GROUPAMERICA INSURANCE COMPANY
P.O. BOX 1840, HARTFORD, CONNECTICUT 06144-1840
1-800-443-3221
GROUP POLICY NUMBER 908496-A
NAME OF POLICYHOLDER Pacific Capital Bancorp
TYPE OF COVERAGE Long Term Disability Insurance
EFFECTIVE DATE January 1, 1995
INITIAL POLICY TERM Two Years
PREMIUM DUE DATES January 1, 1995, and the first day of each
calendar month thereafter
POLICY DELIVERED IN California and governed by the laws of that
state.
GroupAmerica Insurance Company agrees to pay the benefits provided by this Group
Policy, in accordance with the provisions of this Group Policy.
The consideration for this Group Policy is the application of the Policyholder
and the payment by the Policyholder of premiums as provided herein.
The Group Policy is issued for the Initial Policy Term shown above, ending on
the first day after the end of such policy term at 12:01 A.M. Standard Time at
the Policyholder's address. This Group Policy may be renewed for successive
renewal periods by the payment of the premium on each renewal date, provided the
number of persons insured on each renewal date is neither less than the Minimum
Participation Number nor less than the Minimum Participation Percentage (shown
in the Policy Data). The length of each renewal period will be determined by us,
but will not be less than 12 months.
All provisions on this and the following pages are a part of this Group Policy.
The Certificate Of Insurance issued for delivery to each insured Member will
include Section One of this Group Policy. The definitions of terms in Section
One apply whenever the terms are used anywhere in this Group Policy. "You" and
"your" refer to the insured Member. "We", "us", and "our" refer to GroupAmerica
Insurance Company. Other defined terms are printed with an initial capital
letter.
GroupAmerica Insurance Company
By
Secretary President
Group Insurance Policy
GP292-LTD
REQUIRED CALIFORNIA NOTICE
To Our California Policyholders and Certificate Holders:
We are here to serve you ...
As our policyholder or certificate holder, your satisfaction is very
important to us. Should you have a valid claim, we fully expect to provide
a fair settlement in a timely fashion. In the event you need to contact
someone about this policy for any reason, please contact your agent. If you
have additional questions, you may contact GroupAmerica Insurance Company
at the following address and toll-free telephone number:
GroupAmerica Insurance Company
P.O. Box 1840
Hartford, Connecticut 06144-1840
Telephone number: 1-800-443-3221
If you are not satisfied...
Should you feel you are not being treated fairly and you have been unable
to contact or obtain satisfaction from us or the agent, we want you to know
you may contact the California Department of Insurance with your complaint
and seek assistance from the governmental agency that regulates insurance.
To contact the Department, write or call:
Consumer Affairs Division
California Department of Insurance
300 South Spring Street
Los Angeles, CA 90013
Telephone number: 1-800-927-HELP
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California Life and Health Insurance
Guarantee Association Act
Summary Document and Disclaimer
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Residents of California who purchase life and health insurance and annuities
should know that the insurance companies licensed in this state to write these
types of insurance are members of the California Life and Health Insurance
Guarantee 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 Guarantee 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 through the Association is not unlimited, as noted in the
box below, and is not a substitute for consumers' care in selecting insurers.
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The California Life and Health Insurance Guarantee 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 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 Guarantee Association to induce you to purchase any
kind of insurance policy.
Policyholders with additional questions should first contact their insurer or
agent or may then contact:
Executive Director or Allegra Willison, Staff Counsel
California Life and Health Insurance California Department of Insurance
Guarantee Association 45 Fremont Street, 24th Floor
P.O. Box 70069 San Francisco, CA 9410
Los Angeles, CA 90070
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The state law that provides for this safety-net coverage is called the
California Life and Health Guarantee 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 rights or obligations of the Association.
COVERAGE
Generally, individuals will be protected by the California Life and Health
Insurance Guarantee 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 Guarantee
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 guarantee association protects insureds who live outside that state.
The Guarantee 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.
LIMITS ON AMOUNT OF COVERAGE
The Act limits the Association to pay benefits as follows:
LIFE AND ANNUITY BENEFITS
80% of what the 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.
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 health insurance policies to which
the Act applies.
