to
the Group Policyholder is considered to be notice given to an Employer.
(3) All requests, notices, proofs of claim and applications must be made in
writing to the Company at its Executive Offices.
(4) Words of the masculine gender include the feminine. BPL2
PREMIUMS
PAYMENT
The first premium is due on the effective date of this policy. After that,
premiums are due on the first day of each insurance month. Premiums must be paid
at the Company's Executive Offices. Any premium not paid on time will be in
default.
GRACE PERIOD
After the first premium has been paid, 31 days are allowed to pay a premium in
default. During this time, the policy will stay in force. If the premium is not
paid by the end of the days of grace, this policy will terminate. The Group
Policyholder is liable for a pro rata premium for the time this policy is in
force during the grace period and for all other unpaid premiums.
CALCULATION
The amount of each premium is the sum of the premiums for each insured Employee.
If a premium has been waived for an Employee under the DISABILITY BENEFIT
section, it will not be included in the calculation. Until the company changes
the rate, it will be:
(1) $0.22 for each $1,000 of Life Insurance then in force.
(2) $0.02 for each $1,000 of AD&D (Principal Sum) then in force.
(3) $1.85 for each Employee insured in respect of his Dependents for Dependent
Life Insurance.
Page 2
PREMIUMS (Continued)
ADJUSTMENTS
The premiums will be adjusted retroactively to reflect changes in insurance
amounts. The Company must be notified promptly of a change. For a decrease in,
or termination of, insurance, a credit will be given only for the 4 month period
prior to receipt of such notice.
EXPERIENCE RATING
After the end of the first insurance year or at any time after that, this policy
may be experience rated by the Company. BPL3
RENEWAL CHANGES
After the end of the first insurance year, the Company may change the premium
rates. Changes can be made on the first day of any insurance month. Written
notice will be sent to the Group Policyholder 31 days before a change is made.
Once the change is made, the Company cannot make another change for 12 months.
However, a change can be made at any time if:
(1) the policy provisions are changed at the request of the Group Policyholder;
(2) there is a change in benefits required by a change in state or federal law;
or
(3) there is a change in the number of Employees insured under this policy which
equals or exceeds:
(A) 10% in any insurance month when compared to the previous insurance
month; or
(B) 20% at any time within an insurance year when compared to the number of
Employees insured in the first month of that insurance year;
except that no increase in premium rates will take effect before 31 days after
the date written notice of such increase is given to the Group Policyholder by
the Company. BPL34
Page 3
GENERAL PROVISIONS
FURNISHING OF INFORMATION: ACCESS TO RECORDS
The Group Policyholder must forward to the Company:
(1) required information about the eligibility of Employees;
(2) any Employee applications; and
(3) details about changes in insurance.
The Company may inspect the Group Policyholder's records of Employees'
insurance. Such inspection can take place while this policy is in force and
during the first year after it terminates.
ENTIRE CONTRACT
The contract consists of:
(1) this policy;
(2) the attached application for this policy;
(3) any Employee applications; and
(4) any notices of Proof of Good Health.
Except for fraud, statements made by the Group Policyholder, or by an Employee,
are deemed representations and not warranties. Only statements contained in:
(1) the Group Policyholder's application for this policy;
(2) any Employee applications; or
(3) any notices of Proof of Good Health;
will void any insurance under this policy, or be used in defense to a claim
under it.
AUTHORITY
The provisions of this policy cannot be changed or waived except by written
agreement. Such agreement must be signed by:
(1) the President, or a Vice-President; and
(2) the Secretary, or Actuary;
Page 4
GENERAL PROVISIONS (Continued)
of the Company. Only by such a signed agreement can:
(1) a premium in default be accepted;
(2) the time for a premium payment be extended;
(3) any of the Company's rights be waived;
(4) the Company be bound by any promise regarding benefits; or
(5) any applications be accepted. BPL4
INDIVIDUAL BOOKLET/CERTIFICATE
The Company will issue Booklet/Certificates to the Group Policyholder to give
each insured Employee. Such Booklet/Certificate will:
(1) describe the insurance to which an Employee is entitled;
(2) describe the CONVERSION PRIVILEGE;
(3) detail how an Employee's insurance can reduce or terminate; and
(4) state that the Employee may inspect this policy at the Group Policyholder's
office. BPL4a
TERMINATION OF THE POLICY
The Group Policyholder may terminate this policy by giving 31 days written
notice to the Company.
The Company may terminate this policy:
(1) if the Group Policyholder fails to:
(A) adhere to the terms and conditions set out in this policy; or
(B) pay the required premium as set out in the PREMIUMS section; or
(2) if the number of insured Employees is less than
(A) 25; or
(B) 75% of those eligible for insurance.
