HomeMy WebLinkAboutGroup Term/Dependent/Supplemental Certificate of Insurance
GROUP TERM LIFE INSURANCE
City of Iowa City
Iowa City, Iowa
All Active, Full Time and Part Time Non-Union and Union Employees
MADISON NATIONAL LIFE INSURANCE COMPANY, INC.
Mailing: PO Box 5008, Madison, WI 53705 • Phone: 1-800-356-9601
Home Office: 1241 John Q. Hammons Drive, Madison, WI 53717
AMENDMENT #1
GROUP TERM LIFE INSURANCE ISSUED TO
CITY OF IOWA CITY
PLAN NUMBER 4161
Class Number - Description: All Insured Classifications
This Amendment is made a part of the Group Term Life Certificate of Insurance (“Certificate”) to which it is
attached. The provisions of this Amendment are effective on July 1, 2024 and will expire concurrently with the
Contract.
In consideration of issuance, the Certificate is hereby amended and modified, as follows:
1. Under ‘II. ELIGIBILITY FOR INSURANCE’, the item entitled ‘B. Dependent Life Insurance
Eligibility.’, ‘2.’, ‘c) Child means’ is hereby deleted in its entirety and replaced with:
‘c) Child means Your unmarried Child until age 26. Child incudes a stepchild or legal ward, a Child placed
in the home for adoption and/or a legally adopted Child.’
2. Under ‘IV. WHEN COVERAGE ENDS’, the item entitled ‘C. Paid Leave of Absence.’, ‘2.’, ‘c)’ is hereby
deleted in its entirety.
3. Under ‘IV. WHEN COVERAGE ENDS’, the item entitled ‘D. Unpaid Leave of Absence.’, ‘2.’, ‘c)’ is
hereby deleted in its entirety.
4. Under ‘IV. WHEN COVERAGE ENDS’, the item entitled ‘E. Physical Disease or Injury.’, ‘2.’, ‘c)’ is
hereby deleted in its entirety.
5. Under ‘IV. WHEN COVERAGE ENDS’, the item entitled ‘F. Military Leave of Absence.’, ‘2.’, ‘c)’ is
hereby deleted in its entirety.
All other terms, provisions and conditions of the Certificate remain unchanged. Provisions under this Amendment
are subject to all the terms and conditions, limitations and exclusions of the Certificate.
GTL-END-0410-C
MADISON NATIONAL LIFE INSURANCE COMPANY, INC .
Mailing: PO Box 5008, Madison, WI 53705 • Phone: 1-800-356-9601
Home Office: 1241 John Q. Hammons Drive, Madison, WI 53717
GROUP TERM LIFE INSURANCE
CERTIFICATE OF INSURANCE
PLEASE READ THIS CERTIFICATE CAREFULLY
This Certificate of Insurance (hereinafter referred to as “Certificate”) is evidence of insurance provided under the
Group Policy issued to the Group Policyholder (hereinafter referred to as “Policyholder”). This Certificate
describes the essential features of such insurance.
Madison National Life Insurance Company, Inc., in performing its obligations under the Group Policy, is acting
only as a life insurer with respect to the Group Policy and is not in any way acting as a plan administrator, a plan
sponsor or a plan trustee for the purposes of the Employee Retirement Income Security Act of 1974 (ERISA), as
amended, or any other federal or state laws.
No coverage under the Group Policy is in effect until approved in writing by Us and issued and delivered to the
Policyholder. All terms, conditions and other provisions of the Group Policy are governed by the laws of the state
in which the Policyholder is located. All provisions on this and the following pages are part of this Certificate.
The Group Policy is on file and available for review at the main office of the Policyholder.
The President and Secretary of Madison National Life Insurance Company, Inc witness this Certificate:
Marita Zuraitis Donald M. Carley
President Corporate Secretary
WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any
claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty
of a felony.
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TABLE OF CONTENTS
SCHEDULE OF BENEFITS - CLASS 01 ........................................................................................................... 3
SCHEDULE OF BENEFITS - CLASS 02 ........................................................................................................... 6
I. DEFINITIONS........................................................................................................................................ 9
II. ELIGIBILITY FOR INSURANCE ........................................................................................................ 11
III. BECOMING INSURED ....................................................................................................................... 12
IV. WHEN COVERAGE ENDS ................................................................................................................. 13
V. LIFE INSURANCE - WAIVER OF PREMIUM BENEFIT ................................................................... 17
VI. LIFE INSURANCE - LIVING BENEFIT ............................................................................................. 19
VII. LIFE EXCLUSIONS............................................................................................................................. 20
VIII. LIFE INSURANCE CONVERSION BENEFIT .................................................................................... 20
IX. LIFE INSURANCE PORTABILITY BENEFIT .................................................................................... 21
X. ACCIDENTAL DEATH & DISMEMBERMENT INSURANCE .......................................................... 22
XI. CLAIMS PROVISIONS ....................................................................................................................... 23
XII. GENERAL PROVISIONS ................................................................................................................... 25
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SCHEDULE OF BENEFITS – CLASS 01
A. Administrative
1. Employer: City of Iowa City
2. Plan Number: 4161
3. Initial Plan Effective Date: July 1, 2009
4. Benefits Revised Date: July 1, 2024
5. Evidence of Insurability Requirements: Applies to Late Enrollees, Increases in Benefits and
Amounts over Guarantee Issue Amounts, except as
specified under the Annual Open Enrollment Period.
Annual Open Enrollment Period for Employee Supplemental Life Insurance:
Madison National Life will agree to an Annual Open Enrollment Period per the following guidelines:
- Employees who are currently enrolled in Employee Supplemental Life may increase coverage by one
$10,000 increment without Evidence of Insurability. The combined amount (in force plus additional
election) is subject to the Guarantee Issue amount.
- Prior declined/incomplete applicants are not eligible.
6. Eligible Class: 01 All Active, Full Time and Part Time Non-Union
Employees
7. Minimum Hourly Work Requirement: 20 hours per week
8. Waiting Period for Employee Basic and Dependent Basic Insurance Coverage:
None - Executive, Administrative and Confidential
Employees; 90 days - All Other Eligible Employees
Waiting Period for Employee Supplemental and Dependent Supplemental Insurance Coverage:
None
9. New Employee Eligibility Date for Employee Basic and Dependent Basic Insurance:
Upon completion of the Waiting Period
New Employee Eligibility Date for Employee Supplemental and Dependent Supplemental Insurance:
First of the month following or coinciding with
completion of the Waiting Period
10. Leaves / Layoffs: Coverage with premium payment while on FMLA
leave; Coverage with premium payment for up to 12
months while on Paid or Unpaid Leave; Coverage with
premium payment for up to 24 months while not
Actively at Work due to Physical Disease or Injury;
Coverage with premium payment for up to 12 months
while on Military Leave
11. Employee Premium Contribution
Employee Basic Insurance: 0%
Employee Supplemental Insurance: 100%
Dependent Basic Insurance: 100%
Dependent Supplemental Insurance: 100%
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12. Participation Requirements
Employee Basic Insurance: 100%
Employee Supplemental Insurance: None
Dependent Basic Insurance: None
Dependent Supplemental Insurance: None
13. Insurance Reduction Schedule
Employee Basic Insurance: No reductions. Basic Life and AD&D Insurance
terminate at retirement.
Employee Supplemental Insurance: Supplemental Life Insurance reduces to 65% at age 70,
reduces to 45% at age 75, reduces to 30% at age 80,
reduces to 20% at age 85, reduces to 15% at age 90,
reduces to 10% at age 95 and terminates at retirement.
Dependent Basic Insurance: Basic Life Insurance for the Dependent Spouse
terminates upon the Insured Employee’s retirement.
Basic Life Insurance for Dependent Children terminates
at the earlier of the Insured Employee’s retirement or
the child’s attainment of the Limiting Age.
Dependent Supplemental Insurance: Spouse Supplemental Life Insurance reduces to 65% at
the Spouse’s attainment of age 70, reduces to 45% at
the Spouse’s attainment of age 75, reduces to 30% at
the Spouse’s attainment of age 80, reduces to 20% at
the Spouse’s attainment of age 85, reduces to 15% at
the Spouse’s attainment of age 90, reduces to 10% at
the Spouse’s attainment of age 95 and terminates upon
the Insured Employee’s retirement. Child Supplemental
Life Insurance terminates at the earlier of attainment of
the Limiting Age or when the Insured Employee’s
coverage terminates.