POLICY DATA
GROUP POLICY NUMBER 908496-A
INITIAL MONTHLY PREMIUM RATE:
LONG TERM DISABILITY 32% of the first $11,999 of the
INSURANCE Predisability Earnings of each insured
Member
MINIMUM PARTICIPATION NUMBER 10 insured Members
MINIMUM PARTICIPATION PERCENTAGE 100% of eligible Members
TABLE OF CONTENTS
SECTION ONE - COVERAGE PROVISIONS ......................................... 1
Part 1 BECOMING INSURED ................................................. 1
Part 2 LONG TERM DISABILITY INSURING CLAUSE ............................. 2
Part 3 SCHEDULE OF LONG TERM DISABILITY INSURANCE ....................... 2
A. ELIMINATION PERIOD ............................................... 2
B MAXIMUM BENEFIT PERIOD ........................................... 2
C AMOUNT OF LTD BENEFIT............................................. 4
Part 4 EXCLUSIONS AND LIMITATIONS ....................................... 4
Part 5 DEFINITION OF DISABILITY.......................................... 5
Part 6 DEFINITION OF PREDISABILITY EARNINGS ............................ 7
Part 7 DEFINITION OF INCOME FROM OTHER SOURCES ......................... 7
Part 8 OTHER BENEFITS AND PROVISIONS ................................... 10
A RETURN TO WORK PROVISION ........................................ 10
B SURVIVORS BENEFIT ............................................... 10
C WAIVER OF PREMIUM ............................................... 10
D BENEFITS AFTER INSURANCE ENDS OR IS CHANGED ..................... 10
Part 9 WHEN INSURANCE ENDS ............................................. 11
Part 10. BECOMING INSURED AGAIN AFTER INSURANCE ENDS ..................... 11
Part 11. CLAIMS PROVISIONS AND PROCEDURES FOR LTD BENEFITS ............... 12
Part 12. TIME LIMITS ON LEGAL ACTIONS .................................... 14
Part 13. INCONTESTABLE CLAUSES ........................................... 14
Part 14. ALLOCATION OF AUTHORITY ......................................... 15
Part 15. ASSIGNMENT NOT PERMITTED ........................................ 15
Part 16. GENERAL DEFINITIONS ............................................. 15
SECTION TWO - POLICYHOLDER PROVISIONS .................................... 17
Part 1. PREMIUMS ......................................................... 17
Part 2. CERTIFICATES ..................................................... 18
Part 3. RECORDS AND REPORTS .............................................. 18
Part 4. MISSTATEMENT OF AGE .............................................. 19
Part 5. ENTIRE CONTRACT; CHANGES ......................................... 19
Part 6. EFFECT ON WORKER'S COMPENSATION .................................. 19
INDEX OF DEFINED TERMS
ACTIVE WORK ............................................................... 2
ACTIVELY AT WORK .......................................................... 2
CONTRIBUTORY .............................................................. 16
CPI-W ..................................................................... 7
DISABILITY ................................................................ 5
DISABLED .................................................................. 5
ELIMINATION PERIOD ........................................................ 2
EMPLOYER .................................................................. 15
EVIDENCE OF INSURABILITY .................................................. 15
GROUP POLICY .............................................................. 15
HOSPITAL .................................................................. 5
INCOME FROM OTHER SOURCES ................................................. 7
INDEXED PREDISABILITY EARNINGS ............................................ 6
INSURANCE ................................................................. 15
LONG TERM DISABILITY INSURANCE ............................................ 15
LTD BENEFIT ............................................................... 4,15
MAXIMUM BENEFIT PERIOD .................................................... 2
MAXIMUM LTD BENEFIT ....................................................... 4
MEMBER .................................................................... 1
MENTAL DISORDER ........................................................... 5
MINIMUM LTD BENEFIT ....................................................... 4
NONCONTRIBUTORY ........................................................... 16
PHYSICIAN ................................................................. 5
PREDISABILITY EARNINGS .................................................... 7
PREEXISTING CONDITION ..................................................... 4
PRIOR PLAN ................................................................ 15
RESIDUALLY DISABLED ....................................................... 6
TOTALLY DISABLED .......................................................... 6
WAR ....................................................................... 4
SECTION ONE - COVERAGE PROVISIONS
Part 1. BECOMING INSURED
To become insured you must meet each of the requirements of A through E plus the
Active Work requirement.
A. DEFlNITION OF MEMBER
You must be a Member. You are a MEMBER if you are all of the following:
1. An active employee of the Employer, other than a temporary or seasonal
employee or a full time member of the armed forces of any country.
2. Regularly scheduled to work at least 21 hours each week.
3. A citizen or resident of the United States or Canada.
B. ELIGIBILITY FOR INSURANCE
1. For each Member with Predisability Earnings of $2,000 or more
You must be eligible for Insurance. You are eligible for Insurance on
the effective date of the Group Policy if you are a Member on that
date. Otherwise, you will become eligible for Insurance on the date you
become a Member.
2. For all other Members
You must be eligible for Insurance. You are eligible for Insurance on
the effective date of the Group Policy if you are a Member on that
date. Otherwise, you will become eligible for Insurance on the first
day after 90 consecutive days as a Member.
C. APPLICATION FOR INSURANCE
Your Insurance is Noncontributory. No application for Insurance is
required.
D. EVIDENCE OF INSURABILITY
Your Insurance is Noncontributory; Evidence Of Insurability is not
required to become insured.
E. EFFECTIVE DATE OF INSURANCE
Your Insurance will become effective on the date you become eligible,
if you meet the Active Work requirement on that date.
F. ACTIVE WORK REQUIREMENT
You must meet an Active Work requirement to become insured.
You automatically meet the Active Work requirement on the date your
Insurance is scheduled to become effective unless you were Disabled on
the day before that date. If you were Disabled on the day before the
scheduled effective date of your Insurance, the effective date of your
Insurance will be delayed until the first day after you complete one
full day of Active Work as a Member.
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For purposes of this Active Work requirement, you are Disabled if you
are currently unable, as a result of your sickness, accidental bodily
injury, or pregnancy, to perform the substantial and material duties of
your own occupation.
ACTIVE WORK and ACTIVELY AT WORK mean performing the usual duties of
your job at the Employer's usual place of business.
This Active Work requirement also applies to any increase in your
Insurance.
Continuity of coverage provision for each Member insured under the
Prior Plan who fails to meet the Active Work requirement of the Group
Policy:
If you are a Member who was insured under the Prior Plan on the last
day before the effective date of the Group Policy, you can become
insured under the Group Policy on the effective date of the Group
Policy without meeting the Active Work requirement. However, the
benefits we pay for a new period of Disability beginning after you
become insured under the Group Policy, but before you meet the Active
Work requirement, will be the benefits payable under the Group Policy
or the benefits which would have been payable under the Prior Plan if
the Prior Plan had remained in force, whichever are less, reduced by
any benefits payable under the Prior Plan.
Part 2. LONG TERM DISABILITY INSURING CLAUSE
Subject to all the terms of the Group Policy, we will pay the LTD Benefit
described in Part 3 upon receipt of satisfactory written proof that you have
become Disabled while insured under the Group Policy.
Part 3. SCHEDULE OF LONG TERM DISABILITY INSURANCE
You must read each section to understand when LTD Benefits are payable and how
LTD Benefits are calculated.
A. ELIMINATION PERIOD
ELIMINATION PERIOD means the length of time you must be continuously
Disabled before LTD Benefits become payable.
