HomeMy WebLinkAboutAgreement A-21-084 with Standard Insurance Company.pdf-1-
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A G R E E M E N T
THIS AGREEMENT is made and entered into this ___ day of ________ 2021, by and between
the COUNTY OF FRESNO, a Political Subdivision of the State of California, hereinafter referred to as
"COUNTY", and Standard Insurance Company , an Oregon Corporation whose address is 1100 SW 6th
Avenue, Portland, OR 97204, hereinafter referred to as "CONTRACTOR".
W I T N E S S E T H:
WHEREAS, the County of Fresno desires to continue to provide Long Term Disability Insurance
coverage to its Department Heads, Senior Management, and Management employees (collectively,
“Management Employees”); and
WHEREAS, through the COUNTY’s consultant Keenan & Associates, qualified vendors responded
to solicited bids for Long Term Disability Insurance rates; and
WHEREAS, CONTRACTOR submitted the most responsive bid for Long Term Disability Insurance
services;
NOW, THEREFORE, in consideration of the mutual covenants, terms and conditions herein
contained, the parties hereto agree as follows:
1.OBLIGATIONS OF THE CONTRACTOR
A.Beginning April 1, 2021, CONTRACTOR shall provide active permanent
Management Employees, working at least 20 hours or more per week, with noncontributory Long-term
Disability (hereafter “LTD”) Insurance coverage through a group insurance policy issued by
CONTRACTOR, as described in Exhibit A (Management Long-Term Disability Policy) and Exhibit B
(Application for Group Insurance), both of which are attached hereto and incorporated herein by
reference.
COUNTY and CONTRACTOR (collectively, the “Parties”) intend that the Exhibit A
attached to this Agreement and stamped “DRAFT” is final for purposes of this Agreement. The parties
understand that CONTRACTOR will issue a final Management Long-Term Disability Policy in the form of
Exhibit A without the “DRAFT” stamp as the official policy upon execution of the Agreement by both
Parties.
Agreement No. 21-084
23rd March
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B.CONTRACTOR shall pay the COUNTY’s matching FICA and Medicare taxes and
prepare W-2s for members receiving LTD Benefits.
C.CONTRACTOR shall provide Employee Assistance Program services including
three (3) face-to-face counseling sessions per issue, per twelve (12) month period, to all active Regular
Management Employees who receive LTD insurance coverage under this Agreement. There will be no
additional charge for these services.
2.OBLIGATIONS OF THE COUNTY
A.COUNTY shall pay premiums to the CONTRACTOR for the services described in
Section 1 of this Agreement.
3.TERM
The term of this Agreement shall be for a period of three (3) years, commencing on April 1, 2021,
through and including March 31, 2024. This Agreement may be extended for two (2) additional consecutive
twelve (12) month periods upon written approval of both parties no later than thirty (30) days prior to the first
day of the next twelve (12) month extension period. The Director of Human Resources or his or her
designee is authorized to execute such written approval on behalf of COUNTY based on CONTRACTOR’S
satisfactory performance.
4.TERMINATION
A.Non-Allocation of Funds - The terms of this Agreement, and the services to be
provided hereunder, are contingent on the approval of funds by the appropriating government agency.
Should sufficient funds not be allocated, the services provided may be modified, or this Agreement
terminated, at any time by giving the CONTRACTOR thirty (30) days advance written notice.
B.Breach of Contract - The COUNTY may immediately terminate this Agreement in
whole or in part, where in the determination of the COUNTY there is:
1)An illegal or improper use of funds;
2)A failure to comply with any term of this Agreement;
3)A substantially incorrect or incomplete report submitted to the COUNTY;
4)Improperly performed service.
In no event shall any payment by the COUNTY constitute a waiver by the COUNTY of any breach
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of this Agreement or any default which may then exist on the part of the CONTRACTOR. Neither shall such
payment impair or prejudice any remedy available to the COUNTY with respect to the breach or default.
The COUNTY shall have the right to demand of the CONTRACTOR the repayment to the COUNTY of any
premiums paid to the CONTRACTOR under this Agreement, which in the judgment of the COUNTY were
not earned premiums in accordance with the terms of this Agreement. The CONTRACTOR shall promptly
refund any such funds upon the parties reaching mutual agreement as to the amount of unearned
premiums, if any, due and owing to the COUNTY.
C. Without Cause - Under circumstances other than those set forth above, this
Agreement may be terminated by COUNTY upon the giving of thirty (30) days advance written notice of an
intention to terminate to CONTRACTOR.
5. COMPENSATION/INVOICING: COUNTY agrees to pay CONTRACTOR and
CONTRACTOR agrees to receive compensation as follows:
A. In the first three (3) years of the agreement, $0.152 per $100.00 of covered payroll
per covered Management employee, per pay period.
B. For year four, $0.152 per $100.00 of covered payroll per covered Management
employee, per pay period, if, at the end of year three, the incurred loss ratio is .75 or less.
C. For year five, $0.152 per $100.00 of covered payroll per covered Management
employee, per pay period, if, at the end of year four, the incurred loss ratio is .75 or less.
D. If the incurred loss ratio, as described in subparagraphs B and C of this Section 5, is
greater than .75, CONTRACTOR may request an increase in the cost per $100.00 of covered biweekly
payroll. Such increase must be agreed upon in writing by COUNTY and CONTRACTOR.
For purposes of this Agreement, the Incurred Loss Ratio is equal to the total incurred claims from
the inception of the Agreement, divided by the total premiums paid by COUNTY to CONTRACTOR under
this Agreement.
In no event shall services performed under this Agreement be in excess of $530,000.00 during the
term of this Agreement. It is understood that all expenses incidental to CONTRACTOR'S performance of
services under this Agreement shall be borne by CONTRACTOR. COUNTY shall remit premiums to
CONTRACTOR, on a biweekly basis, for each covered Management employee receiving pay. Premiums
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shall be remitted by COUNTY to CONTRACTOR prior to the end of the 90-day Grace Period as provided in
Exhibit A.
6.INDEPENDENT CONTRACTOR: In performance of the work, duties and obligations
assumed by CONTRACTOR under this Agreement, it is mutually understood and agreed that
CONTRACTOR, including any and all of the CONTRACTOR'S officers, agents, and employees will at all
times be acting and performing as an independent contractor, and shall act in an independent capacity and
not as an officer, agent, servant, employee, joint venturer, partner, or associate of the COUNTY.
Furthermore, COUNTY shall have no right to control or supervise or direct the manner or method by which
CONTRACTOR shall perform its work and function. However, COUNTY shall, subject to applicable law,
retain the right to administer this Agreement so as to verify that CONTRACTOR is performing its obligations
in accordance with the terms and conditions thereof.
CONTRACTOR and COUNTY shall comply with all applicable provisions of law and the rules and
regulations, if any, of governmental authorities having jurisdiction over matters the subject thereof.
Because of its status as an independent contractor, CONTRACTOR shall have absolutely no right
to employment rights and benefits available to COUNTY employees. CONTRACTOR shall be solely liable
and responsible for providing to, or on behalf of, its employees all legally-required employee benefits. In
addition, CONTRACTOR shall be solely responsible and save COUNTY harmless from all matters relating
to payment of CONTRACTOR'S employees, including compliance with Social Security withholding and all
other regulations governing such matters. It is acknowledged that during the term of this Agreement,
CONTRACTOR may be providing services to others unrelated to the COUNTY or to this Agreement.
7.MODIFICATION: Any matters of this Agreement may be modified from time to time by the
written consent of all the parties without, in any way, affecting the remainder.
8.NON-ASSIGNMENT: Neither party shall assign, transfer or sub-contract this Agreement
nor their rights or duties under this Agreement without the prior written consent of the other party. Consent
for the requirements of this section shall not be unreasonably withheld. Further, the parties agree a
subcontractor shall be any party that the CONTRACTOR retains solely and exclusively for the purposes of
providing insurance coverage and services to the COUNTY.
9.HOLD HARMLESS: CONTRACTOR agrees to indemnify, save, hold harmless, and at
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COUNTY'S request, defend the COUNTY, its officers, agents, and employees from any and all costs and
expenses (including attorney’s fees and costs), damages, liabilities, claims, and losses occurring or
resulting to COUNTY in connection with the performance, or failure to perform, by CONTRACTOR, its
officers, agents, or employees under this Agreement, and from any and all costs and expenses (including
attorney’s fees and costs), damages, liabilities, claims, and losses occurring or resulting to any person, firm,
or corporation who may be injured or damaged by the performance, or failure to perform, of
CONTRACTOR, its officers, agents, or employees under this Agreement.
10. INSURANCE
Without limiting the COUNTY's right to obtain indemnification from CONTRACTOR or any third
parties, CONTRACTOR, at its sole expense, shall maintain in full force and effect, the following insurance
policies or a program of self-insurance, including but not limited to, an insurance pooling arrangement or
Joint Powers Agreement (JPA) throughout the term of the Agreement:
A. Commercial General Liability
Commercial General Liability Insurance with limits of not less than Two Million Dollars
($2,000,000.00) per occurrence and an annual aggregate of Four Million Dollars ($4,000,000.00). This
policy shall be issued on a per occurrence basis.
In the event, the CONTRACTOR purchases an Umbrella or Excess insurance policy(ies) to meet
the “Minimum Limits of Insurance,” this insurance policy(ies) shall “follow form” and afford no less coverage
than the primary insurance policy(ies). In addition, such Umbrella or Excess insurance policy(ies) shall also
apply on a primary and non-contributory basis for the benefit of the COUNTY, its officers, officials,
employees, agents and volunteers.
B. Automobile Liability
Comprehensive Automobile Liability Insurance with limits of not less than One Million Dollars
($1,000,000.00) per accident for bodily injury and for property damages. Coverage should include any auto
used in connection with this Agreement.
C. Professional Liability
If CONTRACTOR employs licensed professional staff, (e.g., Ph.D., R.N., L.C.S.W., M.F.C.C.) in
providing services, Professional Liability Insurance with limits of not less than One Million Dollars
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($1,000,000.00) per occurrence, Three Million Dollars ($3,000,000.00) annual aggregate.
D.Worker's Compensation
A policy of Worker's Compensation insurance as may be required by the California Labor
Code.