The Company must give written notice of termination to the Group Policyholder 31
days in advance. BPL5
Page 5
To be attached to and made part of the Group Policy No. 256374GL
issued by
GREAT-WEST LIFE & ANNUITY INSURANCE COMPANY
to
PACIFIC CAPITAL BANCORP
This Group Policy is hereby deleted as of January 31, 1995 and replaced with the
attached Group Policy.
Dated at Englewood, Colorado this 13th day of April, 1995
GREAT-WEST LIFE & ANNUITY INSURANCE COMPANY
/s/ D.C. Lennox /s/ William McCallum
- ------------------------------ ------------------------------
Senior Vice-President, General President
Counsel and Secretary
/s/ Debe Hickman
------------------------
For the Actuary
Accepted and attached to the Contract by PACIFIC CAPITAL BANCORP
this day of , 19 .
BY /s/ Naomi Walling
-------------------------------------
TITLE VP Human Resources
----------------------------------
Page 1
GREAT-WEST LIFE & ANNUITY INSURANCE COMPANY
EXECUTIVE OFFICES - ENGLEWOOD, COLORADO
(the Company)
AGREES, under the application of
PACIFIC CAPITAL BANCORP
(the Group Policyholder)
to insure the lives of Employees (Insured Persons) according to the terms of
this policy.
This policy is issued in consideration of the payment of the required premiums.
The Life Insurance and Accidental Death, Dismemberment and Loss of Sight (AD&D)
benefits to which an Insured Person is entitled are described in the
Booklet/Certificate which is attached to and forms a part of this policy.
Group Policy Effective Date:
This policy will take effect on FEBRUARY 1,1995 at 12:01 a.m., standard time at
the Group Policyholder's address.
Currency:
All money payable under this policy is payable in the lawful money of the United
States of America.
All provisions:
(1) on the following pages of this policy; and
(2) in the sections of the Booklet/Certificate that apply to Life Insurance and
AD&D Benefits;
form a part of this policy as fully as if they were stated over the signatures
below and are referred to herein as the Group Policy.
This policy has been executed by the Company at its Executive Offices.
/s/ D.C. Lennox /s/ William McCallum
- ------------------------------ ------------------------------
Senior Vice-President, General President
Counsel and Secretary
/s/ Debe Hickman
------------------------
For the Actuary
Group Term Life Insurance
- - Contributory
- - Non-Participating
Policy Format No. GL 193 Group Policy No. 256374GL BPL1
Page 1
MISCELLANEOUS PROVISIONS
(1) Insurance months and years start from the Group Policy Effective Date.
(2) The Group Policyholder's actions will bind the Employer. Notice given to
the Group Policyholder is considered to be notice given to an Employer.
(3) All requests, notices, proofs of claim and applications must be made in
writing to the Company at its Executive Offices.
(4) Words of the masculine gender include the feminine. BPL2
PREMIUMS
PAYMENT
The first premium is due on the effective date of this policy. After that,
premiums are due on the first day of each insurance month. Premiums must be paid
at the Company's Executive Offices. Any premium not paid on time will be in
default.
GRACE PERIOD
After the first premium has been paid, 31 days are allowed to pay a premium in
default. During this time, the policy will stay in force. If the premium is not
paid by the end of the days of grace, this policy will terminate. The Group
Policyholder is liable for a pro rata premium for the time this policy is in
force during the grace period and for all other unpaid premiums.
Page 2
PREMIUMS (Continued)
CALCULATION
The amount of each premium is the sum of the premiums for each insured Employee.
If a premium has been waived for an Employee under the DISABILITY BENEFIT
section, it will not be included in the calculation. Until the Company changes
the rate, it will be:
(1) $0.22 for each $1,000 of Life Insurance then in force.
(2) $0.02 for each $1,000 of AD&D (Principal Sum) then in force.
(3) $1.85 for each Employee insured in respect of his Dependents for Dependent
Life Insurance.
(4) for Optional Life Insurance, an amount determined in accordance with the
following schedule, based on the individual's age on the date on which the
premium is calculated.