Your Elimination Period is the first 90 days of each period of
continuous Disability.
Your Elimination Period begins on the date you become Disabled. No LTD
Benefits are ever payable for the Elimination Period.
Temporary Recovery during the Elimination Period:
For purposes of serving the Elimination Period, all separate periods of
Disability from the same cause or causes will be added together and
treated as one period of continuous Disability. However, you must serve
the full 90 day Elimination Period within a period of 105 consecutive
days.
For purposes of this provision, a period of Temporary Recovery means
any time when we do not consider you Disabled as defined in Part 5.
B. MAXIMUM BENEFIT PERIOD
MAXIMUM BENEFIT PERIOD means the longest period of time for which LTD
Benefits are payable for any one period of continuous Disability,
whether from one or more causes.
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Your Maximum Benefit Period is equal to the period shown below or the period
which lasts until your Normal Retirement Age under the 1983 amendments to the
federal Social Security Act, whichever is longer.
Your Maximum Benefit Period is determined as follows:
Your Age When Your Maximum
Disability Begins Benefit Period
58 or younger .............. To age 65
59 ......................... To age 65 or 5 years, whichever is longer
60 ......................... 5 years
61 ......................... 4 years
62 ......................... 3 years 6 months
63 ......................... 3 years
64 ......................... 2 years 6 months
65 ......................... 2 years
66 ......................... 1 year 9 months
67 ......................... 1 year 6 months
68 ......................... 1 year 3 months
69 or older ................ 1 year
Your Normal Retirement Age under the 1983 amendments to the federal Social
Security Act is determined by the year of your birth, as follows
Year of Birth Normal Retirement Age
Before 1938 ................ Age 65
1938 ....................... Age 65 and 2 months
1939 ....................... Age 65 and 4 months
1940 ....................... Age 65 and 6 months
1941 ....................... Age 65 and 8 months
1942 ....................... Age 65 and 10 months
1943 through 1954 .......... Age 66
1955 ....................... Age 66 and 2 months
1956 ....................... Age 66 and 4 months
1957 ....................... Age 66 and 6 months
1958 ....................... Age 66 and 8 months
1959 ....................... Age 66 and 10 months
After 1959.................. Age 67
Your Maximum Benefit Period begins at the end of the Elimination Period. During
the Maximum Benefit Period, LTD Benefits are paid at the end of each monthly
period for which you qualify for LTD Benefits. LTD Benefits will stop at your
death or at any time during the Maximum Benefit Period when you no longer
qualify for LTD Benefits. LTD Benefits will stop at the end of the Maximum
Benefit Period even if you are still Disabled.
Temporary Recovery during the Maximum Benefit Period:
For purposes of continuing LTD Benefits during the Maximum Benefit Period, any
two periods of Disability from the same cause or causes will be added together
and treated as one period of continuous Disability if they are separated by a
period of Temporary Recovery of less than 180 days. Thus, a new Elimination
Period will not be required, the Predisability Earnings used to compute your LTD
Benefit will not change, and the Maximum Benefit Period will be the balance of
the Maximum Benefit Period remaining unused before the period of Temporary
Recovery.
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No LTD Benefits will be payable under this provision after benefits
become payable to you under any other group long term disability
insurance policy. This rule prevents double coverage if you become
insured under another policy while you are working during a period of
Temporary Recovery.
For purposes of this provision, a period of Temporary Recovery means
any time when we do not consider you Disabled as defined in Part 5.
C. AMOUNT OF LTD BENEFIT
Your monthly LTD BENEFIT equals your Maximum LTD Benefit reduced by
your Income From Other Sources.
Your MAXIMUM LTD BENEFIT equals A or B, whichever is less, where:
A = 66 2/3% of your Predisability Earnings
B = $8,000
Your monthly LTD Benefit during a period of Disability will be
determined by your Maximum LTD Benefit in effect on your last day of
Active Work before you become Disabled.
The MINIMUM LTD BENEFIT is $100 or 10% of your Maximum LTD Benefit,
whichever is greater.
Predisability Earnings are defined in Part 6.
Income From Other Sources is defined in Part 7.
Part 4. EXCLUSIONS AND LIMITATIONS
A. RISKS NOT COVERED
1. WAR: You are not covered for a disability caused or contributed to
by war or any act of war
WAR means declared or undeclared war, whether civil or
international, and any substantial armed conflict between organized
forces of a military nature.
2. INTENTIONALLY SELF-INFLICTED INJURY: You are not covered for a
disability caused or contributed to by an intentionally self-
inflicted injury.
3. PREEXISTING CONDITION: You are not covered for a disability caused
or contributed to by a Preexisting Condition or medical or surgical
treatment of a Preexisting Condition unless, on the date you become
Disabled, you have been continuously insured under the Group Policy
for at least 12 months.
PREEXISTING CONDITION means a mental or physical condition for
which you have done any of the following at any time during the 90
day period just before the effective date of your Insurance under
the Group Policy:
a. Consulted a Physician.
b. Received medical treatment or services.
c. Taken prescribed drugs or medications.
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Continuity of coverage provision for each Member insured under the
Prior Plan:
This Preexisting Condition exclusion will not apply to your
Disability from a Preexisting Condition if all of the following are
true:
a. You were insured under the Prior Plan on the last day before the
effective date of the Group Policy.
b. You were continuously insured under the Group Policy from the
effective date of the Group Policy through the date you became
Disabled from the Preexisting Condition.
c. Benefits would have been payable under the Prior Plan if the
Prior Plan had remained in force, taking into consideration the
preexisting condition exclusion or limitation, if any, of the
Prior Plan.
However, the LTD Benefit we pay will be the benefit payable under
the Group Policy or the benefit which would have been payable under
the Prior Plan if the Prior Plan had remained in force, whichever is
less.