Additional Requirements Relating to Insurance
CONTRACTOR shall obtain endorsements to the Commercial General Liability insurance naming
the County of Fresno, its officers, agents, and employees, individually and collectively, as additional
insured, but only insofar as the operations under this Agreement are concerned. Such coverage for
additional insured shall apply as primary insurance and any other insurance, or self-insurance, maintained
by COUNTY, its officers, agents and employees shall be excess only and not contributing with insurance
provided under CONTRACTOR's policies herein. This insurance shall not be cancelled or changed without
a minimum of thirty (30) days advance written notice given to COUNTY.
CONTRACTOR hereby waives its right to recover from COUNTY, its officers, agents, and
employees any amounts paid by the policy of worker’s compensation insurance required by this
Agreement. CONTRACTOR is solely responsible to obtain any endorsement to such policy that may be
necessary to accomplish such waiver of subrogation, but CONTRACTOR’s waiver of subrogation under
this paragraph is effective whether or not CONTRACTOR obtains such an endorsement.
Within Thirty (30) days from the date CONTRACTOR signs and executes this Agreement,
CONTRACTOR shall provide certificates of insurance and endorsement as stated above for all of the
foregoing policies, as required herein, to the County of Fresno, (Name and Address of the official who will
administer this contract), stating that such insurance coverage have been obtained and are in full force; that
the County of Fresno, its officers, agents and employees will not be responsible for any premiums on the
policies; that such Commercial General Liability insurance names the County of Fresno, its officers, agents
and employees, individually and collectively, as additional insured, but only insofar as the operations under
this Agreement are concerned; that such coverage for additional insured shall apply as primary insurance
and any other insurance, or self-insurance, maintained by COUNTY, its officers, agents and employees,
shall be excess only and not contributing with insurance provided under CONTRACTOR's policies herein;
and that this insurance shall not be cancelled or changed without a minimum of thirty (30) days advance,
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written notice given to COUNTY.
In the event CONTRACTOR fails to keep in effect at all times insurance coverage as herein
provided, the COUNTY may, in addition to other remedies it may have, suspend or terminate this
Agreement upon the occurrence of such event.
All policies shall be issued by admitted insurers licensed to do business in the State of California,
and such insurance shall be purchased from companies possessing a current A.M. Best, Inc. rating of A
FSC VII or better.
11.AUDITS AND INSPECTIONS: Subject to applicable privacy laws and regulations, the
CONTRACTOR shall at any time during business hours, and as often as the COUNTY may deem
necessary, make available to the COUNTY for examination all of its records and data with respect to the
matters covered by this Agreement. The CONTRACTOR shall, upon request by the COUNTY, permit the
COUNTY to audit and inspect all of such records and data necessary to ensure CONTRACTOR'S
compliance with the terms of this Agreement.
If this Agreement exceeds ten thousand dollars ($10,000.00), subject to applicable privacy laws and
regulations, CONTRACTOR shall be subject to the examination and audit of the Auditor General for a
period of three (3) years after final payment under contract (Government Code Section 8546.7).
12.NOTICES: The persons and their addresses having authority to give and receive notices
under this Agreement include the following:
COUNTY CONTRACTOR
COUNTY OF FRESNO Standard Insurance Company
Director of Human Resources Kevin Erdahl, 2nd VP Underwriting
2220 Tulare Street, 14th Floor 900 SW 5th Avenue
Fresno, CA 93721 Portland, OR 97204
All notices (except legal service of process which must be served in accordance with applicable
law) between the COUNTY and CONTRACTOR provided for or permitted under this Agreement must be in
writing and delivered either by personal service, by first-class United States mail, by an overnight
commercial courier service, or by telephonic facsimile transmission. A notice delivered by personal service
is effective upon service to the recipient. A notice delivered by first-class United States mail is effective
three COUNTY business days after deposit in the United States mail, postage prepaid, addressed to the
recipient. A notice delivered by an overnight commercial courier service is effective one COUNTY business
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day after deposit with the overnight commercial courier service, delivery fees prepaid, with delivery
instructions given for next day delivery, addressed to the recipient. A notice delivered by telephonic
facsimile is effective when transmission to the recipient is completed (but, if such transmission is completed
outside of COUNTY business hours, then such delivery shall be deemed to be effective at the next
beginning of a COUNTY business day), provided that the sender maintains a machine record of the
completed transmission. For all claims arising out of or related to this Agreement, nothing in this section
establishes, waives, or modifies any claims presentation requirements or procedures provided by law,
including but not limited to the Government Claims Act (Division 3.6 of Title 1 of the Government Code,
beginning with section 810).
13.GOVERNING LAW: Venue for any action arising out of or related to this Agreement shall
only be in state or federal court in Fresno County, California.
The rights and obligations of the parties and all interpretation and performance of this Agreement
shall be governed in all respects by the laws of the State of California.
14.DISCLOSURE OF SELF-DEALING TRANSACTIONS
This provision is only applicable if the CONTRACTOR is operating as a corporation (a for-profit
or non-profit corporation) or if during the term of the agreement, the CONTRACTOR changes its status
to operate as a corporation.
Members of the CONTRACTOR’s Board of Directors shall disclose any self-dealing transactions
that they are a party to while CONTRACTOR is providing goods or performing services under this
agreement. A self-dealing transaction shall mean a transaction to which the CONTRACTOR is a party
and in which one or more of its directors has a material financial interest. Members of the Board of
Directors shall disclose any self-dealing transactions that they are a party to by completing and signing a
Self-Dealing Transaction Disclosure Form, attached hereto as Exhibit C and incorporated herein by
reference, and submitting it to the COUNTY prior to commencing with the self-dealing transaction or
immediately thereafter.
15.COMPLIANCE WITH LAWS
All services performed by CONTRACTOR under this Agreement shall be in strict conformance with
all applicable Federal, State of California and/or local laws and regulations, including those related to
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confidentiality.
16.ENTIRE AGREEMENT: This Agreement constitutes the entire agreement between the
CONTRACTOR and COUNTY with respect to the subject matter hereof and supersedes all previous
Agreement negotiations, proposals, commitments, writings, advertisements, publications, and
understanding of any nature whatsoever unless expressly included in this Agreement. In the event of any
inconsistency in interpreting the documents which constitute this Agreement, the inconsistency shall be
resolved by giving precedence in the following order of priority: (1) the text of this Agreement (excluding
Exhibit "A", the Management Long-term Disability Policy and Exhibit B, the Application for Group
Insurance)); (2) Exhibit "A" Management Long-term Disability Policy; and (3) Exhibit “B”, the Application for
Group Insurance.
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1 IN WITNESS WHEREOF , the parties hereto have executed this Agreement as of the day and year
2 first hereinabove written .
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CONTRACTOR
~~
(Authorized Signature)
03/04 /202 1
7 Kevin Erdahl, 2nd VP , Underwriting
Print Name & Title
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900 SW 5th Ave
Portland , OR 97204
Mailing Address
FOR ACCOUNTING USE ONLY:
Fund : 1060
Subclass : 10000
ORG: 89250200
Account: 7295
Steve ran au , Chairman of the Board of
Supervisors of the County of Fresno
ATTEST:
Bernice E. Seidel
Clerk of the Board of Supervisors
County of Fresno , State of California
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NOTICE OF PROTECTION PROVIDED BY
CALIFORNIA LIFE AND HEALTH INSURANCE GUARANTEE ASSOCIATION
This notice provides a brief summary regarding the protections provided to policyholders by the
California Life and Health Insurance Guarantee Association ("the Association"). The purpose of the
Association is to assure that policyholders will be protected, within certain limits, in the unlikely event
that a member insurer of the Association becomes financially unable to meet its obligations. Insurance
companies licensed in California to sell life insurance, health insurance, annuities and structured
settlement annuities are members of the Association. The protection provided by the Association is not
unlimited and is not a substitute for consumers’ care in selecting insurers. This protection was
created under California law, which determines who and what is covered and the amounts of coverage.
Below is a brief summary of the coverages, exclusions and limits provided by the Association. This
summary does not cover all provisions of the law; nor does it in any way change anyone’s rights or
obligations or the rights or obligations of the Association.
COVERAGE
•Persons Covered
Generally, an individual is covered by the Association if the insurer was a member of the
Association and the individual lives in California at the time the insurer is determined by a court to
be insolvent. Coverage is also provided to policy beneficiaries, payees or assignees, whether or not
they live in California.
•Amounts of Coverage
The basic coverage protections provided by the Association are as follows.
•Life Insurance, Annuities and Structured Settlement Annuities
For life insurance policies, annuities and structured settlement annuities, the Association will
provide the following:
•Life Insurance
80% of death benefits but not to exceed $300,000
80% of cash surrender or withdrawal values but not to exceed $100,000
•Annuities and Structured Settlement Annuities
80% of the present value of annuity benefits, including net cash withdrawal and net cash
surrender values but not to exceed $250,000
The maximum amount of protection provided by the Association to an individual, for all life
insurance, annuities and structured settlement annuities is $300,000, regardless of the
number of policies or contracts covering the individual.
•Health Insurance
The maximum amount of protection provided by the Association to an individual, as of July 1,
2016, is $546,741. This amount will increase or decrease based upon changes in the health
care cost component of the consumer price index to the date on which an insurer becomes an
insolvent insurer. Changes to this amount will be posted on the Association’s website
www.califega.org.
Exhibit A Page 1 of 30
COVERAGE LIMITATIONS AND EXCLUSIONS FROM COVERAGE
The Association may not provide coverage for this policy. Coverage by the Association generally
requires residency in California. You should not rely on coverage by the Association in selecting an
insurance company or in selecting an insurance policy.
The following policies and persons are among those that are excluded from Association coverage:
•A policy or contract issued by an insurer that was not authorized to do business in California
when it issued the policy or contract
•A policy issued by a health care service plan (HMO), a hospital or medical service organization,
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
•If the person is provided coverage by the guaranty association of another state
•Unallocated annuity contracts; that is, contracts which are not issued to and owned by an
individual and which do not guaranty annuity benefits to an individual
•Employer and association plans, to the extent they are self-funded or uninsured
•A policy or contract providing any health care benefits under Medicare Part C or Part D
•An annuity issued by an organization that is only licensed to issue charitable gift annuities
•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 certain investment elements of a variable life
insurance policy or a variable annuity contract
•Any policy of reinsurance unless an assumption certificate was issued
•Interest rate yields (including implied yields) that exceed limits that are specified in Insurance
Code Section 1607.02(b)(2)(C).
NOTICES
Insurance companies or their agents are required by law to give or send you this notice.