B. Basic Life Insurance
Employee Basic Life: 1 times Annual Salary rounded to the next higher
$1,000
Guarantee Issue: $300,000
Maximum Issue: $300,000
Dependent Spouse Basic Life: $5,000
Guarantee Issue: $5,000
Dependent Child Basic Life:
Age: 15 days to 6 months: $5,000
Guarantee Issue: $5,000
Age: 6 months through Limiting Age: $5,000
Guarantee Issue: $5,000
C. Supplemental Life Insurance
Employee Supplemental Life: $10,000 increments
Guarantee Issue: $250,000 if age 59 or younger; $150,000 if age 60-69;
$0 if age 70 or older
Maximum Issue: $300,000, not to exceed 6 times Annual Salary
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Spouse Supplemental Life: $10,000 increments
Guarantee Issue: $30,000
Maximum Issue: The lesser of $300,000 or 100% of the Insured
Employee’s elected and approved Supplemental Life
amount.
Child Supplemental Life
Age: Birth through 13 days: Choice of $2,000, $5,000 or $10,000*
Guarantee Issue: $10,000
Age: 14 days to 6 months: Choice of $2,000, $5,000 or $10,000*
Guarantee Issue: $10,000
Age: 6 months through Limiting Age: Choice of $2,000, $5,000 or $10,000*
Guarantee Issue: $10,000
*An Employee may only elect one amount that will cover all children. An Employee may not choose a
different amount of coverage for each child.
D. Additional Benefits
1. Conversion of Insurance Benefit: Included
2. Waiver of Premium Benefit: Included
3. Living Benefit: Included
4. Portability Benefit: Included
E. Accidental Death and Dismemberment (AD&D) Insurance
1. Basic AD&D Insurance
Employee Basic AD&D Insurance: 1 times Annual Salary rounded to the next higher
$1,000
Guarantee Issue: $300,000
Maximum Issue: $300,000
GTL-C700-0608 Rev. 11-11-2024
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SCHEDULE OF BENEFITS – CLASS 02
A. Administrative
1. Employer: City of Iowa City
2. Plan Number: 4161
3. Initial Plan Effective Date: July 1, 2009
4. Benefits Revised Date: July 1, 2024
5. Evidence of Insurability Requirements: Applies to Late Enrollees, Increases in Benefits and
Amounts over Guarantee Issue Amounts, except as
specified under the Annual Open Enrollment Period.
Annual Open Enrollment Period for Employee Supplemental Life Insurance:
Madison National Life will agree to an Annual Open Enrollment Period per the following guidelines:
- Employees who are currently enrolled in Employee Supplemental Life may increase coverage by one
$10,000 increment without Evidence of Insurability. The combined amount (in force plus additional
election) is subject to the Guarantee Issue amount.
- Prior declined/incomplete applicants are not eligible.
6. Eligible Class: 02 All Active, Full Time and Part Time Union
Employees
7. Minimum Hourly Work Requirement: 20 hours per week
8. Waiting Period for Employee Basic and Dependent Basic Insurance Coverage:
None - Police Officers; 90 days - All Other Eligible
Employees
Waiting Period for Employee Supplemental and Dependent Supplemental Insurance Coverage:
None
9. New Employee Eligibility Date for Employee Basic and Dependent Basic Insurance:
Upon completion of the Waiting Period
New Employee Eligibility Date for Employee Supplemental and Dependent Supplemental Insurance:
First of the month following or coinciding with
completion of the Waiting Period
10. Leaves / Layoffs: Coverage with premium payment while on FMLA
leave; Coverage with premium payment for up to 12
months while on Paid or Unpaid Leave, Coverage with
premium payment for up to 24 months while not
Actively at Work due to Physical Disease or Injury,
Coverage with premium payment for up to 12 months
while on Military Leave
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11. Employee Premium Contribution
Employee Basic Insurance: 0%
Employee Supplemental Insurance: 100%
Dependent Basic Insurance: 100%
Dependent Supplemental Insurance: 100%
12. Participation Requirements
Employee Basic Insurance: 100%
Employee Supplemental Insurance: None
Dependent Basic Insurance: None
Dependent Supplemental Insurance: None
13. Insurance Reduction Schedule
Employee Basic Insurance: No reductions. Basic Life Insurance terminates at
retirement.
Employee Supplemental Insurance: Supplemental Life Insurance reduces to 65% at age 70,
reduces to 45% at age 75, reduces to 30% at age 80,
reduces to 20% at age 85, reduces to 15% at age 90,
reduces to 10% at age 95 and terminates at retirement.
Dependent Basic Insurance: Basic Life Insurance for the Dependent Spouse
terminates upon the Insured Employee’s retirement.
Basic Life Insurance for Dependent Children terminates
at the earlier of the Insured Employee’s retirement or
the child’s attainment of the Limiting Age.
Dependent Supplemental Insurance: Spouse Supplemental Life Insurance reduces to 65% at
the Spouse’s attainment of age 70, reduces to 45% at
the Spouse’s attainment of age 75, reduces to 30% at
the Spouse’s attainment of age 80, reduces to 20% at
the Spouse’s attainment of age 85, reduces to 15% at
the Spouse’s attainment of age 90, reduces to 10% at
the Spouse’s attainment of age 95 and terminates upon
the Insured Employee’s retirement. Child Supplemental
Life Insurance terminates at the earlier of attainment of
the Limiting Age or when the Insured Employee’s
coverage terminates.
B. Basic Life Insurance
Employee Basic Life: 1 times Annual Salary rounded to the next higher
$1,000
Guarantee Issue: $300,000
Maximum Issue: $300,000
Dependent Spouse Basic Life: $5,000
Guarantee Issue: $5,000
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Dependent Child Basic Life:
Age: 15 days to 6 months: $5,000
Guarantee Issue: $5,000
Age: 6 months through Limiting Age: $5,000
Guarantee Issue: $5,000
C. Supplemental Life Insurance
Employee Supplemental Life: $10,000 increments
Guarantee Issue: $250,000 if age 59 or younger; $150,000 if age 60-69;
$0 if age 70 or older
Maximum Issue: $300,000, not to exceed 6 times Annual Salary
Spouse Supplemental Life: $10,000 increments
Guarantee Issue: $30,000
Maximum Issue: The lesser of $300,000 or 100% of the Insured
Employee’s elected and approved Supplemental Life
amount.
Child Supplemental Life
Age: Birth through 13 days: Choice of $2,000, $5,000 or $10,000
Guarantee Issue: $10,000
Age: 14 days to 6 months: Choice of $2,000, $5,000 or $10,000
Guarantee Issue: $10,000
Age: 6 months through Limiting Age: Choice of $2,000, $5,000 or $10,000
Guarantee Issue: $10,000
*An Employee may only elect one amount that will cover all children. An Employee may not choose a
different amount of coverage for each child.
D. Additional Benefits
1. Conversion of Insurance Benefit: Included
2. Waiver of Premium Benefit: Included
3. Living Benefit: Included
4. Portability Benefit: Included
GTL-C700-0608 Rev. 11-11-2024
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I. DEFINITIONS
Active Work and Actively at Work are defined in the “Eligibility for Insurance” section.
Annual Salary: Your current salary or wage from your Employer for the previous twelve months. Annual Salary
does not include extra pay, annuity contributions, commissions, bonuses, overtime pay or any other extra
compensation.
Contributory means that You pay all or a portion of the premium for insurance.
Disabled or Disability means that as a result of Physical Disease or Injury, you are unable to perform with
reasonable continuity a majority of the material duties of any occupation for which you are qualified by education,
training and experience, and you are under the Regular Care and Attendance of a Physician.
Eligible Class means an employment classification defined by the Employer and specified in the “Schedule of
Benefits.” You must be a member of an Eligible Class in order to be eligible for insurance under the Group Policy.
Eligible Dependent is defined in the “Eligibility for Insurance” section.
Eligible Employee is defined in the “Eligibility for Insurance” section.
Employee is defined in the “Eligibility for Insurance” section.
Employer means an Employer (including approved affiliates and subsidiaries) participating in the Policyholder
Trust to whom We have assigned a Plan Number and issued a Joinder Agreement.
Evidence of Insurability
1. Providing Evidence of Insurability means that a person applying for coverage under the Group Policy must:
a) complete and sign Our Evidence of Insurability application and return the original application to Us.
The application must be received by Us no later than 60 days from the date of signing; and
b) authorize Us to obtain information about the applicant’s health; and
c) undergo a physical examination, if required by Us, which may include diagnostic testing; and
d) provide any additional information about the applicant’s insurability that We may reasonably require.
2. If any applicant is required to provide Evidence of Insurability, the applicant will be responsible for all
costs associated with providing Evidence of Insurability.
3. In each case where Evidence of Insurability is required, We base Our decision whether to approve coverage
on the information provided during the underwriting process. If We learn that the information relied on to
approve coverage was incorrect, or that relevant information was omitted, We may retroactively rescind
coverage and deny claims.