B. LIMITATIONS
1. REGULAR CARE OF A PHYSICIAN: No LTD Benefits will be paid for any
period of Disability when you are not under the regular care of a
Physician.
PHYSICIAN means a licensed medical professional, other than
yourself, diagnosing and treating you within the scope of the
license.
2. MENTAL DISORDER: Payment of LTD Benefits is limited to 24 months
for each period of Disability caused or contributed to by a Mental
Disorder. However, if you are a resident patient in a Hospital at
the end of the 24 months, this limitation will not apply while you
remain continuously confined.
MENTAL DISORDER means a mental, emotional, or behavioral disorder.
HOSPITAL means a legally operated hospital providing full-time
medical care and treatment under the direction of a full-time staff
of licensed physicians (M.D. or D.O.). Rest homes, nursing homes,
convalescent homes, homes for the aged, and facilities primarily
affording custodial, educational, or rehabilitative care are not
Hospitals.
3. WORK EARNINGS: No LTD Benefits will be paid for any period when your
work earnings exceed 80% of your Indexed Predisability Earnings.
Part 5. DEFINITION OF DISABILITY
You will be considered DISABLED during the Elimination Period if you are Totally
Disabled as defined below, and you are not working at all.
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You will be considered Disabled during the Maximum Benefit Period if you are
either Totally Disabled or Residually Disabled, as defined below:
TOTALLY DISABLED:
1. You are only required to be Totally Disabled from your own
occupation during the Elimination Period and the first 60 months of the
Maximum Benefit Period.
You are Totally Disabled from your own occupation if you are currently
unable, as a result of your sickness, accidental bodily injury, or
pregnancy, to perform the substantial and material duties of your own
occupation, and you are not working at all.
2. You must be Totally Disabled from all occupations after the first 60
months of the Maximum Benefit Period.
You are Totally Disabled from all occupations if you are currently
unable, as a result of your sickness, accidental bodily injury, or
pregnancy, to perform the substantial and material duties of any
occupation for which you are reasonably fitted by education, training,
and experience, and you are not working at all.
RESIDUALLY DISABLED:
1. You are Residually Disabled during the first 60 months of the Maximum
Benefit Period if you are currently unable, as a result of your
sickness, accidental bodily injury, or pregnancy to perform the
substantial and material duties of your own occupation, and you
satisfy one of the following conditions:
a. You are working in your own occupation, and you are currently
unable, as a result of your sickness, accidental bodily injury, or
pregnancy, to earn more than 80% of your Indexed Predisability
Earnings.
b. You are working in another occupation or specialty, and your actual
work earnings do not exceed 80% of your Indexed Predisability
Earnings.
2. You are Residually Disabled after the first 60 months of the Maximum
Benefit Period if you are working in your own occupation or any other
occupation or specialty, and you are currently unable, as a result of
your sickness, accidental bodily injury, or pregnancy, to earn more
than 80% of your Indexed Predisability Earnings from work in that
occupation or any other occupation for which you are reasonably
fitted by education, training, and experience.
The Return To Work Provision in Part 8A explains the effect your work earnings
will have on the amount of your LTD Benefit. No LTD Benefits will be paid for
any period when your earnings from work in your own occupation or another
specialty or occupation exceed 80% of your Indexed Predisability Earnings.
You will not be considered Disabled solely because of the loss or restriction of
your license to engage in your own occupation.
INDEXED PREDISABILITY EARNINGS used for purposes of the income protection
guarantee in the definition of Disability means an amount determined as follows:
Until you have been Disabled for one year, your Indexed Predisability Earnings
will equal your Predisability Earnings on your last full day of Active Work
before you became Disabled. Thereafter, we will increase the
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amount of your Indexed Predisability Earnings on each anniversary of the date
you became Disabled. Increases are compounded, and there is no limit on the
number of increases. The amount of each increase to the amount of Indexed
Predisability Earnings in effect during the prior year of Disability will equal
A or B, whichever is less, where:
A = 10% of your Indexed Predisability Earnings during the prior year of
Disability
B = The rate of increase in the Consumer Price Index (CPI-W during the prior
calendar year multiplied by your Indexed Predisability Earning during
the prior year of Disability
There will never be a decrease in your Indexed Predisability Earnings, even if
there is a drop in the Consumer Price Index (CPI-W).
CPI-W means the Consumer Price Index for Urban Wage Earners and Clerical Workers
published by the United States Department of Labor. If the index is discontinued
or changed, we may use another nationally published index which is comparable to
the CPI-W.
Part 6. DEFINITION OF PREDISABILITY EARNINGS
PREDISABILITY EARNINGS means your monthly rate of earnings from the Employer
including commissions, bonuses, and tax deferred contributions you make to a
qualified plan sponsored by the Employer, but excluding overtime pay and any
other extra compensation. The following rules apply to the computation of your
monthly rate of earnings:
Commissions: Your monthly rate of earnings on any date includes the average
monthly commissions paid to you by the Employer during the prior calendar year
(or during the period you were a Member, if you were not a Member throughout the
prior calendar year).
Bonuses: Your monthly rate of earnings on any date includes the average monthly
bonus paid to you by the Employer during the prior three calendar years (or
during the period you were a Member, if you were not a Member throughout the
prior three calendar years).
Weekly Pay: Weekly earnings are multiplied by 4.333 to find your monthly rate of
earnings.
Hourly Pay: Your hourly pay rate is multiplied by the number of hours you are
regularly scheduled to work each month (but not more than 40 hours per week) to
find your monthly rate of earnings. If you do not have regular work hours, your
monthly rate of earrings on any date will be based on the average number of
hours you worked during the prior calendar year (or during the period you were a
Member, if you were not a Member throughout the prior calendar year), but not
more than 40 hours per week.
Part 7. DEFINITION OF INCOME FROM OTHER SOURCES
Income From Other Sources is used to reduce your LTD Benefit and is explained in
the following definition, exceptions, and rules.