Policyholders with additional questions should first contact their insurer or agent. To learn more
about coverages provided by the Association, please visit the Association’s website at
www.califega.org, or contact either of the following:
The California Life and Health Insurance California Department of Insurance
Guarantee Association Consumer Communications Bureau
PO Box 16860 300 South Spring Street
Beverly Hills, CA 90209-3319 Los Angeles CA 90013
(323) 782-0182 (800) 927-4357
Insurance companies and agents are not allowed by California law to use the existence of
the Association or its coverage to solicit, induce or encourage you to purchase any form of
insurance. When selecting an insurance company, you should not rely on Association
coverage. If there is any inconsistency between this notice and California law, then
California law will control.
Page 2 of 30
CALIFORNIA NOTICE OF COMPLAINT PROCEDURE
Should any dispute arise about your premium or about a claim that you have filed, write to the
company that issued the group policy at:
Standard Insurance Company
PO Box 711
Portland, OR 97207
(971)321-7000
If the problem is not resolved, you may also write to the State of California at:
Department of Insurance
Consumer Services Division
300 S. Spring Street, 11th FL
Los Angeles, CA 90013
1-800-927-HELP (4357)
http://www.insurance.ca.gov/0500-about-us/02-department/01-csmcb/consumer-
services.cfm
This notice of complaint procedure is for information only and does not become a part or
condition of this group policy/certificate.
Page 3 of 30
STANDARD INSURANCE COMPANY
A Stock Life Insurance Company
900 SW Fifth Avenue
Portland, Oregon 97204-1282
(503) 321-7000
GROUP LONG TERM DISABILITY INSURANCE POLICY
Policyholder: County of Fresno
Policy Number: 408847-A
Effective Date: April 1, 2021
The consideration for this Group Policy is the application of the Policyholder and the payment by the
Policyholder of premiums as provided herein.
Subject to the Policyholder Provisions and the Incontestability Provisions, this Group Policy (a) is
issued for the Initial Rate Guarantee Period shown in the Coverage Features, and (b) may be renewed
for successive renewal periods by the payment of the premium set by us on each renewal date. The
length of each renewal period will be set by us, but will not be less than 12 months.
For purposes of effective dates and ending dates under this Group Policy, all days begin and end at
12:00 midnight Standard Time at the Policyholder's address.
All provisions on this and the following pages are part of this Group Policy. "You" and "your" mean the
Member. "We", "us", and "our" mean Standard Insurance Company. Other defined terms appear with
their initial letters capitalized. Section headings, and references to them, appear in boldface type.
STANDARD INSURANCE COMPANY
By
GP190-LTD/S399
Page 4 of 30
Table of Contents
COVERAGE FEATURES .............................................................................................. 1
GENERAL POLICY INFORMATION .......................................................................... 1
SCHEDULE OF INSURANCE .................................................................................. 1
PREMIUM CONTRIBUTIONS .................................................................................. 2
PREMIUM AND RENEWALS ................................................................................... 2
INSURING CLAUSE ..................................................................................................... 4
BECOMING INSURED ................................................................................................. 4
WHEN YOUR INSURANCE BECOMES EFFECTIVE ...................................................... 4
ACTIVE WORK PROVISIONS ....................................................................................... 4
CONTINUITY OF COVERAGE ....................................................................................... 5
WHEN YOUR INSURANCE ENDS ................................................................................. 5
WAIVER OF PREMIUM ................................................................................................ 6
REINSTATEMENT OF INSURANCE .............................................................................. 6
DEFINITION OF DISABILITY ........................................................................................ 6
RETURN TO WORK PROVISIONS ................................................................................. 7
REASONABLE ACCOMMODATION EXPENSE BENEFIT ............................................... 9
REHABILITATION PLAN PROVISION ............................................................................ 9
TEMPORARY RECOVERY .......................................................................................... 10
WHEN LTD BENEFITS END ....................................................................................... 10
PREDISABILITY EARNINGS ....................................................................................... 11
DEDUCTIBLE INCOME ............................................................................................. 11
EXCEPTIONS TO DEDUCTIBLE INCOME .................................................................. 12
RULES FOR DEDUCTIBLE INCOME .......................................................................... 13
SURVIVORS BENEFIT ............................................................................................... 14
CONVERSION OF INSURANCE .................................................................................. 15
BENEFITS AFTER INSURANCE ENDS OR IS CHANGED ............................................ 15
EFFECT OF NEW DISABILITY ................................................................................... 15
DISABILITIES EXCLUDED FROM COVERAGE ........................................................... 16
LIMITATIONS ............................................................................................................ 16
CLAIMS ..................................................................................................................... 17
TIME LIMITS ON LEGAL ACTIONS ............................................................................. 19
INCONTESTABILITY PROVISIONS ............................................................................. 20
CLERICAL ERROR, AGENCY, AND MISSTATEMENT .................................................. 20
TERMINATION OR AMENDMENT OF THE GROUP POLICY......................................... 21
DEFINITIONS ............................................................................................................ 21
POLICYHOLDER PROVISIONS ................................................................................... 22
Page 5 of 30
Index of Defined Terms
Active Work, Actively At Work, 4
Allowable Periods, 10
Any Occupation Period, 1
Benefit Waiting Period, 2, 21
Child, 9
Class Definition, 1
Contributory, 21
CPI-W, 21
Deductible Income, 11
Domestic Partner, 22
Eligibility Waiting Period, 1
Employer, 21
Employer(s), 1
Family Care Expenses, 9
Family Member, 9
Grace Period, 23
Group Policy, 21
Group Policy Effective Date, 1
Group Policy Number, 1
Hospital, 17
Indexed Predisability Earnings, 21
Initial Rate Guarantee Period, 2
Injury, 21
L.L.C. Owner-Employee, 21
LTD Benefit, 21
Maximum Benefit Period, 2, 22
Maximum LTD Benefit, 2
Member, 1, 4
Mental Disorder, 17
Minimum LTD Benefit, 2
Minimum Participation Number, 2
Minimum Participation Percentage, 2
Noncontributory, 22
Own Occupation Period, 1
P.C. Partner, 22
Physical Disease, 22
Physician, 22
Policyholder, 1
Predisability Earnings, 11
Preexisting Condition means, 16
Pregnancy, 22
Premium Due Dates, 2
Premium Rates, 2
Prior Plan, 22
Reasonable Accommodation Expense
Benefit, 9
Rehabilitation Plan, 9
Spouse, 22
Survivors Benefit, 14
Temporary Recovery, 10
War, 16
Work Earnings, 8
Page 6 of 30
COVERAGE FEATURES
This section contains many of the features of your long term disability (LTD) insurance. Other
provisions, including exclusions, limitations, and Deductible Income, appear in other sections. Please
refer to the text of each section for full details. The Table of Contents and the Index of Defined Terms
help locate sections and definitions.
GENERAL POLICY INFORMATION
Group Policy Number: 408847-A
Policyholder: County of Fresno
Employer(s): County of Fresno
Group Policy Effective Date: April 1, 2021
Policy Issued in: California
Member means:
1.A regular management employee of the Employer;
2.Actively At Work at least 20 hours each week (for purposes of the Member definition, Actively
At Work will include regularly scheduled days off, holidays, or vacation days, so long as the
person is capable of Active Work on those days); and
3.A citizen or resident of the United States or Canada.
Member does not include a temporary or seasonal employee, a full-time member of the armed
forces of any country, a leased employee, or an independent contractor.
Class Definition: Class 1: Department Heads
Class 2: All other Members
SCHEDULE OF INSURANCE
Eligibility Waiting Period: You are eligible on one of the following dates:
If you are a Member on the Group Policy Effective Date,
you are eligible on that date.
If you become a Member after the Group Policy Effective
Date, you are eligible on the date you become a Member.
Eligibility Waiting Period means the period you must be a Member before you become eligible for
insurance.
Own Occupation Period: The first 36 months for which LTD Benefits are paid.
Any Occupation Period: From the end of the Own Occupation Period to the end of
the Maximum Benefit Period.
LTD Benefit: 60% of the first $18,333 of your Predisability Earnings,
reduced by Deductible Income.
Page 7 of 30
Maximum: $11,000 before reduction by Deductible Income.
Minimum: $100
Benefit Waiting Period: Class 1: 90 working days.
Class 2: 180 working days.
Maximum Benefit Period: Determined by your age when Disability begins, as follows:
Age Maximum Benefit Period
61 or younger ....................................... To age 65, or 3 years 6 months, if longer.
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
PREMIUM CONTRIBUTIONS
Insurance is: Noncontributory
PREMIUM AND RENEWALS
Premium Rates:
LTD Insurance: 0.152% of the first $18,333 of each insured Member's
insured Predisability Earnings.
Premium Due Dates: April 1, 2021 and the first day of each calendar month
thereafter.
Initial Rate Guarantee Period: April 1, 2021 to April 1, 2024
Minimum Participation Number: 10 insured Members
Minimum Participation Percentage: 100% of eligible Members
Contingent Rate Guarantee
The Contingent Rate Guarantee will apply for one year if, on January 1, 2024, both the Incurred Loss
Ratio and Current Loss Ratio for LTD Insurance under the Group Policy are .75 or less.
The Contingent Rate Guarantee will apply for a second year if, on January 1, 2025, both the Incurred
Loss Ratio and Current Loss Ratio for LTD Insurance under the Group Policy are .75 or less.
The premium rates during the Contingent Rate Guarantee will equal the premium rates in effect at the
end of the Initial Rate Guarantee Period.
Calculating Loss Ratios
The Incurred Loss Ratio is the result of the following calculation:
Incurred Loss Ratio = Incurred Claims divided by Earned Premium
Each element is calculated from the Group Policy Effective Date.
Page 8 of 30
The Current Loss Ratio is the result of the following calculation:
Current Loss Ratio = Incurred Claims divided by Earned Premium
With respect to the first year, each element is calculated from the beginning to the end of the 12
month period ending on the day before January 1, 2024.
With respect to the second year, each element is calculated from the beginning to the end of the 12
month period ending on the day before January 1, 2025.
Definitions
Earned Premium = a + b – c, where:
a = Paid premiums.
b = Change in uncollected premium.
c = Change in advance premium.