Age of individual on date of Premium Rate for each Premium Rate for each
calculation $1,000 of Optional Life $1,000 of Optional Life
Insurance, Non-Tobacco Insurance, Tobacco User
User Rates Rates
under age 20 $0.09 $0.14
at least 20 but under age 25 0.09 0.14
at least 25 but under age 30 0.10 0.15
at least 30 but under age 35 0.11 0.16
at least 35 but under age 40 0.12 0.23
at least 40 but under age 45 0.17 0.34
at least 45 but under age 50 0.27 0.54
at least 50 but under age 55 0.41 0.84
at least 55 but under age 60 0.65 1.34
at least 60 but under age 65 0.95 1.90
at least 65 but under age 70 1.39 2.70
at least 70 but under age 75 2.28 4.03
at least 75 but under age 80 3.89 5.75
at least 80 but under age 85 6.30 8.76
at least 85 9.58 13.56
ADJUSTMENTS
The premiums will be adjusted retroactively to reflect changes in insurance
amounts. The Company must be notified promptly of a change. For a decrease in,
or termination of, insurance, a credit will be given only for the 4 month period
prior to receipt of such notice.
Page 3
PREMIUMS (Continued)
EXPERIENCE RATING
After the end of the first insurance year or at any time after that, this policy
may be experience rated by the Company. BPL3
RENEWAL CHANGES
After the end of the first insurance year, the Company may change the premium
rates. Changes can be made on the first day of any insurance month. Written
notice will be sent to the Group Policyholder 31 days before a change is made.
Once the change is made, the Company cannot make another change for 12 months.
However, a change can be made at any time if:
(1) the policy provisions are changed at the request of the Group Policyholder;
(2) there is a change in benefits required by a change in state or federal law;
or
(3) there is a change in the number of Employees insured under this policy which
equals or exceeds:
(A) 10% in any insurance month when compared to the previous insurance
month; or
(B) 20% at any time within an insurance year when compared to the number of
Employees insured in the first month of that insurance year;
except that no increase in premium rates will take effect before 31 days after
the date written notice of such increase is given to the Group Policyholder by
the Company. BPL3a
GENERAL PROVISIONS
FURNISHING OF INFORMATION: ACCESS TO RECORDS
The Group Policyholder must forward to the Company:
(1) required information about the eligibility of Employees;
(2) any Employee applications; and
(3) details about changes in insurance.
The Company may inspect the Group Policyholder's records of Employees'
insurance. Such inspection can take place while this policy is in force and
during the first year after it terminates.
Page 4
GENERAL PROVISIONS (Continued)
ENTIRE CONTRACT
The contract consists of:
(1) this policy;
(2) the attached application for this policy;
(3) any Employee applications; and
(4) any notices of Proof of Good Health.
Except for fraud, statements made by the Group Policyholder, or by an Employee,
are deemed representations and not warranties. Only statements contained in:
(1) the Group Policyholder's application for this policy;
(2) any Employee applications; or
(3) any notices of Proof of Good Health;
will void any insurance under this policy, or be used in defense to a claim
under it.
AUTHORITY
The provisions of this policy cannot be changed or waived except by written
agreement. Such agreement must be signed by:
(1) the President, or a Vice-President; and
(2) the Secretary, or Actuary;
of the Company. Only by such a signed agreement can:
(1) a premium in default be accepted;
(2) the time for a premium payment be extended;
(3) any of the Company's rights be waived;
(4) the Company be bound by any promise regarding benefits; or
(5) any applications be accepted. BPL4
Page 5
GENERAL PROVISIONS (Continued)
INDIVIDUAL BOOKLET/CERTIFICATE
The Company will issue Booklet/Certificates to the Group Policyholder to give
each insured Employee. Such Booklet/Certificate will:
(1) describe the insurance to which an Employee is entitled;
(2) describe the CONVERSION PRIVILEGE;
(3) detail how an Employee's insurance can reduce or terminate; and
(4) state that the Employee may inspect this policy at the Group Policyholder's
office. BPL4a
TERMINATION OF THE POLICY
The Group Policyholder may terminate this policy by giving 31 days written
notice to the Company.
The Company may terminate this policy:
(1) if the Group Policyholder fails to:
(A) adhere to the terms and conditions set
(B) pay the required premium as set out in the PREMIUMS section; or
(2) if the number of insured Employees is less than
(A) 25; or
(B) 75% of those eligible for insurance.
The Company must give written notice of termination to the Group Policyholder 31
days in advance. BPL5
Page 6
Attached to and forming part of the Services Agreement for
Flexible Benefits Account between
GREAT-WEST LIFE & ANNUITY INSURANCE COMPANY
and
PACIFIC CAPITAL BANCORP
The Services Agreement for Flexible Benefits Account which was effective on
JANUARY 1, 1995 and is dated JANUARY 30, 1995 is hereby terminated as of
DECEMBER 31,1994 and replaced by the attached Services Agreement for Flexible
Benefits Account which is effective JANUARY 1, 1995.