Group Policy (Policy) means the group insurance Policy issued by Us to the Policyholder under a specified Plan
Number.
Guarantee Issue is the amount of coverage provided which is not subject to Evidence of Insurability.
Hospital means a legally operated Facility providing full-time medical care and treatment under the direction of a
full-time staff of licensed Physicians, but not including rest homes, nursing homes, convalescent homes, homes for
the aged and facilities primarily affording custodial, educational, or rehabilitative care.
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Injury: Bodily Injury due to an Accident which: (1) results directly and independently of disease, bodily infirmity
or any other causes; (2) solely, directly and independently of all other causes results in medical expense; (3) occurs
after the effective date of the Insured Person's coverage; and (4) occurs while the Insured Person's coverage is in
force. All Injuries sustained in any one Accident, including all related conditions and recurrent symptoms of these
Injuries, are considered a single Injury.
Insured Person means an Eligible Employee, Eligible Dependent or Eligible Retiree whose coverage is in effect
under the Group Policy.
Joinder Agreement means the document entered into between the Policyholder and the Employer describing the
coverage requested by the Employer with respect to its Employees, which has been approved by Us and assigned a
Plan Number.
Late Enrollee means an Employee or Dependent who applies for coverage under the Group Policy more than 31
days after becoming an Eligible Employee or Eligible Dependent.
Limiting Age means the Child age(s) shown in the definition of Child in the Eligibility for Insurance section.
Mental Disorder means any mental, emotional, behavioral, psychological, personality, cognitive, mood or stress
related abnormality, disorder, disturbance, dysfunction or syndrome listed in the latest edition of the American
Psychiatric Association Diagnostic and Statistical Manual or the International Classification of Disease.
Noncontributory means the Employer pays the entire premium for insurance.
Physical Disease means a Physical Disease entity or process that produces structural or functional changes in the
body as diagnosed by a Physician. Physical Disease includes pregnancy and Mental Disorder.
Physician means a licensed medical professional under the laws of a state of the United States of America, acting
within the scope of such license, who is permitted by law to prescribe medications and practice independent of
supervision.
For the purpose of this Group Policy, Physician will not include the Insured Person’s Spouse, parent, brother, sister,
or Child, including these members of a Spouse’s family.
Plan Effective Date means the date on which the Group Policy, with respect to the Employer, becomes effective.
Plan Number means the number used by Us to reference an Employer and the terms of coverage specified under
the Group Policy and Joinder Agreement.
Prior Plan means the Employer’s group life insurance plan in effect on the day immediately preceding the Plan
Effective Date.
Proof of Loss is defined in the “Claims Provisions” section.
Regular Care and Attendance means observation and treatment by a Physician as required by current standards
of medicine for the Injury or Physical Disease causing a Disability, but in any event not less than one such
observation per year.
Retire and Retirement Date means the earlier of:
1. the date You Retire as such term is defined by Your Employer;
2. the date You receive or become eligible to receive, as defined by the Employer, retirement benefits under
any pension plan to which the Employer contributes,
3. or the date You receive or become eligible to receive retirement benefits under, and as defined by, any state
or federal retirement plan or under the Social Security Act or Railroad Retirement Act.
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4. the date You reach the age defined in the “Schedule of Benefits”.
You and Your means the Eligible Employee.
Waiting Period for Insurance Coverage is defined in the “Eligibility for Insurance” and “Schedule of Benefits”.
We, Us and Our means Madison National Life Insurance Company, Inc.
GTL-C600-0608 Rev. 11-11-2024
II. ELIGIBILITY FOR INSURANCE
A. Employee Life Insurance Eligibility.
1. Employee Basic Life Insurance. To be eligible for Employee Basic Life Insurance under the Group Policy,
You must satisfy the following requirements:
a) You must be an Eligible Employee.
(1) Employee means an individual who works for the Employer as a member of an Eligible Class and
who is reported on the Employer’s records for Social Security and tax withholding purposes.
b) You must be a citizen or legal resident of the United States of America or one of its territories.
c) You must be Actively at Work and capable of sustained Active Work.
(1) Active Work and Actively at Work mean working at Your Employer’s usual place of business,
and satisfying the Minimum Hourly Work Requirement. Actively at Work will include regularly
scheduled days off, holidays, or vacation days, so long as You are capable of sustained Active Work
on those days.
(2) Minimum Hourly Work Requirement means the work hours over a specified time period that are
required of You by Your Employer in order to be eligible for coverage. Your Minimum Hourly
Work Requirement is specified in the “Schedule of Benefits”.
(3) The Active Work requirement is waived during the time You are approved for benefits under the
“Waiver of Premium Benefit” section.
d) You must have satisfied Your Waiting Period for Insurance Coverage.
(1) Waiting Period means the period of time that You must be Actively at Work as an Employee for
Your coverage to become effective. Your Waiting Period is specified in the “Schedule of Benefits”.
e) You cannot be a member of more than one Eligible Class.
f) You cannot be a temporary or seasonal Eligible Employee, leased Eligible Employee, or independent
contractor.
2. Employee Supplemental Life Insurance. To be eligible for Employee Supplemental Life Insurance under the
Group Policy, an applicant must be an Eligible Employee and satisfy the additional eligibility requirements,
if any, as listed herein.
B. Dependent Life Insurance Eligibility.
1. The Employee applying for Dependent Life Insurance must be an Eligible Employee insured under the Group
Policy and a member of a class that provides for Dependent Life coverage under the Group Policy.
2. To become eligible for Dependent Life Insurance under the Group Policy, an Eligible Dependent applicant
must meet one of the following definitions:
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a) Dependent means Your Spouse or Child who is not in a Period of Limited Activity. Dependent does
not include a person who is a full-time member of the armed forces of any country. No person may be
considered a Dependent of more than one Eligible Employee. No person can be covered under the
Policy as an Employee and as a Dependent.
(1) Period of Limited Activity means any period of time during which a person is confined in a
Hospital or nursing facility or if not confined, unable to carry on the regular and usual activities of a
healthy person of the same age and sex.
b) Spouse means a person to whom You are legally married and from whom You are not legally
separated.
c) Child means Your unmarried Child until age 21 or age 25 if a full-time student. Full-time student
means a registered student in full-time attendance at an accredited educational institution, including
vocational training. Child includes a stepchild or legal ward, a Child placed in the home for adoption
and/or a legally adopted Child.
d) Disabled Child means Your unmarried adult Child who is, on and after the date on which insurance
would end because of the Child’s age, continuously incapable of self-sustaining employment because of
mental or physical handicap; and chiefly dependent upon You for support and maintenance, or
institutionalized because of mental or physical handicap. You must provide proof of Your Disabled
Child’s status within 31 days after the date on which insurance would otherwise end because of the
Child’s age. Thereafter, We may require further proof of Your Disabled Child’s status, but not more
often than annually. Costs associated with such proof will be Your responsibility.
3. Dependent Supplemental Life: To be eligible for Dependent Supplemental Life Insurance under the Group
Policy, an applicant must be an Eligible Dependent and satisfy the additional eligibility requirements, if any,
listed in the “Schedule of Benefits”.
GTL-C800-0608 Rev. 11-11-2024
III. BECOMING INSURED
A. To become an Insured Person under the Group Policy, an applicant must meet the following requirements as each
may apply:
1. If Evidence of Insurability is required, the applicant must provide such Evidence of Insurability and be
approved for coverage by Us. The “Schedule of Benefits” specifies when Evidence of Insurability is
required.
2. If the insurance is Contributory insurance, the applicant must apply in writing and remit the required
premiums.
B. Effective Dates
1. Employee’s Initial Enrollment
a. Noncontributory insurance not subject to Evidence of Insurability or which is subject to Evidence of
Insurability and has been approved by Us, becomes effective on the date You become an Eligible
Employee, or as specified by your Employer. However, if You initially waive participation in such
coverage and then later wish to participate, applications for Noncontributory insurance will be subject
to Evidence of Insurability and will become effective as shown below.
b. Contributory insurance subject to Evidence of Insurability, and Late Enrollee applications for coverage,
become effective on the first day of the month immediately following the month in which the Evidence
of Insurability is approved by Us, except that if such approval occurs on the first day of a month, such
coverage becomes effective on that day.
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c. Contributory insurance not subject to Evidence of Insurability, if You apply prior to, or within 31
calendar days commencing on, the date You become an Eligible Employee, Contributory insurance not
subject to Evidence of Insurability becomes effective on the date You become an Eligible Employee. If
You do not apply for Contributory insurance prior to, or within 31 days of becoming an Eligible
Employee and subsequently wish to obtain such coverage, Evidence of Insurability will be required and
Your coverage will become effective as provided in subsection b above.