Incurred Claims = a + b + c + d + e, where:
a = Claims paid, including benefits paid and costs incurred under any provision of the Group
Policy.
b = Legal fees, expenses, settlements and judgments paid in connection with lawsuits relating to
claims.
c = Payments of the Employer’s share of Social Security and Medicare tax by Standard (if
applicable).
d = Conversion charges for converting to an individual life insurance policy under the Right To
Convert provision (if applicable).
e = Change in claims reserves, including Incurred But Not Reported (IBNR), pending, active and
outstanding claims reserves.
Page 9 of 30
INSURING CLAUSE
If you become Disabled while insured under the Group Policy, we will pay LTD Benefits according to
the terms of the Group Policy after we receive Proof Of Loss.
LT.IC.CA.1
BECOMING INSURED
To become insured you must be a Member, complete your Eligibility Waiting Period, and meet the
requirements in Active Work Provisions and When Your Insurance Becomes Effective.
You are a Member if you are:
1.A regular management employee of the Employer;
2.Actively At Work at least 20 hours each week (for purposes of the Member definition, Actively
At Work will include regularly scheduled days off, holidays, or vacation days, so long as you are
capable of Active Work on those days); and
3.A citizen or resident of the United States or Canada.
You are not a Member if you are a temporary or seasonal employee, a full-time member of the
armed forces of any country, a leased employee, or an independent contractor.
Eligibility Waiting Period means the period you must be a Member before you become eligible for
insurance. Your Eligibility Waiting Period is shown in the Coverage Features.
(VAR MBR DEF) LT.BI.OT.1
WHEN YOUR INSURANCE BECOMES EFFECTIVE
A.When Insurance Becomes Effective
Subject to the Active Work Provisions, your insurance becomes effective as follows:
Noncontributory Insurance
Noncontributory insurance becomes effective on the date you become eligible.
B.Takeover Provisions
If you were insured under the Prior Plan on the day before the effective date of your Employer's
coverage under the Group Policy, your Eligibility Waiting Period is waived on the effective date of
your Employer's coverage under the Group Policy.
LT.EF.OT.1X
ACTIVE WORK PROVISIONS
A.Active Work Requirement
You must be capable of Active Work on the day before the scheduled effective date of your
insurance or your insurance will not become effective as scheduled. If you are incapable of Active
Work because of Physical Disease, Injury, Pregnancy or Mental Disorder on the day before the
scheduled effective date of your insurance, your insurance will not become effective until the day
after you complete one full day of Active Work as an eligible Member.
Active Work and Actively At Work mean performing with reasonable continuity the Substantial And
Material Acts of your Own Occupation at your Employer's usual place of business.
B.Changes In Insurance
Page 10 of 30
This Active Work requirement also applies to any increase in your insurance.
LT.AW.CA.1
CONTINUITY OF COVERAGE
If your Disability is subject to the Preexisting Condition Exclusion, LTD Benefits will be payable if:
1.You were insured under the Prior Plan on the day before the effective date of your Employer's
coverage under the Group Policy;
2.You became insured under the Group Policy when your insurance under the Prior Plan ceased;
3.You were continuously insured under the Group Policy from the effective date of your insurance
under the Group Policy through the date you became Disabled from the Preexisting Condition; and
4.Benefits would have been payable under the terms of the Prior Plan if it had remained in force,
taking into account the preexisting condition exclusion, if any, of the Prior Plan.
For such a Disability, the amount of your LTD Benefit will be the lesser of:
a.The monthly benefit that would have been payable under the terms of the Prior Plan if it had
remained in force; or
b.The LTD Benefit payable under the terms of the Group Policy, but without application of the
Preexisting Condition Exclusion.
Your LTD Benefits for such a Disability will end on the earlier of the following dates:
a.The date benefits would have ended under the terms of the Prior Plan if it had remained in
force; or
b.The date LTD Benefits end under the terms of the Group Policy.
(PX) LT.CC.OT.1
WHEN YOUR INSURANCE ENDS
Your insurance ends automatically on the earliest of:
1.The date the last period ends for which a premium contribution was made for your insurance.
2.The date the Group Policy terminates.
3.The date your employment terminates.
4.The date you cease to be a Member. However, your insurance will be continued during the
following periods when you are absent from Active Work, unless it ends under any of the above.
a.During the first 90 days of a temporary or indefinite administrative or involuntary leave of
absence or sick leave, provided your Employer is paying you at least the same Predisability
Earnings paid to you immediately before you ceased to be a Member. A period when you are
absent from Active Work as part of a severance or other employment termination agreement is
not a leave of absence, even if you are receiving the same Predisability Earnings.
b.During a leave of absence if continuation of your insurance under the Group Policy is required
by a state-mandated family or medical leave act or law.
c.During any other temporary leave of absence approved by your Employer in advance and in
writing and scheduled to last 90 days or less. A period of Disability is not a leave of absence.
d.During the period you are absent from Active Work due to a regularly scheduled school break
or vacation.
Page 11 of 30
e.During the Benefit Waiting Period.
LT.EN.CA.1
WAIVER OF PREMIUM
We will waive payment of premium for your insurance while LTD Benefits are payable.
LT.WP.OT.1
REINSTATEMENT OF INSURANCE
If your insurance ends, you may become insured again as a new Member. However, the following will
apply:
1.If you cease to be a Member because of a covered Disability following the Benefit Waiting Period,
your insurance will end; however, if you become a Member again immediately after LTD Benefits
end, the Eligibility Waiting Period will be waived and, with respect to the condition(s) for which LTD
Benefits were payable, the Preexisting Condition Exclusion will be applied as if your insurance had
remained in effect during that period of Disability.
2.If your insurance ends because you cease to be a Member for any reason other than a covered
Disability, and if you become a Member again within 90 days, the Eligibility Waiting Period will be
waived.
3.If your insurance ends because you are on a federal or state-mandated family or medical leave of
absence, and you become a Member again immediately following the period allowed, your
insurance will be reinstated pursuant to the federal or state-mandated family or medical leave act
or law.
4.The Preexisting Conditions Exclusion will be applied as if insurance had remained in effect in the
following instances:
a.If you become insured again within 90 days.
b.If required by federal or state-mandated family or medical leave act or law and you become
insured again immediately following the period allowed under the family or medical leave act or
law.
5.In no event will insurance be retroactive.
LT.RE.OT.2X
DEFINITION OF DISABILITY
You are Disabled if you meet the following definitions during the periods they apply:
A.Own Occupation Definition Of Disability.
B.Any Occupation Definition Of Disability.
A.Own Occupation Definition Of Disability
During the Benefit Waiting Period and the Own Occupation Period you are required to be Totally
Disabled from your Own Occupation or Partially Disabled from your Own Occupation.
1.Total Disability Definition: You are Totally Disabled from your Own Occupation if, as a result of
Physical Disease, Injury, Pregnancy or Mental Disorder, you are unable to perform with
reasonable continuity the Substantial And Material Acts necessary to pursue your Own
Occupation and you are not working in your Own Occupation.
Page 12 of 30
2.Partial Disability Definition: You are Partially Disabled from your Own Occupation if you are
not Totally Disabled and you are actually working in your Own Occupation but, as a result of
Physical Disease, Injury, Pregnancy or Mental Disorder, you are unable to earn 80% or more of
your Indexed Predisability Earnings.
Note: You are not Disabled from your Own Occupation merely because your right to perform your
Own Occupation is restricted, including a restriction or loss of license. The loss of a professional
license, occupational license, or certification does not, in itself, constitute Disability.
During the Own Occupation Period you may work in another occupation while you meet the Own
Occupation definition of Disability. However, your Work Earnings may be Deductible Income and
LTD Benefits will end when your Work Earnings meet or exceed 80% of your Indexed Predisability
Earnings. See Return To Work Provisions, Deductible Income, and When LTD Benefits End.
Own Occupation may be interpreted to mean the employment, business, trade or profession that
involves the Substantial And Material Acts of the occupation you are regularly performing for your
Employer when Disability begins. Own Occupation is not necessarily limited to the specific job
you perform for your Employer.
Substantial And Material Acts means the important tasks, functions and operations generally
required by employers from those engaged in your Own Occupation that cannot be reasonably
omitted or modified. In determining what Substantial And Material Acts are necessary to pursue
your Own Occupation, we will first look at the specific duties required by your job. If you are
unable to perform one or more of these duties with reasonable continuity, we will then determine
whether those duties are customarily required of other individuals engaged in your Own
Occupation. If any specific, material duties required of you by your job differ from the material
duties customarily required of other individuals engaged in your Own Occupation, then we will not
consider those duties in determining what Substantial And Material Acts are necessary to pursue
your Own Occupation
Your Own Occupation Period is shown in the Coverage Features.
B.Any Occupation Definition Of Disability
During the Any Occupation Period you are required to be Totally Disabled from all occupations or
Partially Disabled.
1.Total Disability Definition: You are Totally Disabled from all occupations if, as a result of
Physical Disease, Injury, Pregnancy or Mental Disorder, you are unable to engage with
reasonable continuity in Any Occupation.
2.Partial Disability Definition: You are Partially Disabled if you are not Totally Disabled and you
are actually working in an occupation but, as a result of Physical Disease, Injury, Pregnancy or
Mental Disorder, you are unable to engage with reasonable continuity in that occupation or
Any Occupation.
Any Occupation means all occupations or employment which you could reasonably be expected to
perform satisfactorily in light of your age, education, training, experience, station in life, and
physical and mental capacity that exists within any of the following locations: (i) a reasonable
distance or travel time from your residence in light of the commuting practices of your community;
or (ii) a distance or travel time equivalent to the distance or travel time you traveled to work before
becoming Disabled; or (iii) the regional labor market, if you reside or resided prior to becoming
Disabled in a metropolitan area.
Your Any Occupation Period is shown in the Coverage Features.
(OWN_ANY) LT.DD.CA.1
RETURN TO WORK PROVISIONS
A.Return To Work Incentive
Page 13 of 30
You may serve your Benefit Waiting Period while working if you meet the Own Occupation
Definition Of Disability.
You are eligible for the Return To Work Incentive on the first day you work after the Benefit
Waiting Period if LTD Benefits are payable on that date. The Return To Work Incentive changes 24
months after that date, as follows:
1.During the first 24 months, your Work Earnings will be Deductible Income as determined in a.,
b. and c:
a.Determine the amount of your LTD Benefit as if there were no Deductible Income, and add
your Work Earnings to that amount.
b.Determine 100% of your Indexed Predisability Earnings.
c.If a. is greater than b., the difference will be Deductible Income.
2.After those first 24 months, 50% of your Work Earnings will be Deductible Income.