A. DEFINITION OF INCOME FROM OTHER SOURCES
INCOME FROM OTHER SOURCES means:
1. Any sick pay or other salary continuation (other than vacation pay)
paid to you by the Employer which, when added to the amount of your
Maximum LTD Benefit, exceeds 100% of your Predisability Earnings.
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2. The amount determined from the Return To Work Provision in Part 8A,
if you work while you are Disabled. Part 8A explains the effect your
work earnings will have on the amount of your LTD Benefit.
3. Any amount you receive or are eligible to receive as a result of
your disability under any worker's compensation law or similar law
including amounts for partial or total disability, whether
permanent, temporary, or vocational.
4. Any amount you, your spouse, or your children receive or are
eligible to receive because of your disability or retirement under
the Federal Social Security Act, the Canada Pension Plan, the
Quebec Pension Plan, or any similar plan or act. Early retirement
benefits payable prior to normal retirement age under the plan
or act will not be used to reduce the amount of your LTD Benefit
unless they are actually received.
Benefits your spouse or children receive or are eligible to receive
because of your disability will be considered Income From Other
Sources regardless of marital status, custody, or place of
residence.
5. The amount you receive or are eligible to receive because of your
disability under any group insurance coverage, other than group
credit insurance or group mortgage disability insurance.
6. The amount you receive or are eligible to receive because of your
disability under any state unemployment compensation disability
benefit law or state disability income benefit law.
7. Any disability or retirement benefits paid to you under the
Employer's defined benefit retirement plan, except:
a. Any lump sum distribution of your entire interest in the plan.
b. Any amount which is attributable to your contributions to the
plan.
c. Any amount which you could have received upon termination of
employment without being disabled or retired.
8. Any amount received by compromise, settlement, or other method
as a result of a claim for any of the above.
B. EXCEPTIONS TO INCOME FROM OTHER SOURCES
The following will not be used to reduce the amount of your LTD
Benefit:
1. Any cost of living increase in any Income From Other Sources,
provided that the increase becomes effective while you are
Disabled and whil you are eligible to receive the Income From Other
Sources. (This exception does not apply to any increase in your
earnings from any work.)
2. Any amount received as reimbursement for hospital, medical, or
surgical expense.
3. Any amount which represents reasonable attorney's fees incurred
in connection with the claim for Income From Other Sources.
4. Benefits from any individual disability insurance policy.
5. Any amount you receive from the following types of retirement plans:
A defined contribution (money purchase) retirement plan, a profit
sharing plan, a thrift or savings plan, a deferred compensation
plan, a 401(k) plan, an Individual Retirement Account (IRA), a Tax
Sheltered
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Annuity (TSA), a stock ownership plan, a Keogh (HR-10) Plan, or a
retirement plan under a Professional Service Corporation with
respect to principals or shareholders.
6. Any benefits under the Federal Social Security Act received by, or
on behalf of, your dependent child age 18 or over.
C. RULES FOR INCOME FROM OTHER SOURCES
1. Monthly Equivalents
Each month your LTD Benefit will be reduced by the Income From Other
Sources for the same monthly period, even if you actually receive
the Income From Other Sources in another month.
If you receive any Income From Other Sources periodically other than
monthly, we will determine the monthly equivalent and use that
amount to reduce your LTD Benefit.
If you receive any Income From Other Sources in a lump sum, we will
prorate the lump sum over the period of time for which the lump sum
was paid and use that amount to reduce your LTD Benefit. If no
period of time is stated, we will determine the maximum period of
time to which the lump sum is fairly attributable and prorate the
lump sum over that period of time.
Each month we will determine the amount of your LTD Benefit using
the Income From Other Sources for the same monthly period, even if
you actually receive the Income From Other Sources in another month.
2. Your Duty To Pursue Income From Other Sources
You must pursue Income From Other Sources for which you may be
eligible. We may ask for written documentation of your pursuit of
Income From Other Sources. You must provide it within 60 days after
we mail you our request. Otherwise, we may reduce your LTD Benefits
by the amount we estimate you would be eligible to receive upon
proper pursuit of the Income From Other Sources.
3. Income From Other Sources Which Is Pending
If you are actively pursuing a claim for Income From Other Sources,
we will not deduct that Income From Other Sources until it becomes
payable. You must notify us of the amount of the Income From Other
Sources when it is received. You must repay us for any resulting
overpayment of your claim.
4. Overpayment Of Claim
We will notify you of the amount of any overpayment of your claim
under any group disability insurance policy issued by us. You must
immediately repay us the amount of the overpayment. You will not
receive any LTD Benefits until we have been repaid in full. In the
meantime, any LTD Benefits becoming payable, including the Minimum
LTD Benefit, will be applied to reduce the amount of the
overpayment. We may charge you interest at the legal rate for any
overpayment which is not repaid within 30 days after we first mail
you notice of the amount of the overpayment.
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Part 8 OTHER BENEFITS AND PROVISIONS
A. RETURN TO WORK PROVISION
This provision is designed to give you an incentive to work to the
extent of your ability while you are Disabled.
If you work while you are Disabled, the amount of your LTD Benefit will
only be reduced as follows:
1. Income Protection Plus:
During the first 12 months of LTD Benefit payments while you are
working, the Income From Other Sources used to reduce the amount of
your LTD Benefit will include the amount, if any, by which the sum of
your Maximum LTD Benefit plus your earnings from work you perform while
you are Disabled exceeds 100% of your Indexed Predisability Earnings.
2. 50% Return To Work Benefit:
After the first 12 months of LTD Benefit payments while you are
working, the Income From Other Sources used to reduce the amount of
your LTD Benefit will include one-half the amount of your earnings from
work you perform while you are Disabled, but only if your work earnings
exceed 20% of your Indexed Predisability Earnings.