2. Increases in Insurance
a. Evidence of Insurability Required. An increase of insurance that is subject to Evidence of Insurability
becomes effective on the first day of the month immediately following the month in which the Evidence
of Insurability is approved by Us, except that if such approval occurs on the first day of a month, such
coverage becomes effective on that day.
b. Evidence of Insurability Not Required. An increase of insurance that is not subject to Evidence of
Insurability becomes effective as follows:
1) Based on change in Your classification, age or earnings on the date of such change;
2) Addition of a Dependent: on the date the Dependent becomes an Eligible Dependent, if You
apply within 31 days of such date. Applicant will be treated as a Late Enrollee if application is
not made timely. However, while Your Dependent Life Insurance is in effect, each new
Dependent becomes insured immediately.
3. Decreases in Insurance
a. A decrease in life insurance based on a change in Your classification, earnings, age or Your Dependent’s
age, becomes effective on the date of the change.
b. Any other decrease in insurance becomes effective on the first day of the calendar month following the
date Your Employer receives Your written request for the decrease, except that if such event occurs on
the first day of a month, the decrease in coverage becomes effective on that day.
4. Delayed Effective Date. If You are incapable of sustained Active Work due to Injury or Physical Disease on
the day before the scheduled effective date of Your insurance or the effective date of a change in Your
insurance, such insurance will not become effective until the day after You are capable of sustained Active
Work and complete one day of Active Work as an Eligible Employee.
5. If Your coverage ends, You may become covered again, subject to the following:
a. If Your coverage ends because You fail to make the required contribution while on an approved Family
Medical Leave of absence, and then You return to Active Work and enroll for coverage within 31 days
of the earlier of a) the end of the period of leave You and Your Employer agreed upon, or b) the end of
the 12-week period following the date Your leave began, then the Waiting Period will be waived.
Coverage is limited to what You had in effect prior to coverage ending or the coverage that is now
available for Your Class, as determined by Us.
b. In all other cases, if Your coverage ends because You fail to make the required contribution, You must
provide Evidence of Insurability to become covered again.
c. In no event will insurance coverage be retroactive.
d. If You cease to be an Eligible Employee and coverage ends, and then You return to Active Work with
the Employer again within 3 months, the Waiting Period will be waived on the first day of Your return
to Active Work.
GTL-C800-0608
IV. WHEN COVERAGE ENDS
A. Except as otherwise provided for under this Certificate, coverage will cease on the earliest of the following to
occur:
1. the date the Group Policy terminates or the date Your Employer’s coverage under the Group Policy
terminates;
2. the date You cease to be an Eligible Employee;
3. if premium is not paid when required, the last day of the period for which premium was paid;
4. the date You become eligible for coverage as an employee under another group term life insurance policy;
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5. Your Retirement Date, unless You become insured for Retiree Life Insurance under the Group Policy.
6. for Dependent coverage, the date a Dependent is no longer eligible for Dependent coverage.
7. for AD&D coverage, the earlier of the date Your corresponding life insurance ends or Your Retirement
Date.
B. Approved FMLA Leave of Absence – Contributory or Noncontributory Coverage
1. With regard to the Federal Family and Medical Leave Act (FMLA) of 1993, as amended, the Employer
and Employee must be eligible for FMLA in order to receive it. If You are on an approved FMLA leave,
coverage will continue until the later of the leave period required by FMLA or the leave period required
by applicable state law, provided that :
a) The FMLA leave is approved in advance by the Employer and such approval includes documentation
of the beginning and ending dates of the FMLA leave; and
b) The documentation of the advance approval of the FMLA leave beginning and end dates is available
to Us at Our request; and
c) FMLA leaves of absence and the right to continue coverage during FMLA leaves are available to all
Employees in the same Eligible Class under the Group Policy; and
d) the Employer remits the required premium for coverage.
C. Paid Leave of Absence. If You are on a paid leave of absence, coverage will continue subject to the following:
1. Noncontributory coverage
a) Coverage will continue provided that:
(1) The paid leave of absence is approved in advance by the Employer and such approval includes
documentation of the beginning and ending dates of the paid leave of absence; and
(2) The documentation of the advance approval of the paid leave of absence beginning and end
dates is available to Us at Our request; and
(3) paid leaves of absence and the right to continue coverage during paid leaves are available to all
Employees in the same Eligible Class under the Group Policy; and
(4) the Employer remits the required premium for coverage.
b) Unless You return to active, eligible status on or before the date the paid leave of absence is scheduled
to end, coverage extended during a paid leave of absence will terminate on the earlier of:
(1) the date the paid leave of absence is scheduled to end; or
(2) 12 months from the date the paid leave of absence began.
2. Contributory Coverage
a) Coverage will continue provided that:
(1) The paid leave of absence is approved in advance by the Employer and such approval includes
documentation of the beginning and ending dates of the paid leave of absence; and
(2) The documentation of the advance approval of the paid leave of absence beginning and end
dates is available to Us at Our request; and
(3) paid leaves of absence and the right to continue coverage during paid leaves of absence are
available to all Employees in the same Eligible Class under the Group Policy; and
(4) You continue to pay the required premium to the Employer without interruption and the
Employer continues to remit premium to Us on Your behalf.
b) Unless You return to active, eligible status on or before the date the paid leave of absence is scheduled
to end, coverage extended during a paid leave of absence will terminate on the earlier of:
(1) the date the paid leave of absence is scheduled to end;
(2) 12 months from the date the paid leave of absence began.
(3) the date You fail to pay the premium as required.
c) If You choose not to continue coverage or Your coverage terminates during a paid leave of absence
and You subsequently wish to obtain coverage, You will be treated as a Late Enrollee and be required
to provide Evidence of Insurability.
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D. Unpaid Leave of Absence - If You are on an unpaid leave of absence, coverage will continue subject to the
following:
1. Noncontributory Coverage
a) Coverage will continue provided that:
(1) The unpaid leave of absence is approved in advance by the Employer and such approval
includes documentation of the beginning and ending dates of the unpaid leave of absence; and
(2) The documentation of the advance approval of the unpaid leave of absence beginning and end
dates is available to Us at Our request; and
(3) unpaid leaves of absence and the right to continue coverage during unpaid leaves of absence
are available to all Employees in the same Eligible Class under the Group Policy; and
(4) the Employer remits the required premium for coverage.
b) Unless You return to active, eligible status on or before the date the unpaid leave of absence is
scheduled to end, coverage extended during an unpaid leave of absence will terminate on the earlier
of:
(1) the date the unpaid leave of absence is scheduled to end; or
(2) 12 months from the date the unpaid leave of absence began.
2. Contributory Coverage
a) Coverage will continue provided that:
(1) The unpaid leave of absence is approved in advance by the Employer and such approval
includes documentation of the beginning and ending dates of the unpaid leave of absence; and
(2) The documentation of the advance approval of the unpaid leave of absence beginning and end
dates is available to Us at Our request; and
(3) unpaid leaves of absence and the right to continue coverage during unpaid leave of absence are
available to all Employees in the same Eligible Class under the Group Policy; and
(4) You continue to pay the required premium to the Employer without interruption and the
Employer continues to remit premium to Us on Your behalf.
b) Unless You return to active, eligible status on or before the date the unpaid leave of absence is
scheduled to end, coverage extended during an unpaid leave of absence will terminate on the earlier
of:
(1) the date the unpaid leave of absence is scheduled to end;
(2) 12 months from the date the unpaid leave of absence began.
(3) the date You fail to pay the premium as required.
c) If You choose not to continue coverage or Your coverage terminates during an unpaid leave of absence
and You subsequently wish to obtain coverage, You will be treated as a Late Enrollee and be required
to provide Evidence of Insurability.
E. Physical Disease or Injury. If You are not Actively at Work because of Physical Disease or Injury, coverage
will continue subject to the following:
1. Noncontributory coverage
a) Coverage will continue provided that:
(1) We receive written notice of Your absence from Active Work; and
(2) the right to continue coverage while not Actively at Work because of Physical Disease or Injury
is available to all Employees in the same Eligible Class under the Group Policy; and
(3) the Employer remits the required premium for coverage.
b) Unless You return to Active Work, coverage extended while not Actively at Work because of Physical
Disease or Injury will terminate on the earlier of:
(1) 24 months from the date the Physical Disease or Injury began; or
(2) upon termination of employment with the Employer.
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2. Contributory Coverage
a) Coverage will continue provided that:
(1) We receive written notice of Your absence from Active Work; and
(2) the right to continue coverage while not Actively at Work because of Physical Disease or Injury
is available to all Employees in the same Eligible Class under the Group Policy; and
(3) You continue to pay the required premium to the Employer without interruption and the
Employer continues to remit premium to Us on Your behalf.
b) Unless You return to Active Work, coverage extended while not Actively at Work because of Physical
Disease or Injury will terminate on the earlier of:
(1) 24 months from the date the Physical Disease or Injury began; or
(2) upon termination of employment with the Employer; or
(3) the date You fail to pay the premium as required.
c) If You choose not to continue coverage or Your coverage terminates while You are not Actively at
Work because of Physical Disease or Injury and You subsequently wish to obtain coverage, You will
be treated as a Late Enrollee and be required to provide Evidence of Insurability.
F. Military Leave of Absence. If You are on a military leave of absence not due to Declared or Undeclared Acts
of War, coverage will continue subject to the following:
1. Noncontributory coverage
a) Coverage will continue provided that:
(1) The military leave is approved in advance by the Employer and such approval includes
documentation of the beginning and ending dates of the military leave; and
(2) The documentation of the advance approval of the military leave beginning and end dates is
available to Us at Our request; and
(3) military leaves and the right to continue coverage during such leaves are available to all
Employees in the same Eligible Class under the Group Policy; and
(4) the Employer remits the required premium for coverage.
b) Unless You return to active, eligible status on or before the date the military leave of absence is
scheduled to end, coverage extended during a military leave will terminate on the earlier of:
(1) the date the military leave of absence is scheduled to end; or
(2) 12 months from the date the military leave of absence began; or
(3) upon termination of employment with the Employer.
2. Contributory Coverage
a) Coverage will continue provided that:
(1) The military leave of absence is approved in advance by the Employer and such approval
includes documentation of the beginning and ending dates of the military leave of absence; and
(2) The documentation of the advance approval of the military leave of absence beginning and end
dates is available to Us at Our request; and
(3) military leaves of absence and the right to continue coverage during such leaves are available to
all Employees in the same Eligible Class under the Group Policy; and
(4) You continue to pay the required premium to the Employer without interruption and the
employer continues to remit premium to Us on Your behalf.
b) Unless You return to active, eligible status on or before the date the military leave of absence is
scheduled to end, coverage extended during such leave will terminate on the earlier of:
(1) the date the military leave of absence is scheduled to end; or
(2) 12 months from the date the military leave of absence began; or
(3) upon termination of employment with the Employer; or
(4) the date You fail to pay the premium as required.
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c) If You choose not to continue coverage or Your coverage terminates during a military leave of
absence and You subsequently wish to obtain coverage, You will be treated as a Late Enrollee and
be required to provide Evidence of Insurability.
G. Termination or Amendment of the Group Policy and Employer Coverage
1. The Group Policy may be terminated, changed or amended in whole or in part by Us or the Policyholder
according to the terms of the Group Policy. Any such change or amendment may apply to current or future
Employers and eligible persons covered under the Group Policy or to any separate classes or categories
thereof. An Employer’s coverage under the Group Policy may be terminated, changed or amended in
whole or in part by Us or the Employer according to the terms of the Group Policy.
2. We may change the Group Policy and any Employer’s coverage under the Group Policy in whole or in
part: (i) when any change or clarification in law or governmental regulation affects Our obligations under
the Group Policy, or (ii) with the Policyholder’s or Employer’s consent.
3. We may terminate an Employer’s coverage on any premium due date by giving the Employer not less than
60 days advance notice. An Employer may terminate coverage under the Group Policy in whole, and may
terminate insurance for any class or group of eligible persons, at any time by giving Us advanced written
notice at least 60 days prior to such termination. Insurance will terminate automatically for nonpayment
of premium.
4. Benefits are limited to the terms of Your Employer’s coverage under the Group Policy, including any valid
amendments. No change or amendment of Your Employer’s coverage under the Group Policy will be
valid unless it is approved in writing by one of Our executive officers and delivered to Your Employer.
The Policyholder, Your Employer and their Eligible Employees or representatives have no right or
authority to change or amend the Group Policy or Your Employer’s coverage under the Group Policy or
to waive any terms or provisions thereof without Our signed, written approval.
GTL-C800-0608 Rev. 11-11-2024
V. LIFE INSURANCE - WAIVER OF PREMIUM BENEFIT
A. Waiver of Premium Definitions
1. Elimination Period means the period of 6 months beginning on the date You become Disabled.
2. Life Insurance under this Waiver of Premium Benefit means all of the Life Insurance, as listed in the
Schedule of Benefits, in force under the Group Policy on the day before the day You become Disabled.
3. Proof of Disability means documented clinical findings that prove that You are Disabled.
B. Waiver of Premium does not apply to AD&D Insurance or Dependent Life.
C. Your Life Insurance will be continued as provided for under this section without payment of premium, if all
of the following conditions are met:
1. You become Disabled prior to age 60 while insured under the Group Policy;
2. You remain Disabled without interruption for the duration of the Elimination Period;
3. You provide Us with written notice of Your Disability within the later of 30 days after the end of Your
Elimination Period or an approved leave of absence not to exceed 12 months
4. You provide Us with satisfactory written Proof of Disability within 6 months from the last day of the
Elimination Period;
5. Your claim is approved by Us.
D. When the Waiver of Premium Benefit Begins. If You qualify and are approved for the Waiver of Premium
Benefit, Your premium will be waived beginning on the first day of the month immediately following the end
of Your Elimination Period.
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E. When Waiver of Premium Ends. Waiver of Premium ends on the earliest to occur of the following:
1. The date You cease to be Disabled;
2. The 91st day following the date We mail to You a request for additional Proof of Disability with which
You fail to comply;
3. The date You refuse to submit to a medical examination or to cooperate with Our chosen health care
provider;
4. The date You refuse to submit to or undergo vocational rehabilitation (which determines employment
opportunities, if any, for individuals with disabilities);
5. The date at which You’ve resided outside of the United States of America, or one of its territories during
any 6 consecutive months for which premium had been waived;
6. The effective date of an individual life insurance policy issued to You under the "Life Insurance
Conversion Benefit" section;
7. The premium due date immediately prior to Your 65th birthday;
8. The date You Retire, unless such Retirement is due to a Disability.
F. Premiums
1. Premium payment must continue until the later of the end of Your Elimination Period or the date Your
claim for the Waiver of Premium Benefit is approved by Us.
2. If Your Waiver of Premium benefit terminates because You cease to be Disabled or You fail to submit to a
medical exam or cooperate with the examiner, for coverage to continue, You must be an Eligible
Employee and premiums must resume on the next premium due date, or You must continue coverage as
provided for under the "Life Insurance Conversion Benefit" section.
3. If We approve Your claim for the Waiver of Premium Benefit, We will refund up to 12 months of the
premiums that were paid for Life Insurance in place after the date You became Disabled.
G. Amount of Insurance
1. The amount of Life Insurance continued under the Waiver of Premium Benefit is the amount in effect on
the day before You became Disabled, if you were Actively at Work.
2. Insurance will be reduced or terminated according to the Group Policy provisions in effect on the day
before You became Disabled.
3. Your Life Insurance amount will not increase while Your Life Insurance premiums are being waived.
H. We will not waive premiums if Your Disability results from intentionally self-inflicted Injuries or Physical
Diseases, while sane or insane, or from Your voluntary participation in an illegal activity.
I. If You die during the Elimination Period and are otherwise eligible for the Waiver of Premium Benefit, the
Elimination Period will not apply.
J. We may require further Proof of Disability in intervals that are reasonable based on Your type of Disability.
K. Investigation Of Claim
With respect to benefits that are claimed during an Insured Person's lifetime, We may require him or her to
undergo examination at reasonable intervals, at Our expense. Any such examinations will be conducted by
appropriate Physician of Our choice. We may deny or suspend benefits if You fail to attend an examination,
or do not give full effort and cooperation to the examiner.
GTL-C900-0608
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VI. LIFE INSURANCE - LIVING BENEFIT
Terminally Ill and Terminal Illness mean a medical condition that is expected to result in Your death within
12 - 24 months.
A. If You become Terminally Ill while covered for life insurance under the Group Policy You may elect to receive
the Living Benefit as provided for under this section.
B. The Living Benefit will be an amount equal to 80% of Your Employee Basic Life Insurance plus Your
Employee Supplemental Life Insurance in effect on the date Your election is made, subject to a minimum of
$3,000 and a maximum of $500,000. The amount payable will be equal to the Living Benefit less applicable
amounts, if any, charged for an investment loss (interest) and administrative fees.
C. The payment will be made in one lump sum to You or to the payee You appropriately assign.
D. The Living Benefit will not be available if:
1. You have any portion of any Life Insurance or ownership rights thereof absolutely or irrevocably assigned
or transferred;
2. You have made an irrevocable beneficiary designation;
3. the insurance proceeds are subject to a court order under a divorce decree, separate maintenance agreement
or property settlement agreement;
4. You have filed for bankruptcy, unless You give Us written approval from the bankruptcy court for payment
of the Living Benefit.
E. No payment will be made under this election unless and until We receive and approve of all of the following:
1. Your signed and notarized election of this option on a form furnished by Us;
2. signed and witnessed written statements of all irrevocable beneficiaries and assignees (and Spouse in
marital property states) consenting to Your election of this option; and
3. satisfactory written proof from a Physician other than Yourself or a member of Your or Your Spouse's
immediate family that You have been diagnosed as being Terminally Ill and that You are of sound mind
and under no constraint or undue influence.
F. We may require a second opinion and examination of Your condition at Our own expense by a Physician of
Our choice.
G. Payment of the Living Benefit will reduce correspondingly the face amount of Your life insurance benefits
under the Group Policy. This will result in reduced life insurance proceeds payable to Your beneficiary at Your
death. Furthermore, any amount of insurance that would otherwise be continued will be reduced proportionately,
as will the maximum face amount available under the “Life Insurance Conversion Benefit” section.
H. Premium payments must continue to be paid for Your life insurance unless You qualify to have Your life
insurance premium waived. The premium due will be based on the amount of insurance remaining in force
after deducting the amount of the Living Benefit.
I. Payment of the Living Benefit will not affect the amount of, or change an existing beneficiary designation for,
the AD&D Benefit, if any, in effect and kept in force under the Group Policy.
J. Your election together with Our payment of the Living Benefit constitute a valid and effective beneficiary
designation change, but only with respect to the specified life insurance benefits, and only to the extent affected
by the Living Benefit payment, and applicable interest and fees, if any, charged thereon.
K. Payment of the Living Benefit will be exempt from the claims of creditors and from legal process to the extent
permitted by law.
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L. All other provisions of the Group Policy, including the effective date provisions of any benefit increases and
the provisions on benefit reductions because of amendments to the plan or benefit classification changes or
Your attained age, remain valid and in effect. Any such life insurance benefit reduction will be calculated based
on Your life insurance amount in effect immediately before the Living Benefit payment.
M. You are responsible for any tax consequences related to this benefit.
GTL-C1000-0608 Rev. 11-11-2024
VII. LIFE EXCLUSIONS
A. Suicide Exclusion
1. Except as provided for below, no death benefits will be payable for a death of an Insured Person occurring
within 2 years from the Insured Person’s effective date of coverage under the Group Policy, if such death
was caused by suicide, attempted suicide, or any other intentionally self-inflicted Injury or Physical Disease,
while sane or insane. This Suicide Exclusion shall reapply to increases of such insurance as of the effective
date of the increase.
2. We will refund all premiums paid for any coverage under which benefits are excluded from payment under
this provision.
3. If You were covered under the Prior Plan on the day before the Effective Date under the Group Policy,
credit will be given for the time You were insured under the Prior Plan.
4. This exclusion does not apply to insurance coverage which is 100% paid for by the Employer or Employee
Basic Life Insurance.
GTL-C1200-0608
VIII. LIFE INSURANCE CONVERSION BENEFIT
A. When Coverage Ends.
1. If an Insured Person’s coverage under the Policy ends, the Insured Person may, as described below, apply for
Our individual life insurance policy without submitting Evidence of Insurability.
a. The Insured Person must complete an application, pay the first premium, and send them to Us within
the 31-day period immediately following the date coverage ends under the Policy (the Conversion
Period).
b. The individual policy will become effective on the first day following the date coverage under the Policy
ends.
c. The Insured Person may convert all or part of the amount of life insurance benefit, as shown in the
“Schedule of Benefits”.
2. If an Insured Person has been insured under the Policy for at least five years and is no longer eligible due to
cancellation of the Policy or cancellation of the class of insureds in which the Employee belonged, an Insured
Person may convert the lesser of: (1) $10,000 or (2) all or part of the amount for which the Insured Person is
no longer eligible for under the Policy.
B. Premiums.
1. Premiums for such individual life policy will be based on: (1) Our usual rate for the amount and type of
individual policy; (2) the Insured Person’s class of risk; and (3) the Insured Person’s attained age.
2. If an Insured Person dies during the Conversion Period, the maximum amount of life insurance to which he
or she would have been entitled to under such individual policy shall be payable as a claim under the Group
Policy, whether or not application for the individual policy or the payment of the first premium has been
made.
3. The rights or benefits granted under this provision are in lieu of any other rights or benefits granted under
the Group Policy.
GTL-C1300-0608
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IX. LIFE INSURANCE PORTABILITY BENEFIT
A. Schedule of Portable Coverage.
1. Portable Coverage is available for the following types of insurance You have in effect on the last day of
Your employment with the Employer:
a) Employee Basic Life Insurance;
b) Dependent Basic Life Insurance;
c) Dependent Supplemental Life Insurance;
d) Employee Supplemental Life Insurance.
B. When Coverage Ends. If Your life insurance coverage under the Group Policy ends because Your employment
with the Employer terminates, You may be eligible to purchase portable group life insurance without
submitting Evidence of Insurability. You may purchase all or some of Your life insurance in force at the time
Your employment ends, but not less than a minimum of $1,000.
C. Eligibility. To be eligible for Portable Coverage, You must meet the following requirements on Your last day
of employment with the Employer.
1. You must be an Insured Person and have been insured under the Group Policy for at least 3 consecutive
months ending on Your last day of employment with the Employer;
2. You must be under the Social Security Normal Retirement Age as stated in the 1983 revision or any
subsequent revisions of the United States Social Security Act;
3. You cannot be Disabled;
4. You cannot be covered under any other group term life insurance plan.
D. Application and Premium Payment
1. You must apply in writing and pay the first premium within 31 days after Your last day of employment
with the Employer.
2. Premium checks are payable to Madison National Life Insurance Company, Inc., and must be made
directly to Us in a timely manner as specified by Us at the time coverage is ported.
E. Effective Date of Portable Coverage. Provided the above requirements are met, Portable Coverage will
become effective the first day immediately following Your last day of coverage through the Employer.
F. The following Benefits/Sections are Excluded from being portable under this Section:
1. Any coverages not specifically listed under the "Schedule of Portable Coverage" subsection above;
2. Waiver of Premium;
3. Living Benefit.
G. Other Portability Terms and Requirements.
1. If You do not purchase Portable Coverage for Yourself, You may not purchase Portable Coverage for any
Dependent.
2. Refer to the "Life Insurance Conversion Benefit" section for information on eligibility to convert Your
group insurance to an individual life insurance policy. The combined amounts of Portable Coverage and
coverage obtained under the "Life Insurance Conversion Benefit" section cannot exceed the amount in
effect under the Group Policy on the last day of Your employment with the Employer.
3. You may reduce Your amount of Portable Coverage at any time by providing Us with a written request.
Such a reduction will be effective on the first day of the month following the month in which the request
was received. You may not increase Your Portable Coverage.
4. Your Portable Coverage is governed by the terms of the Group Policy, and will be reduced or terminated
according to the terms therein.
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5. In the event of termination of Your Employer’s coverage under the Group Policy, Your Portable Coverage
will be provided under a separate group insurance policy, and will contain provisions that may differ from
Your coverage through Your Employer under the Group Policy. You will receive Your coverage
information when You purchase the Portable Coverage.
6. If You do not complete and submit a new beneficiary designation form with Your application for Portable
Coverage, Your beneficiary designation on file under the Group Policy will apply to Your Portable
Coverage.
GTL-C1500-0608
X. ACCIDENTAL DEATH & DISMEMBERMENT INSURANCE
A. If an Insured Person has an Accident while insured for Accidental Death and Dismemberment (AD&D) Insurance
and the Accident results in a Loss (as defined below), We will pay benefits according to the terms of the Group
Policy after We receive Proof of Loss.
B. Eligibility. An Insured Person must be a member of a class that is eligible for AD&D coverage under the Group
Policy as specified in the “Schedule of Benefits”.
C. Definitions for AD&D Insurance
1. Loss means Loss of one or more of the body parts or bodily functions listed under “AD&D Benefit” below,
or as otherwise provided for under this “Accidental Death and Dismemberment Insurance” section, which:
a. is caused solely and directly by an Accident;
b. occurs independently of all other causes;
c. occurs within 90 days after the Accident; and
d. while the Insured Person is covered under the Group Policy.
2. Accident: A sudden, unexpected and unforeseen, identifiable event causing bodily Injury, directly produced
by specific accidental contact with another body or object. The Accident must occur while You are covered
under the Group Policy.
3. With respect to a hand or foot, Loss means actual and permanent severance from the body at or above the
wrist or ankle joint.
4. With respect to sight, speech or hearing, Loss means entire and irrecoverable Loss of that function.
D. AD&D Benefit. The AD&D Benefit is equal to a percentage of the AD&D Insurance Amount in effect on the
date of the Accident, subject to the AD&D Reduction Schedule provision set forth in the “Schedule of Benefits”.
The AD&D Insurance Amount is shown in the “Schedule of Benefits”. The percentage is shown below.
Covered Losses: Maximum Amount Payable
Loss of Life.............................................................................................. 100%
Loss of both Hands or both Feet .............................................................. 100%
Loss of one Hand or one Foot ................................................................... 50%
Loss of one Hand and one Foot ................................................................ 100%
Loss of Entire Sight of both Eyes ............................................................. 100%
Loss of Entire Sight in one Eye ................................................................ 50%
Loss of one Hand or one Foot and Entire Sight of one Eye ....................... 100%
E. Unless otherwise specified, no more than 100% of the applicable AD&D Insurance Amount will be paid for all
Losses resulting from one Accident. If an age reduction applies, the benefit reduces on the date You attain that
age.
GTL-C1600-0608
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F. AD&D Insurance Exclusions. No AD&D Benefit is payable if the Loss is caused or contributed to by any of the
following:
1. War or Act of War. War means a state or period of declared or undeclared war whether civil or international,
or any substantial armed conflict with organized forces of a military nature between nations, states or
parties;
2. Suicide, attempted suicide or other intentionally self-inflicted Injury, while sane or insane, within the first 2
years of coverage;
3. Committing or attempting to commit a felony or assault, or actively participating in a violent disorder or
riot. Actively participating does not include being at the scene of a violent disorder or riot while performing
Your official duties;
4. Any Injury sustained while under the voluntary use or consumption of any poison, illegal drugs, or
controlled substance, unless used or consumed according to the directions of a Physician;
5. Physical Disease existing at the time of the Accident;
6. Medical negligence and malpractice;
7. Bacterial infections (except due to accidental food poisoning or caused by an accidental wound);
8. Any Injury sustained which is probable, expected or a natural result of being legally intoxicated as defined
by the laws of the jurisdiction in which the Injury is sustained;
9. Any Loss incurred for which any government body or its agencies are liable while the insured is on active
duty or training in the Armed Forces, National Guard or Reserves, of any state or country.
GTL-C2100-0608
XI. CLAIMS PROVISIONS
A. Filing A Claim
1. To file a claim for benefits under this Certificate, the claimant (depending on the benefit the claimant could
be an Insured Person, a beneficiary or personal representative of an Insured Person) must provide Us with
Proof of Loss in a timely manner. Or, upon receipt of written notice of claim, We will send the claimant a
Claim Form for filing Proof of Loss. If the claimant does not receive such forms within 15 days after the
giving of such notice, the claimant can send us, without the Claim Form, the written proof covering the
occurrence.
2. Proof of Loss.
a. Proof of Loss must be provided in writing to Us, at the claimant’s expense, within 90 days after the
date of the loss if reasonably possible. If that is not reasonably possible, Proof of Loss must be provided
no later than one year after expiration of that 90-day period, or the claim will be denied. The time limits
under this section shall not apply while the claimant lacks legal capacity.
b. Proof of Loss means satisfactory written proof that a loss occurred for which the Group Policy provides
benefits, which is not subject to any exclusion, and which meets all other conditions for benefits. Proof
of Loss includes any other information We may reasonably require in support of a claim for benefits
under the Group Policy.
B. Notice of Decision on Claim
1. We will evaluate a claim for benefits promptly after We receive it. Within 30 days after We receive the
claim We will send the claimant:
a. a written decision on the claim; or
b. a notice that We are extending the period to decide the claim for an additional 45 days.
2. If the claim is approved, We will pay benefits within 30 days after the Proof of Loss requirement is satisfied.
3. If We extend the period to decide the claim, We will notify the claimant of the following:
a. the reasons for the extension;
b. when We expect to decide the claim; and
c. any additional information We require to decide the claim.
4. If We request additional information, the claimant will have 45 days to provide the information. If the
claimant does not provide the requested information within 45 days, We may decide the claim based on the
information We have received.
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5. If We deny any part of the claim, We will send the claimant a written notice of denial containing:
a. the reasons for Our decision;
b. reference to the parts of the Group Policy on which Our decision is based;
c. a description of any additional information required to support the claim;
d. information concerning the claimant's right to a review of Our decision.
C. Payment of Claims.
Upon receipt of proper Proof of Loss, benefits will be paid within 30 days. If any claims payment interest
accrues, interest will be paid in the amount determined by the State in which the claims are incurred.
Death Claims: If an Insured Person dies while insured for life insurance under the Group Policy, We will pay
benefits according to the “Schedule of Benefits”, after We receive Proof of Loss, as follows.
1. The death benefit will be paid in a single sum or by any other method agreeable to Us and the beneficiary.
Payment of the benefit will extinguish Our liability under the Group Policy for which the death benefit has
been paid.
2. No Surviving Beneficiary. If You do not name a beneficiary, or if You are not survived by any named
beneficiary, benefits will be paid to Your estate.
3. Dependent Benefits. Dependent Life Insurance benefits that are payable, but unpaid at the Insured
Person’s death, will be paid in equal shares to the first surviving class of the following, if the Eligible
Employee is dead:
a. The children of the Dependent.
b. The parents of the Dependent.
c. The Insured Person’s estate.
The following Dependent benefits, payable under the Group Policy, will be paid to the Eligible Employee
if he or she is living:
a. AD&D Insurance benefits;
b. Life Insurance benefits;
c. Supplemental Life Insurance benefits payable because of the death of Your insured Spouse or Child;
d. Living Benefit.
4. Facility of Payment. If the benefits provided by the Group Policy are payable to the Insured Person’s estate
or to a beneficiary who is a minor or otherwise not legally competent to give a valid release, We may pay
up to $500 to any person related to the Insured Person by blood or marriage. Any payment made in good
faith will fully release Us to the limit of the payment. If a beneficiary is a minor, or is not able to give a
valid release for any payment of benefits made, We will pay the life proceeds to the legally appointed
guardian. The guardian must provide Us with adequate written proof of such appointment. This provision
does not prevent Us from making payment to or for the benefit of a minor beneficiary in accordance with
the applicable state law. Payment made before We have received written notice at Our home office of a
valid claim by some other person releases Us from further obligation.
D. Review Procedure.
1. If all or part of a claim is denied, the claimant may request a review. The claimant must request a review
in writing within 60 days after receiving notice of the denial.
2. The claimant may send Us written comments or other items to support the claim. The claimant may review
and receive copies of any non-privileged information that is relevant to the request for review. There will
be no charge for such copies. Our review will include any written comments or other items the claimant
submits to support the claim.
3. We will review the claim promptly after We receive the request. Within 60 days after We receive the
request for review We will send the claimant:
a. a written decision on review; or
b. a notice that We are extending the review period for 60 days. If the extension is due to the claimant's
failure to provide information necessary to decide the claim on review, the extended time period for
review of the claim will not begin until the claimant provides the information or otherwise responds.
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4. If We extend the review period, We will notify the claimant of the following:
a. the reasons for the extension;
b. when We expect to decide the claim on review; and
c. any additional information We require to decide the claim.
5. If We request additional information, the claimant will have 45 days to provide the information. If the
claimant does not provide the requested information within 45 days, We may conclude Our review of the
claim based on the information We have received.
6. If We deny any part of the claim on review, the claimant will receive a written notice of denial containing:
a. the reasons for Our decision.
b. references to the provisions of the Group Policy on which Our decision is based.
c. information concerning the claimant's right to receive, free of charge, copies of non-privileged
documents and records relevant to the claim.
7. The Group Policy does not provide voluntary alternative dispute resolution options.
GTL-C2200-0608
XII. GENERAL PROVISIONS
A. Naming a Beneficiary.
1. At the time You became insured under the Group Policy, You should have named a beneficiary of the
proceeds of Your life insurance on the enrollment form.
2. You may have named primary beneficiaries and secondary beneficiaries. A secondary beneficiary will
become a primary beneficiary if the named primary beneficiary is not living at the time of Your death. Two
or more surviving primary beneficiaries will share equally, unless You specify otherwise.
3. AD&D Insurance death benefits will be distributed according to the beneficiary designation of Your
corresponding life insurance.
4. You may change Your beneficiary designation at any time, subject to the following:
a) The designation must be made in writing on a form suitable to Us;
b) The designation must be dated and signed by You (and by your Spouse where required by law);
c) The designation must relate and refer to the insurance provided under the Group Policy;
d) If applicable, We must have the written consent of all irrevocable beneficiaries;
e) You must not have assigned the ownership of Your insurance.
5. When a valid change of beneficiary is received by Us, the change will relate back to and take effect as of
the date it was signed. This is the case whether You are alive or not when We receive the request. Even
though the change of beneficiary will relate back to the date it was signed, it will be without prejudice to
Us on account of any payment We have already made.
6. If We approve it, a written designation signed and dated by You under the Prior Plan will be accepted as
Your beneficiary designation under the Group Policy.
B. Simultaneous Death Provision.
If a beneficiary dies on the same day You die, or within 120 hours from Your time of death, benefits will be
paid as if that beneficiary had died before You, unless Proof of Loss with respect to Your death is delivered to
Us before the date of the beneficiary’s death.
C. Entire Contract, Changes
1. This Certificate, including the Enrollment Form, Group Policy and any Riders, Amendment or attached
papers, if any, constitutes the entire contract of Insurance. No change in this Certificate shall be valid until
approved by an executive officer of Our company and unless such approval is endorsed hereon or attached
hereto. No agent has authority to change this Certificate or waive any of its provisions.
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2. Except for those functions which the Group Policy specifically reserves to the Policyholder or Employer,
We have authority to control, manage, and interpret the Group Policy, to administer claims and to resolve
all questions arising in the administration, interpretation and application of the Group Policy.
3. Our authority includes, but is not limited to the following:
a) the right to resolve all matters when a review has been requested;
b) the right to establish and enforce rules and procedures for the administration of the Group Policy and
any claim under it;
c) the right to determine eligibility for insurance, entitlement to benefits, the amount of benefits payable
and the sufficiency and the amount of information We may reasonably require to make determinations.
D. Incontestability of Insurance
1. Any statement made to obtain or to increase insurance is a representation and not a warranty.
2. No misrepresentation will be used as a basis for reducing or denying a claim or contesting the validity of
insurance unless:
a) the insurance would not have been approved if We had known the truth; and
b) We have given You or any other person claiming benefits a copy of the signed written instrument which
contains the misrepresentation.
3. After insurance has been in effect for 2 years, during the lifetime of the Insured Person, We will not use a
misrepresentation as a basis for reducing or denying a claim, unless it was a fraudulent misrepresentation.
E. Incontestability of the Group Policy or Employer Coverage under the Group Policy
1. No misrepresentation by the Policyholder or Your Employer will be used as a basis for denying a claim, or
for denying the validity of the Group Policy or Your Employer’s coverage under the Group Policy unless:
a) the Group Policy would not have been issued or Your Employer’s coverage under the Group Policy
would not have been approved if We had known the truth; and
b) We have given the Policyholder or Employer a copy of a written instrument signed by the Policyholder
or Employer which contains the misrepresentation.
2. The validity of Your Employer’s coverage under the Group Policy will not be contested after it has been
in force for 2 years, except for nonpayment of premium or fraudulent misrepresentations.
F. Clerical Error
1. Clerical error by Us, the Policyholder, Your Employer, or their respective Eligible Employees or
representatives will not:
a) cause a person to become insured under the Group Policy or a provision of it.
b) invalidate insurance otherwise validly in force.
c) continue insurance otherwise validly terminated.
d) cause an Employer to obtain coverage under the Group Policy or a provision of it.
2. In the event that a clerical error results in an incorrect rate, We reserve the right to adjust the rate
accordingly.
3. The payment of premium, by itself, will not obligate Us to provide benefits to anyone who is not eligible
for coverage under the Group Policy.
4. Your Employer acts on its own behalf as Your agent, and not as Our agent. Your Employer has no authority
to alter, expand or extend Our liability or to waive, modify or compromise any defense or right We may
have under the Group Policy.
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G. Misstatement
1. Age or Gender
If the age or gender, or both, of a person has been misstated, We will make an equitable adjustment of
premiums, benefits or both. The adjustment will be based on:
a) the amount of insurance based on the correct age and gender; and
b) the difference between the premiums paid and the premiums which would have been paid if the age
and gender had been correctly stated.
2. A legal action may not be brought to recover on this Certificate within 60 days after written Proof of Loss
has been given as required. No such action may be brought after 3 years from the time written proof was
required to be given.
H. Assignment
An Insured may not assign any of his or her rights, privileges or benefits under the Group Policy, unless
approved by Us.
I. Conformity With State Laws
If any provision of this Certificate is contrary to any law to which it is subject, such provision is hereby
amended to conform to the minimum requirements of such law.
GTL-C2300-0608
IA-LHIGA 1121
NOTICE OF PROTECTION PROVIDED BY
IOWA LIFE AND HEALTH INSURANCE GUARANTY ASSOCIATION
This notice provides a brief summary of the Iowa Life and Health Insurance Guaranty Association Act
(the "Association") and the protection it provides for policyholders. This safety net was created under
Iowa law, located at Iowa Code Chapter 508C, which determines who and what is covered and the
amounts of coverage.
The Association was established to provide protection in the unlikely event that your life, annuity,
health insurance company or health maintenance organization becomes financially unable to meet its
obligations and is taken over by its Insurance Department. If this should happen, the Association will
typically arrange to continue coverage and pay claims, in accordance with Iowa law, with funding from
assessments paid by other insurance companies.
The basic protections provided by the Association are:
Life Insurance:
• $300,000 in death benefits
• $100,000 in net cash surrender and withdrawal values
Health Insurance:
• $500,000 for health benefit plans (see definition below)
• $300,000 in disability income protection insurance benefits
• $300,000 in long-term care insurance benefits
• $100,000 in other types of health insurance benefits, including net cash surrender and
withdrawal values
Annuities:
• $250,000 in the present value of annuity benefits, including net cash surrender and
withdrawal values
The maximum amount of protection for each individual, regardless of the number of policies or contracts,
is $350,000. Special rules may apply with regard to health benefit plans.
"Health benefit plan" is defined in the applicable Iowa law and generally includes hospital or medical
expense policies, contracts or certificates, or HMO subscriber contracts that provide comprehensive
forms of coverage for hospitalization or medical services, but excludes policies that provide coverages
for limited benefits (such as dental-only or vision-only insurance), Medicare Supplement insurance,
disability income insurance and long-term care insurance.
Note: Certain policies and contracts may not be covered or fully covered. If coverage is available, it
will be subject to substantial limitations and exclusions. For example, coverage does not extend to any
portion(s) of a policy or contract that the insurer does not guarantee, such as certain investment additions
to the account value of a variable life insurance policy or a variable annuity contract. There are also
various residency requirements under Iowa law.
Benefits provided by a long-term care rider to a life insurance policy or annuity contract shall be
considered the same type of benefits as the base life insurance policy or annuity contract to which
the long-term rider relates.
IA-LHIGA 1121
To learn more about the Association and the protections it provides, as well as those relating to group
contracts or retirement plans, please visit the Association's website at www.ialifega.org, or contact:
Iowa Life and Health Insurance Guaranty Association
700 Walnut Street, Suite 1600
Des Moines, IA 50309
(515) 248-5712
Iowa Insurance Division
1963 Bell Ave, Suite 100
Des Moines, IA 50315
(515) 654-6600
Information about the financial condition of insurers is available from a variety of sources, including
financial rating agencies such as AM Best Company, Fitch Ratings Inc., Moody's Investors Service, and
S&P Global Ratings.
The Association is subject to the supervision of the Commissioner of the Iowa Insurance Division.
Persons who desire to file a complaint to allege a violation of the laws governing the Association may
contact the Iowa Insurance Division. State law provides that any suit against the Association shall be
brought in the Iowa District Court in Polk County, Iowa.
Insurance companies and agents are not allowed by Iowa law to use the existence of the
Association or its coverage to encourage you to purchase any form of insurance or HMO
coverage. When selecting an insurance company, you should not rely on Association coverage. If
there is any inconsistency between this notice and Iowa law, then Iowa law will control.
Notice/NIS(NISW) 0320
NOTICE
This notice describes identities of and relationships among the Insurer, Administrator, and Policyowner of this
insurance.
Insurer: Madison National Life Insurance Company, Inc. (MNL) is the insurance underwriter of this insurance.
Third Party Administrator: National Insurance Services (NIS) is the administrator for this group insurance.
NIS provides administrative services for insurance issued to groups, including, but not limited to underwriting,
premium billing, premium collection, client services, and policy and certificate issuance.
There is no ownership affiliation between MNL and NIS.
Policyowner: The Policyowner of your policy/certificate of insurance is the National Insurance Services
Insurance Trust (Trust).
Employer: Your Employer participates in the group insurance under the group policy issued to the Trust.
NIS is the Administrator of the Trust.