B.Work Earnings Definition
Work Earnings means your gross monthly earnings from work you perform while Disabled. Work
Earnings includes:
1.Earnings from your Employer.
2.Earnings from any other employer or self employment for which you become employed after the
date of your Disability.
3.Any increases, except regularly scheduled increases, in earnings from employment from any
other employer or self employment in which you were engaged prior to the date of your
Disability.
4.Any sick pay, vacation pay, annual or personal leave pay, severance pay, or other salary
continuation earned or accrued while working.
Earnings from work you perform will be included in Work Earnings when you have the right to
receive them. If you are paid in a lump sum or on a basis other than monthly, we will prorate your
Work Earnings over the period of time to which they apply. If no period of time is stated, we will
use a reasonable one.
In determining your Work Earnings we:
1.Will use the financial accounting method you use for income tax purposes, if you use that
method on a consistent basis.
2.Will not be limited to the taxable income you report to the Internal Revenue Service.
3.May ignore expenses under section 179 of the IRC as a deduction from your gross earnings.
4.May ignore depreciation as a deduction from your gross earnings.
5.May adjust the financial information you give us in order to clearly reflect your Work Earnings.
If we determine that your earnings vary substantially from month to month, we may determine
your Work Earnings by averaging your earnings over the most recent three-month period. LTD
Benefits will end on the date your average Work Earnings over the last three months equal or
exceed 80% of your Indexed Predisability Earnings.
B.Family Care Expenses Adjustment
If you must pay Family Care Expenses in order to work, we will reduce the amount of the Work
Earnings used in determining your Deductible Income, subject to the following:
Page 14 of 30
1.Your Work Earnings will be reduced by the first $250 per Family Member of the monthly
Family Care Expenses you pay, but not to exceed a total of $500 for all Family Members.
2.The Work Earnings and the Family Care Expenses must be for the same period.
3.You must give us satisfactory proof of the Family Care Expenses you pay.
4.The Work Earnings reduction by Family Care Expenses will end 24 months after it begins.
Family Care Expenses means the amount you pay to a licensed care provider for the care of your
Family which is necessary in order for you to work.
Family Member means:
1.Your Child; or
2. Your Spouse, parent, grandparent, sibling, or other close family member residing in your home
who is:
a.Continuously incapable of self-sustaining employment because of mental retardation or
physical handicap ; and
b.Chiefly dependent upon you for support and maintenance.
Child means:
1.Your child residing in your home (including your stepchild, the child of your Spouse and an
adopted child), from live birth through age 11; or
2.Your child, age 12 or older, residing in your home (including your stepchild, the child of your
Spouse and an adopted child) who is:
a.Continuously incapable of self-sustaining employment because of mental retardation or
physical handicap ; and
b.Chiefly dependent upon you for support and maintenance.
(NO RESP_FAMILY CR_DOMP) LT.RW.CA.1
REASONABLE ACCOMMODATION EXPENSE BENEFIT
If you return to work in any occupation for any employer, not including self-employment, as a result of
a reasonable accommodation made by such employer, we will pay that employer a Reasonable
Accommodation Expense Benefit of up to $25,000, but not to exceed the expenses incurred.
The Reasonable Accommodation Expense Benefit is payable only if the reasonable accommodation is
approved by us in writing prior to its implementation.
LT.RA.OT.1
REHABILITATION PLAN PROVISION
While you are Disabled you may qualify to participate in a Rehabilitation Plan. Rehabilitation Plan
means a written plan, program or course of vocational training or education that is intended to
prepare you to return to work.
To participate in a Rehabilitation Plan you must apply on our forms or in a letter to us. The terms,
conditions and objectives of the plan must be accepted by you and approved by us in advance. We
have the sole discretion to approve your Rehabilitation Plan.
While you are participating in an approved Rehabilitation Plan, your LTD Benefit will be increased by
10% of your Predisability Earnings. Your LTD Benefit may not exceed the Maximum LTD Benefit
shown in the Coverage Features as a result of this increase.
Page 15 of 30
An approved Rehabilitation Plan may include our payment of some or all of the expenses you incur in
connection with the plan, including:
a.Training and education expenses.
b.Family care expenses.
c.Job-related expenses.
d.Job search expenses.
(WITH REHAB INC BFT) LT.RH.OT.1
TEMPORARY RECOVERY
You may temporarily recover from your Disability and then become Disabled again from the same
cause or causes without having to serve a new Benefit Waiting Period. Temporary Recovery means you
cease to be Disabled for no longer than the applicable Allowable Period. See Definition Of Disability.
A.Allowable Periods
1.During the Benefit Waiting Period: a total of 90 days of recovery.
2.During the Maximum Benefit Period: 180 days for each period of recovery.
B.Effect Of Temporary Recovery
If your Temporary Recovery does not exceed the Allowable Periods, the following will apply.
1.The Predisability Earnings used to determine your LTD Benefit will not change.
2.The period of Temporary Recovery will not count toward your Benefit Waiting Period, your
Maximum Benefit Period or your Own Occupation Period.
3.No LTD Benefits will be payable for the period of Temporary Recovery.
4.No LTD Benefits will be payable after benefits become payable to you under any other disability
insurance plan under which you become insured during your period of Temporary Recovery.
5.Except as stated above, the provisions of the Group Policy will be applied as if there had been
no interruption of your Disability.
(NEW TR PERIOD) LT.TR.OT.1
WHEN LTD BENEFITS END
Your LTD Benefits end automatically on the earliest of:
1.The date you are no longer Disabled.
2.The date your Maximum Benefit Period ends.
3.The date you die.
4.The date benefits become payable under any other LTD plan under which you become insured
through employment during a period of Temporary Recovery.
5.The date you fail to provide proof of continued Disability and entitlement to LTD Benefits.
6.The date your Work Earnings equal or exceed 80% of your Indexed Predisability Earnings.
LT.BE.CA.1
Page 16 of 30
PREDISABILITY EARNINGS
Your Predisability Earnings will be based on your earnings in effect on your last full day of Active
Work. Any subsequent change in your earnings after that last full day of Active Work will not affect
your Predisability Earnings.
Predisability Earnings means your monthly rate of earnings from your Employer, including:
1.Contributions you make through a salary reduction agreement with your Employer to:
a.An Internal Revenue Code (IRC) Section 401(k), 403(b), 408(k), 408(p), or 457 deferred
compensation arrangement; or
b.An executive nonqualified deferred compensation arrangement.
2.Amounts contributed to your fringe benefits according to a salary reduction agreement under
an IRC Section 125 plan.
Predisability Earnings does not include:
1.Bonuses.
2.Commissions.
3.Overtime pay.
4.Shift differential pay.
5.Stock options or stock bonuses.
6.Your Employer's contributions on your behalf to any deferred compensation arrangement or
pension plan.
7.Any other extra compensation.
If you are paid on an annual contract basis, your monthly rate of earnings is one-twelfth (1/12th) of
your annual contract salary.
If you are paid hourly, your monthly rate of earnings is based on your hourly pay rate multiplied by
the number of hours you are regularly scheduled to work per month, but not more than 173 hours. If
you do not have regular work hours, your monthly rate of earnings is based on the average number of
hours you worked per month during the preceding 12 calendar months (or during your period of
employment if less than 12 months), but not more than 173 hours.
(BASE_NO STOCK) LT.PD.OT.1
DEDUCTIBLE INCOME
Subject to Exceptions To Deductible Income, Deductible Income means:
1.Sick pay, annual or personal leave pay, severance pay, or other salary continuation, including
donated amounts, (but not vacation pay) paid to you by your Employer, as determined below:
a.Determine the amount of your LTD Benefit as if there were no Deductible Income, and add
your sick pay or other salary continuation to that amount.
b.Determine 100% of your Indexed Predisability Earnings.
c.If a. is greater than b., the difference will be Deductible Income.
2.Your Work Earnings, as described in the Return To Work Provisions.
3.Any amount you receive or are entitled to receive because of your disability, including amounts for
partial or total disability, whether permanent, temporary, or vocational, under any of the following:
Page 17 of 30
a.A workers' compensation law;
b.The Jones Act;
c.Maritime Doctrine of Maintenance, Wages, or Cure;
d.Longshoremen's and Harbor Worker's Act; or
e.Any similar act or law.
4.Any amount you, your Spouse, or your child under age 18 receive or are entitled to receive because
of your Disability or you receive because of your retirement under:
a.The Federal Social Security Act;
b.The Canada Pension Plan;
c.The Quebec Pension Plan;
d.The Railroad Retirement Act; or
e.Any similar plan or act.
Amounts that are entitled to be received will be deducted in accordance with the Estimating and
Deducting section of Rules For Deductible Income.
Full offset: Both the primary benefit (the benefit awarded to you) and dependents benefit are
Deductible Income.
Benefits your Spouse or a child receives or are entitled to receive because of your Disability are
Deductible Income regardless of marital status, custody, or place of residence. The term "child"
has the meaning given in the applicable plan or act.
5.Any amount you receive or are entitled to receive because of your disability under any state
disability income benefit law or similar law.
6.Any amount you receive or are entitled to receive because of your Disability or amount you receive
because of your retirement under your Employer's retirement plan, including a public employee
retirement system, a state teacher retirement system, and a plan arranged and maintained by a
union or employee association for the benefit of its members.
Retirement benefits received will not include amounts rolled over or transferred to any eligible
retirement plan as defined by the Internal Revenue Code.
7.Any earnings or compensation included in Predisability Earnings which you receive or have a right
to receive while LTD Benefits are payable.
8.Any amount you receive under any unemployment compensation law or similar act or law.
9.Any amount of third party liability payments you receive by judgment, settlement or otherwise (less
attorneys' fees).
10.Any amount you receive by compromise, settlement, or other method as a result of a claim for any
of the above, whether disputed or undisputed.
(CA DOM_OTHR OFFST_PUB_WITH 3RD) LT.DI.CA.1
EXCEPTIONS TO DEDUCTIBLE INCOME
Deductible Income does not include:
1.Any cost of living increase in any Deductible Income other than Work Earnings, if the increase
becomes effective while you are Disabled and while you are eligible for the Deductible Income.
2.Reimbursement for hospital, medical, or surgical expense.
Page 18 of 30
3.Reasonable attorneys fees incurred in connection with a claim for Deductible Income.
4.Benefits from any individual disability insurance policy.
5.Early retirement benefits under the Federal Social Security Act which are not actually received.