B. SURVIVORS BENEFIT
If you die while LTD Benefits are payable to you, we will pay a lump
sum Survivors Benefit. The following rules will apply:
1. The Survivors Benefit will equal three times the amount of your
Maximum LTD Benefit.
2. Any Survivors Benefit payable will first be applied to reduce the
amount of any outstanding overpayment of your claim for LTD
Benefits.
3. The Survivors Benefit will be paid to your surviving spouse. If you
are not survived by a spouse, the Survivors Benefit will be paid in
equal shares to your surviving children. If you are not survived by
a spouse or any children, the Survivors Benefit will be paid to your
estate.
C. WAIVER OF PREMIUM
Your Long Term Disability Insurance in effect when you become Disabled
will be continued without payment of premiums while LTD Benefits are
payable.
If a period of continuous Disability is extended by a new cause while
LTD Benefits are payable, LTD Benefits will continue while you remain
Disabled (subject to the terms of the Group Policy), but not beyond the
end of the original Maximum Benefit Period.
D. BENEFITS AFTER INSURANCE ENDS OR IS CHANGED
Your right to receive LTD Benefits for a period of continuous
Disability which begins while you are insured under the Group Policy
will not be affected by:
1. The termination of the Group Policy alter the date you become
Disabled.
2. The termination of your Insurance while the Group Policy remains in
force.
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3. The termination of this Insurance for your classification of
employees of the Employer.
4. Any amendment to the Group Policy approved after the date you become
Disabled.
Part 9. WHEN INSURANCE ENDS
Your Insurance will end automatically on the earliest of the following dates:
1. The date you cease to be a Member as defined in Part 1A.
2. The date you become a full time member of the armed forces of any
country.
3. The date the Group Policy terminates or is amended to terminate
coverage for your classification of employees.
4. The date you cease to be Actively At Work for the Employer on your
regular work days for any reason, including temporary layoff or the
elimination of your job. However, your Insurance will be continued
(unless it ends under any of the above items) during the following
periods while you are absent from Active Work:
a. While you are receiving full salary (including sick pay and vacation
pay) from the Employer, but not beyond the date you are laid off,
the date your job is eliminated, the effective date of a severance
agreement, or the date your job is terminated by you or the
Employer.
b. During the Elimination Period and while LTD Benefits are payable.
c. During the first 30 days of a leave of absence approved by the
Employer.
d. For up to 17 weeks during a period of family or medical leave
approved by the Employer in accordance with the Employer's uniform
family and medical leave policy patterned after the federal Family
and Medical Leave Act of 1993 or applicable state law.
Part 10. BECOMING INSURED AGAIN AFTER INSURANCE ENDS
You may become insured again under the Group Policy after your Insurance ends.
The general rule is that you may become insured again on the same basis as a new
Member, as provided in Part 1. However, the following special rules apply to
becoming insured again under the Group Policy after your Insurance ends:
1. If your Insurance ends because you cease to be a Member or because you
cease to be Actively At Work for the Employer on your regular work
days, you will not be required to satisfy the eligibility waiting
period shown in Part 1B again if you qualify as a Member and return to
Active Work for the Employer within 90 days after your Insurance ends.
2. If your Insurance ends because you become a full time member of the
armed forces of the United States, you will not be required to satisfy
the eligibility waiting period shown in Part 1B again if you qualify as
a Member and return to Active Work for the Employer within 90 days
after you leave active military service.
3. If you are immediately eligible for Insurance under rule 1 or 2 and you
apply for Insurance within 31 days after you become eligible, you will
not be required to provide satisfactory Evidence Of Insurability to
become insured again for a Maximum LTD Benefit up to the amount in
effect when your Insurance ended.
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Your Insurance will become effective again on the date determined from Part 1,
and will not be retroactive to the date your Insurance ended. Your Insurance
will be subject to the Preexisting Condition exclusion or limitation in Part 4,
if any, as follows:
1. If you become insured again more than 90 days after your Insurance
ends, the Preexisting Condition provision will apply to any condition
which is a Preexisting Condition on the date you become insured again.
2. If you become insured again within 90 days after your Insurance ends,
the Preexisting Condition provision will apply to any condition which
was a Preexisting Condition at the start of the prior period of
Insurance. For this purpose only, the two periods of Insurance will be
treated as one period of continuous Insurance and the period when you
were not insured will be ignored. (The same principles will apply if
your Insurance ends two or more times and each time you become insured
again within 90 days. The three or more periods of Insurance will be
added together for purposes of the Preexisting Condition exclusion or
limitation).
Note: After LTD Benefits for a period of Disability end, your Insurance will
continue without any interruption if you are a Member and immediately return to
Active Work for the Employer. This Part 10 will not apply since your Insurance
continues while you are receiving LTD Benefits.
Part 11. CLAIMS PROVISIONS AND PROCEDURES FOR LTD BENEFITS
A. PAYMENT OF BENEFITS; TIME OF PAYMENT
LTD Benefits will be paid to you. Any LTD Benefit remaining unpaid at
your death will be paid to the person or persons receiving the
Survivors Benefit or to your estate.
All benefits payable under the Group Policy will be paid within 60 days
after we receive satisfactory written proof of loss in connection with
the claim for benefits. All accrued LTD Benefits payable under the
Group Policy will be paid not less frequently than monthly during the
continuance of the period for which benefits are payable. Any benefits
remaining unpaid at the end of that period will be paid as soon as
possible after the receipt of satisfactory written proof of loss in
connection with the claim for benefits.
B. TIME LIMITS FOR FILING A CLAIM
You must claim LTD Benefits within 120 days after the end of the
Elimination Period or as soon thereafter as reasonably possible and, in
any case, within one year after the end of that 120 day period. Claims
not filed within these time limits will be denied and no LTD Benefit
will be paid. These limits will not apply during any period when you
lacked the legal capacity to file a claim.
C. FILING A CLAIM
All claims for LTD Benefits should be submitted on our forms. You
should obtain claim forms from the Policyholder or the Plan
Administrator.
You may also request claim forms from us. If we fail to provide you
with claim forms within 15 days of your request, you may submit your
claim in a letter stating the occurrence, character, and extent of the
event for which the claim is made.
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D. PROOF OF LOSS
No LTD Benefits will be paid unless you provide us with satisfactory
written proof of loss at your expense. If your claim is approved, no
LTD Benefits will be continued beyond the end of the period for which
you have provided us with satisfactory written proof of loss at your
expense.
You must submit the following documents at your expense:
1. A completed claim statement signed by you.
2. A completed claim statement signed by the Policyholder.
3. A completed claim statement signed by your treating Physician.
4. Your written authorization for us to obtain the records and
information (including tax returns) needed to determine your
eligibility for LTD Benefits.
5. Such other documents as we may reasonably require, including copies
of your tax returns.
We will require you to submit additional documentation of your claim at
your expense at reasonable intervals while you are receiving LTD
Benefits.
E. INVESTIGATION OF YOUR CLAIM
We have the right at any time to conduct an investigation of your
claim.
F. INDEPENDENT EXAMINATION
We have the right to have you examined at our expense at reasonable
intervals while you are claiming LTD Benefits. Any such examinations
will be conducted by one or more Physicians or vocational specialists
of our choice.
We have the right to defer or suspend payment of LTD Benefits if you
fail to attend an examination or fail to cooperate with the person
conducting the examination. In such a case LTD Benefits may be resumed,
provided that the required examination occurs within a reasonable time
and LTD Benefits are otherwise payable.
G. NOTICE OF DECISION ON CLAIM
You will receive a written decision on your claim within a reasonable
period of time after we receive your claim.
If we deny all or any part of your claim, you will receive a written
notice of denial containing:
1. The reasons for the denial.
2. Reference to the provisions of the Group Policy on which the denial
is based.
3. A description of any additional information or documentation you
must submit to obtain benefits and an explanation of why such
information or documentation is required.
4. Notice of your right to a review of the denial.
5. A description of the review procedure.
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If you do not receive a written decision on your claim within 60 days
after your claim is received, you will have an immediate right to
request a review under the review procedure, as if your claim had been
denied.
H. REVIEW PROCEDURE
You have a right to a review of any denial by us of all or any part of
your claim. To obtain a review, you should send a written request for
review to us within 60 days alter you receive notice of the denial. No
special form is required.
As a part of your request for review, you may submit issues and
comments in writing and provide additional documentation in support of
your claim. You may review pertinent documents related to your request
for review.
We will review your claim promptly after receiving your request for
review. You will receive written notice of our decision within 60 days
alter your request for review is received, or within 120 days if
special circumstances require an extension. The written decision you
receive will include the reasons for the decision and reference to the
provisions of the Group Policy on which the decision is based.
You may authorize another person to act for you under this review
procedure.
Part 12. TIME LIMITS ON LEGAL ACTIONS
No action at law or in equity may be brought to recover under the Group Policy
until 60 days after written proof of loss has been provided to us.
Part 13. INCONTESTABLE CLAUSES
A. INCONTESTABLE CLAUSE FOR YOUR INSURANCE
Any statement you make to obtain Insurance is a representation and not
a warranty. No misrepresentation by you will be used to reduce or deny
your claim or to deny the validity of your Insurance unless all of the
following are true:
1. Your Insurance would not have been approved if we had known the
truth.
2. Your misrepresentation is contained in a written instrument signed
by you.
3. You have been given a copy of the written instrument containing
your misrepresentation.
After your Insurance has been in effect for two years, we will not use
a misrepresentation by you to reduce or deny your claim or to deny the
validity of your Insurance, unless it was a fraudulent
misrepresentation made with actual intent to deceive.
B. INCONTESTABLE CLAUSE FOR GROUP POLICY
Any statement made by the Policyholder to obtain the Group Policy is a
representation and not a warranty. No misrepresentation by the
Policyholder will be used to deny a claim or to deny the validity of
the Group Policy unless all of the following are true:
1. The Group Policy would not have been issued by us if we had known
the truth.
2. The misrepresentation is contained in a written instrument signed
by the Policyholder.
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3. A copy of the written instrument has been given to the
Policyholder.
The validity of the Group Policy will not be contested after it has
been in effect for two years, except for non-payment of premiums or a
fraudulent misrepresentation made with actual intent to deceive.
Part 14. ALLOCATION OF AUTHORITY
Except for those functions which the Group Policy specifically reserves to the
Employer, we have the full and exclusive authority to administer claims and to
interpret the Group Policy and resolve all questions arising in the
administration, interpretation, and application of the Group Policy.
Our authority includes, but is not limited to, the following:
1. The right to resolve all matters when a review has been requested.
2. The right to establish and enforce rules and procedures for the
administration of the Group Policy and any claim under it.
3. The right to determine (a) your eligibility for Insurance, (b) your
entitlement to benefits, and (c) the amount of the benefits payable to
you.
Part 15. ASSIGNMENT NOT PERMITTED
Your Certificate is not assignable. The Insurance provided and benefits payable
are not assignable.
Part 16. GENERAL DEFINITIONS
EMPLOYER means Pacific Capital Bancorp and First National Bank of Central
California.
GROUP POLICY means our group policy number 908496-A issued to the Policyholder.
PRIOR PLAN means the Employer's group long term disability insurance program in
effect on December 31, 1994 under Standard Insurance Company policy number
484382.
LONG TERM DISABILITY INSURANCE means your disability insurance under the Group
Policy.
INSURANCE means your Long Term Disability Insurance under the Group Policy.
LTD BENEFIT means the monthly Long Term Disability Insurance benefit payable to
you according to the terms of the Group Policy.