Dated at Englewood, Colorado this 13th day of April 1995
GREAT-WEST LIFE & ANNUITY INSURANCE COMPANY
/s/ D.C. Lennox /s/ William McCallum
- ------------------------------ ------------------------------
Senior Vice-President, General President
Counsel and Secretary
/s/ Debe Hickman
------------------------
For the Actuary
The terms of this Agreement are accepted by PACIFIC CAPITAL BANCORP
this day of , 19 .
BY /s/ Naomi Walling
--------------------------------
TITLE VP Human Resources
------------------------------
Page 1
SERVICES AGREEMENT FOR FLEXIBLE BENEFITS ACCOUNT
AGREEMENT entered into on JANUARY 1,1995 between GREAT-WEST LIFE & ANNUITY
INSURANCE COMPANY, hereinafter referred to as "GREAT-WEST" and
PACIFIC CAPITAL BANCORP
(hereinafter referred to as "the Contractholder")
It is hereby provided that the Contractholder has established a Flexible
Benefits Account Plan for the benefit of its Employees and Dependents
(hereinafter referred to as the "Plan"). The purpose of that Plan is to offer
eligible Employees a choice of benefits under a plan that is designed to comply
with Sections 105, 106, 125 and 129 of the Internal Revenue Code and the
regulations issued thereunder. The Contractholder hereby retains GREAT-WEST to
provide certain services for the Plan in accordance with the following terms and
conditions.
DEFINITIONS
Unless specifically defined herein, the meaning of all terms used in this
Agreement will be the same as those used in the Plan and/or the group health
policy/plan sponsored by the Contractholder.
ADMINISTRATIVE SERVICES
Great-West agrees to perform services involving the performance of
non-discretionary duties as specified in the SCHEDULE OF SERVICES (Schedule A),
which is attached to and forms part of this Agreement.
To facilitate the performance of such duties, the Contractholder agrees to:
(1) establish a bank account for all deposits made under the Plan. The
Contractholder will inform Great-West of the appropriate bank account
number and transit number and will send to Great-West a copy of the
corresponding MICR Sheet/Specification Sheet and any other information
necessary to enable Great-West to produce benefit payment checks from that
account.
(2) provide Great-West with a monthly list of:
(A) Employees who have elected to participate under each of the options
described in the Plan; and
(B) the amounts deposited into the bank account in respect of each such
Employee.
Page 1
SERVICES AGREEMENT FOR FLEXIBLE BENEFITS ACCOUNT (Continued)
FURNISHING OF INFORMATION; ACCESS TO RECORDS
The Contractholder will furnish Great-West, on request, with correct and
complete information required by Great-West to provide the services which
Great-West has agreed to perform under this Agreement. Great-West will have the
right to inspect the records of the Contractholder which are pertinent to the
operation of the Plan.
AUTHORITY TO CONTROL AND MANAGE THE PLAN
The Contractholder acknowledges that he has authority to control and manage the
operation of the Plan. It is expressly agreed that under no circumstances will
Great-West be designated as plan administrator or a fiduciary of the Plan.
INDEMNIFICATION AND LIMITATION OF LIABILITY
The Contractholder will indemnify, protect and hold Great-West harmless from any
loss, liability, claim or expense (including attorney's fees, court costs and
expenses of litigation) arising out of any act or omission of the Contractholder
in connection with the Plan. Any premium or other tax assessed against
Great-West in respect of the Plan will be borne by the Contractholder. In no
event will incorrect determination of any benefit be the responsibility of
Great-West.
AGREEMENT TERMINATION
This Agreement may be terminated at any time by either the Contractholder or
Great-West, provided written notice of such termination is given at least one
month in advance. In addition, Great-West may terminate this Agreement
immediately upon:
(1) the date Great-West no longer insures or provides administrative services
for any group life, health, dental or 401(k) plan sponsored by the
Contractholder.
(2) amendment of the Plan in a manner deemed unsatisfactory by Great-West,
provided that Great-West provides 31 days' written notice of such
termination to the Contractholder.
(3) failure of the Contractholder to comply with any term or condition of this
agreement.
In the event of termination of this Agreement, Great-West will have the right to
stop processing claims immediately on the effective date of such termination.
Page 2
SERVICES AGREEMENT FOR FLEXIBLE BENEFITS ACCOUNT (Continued)
PACIFIC CAPITAL BANCORP
/s/ Naomi Walling VP Human Resources Mgr.