6.Group credit or mortgage disability insurance benefits.
7.Accelerated death benefits paid under a life insurance policy.
8.Benefits from the following:
a.Profit sharing plan.
b.Thrift or savings plan.
c.Deferred compensation plan.
d.Plan under IRC Section 401(k), 408(k), 408(p), or 457.
e.Individual Retirement Account (IRA).
f.Tax Sheltered Annuity (TSA) under IRC Section 403(b).
g.Stock ownership plan.
h.Keogh (HR-10) plan.
9.California Workers' Compensation benefits for permanent total or permanent partial disability.
(PUB_WITH OTHR OFFST) LT.ED.CA.1
RULES FOR DEDUCTIBLE INCOME
A.Monthly Equivalents
Each month we will determine your LTD Benefit using the Deductible Income for the same monthly
period, even if you actually receive the Deductible Income in another month.
If you are paid Deductible Income in a lump sum or by a method other than monthly, we will
determine your LTD Benefit using a prorated amount. Except as provided below, we will use the
period of time to which the Deductible Income applies. If no period of time is stated, we will use a
reasonable one.
If you receive a lump sum refund, withdrawal or distribution of contributions and earnings from
your Employer's retirement plan, we will determine your LTD Benefit using a lifetime monthly
annuity amount, with no survivor income. The annuity will be based on the amount you receive,
and on the life expectancy of a person your age on the later of:
a.The date the lump sum is paid; and
b.The date LTD Benefits become payable.
For amounts under a workers’ compensation law, the Jones Act, the Maritime Doctrine of
Maintenance, Wages or Cure, the Longshoremen’s and Harbor Worker’s Act, or any similar act or
law, the period of time used to prorate the amount cannot exceed the first to occur of the following:
a.The date you reach age 65, or the end of the Maximum Benefit Period, if later; and
b.The end of the stated period.
B.Your Duty To Pursue Deductible Income
You must pursue Deductible Income for which you may be entitled. We may ask for written
documentation of your pursuit of Deductible Income. You must provide it within 60 days after we
mail you our request.
Page 19 of 30
C.Estimating And Deducting
For any item of Deductible Income that includes amounts you, your Spouse, or your child are
entitled to receive, we may reduce your LTD Benefit by the amount we estimate you would be
entitled to receive if:
1.You have failed to pursue the Deductible Income with reasonable diligence;
2.We have a reasonable, good faith belief that you are entitled to the Deductible Income; and
3.We are able to reasonably estimate the amount that would be payable.
We will not estimate and deduct amounts with respect to a claim for Deductible Income that is
pending, so long as you continue to pursue the claim with reasonable diligence.
D.Retirement Benefits
1.Early retirement benefits will be Deductible Income only if you elect early retirement, or if early
retirement would not reduce your accrued annuity or pension benefits.
2.Retirement benefits received will not include amounts rolled over or transferred to any eligible
retirement plan as defined in the Internal Revenue Code.
E.Pending Deductible Income
We will not deduct pending Deductible Income until it becomes payable. You must notify us of the
amount of the Deductible Income when it is approved. You must repay us for the resulting
overpayment of your claim.
F.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. You will not receive any LTD
Benefits until we have been repaid in full. In the meantime, any LTD Benefits paid, 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.
LT.RU.CA.1
SURVIVORS BENEFIT
If you die while LTD Benefits are payable, and on the date you die you have been continuously
Disabled for at least 180 days, we will pay a Survivors Benefit according to 1 through 4 below.
1.The Survivors Benefit is a lump sum equal to 6 times your LTD Benefit without reduction by
Deductible Income.
2.The Survivors Benefit will first be applied to reduce any overpayment of your claim.
3.The Survivors Benefit will be paid to any one or more of the following:
a.Your surviving Spouse;
b.Your surviving unmarried children, including adopted children, under age 25;
c.Your surviving Spouse's unmarried children, including adopted children, under age 25; or
d.Any person providing the care and support of any person listed in a., b., or c. above.
4.No Survivors Benefit will be paid if you are not survived by any person listed in a., b., or c. above.
(MULTPL_DOM) LT.SB.CA.1
Page 20 of 30
CONVERSION OF INSURANCE
Conversion Of Insurance Benefit
When your insurance ends, you may buy LTD conversion insurance if you meet 1 through 5 below.
1.Your insurance ends for a reason other than:
a.Termination or amendment of the Group Policy;
b.Your failure to make a required premium contribution; or
c.Your retirement.
2.You were continuously insured under your Employer's long term disability insurance plan for at
least one year as of the date your insurance ended.
3.You are not Disabled on the date your insurance ends.
4.You are a citizen or resident of the United States or Canada.
5.You must apply in writing and pay the first premium to us within 31 days after your insurance
ends.
The maximum LTD conversion insurance benefit you may select is the smallest of:
1. $4,000
2.60% of your insured Predisability Earnings on the date your insurance ended; and
3.The LTD Benefit payable if you had become Disabled on the day before your insurance ended and
you had no Deductible Income.
The maximum LTD conversion insurance benefit is reduced by deductible income. The certificate we
will issue to you when your LTD conversion insurance becomes effective will contain other provisions
which will also differ from the Group Policy.
LT.CV.OT.2X
BENEFITS AFTER INSURANCE ENDS OR IS CHANGED
During each period of continuous Disability, we will pay LTD Benefits according to the terms of the
Group Policy in effect on the date you become Disabled. Your right to receive LTD Benefits will not be
affected by:
1.Any amendment to the Group Policy that is effective after you become Disabled.
2.Termination of the Group Policy after you become Disabled.
LT.BA.OT.1
EFFECT OF NEW DISABILITY
If a period of Disability is extended by a new cause while LTD Benefits are payable, LTD Benefits will
continue while you remain Disabled. However, 1 and 2 apply.
1.LTD Benefits will not continue beyond the end of the original Maximum Benefit Period.
2.The Disabilities Excluded From Coverage and Limitations sections will apply to the new cause
of Disability.
LT.ND.CA.1
Page 21 of 30
DISABILITIES EXCLUDED FROM COVERAGE
A.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.
B.Intentionally Self-Inflicted Injury
You are not covered for a Disability caused or contributed to by an intentionally self-inflicted
Injury, while sane or insane.
C.Preexisting Condition
1.Definition
Preexisting Condition means a diagnosed mental or physical condition for which you have
received medical treatment, care or services or have taken prescribed medication at any time
during the 90 day period just before your insurance becomes effective.
2.Exclusion
You are not covered for a Disability caused or substantially contributed to by a Preexisting
Condition or medical or surgical treatment of a Preexisting Condition unless, on the date you
become Disabled, you:
a.Have been continuously insured under the Group Policy for 12 months; and
b.Have been Actively At Work for at least one full day after the end of that 12 months.
D.Criminal Conduct
You are not covered for a Disability caused or contributed to by your committing or attempting to
commit a felony.
LT.XD.CA.1X
LIMITATIONS
A.Care Of A Physician
During the Benefit Waiting Period, you must be receiving care by a Physician which is appropriate
for the condition or conditions causing the Disability. No LTD Benefits will be paid for any period
of Disability when you are not receiving care by a Physician which is appropriate for the condition
or conditions causing the Disability. Appropriate care is the treatment a patient would make a
reasonable decision to accept after duly considering the opinions of medical professionals. This
limitation will not apply after you reach your maximum point of recovery.
B.Rehabilitation Program
No LTD Benefits will be paid for any period of Disability when you are not participating in good
faith in a plan, program or course of medical treatment or vocational training or education
approved by us unless your Disability prevents you from participating.
C.Foreign Residency
Payment of LTD Benefits is limited to 12 months for each period of continuous Disability while you
reside outside of the United States or Canada.
D.Imprisonment
Page 22 of 30
No LTD Benefits will be paid for any period of Disability when you are confined for any reason in a
penal or correctional institution.
E.Mental Disorder
Payment of LTD Benefits is limited to 24 months during your entire lifetime for a Disability caused
or contributed to by a Mental Disorder. However, if you are confined in a Hospital at the end of the
Mental Disorder Limitation Period, this limitation will not apply while you are continuously
confined.
Mental Disorder means any mental, emotional, behavioral, psychological, personality, cognitive,
mood or stress-related abnormality, disorder, disturbance, dysfunction or syndrome, regardless of
cause, (including any biological or biochemical disorder or imbalance of the brain) or the presence
of physical symptoms. Mental Disorder includes, but is not limited to, bipolar affective disorder,
organic brain syndrome, schizophrenia, psychotic illness, manic depressive illness, depression and
depressive disorders, or anxiety and anxiety disorders.
Hospital means a legally operated hospital providing full-time medical care and treatment under
the direction of a full-time staff of licensed Physicians. Rest homes, nursing homes, convalescent
homes, homes for the aged, and facilities primarily affording custodial, educational, or
rehabilitative care are not Hospitals.
F.Alcohol Use, Alcoholism Or Drug Use
Payment of LTD Benefits is limited to 24 months during your entire lifetime for a Disability caused
or contributed to by your use of alcohol, alcoholism, use of any drug, including hallucinogens, or
drug addiction.
G.Rules For Disabilities Subject To Limited Pay Periods
1.If you are Disabled as a result of more than one Physical Disease, Injury or Mental Disorder for
which LTD Benefits are payable for a limited period of time, the limitation periods will run
concurrently for all limited conditions.
2.If you are Disabled as a result of a Mental Disorder or any Physical Disease or Injury for which
LTD Benefits are payable for a limited period of time, and at the same time are Disabled as a
result of a Physical Disease, Injury or Pregnancy that is not subject to such limitation, LTD
Benefits will be payable first for conditions that are subject to a limitation before LTD Benefits
are payable for any condition that is not subject to a limitation.
3.No LTD Benefits will be payable after the ending date of the longest limitation period that
applies to your Disability, unless on that date you continue to be Disabled as a result of a
Physical Disease, Injury or Pregnancy for which payment of LTD Benefits is not limited.
(SBST_MAND REHB_PRIS_FOR RES) LT.LM.CA.1
CLAIMS
A.Notice Of Claim
Written notice of claim must be provided to us within 60 days after the date you claim you became
Disabled, or as soon thereafter as is reasonably possible.
B.Filing A Claim
Claims should be filed on our forms. If we do not provide our forms within 15 days after they are
requested, you may submit your claim in a letter to us. The letter should include the date
disability began, and the cause and nature of the disability. Subject to the time period for
providing notice of claim, such letter will constitute notice and proof of claim.