Providing EVIDENCE OF INSURABILITY, if required, means you must do all of the
following:
1. Complete and sign our health and medical history form.
2. Sign our form authorizing us to obtain information about your health
and other insurance coverage
3. Provide any additional information about your insurability reasonably
required by us and undergo a physical examination and testing, if
required by us.
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All required information must be provided to us at your expense.
CONTRIBUTORY Insurance means you pay all or a part of the cost of your
Insurance. If your Insurance is Contributory, the Employer determines the amount
of your contribution toward the cost of your Insurance.
NONCONTRIBUTORY Insurance means the Employer pays the entire cost of your
Insurance.
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SECTION TWO - POLICYHOLDER PROVISIONS
Part 1. PREMIUMS
A. PREMIUM CHARGES
The premium charge on each premium due date will be an aggregate amount
based on the sum of the premiums due for all Members then insured under
the Group Policy. The premium due with respect to each insured Member
is determined by multiplying the Member's applicable Predisability
Earnings by the premium rate then in effect, as noted on the Policy
Data page.
B. CONTRIBUTIONS FROM MEMBERS
Insurance is Noncontributory; the Policyholder pays the entire cost of
Insurance.
C. CHANGES IN PREMIUM RATES
1. Premium rates may be changed at any time upon mutual agreement
between the Policyholder and us.
2. If the number of insured Members changes by 25% or more, we may
change any one or more of the premium rates on any Premium Due
Date, but not more than once in any twelve month period.
3. We may change any one or more of the premium rates at any time when
a change in any law or governmental regulation affects the amount
payable by us under this Group Policy. Any such change in premium
rates will reflect only the change in our obligations under the
Group Policy.
4. Except as provided in 1, 2, and 3, above, we will not change the
premium rates during the Initial Policy Term or more than once in
any Contract Year thereafter. The Initial Policy Term is shown on
the cover of this Group Policy. Contract Years are successive
twelve month periods computed from the end of the Initial Policy
Term.
We will give the Policyholder prior written notice of any change in the
premium rates at least 31 days before the Premium Due Date on which the
change will be effective.
D. PAYMENT OF PREMIUMS
All premiums are due on the Premium Due Dates shown on the cover of the
Group Policy.
Each premium is payable by the Policyholder on or before the Premium
Due Date direct to us at our Home Office. The payment of each premium
as it becomes due will maintain this Group Policy in force through the
date immediately preceding the next Premium Due Date.
E. TERMINATION OF GROUP POLICY BY THE POLICYHOLDER
The Policyholder may terminate the Group Policy at any time by giving
prior written notice to us. The effective date of the termination will
be the later of (1) the date specified in the notice, and (2) the date
we receive the notice. No coverage under the Group Policy will continue
and no premium charges will accrue after the effective date of the
termination of the Group Policy.
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F. TERMINATION OF GROUP POLICY BY US
We may terminate the Group Policy as follows:
1. On any Premium Due Date if the number of persons insured is less
than the Minimum Participation Number or less than the Minimum
Participation Percentage.
2. On any Premium Due Date if we, in our sole judgement, determine that
the Policyholder has:
a. Failed to promptly furnish any necessary information requested
by us; or
b. Failed to perform any other obligations relating to this Group
Policy.
We will give the Policyholder at least 31 days prior written notice of
any such termination of the Group Policy.
G. GRACE PERIOD
The Group Policy has a 31 day Grace Period for each premium due after
the first premium. If a premium is not paid on or before the Premium
Due Date, the premium may be paid during the following 31 day Grace
Period. The Group Policy will remain in force during the Grace Period,
and the Policyholder is liable to us for the payment of the premium for
that period.
H. TERMINATION OF GROUP POLICY FOR NONPAYMENT OF PREMIUMS
If the required premium is not paid during the Grace Period, the Group
Policy will terminate automatically at 12:01 AM. on the date following
the end of the Grace Period.
The Policyholder is liable for the payment of the premiums for the
coverage continued during the Grace Period.
I. PREMIUM ADJUSTMENTS
Premium adjustments involving a return of unearned premiums to the
Policyholder will be limited to the twelve month period immediately
preceding the date we receive a request for premium adjustment and
evidence that an adjustment should be made.
Part 2. CERTIFICATES
We will issue Certificates to the Policyholder showing the insured Member's
coverage under this Group Policy. The Policyholder will distribute a Certificate
to each insured Member.
Part 3. RECORDS AND REPORTS
The Policyholder must furnish on our forms all information reasonably necessary
to the administration of the Group Policy when required by us. We have the right
at all reasonable times to inspect the payrolls and other records of the
Policyholder which relate to Insurance under this Group Policy.
Clerical error by the Policyholder will not:
1. Cause a Member to become insured.
2. Invalidate Insurance otherwise validly in force.
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3. Continue Insurance otherwise validly terminated.
Part 4. MISSTATEMENT OF AGE
If the age of a Member has been misstated, we will make an equitable adjustment
of the premiums or benefits, or both. The adjustment will be based on either or
both of the following factors:
1. The amount of the Member's Insurance based on the Member's correct age.
2. The difference between the premiums paid and the premiums which would
have been paid if the Member's age had been correctly stated.
Part 5. ENTIRE CONTRACT; CHANGES
The Group Policy and the application of the Policyholder, if any, constitute the
entire contract between the parties.
This Group Policy may be changed in whole or in part. No change in this Group
Policy will be valid unless it is approved in writing by one of our executive
officers and delivered to the Policyholder for attachment to the Group Policy.
No agent has authority to change this Group Policy or to waive any of its
provisions.
Part 6. EFFECT ON WORKER'S COMPENSATION
The coverage provided under the Group Policy is not a substitute for worker's
compensation insurance and does not relieve the Employer of any obligation to
provide worker's compensation insurance.
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