- -------------------------------------------------------------------------------
Authorized Signature, Title and Date
- -------------------------------------------------------------------------------
Mailing Address, City, State and Zip Code
GREAT-WEST LIFE & ANNUITY INSURANCE COMPANY
/s/ Debe Hickman Asst. Acct. Manager 4/13/95
- -------------------------------------------------------------------------------
Authorized Signature, Title and Date
Great-West Life Center, Tower 1
8505 E. Orchard Road
Englewood, CO 80111
Page 3
SCHEDULE A - SCHEDULE OF SERVICES
Description of Services Covered in this
Agreement (Yes/No)
Drafting Assistance Yes
Plan Document
Plan Amendments
Employee brochure and worksheet Yes
Enrollment forms Yes
Assistance in Plan enrollment Yes
Claim forms Yes
Benefit determination in accordance Yes
with the Plan
Benefit payments in accordance Yes
with the Plan
Direct payment of benefits to Plan Yes
participants
Claim reports Yes
Check register Yes
Discrimination Testing Yes
Page 4
FLEXIBLE BENEFITS ACCOUNT PLAN DOCUMENT
Flexible Benefits Account Plan Document
For Employees of
PACIFIC CAPITAL BANCORP
Effective Date:
This FBA Plan Document will take effect on JANUARY 1, 1995 at 12:01 a.m.,
standard time at the Employer's address.
All provisions:
(1) on the following pages of this FBA Plan Document; and
(2) in the Flexible Benefits Account section of the Booklet;
form a part of this FBA Plan Document as fully as if they were stated over the
signatures below.
IN WITNESS WHEREOF, PACIFIC CAPITAL BANCORP has executed this Plan Document at
on this day of , 19 .
PACIFIC CAPITAL BANCORP
by /s/ NAOMI WALLING
--------------------------------
VP Human Resources Mgr.
--------------------------------
Title
Page 1
PURPOSE
The purpose of this Plan is to otter eligible Employees of the Employer a choice
of benefits under a plan that is designed to comply with Sections 105, 106, 125
and 129 of the Internal Revenue Code and the regulations issued thereunder.
The following options are available to eligible Employees under this Plan:
(1) PREMIUM EXPENSE CONVERSION ACCOUNT.
(2) HEALTH CARE ACCOUNT.
(3) DEPENDENT CARE ACCOUNT.
The benefits provided under these options are described in the BENEFIT
PROVISIONS section of this Plan.
FORFEITURES
Any amount remaining in an Employee's Dependent Care Account and Health Care
Account after all claims have been processed for that Plan Year will be
forfeited. These amounts will be deposited into the Employer's benefit plan
surplus. When this happens, the Employee will have no further claim to such
amounts.
Page 2
ADMINISTRATION
The operation of the Plan will be under the supervision of the Employer's Plan
Administrator. It will be a principal duty of the Plan Administrator to see that
the Plan is carried out in accordance with its terms, and for the exclusive
benefit of Employees entitled to participate in the Plan. The Plan Administrator
will have full power to administer the Plan in all of its details; subject,
however, to the pertinent provisions of the Internal Revenue Code. The Plan
Administrator's powers will include, but will not be limited to, the following
authority, in addition to all other powers provided by this Plan:
(1) to make and enforce such rules and regulations as the Plan Administrator
deems necessary or proper for the efficient administration of the Plan;
(2) to decide all questions concerning the Plan and the eligibility of any
person to participate in the Plan and to receive benefits provided under
the Plan;
(3) to interpret the Plan, the Plan Administrator's interpretations in good
faith to be final and conclusive on all persons claiming benefits under the
Plan;
(4) to review reimbursement requests and to authorize the payment of benefits;
and
(5) to appoint such agents. counsel, accountants, consultants and actuaries as
may be required to assist in administering the Plan.
AMENDMENT OR TERMINATION OF PLAN
The Employer, at any time or from time to time, may amend any or all of the
provisions of the Plan without the consent of any Employee. No amendment will
have the effect of reducing any benefit election of any Employee in effect at
the time of such amendment, unless such amendment is made to comply with federal
law or local statute or regulations.
The Employer reserves the right to terminate the Plan, in whole or in part, at
any time. In the event the Plan is terminated, no further additions will be made
to any Employee's accounts, but all benefits will continue to be paid according
to the elections in effect until:
(1) the end of the Plan Year in which the Plan termination occurs; or
(2) the balances of all accounts have been reduced to zero;
whichever occurs first.
Any amounts remaining at the end of the Plan Year (and after the processing of
all claims for such Plan Year) in which Plan termination occurs will be
forfeited and deposited in the benefit plan surplus of the Employer.
Page 3
SEVERABILITY
If any provision of the Plan is held invalid or unenforceable, its invalidity or
unenforceability will not affect any other provisions of the Plan, and the Plan
will be construed and enforced as if such provision had not been included
herein.
Page 4