C.Time Limits On Filing Proof Of Loss
Page 23 of 30
You must give us Proof Of Loss within 90 days after the end of the Benefit Waiting Period. If your
claim was closed, you must give us Proof Of Loss within 90 days after the date LTD Benefits ended.
If you cannot do so, you must give it to us as soon as reasonably possible, but not later than one
year after that 90-day period. If Proof Of Loss is filed outside these time limits, your claim will be
denied. These limits will not apply while you lack legal capacity.
D.Proof Of Loss
Proof Of Loss means written proof that you are Disabled and entitled to LTD Benefits. Proof Of
Loss must be provided at your expense.
For claims of Disability due to conditions other than Mental Disorders, we may require proof of
physical impairment that results from anatomical or physiological abnormalities which are
demonstrable by medically acceptable clinical and laboratory diagnostic techniques. Examples of
clinical and laboratory diagnostic techniques include but are not limited to actual observations
upon physical examinations, blood tests, imaging studies (such as x-rays, MRIs and CT scans),
electrocardiograms (EKG) and electroencephalograms (EEG).
E.Documentation
Completed claims statements, a signed authorization for us to obtain information, and any other
items we may reasonably require in support of a claim must be submitted at your expense. If the
required documentation is not provided within 45 days after we mail our request, your claim may
be denied.
F.Investigation Of Claim
We may investigate your claim at any time.
At our expense, we may have you examined at reasonable intervals by specialists of our choice.
We may deny or suspend LTD Benefits if you fail to attend an examination or cooperate with the
examiner.
G.Time Of Payment
We will pay LTD Benefits within 60 days after you satisfy Proof Of Loss.
LTD Benefits will be paid to you at the end of each month you qualify for them. LTD Benefits
remaining unpaid at your death will be paid to the person(s) receiving the Survivors Benefit. If no
Survivors Benefit is paid, the unpaid LTD Benefits will be paid to your estate.
H.Notice Of Decision On Claim
We will evaluate your claim promptly after you file it. Within 45 days after we receive your claim
we will send you: (a) a written decision on your claim; or (b) a notice that we are extending the
period to decide your claim for 30 days. Before the end of this extension period we will send you:
(a) a written decision on your claim; or (b) a notice that we are extending the period to decide your
claim for an additional 30 days. If an extension is due to your failure to provide information
necessary to decide the claim, the extended time period for deciding your claim will not begin until
you provide the information or otherwise respond.
If we extend the period to decide your claim, we will notify you of the following: (a) the reasons for
the extension; (b) when we expect to decide your claim; (c) an explanation of the standards on
which entitlement to benefits is based; (d) the unresolved issues preventing a decision; and (e) any
additional information we need to resolve those issues.
If we request additional information, you will have 45 days to provide the information. If you do
not provide the requested information within 45 days, we may decide your claim based on the
information we have received.
If we deny any part of your claim, you will receive a written notice of denial containing:
a.The reasons for our decision.
Page 24 of 30
b.Reference to the parts of the Group Policy on which our decision is based.
c.A description of any additional information needed to support your claim.
d.Information concerning your right to a review of our decision.
I.Review Procedure
If all or part of a claim is denied, you may request a review. You must request a review in writing
within 180 days after receiving notice of the denial.
You may send us written comments or other items to support your claim. You may review and
receive copies of any non-privileged information that is relevant to your request for review. There
will be no charge for such copies. You may request the names of medical or vocational experts
who provided advice to us about your claim.
The person conducting the review will be someone other than the person who denied the claim and
will not be subordinate to that person. The person conducting the review will not give deference to
the initial denial decision. If the denial was based on a medical judgment, the person conducting
the review will consult with a qualified health care professional. This health care professional will
be someone other than the person who made the original medical judgment and will not be
subordinate to that person. Our review will include any written comments or other items you
submit to support your claim.
We will review your claim promptly after we receive your request. Within 45 days after we receive
your request for review we will send you: (a) a written decision on review; or (b) a notice that we are
extending the review period for 45 days. If the extension is due to your failure to provide
information necessary to decide the claim on review, the extended time period for review of your
claim will not begin until you provide the information or otherwise respond.
If we extend the review period, we will notify you of the following: (a) the reasons for the extension;
(b) when we expect to decide your claim on review; and (c) any additional information we need to
decide your claim.
If we request additional information, you will have 45 days to provide the information. If you do
not provide the requested information within 45 days, we may conclude our review of your claim
based on the information we have received.
If we deny any part of your claim on review, you will receive 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.Information concerning your right to receive, free of charge, copies of non-privileged documents
and records relevant to your claim.
J.Assignment
The rights and benefits under the Group Policy are not assignable.
(REV PUB WRDG) LT.CL.CA.1
TIME LIMITS ON LEGAL ACTIONS
No action at law or in equity may be brought until 60 days after you have given us Proof Of Loss. No
such action shall be brought after the expiration of three years after the date Proof Of Loss is required
to be given.
LT.TL.CA.1
Page 25 of 30
INCONTESTABILITY PROVISIONS
A.Incontestability Of Insurance
Any statement made to obtain insurance or to increase insurance is a representation and not a
warranty.
No misrepresentation will be used to reduce or deny a claim or contest the validity of insurance
unless:
1.The insurance would not have been approved if we had known the truth; and
2.We have given you or any other person claiming benefits a copy of the signed written
instrument which contains the misrepresentation.
After insurance has been in effect for two years, during the lifetime of the insured, we will not use
a misrepresentation by you to reduce or deny your claim, unless it was a fraudulent
misrepresentation.
B.Incontestability Of The Group Policy
Any statement made by the Policyholder or Employer to obtain the Group Policy is a representation
and not a warranty.
No misrepresentation by the Policyholder or your Employer will be used to deny a claim or to deny
the validity of the Group Policy unless:
1.The Group Policy would not have been issued if we had known the truth; and
2.We have given the Policyholder or Employer a copy of a written instrument signed by the
Policyholder or Employer which contains the misrepresentation.
The validity of the Group Policy will not be contested after it has been in force for two years, except
for fraudulent misrepresentations.
LT.IN.CA.1
CLERICAL ERROR, AGENCY, AND MISSTATEMENT
A.Clerical Error
Clerical error by the Policyholder, your Employer, or their respective employees or representatives
will not:
1.Cause a person to become insured.
2.Invalidate insurance under the Group Policy otherwise validly in force.
3.Continue insurance under the Group Policy otherwise validly terminated.
B.Agency
The Policyholder and your Employer act on their own behalf as your agent, and not as our agent.
The Policyholder and your Employer have 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.
C.Misstatement Of Age
If a person's age has been misstated, we will make an equitable adjustment of premiums, benefits,
or both. The adjustment will be based on:
1.The amount of insurance based on the correct age; and
Page 26 of 30
2.The difference between the premiums paid and the premiums which would have been paid if
the age had been correctly stated.
LT.CE.OT.1
TERMINATION OR AMENDMENT OF THE GROUP POLICY
The Group Policy may be terminated by us or the Policyholder according to its terms. It will terminate
automatically for nonpayment of premium. The Policyholder may terminate the Group Policy in whole,
and may terminate insurance for any class or group of Members, at any time by giving us written
notice.
Benefits under the Group Policy are limited to its terms, including any valid amendment. No change
or amendment will be valid unless it is approved in writing by one of our executive officers and given to
the Policyholder for attachment to the Group Policy. If the terms of the certificate differ from the
Group Policy, the terms stated in the Group Policy will govern. The Policyholder, your Employer, and
their respective employees or representatives have no right or authority to change or amend the Group
Policy or to waive any of its terms or provisions without our signed written approval.
We may change the Group Policy in whole or in part when any change or clarification in law or
governmental regulation affects our obligations under the Group Policy, or with the Policyholder's
consent.
Any such change or amendment of the Group Policy may apply to current or future Members or to any
separate classes or groups of Members.
LT.TA.OT.1
DEFINITIONS
Benefit Waiting Period means the period you must be continuously Disabled before LTD Benefits
become payable. No LTD Benefits are payable for the Benefit Waiting Period. See Coverage Features.
Contributory means insurance is elective and Members pay all or part of the premium for insurance.
CPI-W means the Consumer Price Index for Urban Wage Earners and Clerical Workers published by
the United States Department of Labor. If the CPI-W is discontinued or changed, we may use a
comparable index. Where required, we will obtain prior state approval of the new index.
Eligibility Waiting Period means the period you must be a Member before you become eligible for
insurance. Your Eligibility Waiting Period is shown in the Coverage Features.
Employer means an employer (including approved affiliates and subsidiaries) for which coverage under
the Group Policy is approved in writing by us.
Group Policy means the group LTD insurance policy issued by us to the Policyholder and identified by
the Group Policy Number.
Indexed Predisability Earnings means your Predisability Earnings adjusted by the rate of increase in
the CPI-W. During your first year of Disability, your Indexed Predisability Earnings are the same as
your Predisability Earnings. Thereafter, your Indexed Predisability Earnings are determined on each
anniversary of your Disability by increasing the previous year's Indexed Predisability Earnings by the
rate of increase in the CPI-W for the prior calendar year. The maximum adjustment in any year is
10%. Your Indexed Predisability Earnings will not decrease, even if the CPI-W decreases.
Injury means an injury to the body.
L.L.C. Owner-Employee means an individual who owns an equity interest in an Employer and is
actively employed in the conduct of the Employer's business.
LTD Benefit means the monthly benefit payable to you under the terms of the Group Policy.
Page 27 of 30
Maximum Benefit Period means the longest period for which LTD Benefits are payable for any one
period of continuous Disability, whether from one or more causes. It begins at the end of the Benefit
Waiting Period. No LTD Benefits are payable after the end of the Maximum Benefit Period, even if you
are still Disabled. See Coverage Features.
Noncontributory means (a) insurance is nonelective and the Policyholder or Employer pay the entire
premium for insurance; or (b) the Policyholder or Employer require all eligible Members to have
insurance and to pay all or part of the premium for insurance.
P.C. Partner means the sole active employee and majority shareholder of a professional corporation in
partnership with the Policyholder.
Physical Disease means a physical disease entity or process that produces structural or functional
changes in the body as diagnosed by a Physician.
Physician means a licensed medical professional, diagnosing and treating individuals within the scope
of the license. The term includes a legally licensed physician, dentist, optometrist, podiatrist,
psychologist or chiropractor. Physician does not include you or your Spouse, or the brother, sister,
parent or child of either you or your Spouse.
Pregnancy means your pregnancy, childbirth, or related medical conditions, including complications of
pregnancy.
Prior Plan means your Employer's group long term disability insurance plan in effect on the day before
the effective date of your Employer's participation under the Group Policy and which is replaced by
coverage under the Group Policy.
Spouse means:
1.A person to whom you are legally married; or
2.Your Domestic Partner. Your Domestic Partner means an individual recognized as such under
California state law.
(DOM STAT) LT.DF.CA.1
POLICYHOLDER PROVISIONS
A.Premiums
The premium due on each Premium Due Date is the sum of the premiums for all persons then
insured. Premium Rates are shown in Coverage Features.
B.Contributions From Members
The Policyholder determines the amount, if any, of each Member's contribution toward the cost of
insurance.
C.Changes In Premium Rates
We may change Premium Rates whenever:
1.A change or clarification in law or governmental regulation affects the amount payable under
the Group Policy. Any such change in Premium Rates will reflect only the change in our
obligations.
2.Factors material to underwriting the risk we assumed under the Group Policy with respect to
an Employer, including, but not limited to, number of persons insured, age, Predisability
Earnings, gender, and occupational classification, changes by 25% or more. We may change
Premium Rates due to such changes upon 90 days advance written notice to the Policyholder.
[NOTE: The preceding wording is subject to approval by the California DOI, and may not be
included in a final policy until such approval is received.]
Page 28 of 30
3.The premium contribution arrangement for Members is changed or varies from that stated in
the Group Policy when issued or last renewed.
4.We and the Policyholder or the Employer mutually agree to change Premium Rates.
Except as provided above, Premium Rates will not be changed during the Initial Rate Guarantee
Period shown in Coverage Features. Thereafter, except as provided above, we may change
Premium Rates upon 180 days advance written notice to the Policyholder. Any such change in
Premium Rates may be made effective on any Premium Due Date, but no such change will be
made more than once in any contract year. Contract years are successive 12 month periods
computed from the end of the Initial Rate Guarantee Period.
D.Payment Of Premiums
All premiums are due on the Premium Due Dates shown in Coverage Features.
Each premium is payable on or before its Premium Due Date directly to us at our home office. The
payment of each premium by the Policyholder as it becomes due will maintain the Group Policy in
force until the next Premium Due Date.
E.Grace Period And Termination For Nonpayment
If a premium is not paid on or before its Premium Due Date, it may be paid during the following
Grace Period of 90 days. The Group Policy or an Employer's coverage under the Group Policy will
remain in force during the Grace Period.
If the premium is not paid during the Grace Period, the Group Policy will terminate automatically
at the end of the Grace Period.
The Policyholder is liable for premium for coverage during the Grace Period. We may charge
interest at the legal rate for any premium which is not paid during the Grace Period, beginning
with the first day after the Grace Period.
F.Termination For Other Reasons
The Policyholder may terminate the Group Policy by giving us written notice. The effective date of
termination will be the later of:
1.The date stated in the notice; and
2.The date we receive the notice.
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 shown in Coverage Features.
2.On any Premium Due Date if we determine that the Policyholder has failed to promptly furnish
any necessary information requested by us, or has failed to perform any other obligations
relating to the Group Policy.
The minimum advance notice of termination by us is 180 days.
G.Premium Adjustments
Premium adjustments involving a return of unearned premiums to the Policyholder will be limited
to the 12 months just before the date we receive a request for premium adjustment.
H.Certificates
We will issue certificates to the Policyholder showing the coverage under the Group Policy. The
Policyholder will distribute a certificate to each insured Member. If the terms of the certificate
differ from the Group Policy, the terms stated in the Group Policy will govern.
I.Records And Reports
Page 29 of 30
The Policyholder will furnish on our forms all information reasonably necessary to administer the
Group Policy. We have the right at all reasonable times to inspect the payroll and other records of
the Policyholder which relate to insurance under the Group Policy.
J.Agency And Release
Individuals selected by the Policyholder or by any Employer to secure coverage under the Group
Policy or to perform their administrative function under it, represent and act on behalf of the
person selecting them, and do not represent or act on behalf of Standard. The Policyholder,
Employer and such individuals have 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. The
Policyholder and each Employer hereby release, hold harmless and indemnify Standard from any
liability arising from or related to any negligence, error, omission, misrepresentation or dishonesty
of any of them or their representatives, agents or employees.
K.Notice Of Suit
The Policyholder or Employer shall promptly give us written notice of any lawsuit or other legal
proceedings arising under the Group Policy.
L.Entire Contract, Changes
The Group Policy and the applications of the Policyholder constitute the entire contract between
the parties. A copy of the Policyholder's application is attached to the Group Policy when issued.
The Group Policy may be changed in whole or in part. No change in the Group Policy will be valid
unless it is approved in writing by one of our executive officers and given to the Policyholder for
attachment to the Group Policy. No agent has authority to change the Group Policy, or to waive
any of their provisions.
M.Effect On Workers' Compensation, State Disability Insurance
The coverage provided under the Group Policy is not a substitute for coverage under a workers'
compensation or state disability income benefit law and does not relieve the Employer of any
obligation to provide such coverage.
(NO DIV) LT.PH.OT.1
CA/LTDP2000(CA09)
Page 30 of 30
EXHIBIT B
STANDARD INSURANCE COMPANY
Employee Benefits -Underwriting
Application for Group Insurance
900 SW Fifth Ave. Portland, OR 97204 -1282
Please type or print REQUESTED EFFECTIVE DATE 41112021
APPLICANT
Full Legal Name of Group (Exactly as it is to be shown in the policy.)
County of Fresno
Street Address 2220 Tulare St., 14th Floor
City Fresno State CA Zip Code _9_37_2_1 _____ _
Phone No.(~) 600-1810 ext. 4 Fax No. (~) _4_55_-4_7_8_7 ____ Email hrnaglll@fresnocountyca.gov
Group Contact _H_o_ll_ls_M_a_g_i_ll ___________ Contact's Title Interim Director of Human Resources
Contact's Phone No. if different( __ ) Contact's Fax No. if different( __ ) _________ _
Nature of Business Government ------------------------------------
INSURANCE COVERAGE REQUESTED
D Life Only D Supplemental Life D Dental/Employees
D Life and AD&D D Additional/Optional Life D Dental/Employees and Dep(s)
D Dependent Life D Stand Alone AD&D D Dental/Orthodontia
D Eye Care
[!I LTD
•STD
D Accident * D ____ _
D Critical Illness'
D Hosp ital Indemn ity *
D Statutory {State & Product) ______________________________ _
'I understand and agree if Applicant utilizes an enrollment platform not directly supported by The Standard, that Applicant is required to
and will timely present to each enrollee appropriate disclosures and any state mandated fraud notices which are contained on the supplied
enrollment form.
OTHER INSURANCE
A. Does this insurance supplement other insurance? D Yes 0 No
If yes, specify for each line of coverage and Insurance Carrier: _________ _
B.
ATTEST:
BERNICE E. SEIDEL
Clerk of the Board of Supervisors
Cou~o, State of California
By ~ Deputy Does this insurance replace existing insurance? 0 Yes D No
If yes , specify for each existing line of coverage: LTD • Met Life -------------------------
• Please submit a copy of each in force policy, certificate or plan document.
Effective date of Prior Plan: 411/2014 Termination date of Prior Plan: 3/31/2021 -----------
ACTIVE WORK REQUIREMENT: A person must meet an Active Work requirement to become insured . Members who have not met an
Active Work re~rement are not insured until returning to work for one full day and meeting all other contractual requi~ements.
Initial: <;
Note : Some members who do not meet an Active Work requirement may be eligible for Waiver of Premium with a prior carrier.
APPLICANT AGREES THAT: I hereby apply for Group Insurance as provided in the attached proposal.
The above information is true and correct to the best of the Applicant's know ledge and bel ief. It forms the basis for th is request for group insurance .
If the requested insurance is acceptable to Standard Insurance Company under its current rules and practices and is legally permiss ible,
a Group Policy will be issued in the language customari ly used by Standard. It will be effective on the date determ ined by St andard . No
producer has the authority to guarantee the acceptability of the requested insurance .
Standard may issue separate Group Policies if more than one coverage is requested in this Application . The insurance, if approved, will
be subject to Standard Insurance Company's usual underwr iting requirements, including the exclusions and limitat ions in the Group Policy
and, if applicable, Evidence Of lnsurability. The effective date of insurance for wh ich a person is required to submit satisfactory Evidence Of
lnsurability will be determined in accordance with the terms of the Group Policy, subject to the Active Work requirement. No premiums will
be collected or pa id by the Applicant for such insurance until not ification of approval.
No material descr ibing coverage under the Group Policy will be distributed by the Appl icant to any person to be insured without the prior
written consent of Standard Insurance Company.
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SI 08-7364 1 Of 2 (10/19)
EXHIBIT C
SELF-DEALING TRANSACTION DISCLOSURE FORM
In order to conduct business with the County of Fresno (hereinafter referred to as “County”),
members of a contractor’s board of directors (hereinafter referred to as “County Contractor”), must
disclose any self-dealing transactions that they are a party to while providing goods, performing
services, or both for the County. A self-dealing transaction is defined below:
“A self-dealing transaction means a transaction to which the corporation is a party and in which one
or more of its directors has a material financial interest”
The definition above will be utilized for purposes of completing this disclosure form.
INSTRUCTIONS
(1)Enter board member’s name, job title (if applicable), and date this disclosure is being made.
(2)Enter the board member’s company/agency name and address.
(3) Describe in detail the nature of the self-dealing transaction that is being disclosed to the
County. At a minimum, include a description of the following:
a.The name of the agency/company with which the corporation has the transaction; and
b.The nature of the material financial interest in the Corporation’s transaction that the
board member has.
(4) Describe in detail why the self-dealing transaction is appropriate based on applicable
provisions of the Corporations Code.
(5) Form must be signed by the board member that is involved in the self-dealing transaction
described in Sections (3) and (4).
(1) Company Board Member Information:
Name: Date:
Job Title:
(2)Company/Agency Name and Address:
(3) Disclosure (Please describe the nature of the self-dealing transaction you are a party to):
(4)Explain why this self-dealing transaction is consistent with the requirements of Corporations Code 5233 (a):
(5)Authorized Signature
Signature: Date: