HomeMy WebLinkAbout1970_REPUBLIC NATIONAL LIFE
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REPUBLIC NATIONAL LIFE INSURANCE COMPANY
M041 OFFICE • M111 N. CENTRAL EXPRESSWAY 4 DALLAS, TEXAS
(Herein called the Company)
In Consideration of the application for this Policy made by
_......O. _.TEI(AS . _
(}Icrein called the Group Policyholder)
and the payment by the Group Policyholder of all premiums when due as hereinafter provided, the Company agrees to
make the payments hereinafter provided to the individual or individuals entitled thereto, subject to the provisions and
conditions of this Policy.
The initial premium is due on the date of issue hereof and subsequent premiums shall be due...... MOR;MLX
on MAY ...I 19..69...and on the same day of each................ ~o.NTH thereafter.
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Policy anniversaries shall be ....................A.P.[i.1.6...1.~.. 1.9.ZU....... and the some day of each year thereafter.
The provisions and conditions set forth on the following pages hereof are a part of this Policy as fully as if recited
over the signatures hereto affixed.
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In Witness Whereof, the Republic National Life Insurance Company has by its President and Secretary signed, and
by its Registrar countersigned, this Policy at its Home Office in Dallas, Texas, this 1.sT......_..dayof.......APRIL
19.P9..., which is the date of issue hereof.
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fti President
Secretary
Coun tens igncd ...........................................................Registrar
GROUP ACCIDENT AND SICKNESS INSURANCE POLICY
GROUP POLICY NO. GA....... 11.572------ -NONPARTICIPATING
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OA I000A4 TFTLE PACE
REPUBLIC NATIONAL LIFE INSURANCE COMPANY
DALLAS, TEXAS
ENDORSEMENT TO BE ATTACHED TO AND MADE A PART OF THIS CERTIFICATE.
THE MAJOR MEDICAL EXPENSE BENEFIT 15 HEREBY AMENDED TO INCLUDE THIS
PROVISION:
CGJTOMA TIC ANNUAL REINSTATEMENT OF MAJOR MEDICAL BENEFITS -
ON JANUARY 1ST OF EACH YEAR THERE SHALL BE AN AUTOMATIC RE-
INSTATEMENT FOR EACH INSURED INDIVIDUAL "HOSE MAJOR MEDICAL
MAXIMUM HAS BEEN REDUCED BELOW THE ORIGINAL MAJOR MEDICAL
MAXIMUM BY PAYMENT OF BENEFITS. THE AMOUNT OF SUCH REIN-
STATEMENT SHALL BE EQUAL TO THE LESSER OF THE AMOUNT OF BEN-
EFITS PAID OR $1,000.00, BUT IN NO EVENT SHALL THE MAJOR
MEDICAL MAXIMUM FOR THE INSURED INDIVIDUAL EXCEED THE ORIG-
INAL MAJOR MEDICAL MAXIMUM SPECIFIED BY THE PLAN.
EXCEPT AS STATED IN THIS ENDORSEMENT, NOTHING CONTAINED HEREIN SHALL
BE HELD TO ALTER OR AFFECT ANY OF THE PROVISIONS OF THE POLICY.
REPUBLIC NATIONAL LIFE INSURANCE COMPANY
GEORGE(
VICE-PRE iDENT
ATTEST:
VICE PRES4LT NO
4
A SSISTANT SECRETARY
GC-1165-566
SECTION 11 A - NON-DUPLICA'T'ION PROVISIONS
The provisions of this Section (h.rrin called rhese provisions) are for co-ordination of bcncfits under this Policy with
other benefits. The following Sections of this Policy are subject to these provisions:
Section IG Section 19 Section 22
Section 17 Section 20 Section 23
Section 18 Section 21 Section 24
DEFINITION 01° WORDS AND TERMS USED IN T;IIS SECTION, 'Ihr ward "Plan" means any plan pro-
viding bcncfits or services for or 1>y reason of medical or dental care or rreaunenr, whirl, hcnefits or services are provided by
f a) any group, franchise, hospir.Il, nurlicai nr other rcrvice, prepayment or other coverage arranged tl.rough any
employer, trustee, union, employer benefit or other association; or
(b) any coverage under governmental programs, and any coverage required or provided by any statute; or
(c) any owerage sponsored by, or provided through, a school or other educational institution.
the word "Plan" shall be construed sepanuely with respect it) each Ix)licy, contract, or other arrangement for benefits or
services and separately with respect to that portion of any such }xvlicy, contract, or olicr arrangement which reserves the
right to take the benefits or services of other Plans into eonsidcration in derermining its benefits and that portion which
does not.
The reran "this Plan" means those Sections of this Policy which provide the benefits that are subject to these provisions.
The term "Allowable Expense" means any necessary, reasonable, and customary Item of expense at least a portion
of which is covered under at least one of the Plans covering the individual for whoin claim is made, When a Plan provides
benefits in the form of services rather than cash payments, the reasonable cash value of each service rendered shall be
deemed to be both an Avowable Expense and a benefit paid.
Thk term ;"Ciairn Determination Period" means, for any individual, that portion (if a calendar year during which he
would be eligible to receive benefits under this Policy in the absence of this Section I IA.
EFFEC'T' ON BENEFITS. These provisions shall apply in determining the benefits as to an Individual covered under
this Plan for any Claim Determination Period if, for the Allowable Expense incurred as to much individual during such
period; the stun of
(a) the benefits that would be payable under this Plan in the absence of these provisions; and
(b) the benefits that would be payable under all other Plans in the absence therein of provisions of similar purpose
to these provisions
wot,ld exceed such Allowable Expenses.
As to any Claim Determination Period with respect to which these provisions are applicable, the benefits that would
be payable ender this Plan in the absence of these provisions for the Allowably Expenses Incurred as to such individual
during such Claim Determination Period shall be reduced to the extent necessary so that the sum of such reduced benefits
and all the benefits payable for such Allowable Expenses under all other Plans, except as provided in the next paragraph,
shall not exceed the total of such Allowable ExpGuses. 15cnefits payable under another Plan include the benefits that would.
have been payable had claim been duly made therefor,
if
(a) another Plan which is involved in the preceding paragraph and which contains a provision c(>otdinating
Its bencfrti with those of this Plan would, according to its rules, determine its benefits after the benefits of this
Plan have been determined; and
(b) the rules sr. forth in the next paragraph would require this Plan to dciti mine its benefits before such other
Plan;
then the benefits of such other Plan will be ignored for the purposes of determining the benefits under this Plan.
GENERAL PROVISIONS
1 l !r S ~ ~ r~, I !i l•l I' i ) - 1 .r 1 • l,';+ y ~ t ~ 1
OA-1000RKS" Sodiei IIA-NON DUPIICAIION PROVISIONS
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SECTION 1IA - NON-DUPLICATION PROVISIONS (Continued)
)'or the purlwscs of these provisions the rules cstablislting the order of benefit determination are:
(a ) the benefits of a Plan which covers the individual on whose ex pew vs claim is based other than as a dependent
shall be dctcrmincd before the bent fits of a Plan which covers such individual as a dependent;
(b) the benefits of a Plan which covers the individual on whose expennses claim is based as a dependent of a male
individual shall be determined before the benefits of a Plan whiclt covers such individual as a dependent of a
female individual;
(c) when rules (a) and (b) in this p.uagraph do not establish an order of benefir determination, the bcnef.ts
of a Plan which has covered the individual on whtnc expenses claim it based for the longer period of time
shall be tleterrtined K,fore the benefits of a Plan which has covered tech individual the shorter period of
time.
When these provisions operate to reduce the total amount of benefits uthcrw kc payahlc as to an individual covered
under this Plan during any Claim Ikccnnination Period, each benefit that would be payable in the absence of these provisions
shall be reduced proportionately, and such reduced amount shall be charged against any applicable benefit limit of this Plan.
RIGHT TO RECEIVE AND RELEASF NECESSARY INFORMATION. For the purposes of determining the
applicability of and implementing the terms of these provisons under this Plan or any provision of similar purpose of any
other Plan, the Company may, without the consent of or notice to any individual, redraw to or obtain from any other insur•
ante company or other organization or individual any information, with respect to any individual, which the company
deems to be necessary for such lnirposes. Any individual claiming benefits under this Plan shall rutnish to the Company
such information as may be necessary to implemen, these provisions.
FACILITY OF PAYMENT. \%'henever pa)rnents which should have been made under this Plan in accordance with
these provisions have been made under any other Plans, the Company shall have the right, exercisable alone and in its
sole discretion, to pay over to any organizations malting such other payments any amounts it shall determine to be warranted
in ordet to satisfy the intent of these provisions, and amounts so paid shall be deemed to be benefits paid under th)s Plan
and, to the extent of such payments, the Company shall be fully discharged from liability under this Plan.
RIGHT OF RECOVERY. Whenever payments have been made by the Company with respect to Allowable Experts"
in a total amount, at any time, in excess of ;he maximum amount of payment necessary it that time to satisfy the intent of
these provisions, the Company shall have the right to recover such payments, to the extent of such excess, from atmgng
one or more of the following, as the Company shall determine: airy individuals to or for or with respect to whom such
pa)ments were made, any pther, insurance companies, any other organizations.
INDIVIDUAL POLICIES. Pa) meats or reductions in payments made under the provisions of this Section of the Polity
shall not affect nor be affected by payments made under any individual policy.
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GENERAL, PROVISIONS
ai It10aUtl66 Section 11A - NON OU►LICAIION PROVISIONS
TABLE OF CONTENTS
General Provisions Section
IX Ili n it ions
Contract 2
liligibi?ity
Individual FIfCCtieC Dates _ _ _ _ 4
lmlividual Tertninations . _ _ . - . 5
Individual Kcinstatements _ 6
Premiums 7
Grace PetiOKI . 8
Renewal of Policy . 9
Notice and Proof of Clain„ 10
Payment of liencfi:s.,.. _ . 11
Facility of Payment...... _
Conversion 12A
Schedule of Insurance. 13
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Insurance Provisions
ACCIDENTAL DEATH AND DISMEMBERMENT . . . . . . . . . . . . . . . . 14
HOSPITAL . . . . . . . . . . . . . . . . . . . . . . . . . 16
SURGICAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
PREGNANCY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
PHYSICIAN VISITS . . . . . . . . . . . . . . . . . . . . . . . . 19
SUPPLEMENTARY ACCIDENT . . . . . . . . . . . . . . . . . . . . . . . . . . 21
MAJOR MEDICAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
OA 10001181 TABLE Of CONTENTS
SECTION 1 -DEFINITION OF WORDS AND TERMS USED IN THIS POLICY
The word "Person" means any individual WHO IS A FULL-TIME EMPLOYEE WoRKIt:G A MINIMUM OF
TIiIRTY HOURS A WEEK. WITH THE GROUP POLICYHOLDER.
The word "Dependent" means only a Person's._......w! , , , , if nor legally separated, and each
unmarried child. FQuR_f,eErl„o.aYS,._, but less than nineteen years of age, provided such individual is not eligible under
this Policy for Personal Insurance as hereinafter defined and is not in the Armed Forces of any country. In addition to any
natural born child of the Person, the word "child" includes any legally adopted child, or stepchild or foster child who resides
in the Person's household and is dependent upon such Person for his principal support and maintenance.
THE WORD it DEPENDENT" SHALL ALSO INCLUDE THE UNMARRIED CHILDREN UP TO TWENTY-FOUR
YEARS OF AGE WHO ARE REGULARLY ATTLNDING AN ACCREDITED COLLEGE OR UNIVERSITY.
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The term "actual cost" means those charges for any services, treatment or supplies not in excess of the usual and
customary charges therefor, or not in excess of such charges as would have been made in the absence of this insurance,
The term "Personal Insurance" means the insurance provided under this Policy with respect to a Person insured.
The term "Dependents Insurance" means the insurance provided under this Policy with respect to a Dependent of a
Person insured for Dependents Insurance. Any reference hereinafter made to a Person's Dependent being insured under
any Insurance Provision of this Policy shall mean a Dependent with respect to whom such Person is insured rhev!undcr
for Dependents Insurance.
The vord "physician" means only a legally licensed Doctor of Medicine or Osteopathy.
The term "Hospital" whereter used herein shall mean a lawfully constituted hr,spital, licensed by the state in which
it is located, if the laws of such state provide for licensing a hospital, but, in any event, such hospital shall have provision
for over-night care of patients with a registered graduate nurse (RN) in attendance twempfour hours a day, with a
physician on call, and with provisions within the hospital for feeding of patients and facilities for major operations and for
x-ray and labo-atory tests. The word "Hospital" does not include clinics or rest homes unless they qualify under the
above definition. An institution meeting all the preceding requirements for qualifications as a "hospital", except those
relating to facilities for major operations and x-ray and laboratory tests, which is constituted primarily for the care and
treatment of mental or tuberculosis patients shall be deemed a "Mental" or "Tuberculosis" hospital. Amounts payible for
confinement in such a hospital shall be limited to daily room grid board only.
The term "insurance month" means that period of time beginning at IMI a.m. on the first day of any calendar
month and ending at 12 midnight on the last day of the same calendar month.
OA 10000161 SECTION 1 - DIIINItIONS
SECTION 2 -CONTRACT
ENTIRE POLICY. This Policy, the application of the Group Policyholdct (a wpy of which is attached hereto)
and the individual applications, if any, of Petsons insured shall constitute the cnrire contract bctween the parties. All
statements made by the Group Policyholder or by the Persons insured shall be deemed rcprescntations and not warranties.
No statement made by any Pcrscm insured shall be used in any contest unless a cr py of the instrument containing the
statement is or has been furnished to such Person or to his beneficiary.
No eiAunt ur other individual exctpt an Officer of the Comp,my has authority to make or modify this Policy or extend
the rims f„t payment of aoy premium.
No change in this Policy shall be %.did unless nrtde by crndursemrnr hereon, o• by urnendwent signed by the Group
Policyholder and an Olficcr of the Company. Any change so made shall be binding on each Person insured and on any
other individual of individuals referred to in this Policy.
DfaSkUline pronouns used in this Policy shall include lxsth masculine and feminine gender unless the context
indicates otherwise.
INCONTESTABILITY. No statement made by any Person insured under this Policy relating to his or his Dependents
insurability shall be used in contcsring the validity of the insurance with respect to which such statement was made after
such insurance has been in force prior m the wnttrst for a period of one year during such Person's lifetime not unless it is
contained in a written instrument signed by the Person.
POLICY NONPARTICIPATING-EXPERIENCE RATING PLAN, This Policy is not entitled to share in the
surplus earnings 3f the Company.
At the end of each policy year after the first, this Policy shall be subject to experience rating in accordance witL the
Company's experience rating plan then in use, w)ich experience rating plan shall rake into account those reserves which
the Company shat determine to be necessary or alvisable. Any refund which develops from the experience rating shall he
paid in cash to the Group Policyholder or upon written notice to the Company by the Group Policyholder, may be applied
by the Group Policyholder toward payment of the premiums next falling due under this Policy.
INFORMATION TO BE FURNISHED. The Group Policyholder shall furnish such information as is necessary
to administer this Policy whenever rcquired by he Company, Uerical error on the part of the Group Policy:toldcr in
furnishing such information shall not invalidate insurance otherwise in force, not continue insurance otherwise terminatc d.
Upon discovery of any such error an equitable adjustment shall be made in the premiums.
Records of the Group Policyholder and Participating Units, if any, which relate to this Pulley may be inspcctcd by the
Company at any reasonable time.
CERTIFICATES. The Company will furnish the Group Policyholder an individual certificate for delivery to each
Person insured setting forth, in summary form, the essential features of such Pcrsun's insurance and to whom the benefits
are payable.
FREE CHOICE OF PHYSICIAN. The Pcrson insured shall have free choice of any physician. The Company
shall in no way distutb the physician-patient relationship.
WORKMEN'S COMPENSATION NOT AFFECTED. This Policy is not in lieu of and does not affect any
requirements for coverage by Workmen's Compensation Insurance.
GENERAL PROVISIONS
OA IOOOD161 SEMON Z - CONtRACt
SECTION 3 -ELIGIBILITY
PERSONAL INSURANCE,. Each Person becomes eligible for the Personal Insurance applicable to his classification
on;
~A~ THE BATE OF ISSUE OF THIS POLICY, IF A FULL-TIME EMPLOYEE WORKING A
MINIMUM OF THIRTY POURS A WEEK WITH THE GROUP POLICY11OLDER ON THAT
DATE; OR
{B~ THE DATE OF FULL-TIME EMPLOYMENT WITH THE GROUP POLICYHOLDER, IF
SUCII DATE IS SUBSEQUENT TO THE DATE OF ISSUE OF THIS POLICY.
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DEPENDENTS INSURANCE. Each Person becomes eligible for the Dependents Insurance applicable to his
classification on the latest of the following dares:
(a) the date of issue of this Policy; or
(b) the date he is eligible for Personal Insurance; or
(c) the effective date of Dependents Insurance under this Policy; or
(d) the date he first acquires a Dependent.
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GENERAL PROVISRONS
OA IOOOF161 SICTION 3 -EU0161LITY
SECTION 5 - INDIVIDUAL TERMINATIONS
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The insurance o' any Person insured un'ier this Policy shall cease on the earliest of the following dares?
(a) the date of termination of this Policy; or
(b) the date ending the insurance month as of which he requests that his insurance be terminated, but in no event
Prior to the date of such rcq,,esr; or
(c) the date ending the ins-tram month for which the last premium payment is made on account of his insurance; or
(d) the d to of termination of hi; membership in the (lass or classes eligible for insurance under the Policy; or
(e) the date he enters the Armed Forces of any country; or
(f) THE, DAY FQL,LOWItrG THE DAY .HAT....
termination of his employrrte-it occurs. Cessation of active work shall be deerned termination of employment,
except that
{ I ) if cessation of active work is due to illness or injury, his insurance shall be continued until premium payments
are discontinued by the Group Policyholder, or
(2) if cessation of active work is due to temporary lay-off or approved leave of al sence, his insurance shall
be continued until premium payments are discontinued by the Group Policyholder but in no case beyond
31 DAYS AFTER THE DAY THAT
his cessation of active work occurs. Ilowcver, this continuance in the event of temporary lay-off or
approved lease of absence shall not apply to Weekly Income for Disability insurance benefits. Such benefits
shall cease on the date of the lay-off or leave of absence.
The Dependents Insurance with respect to each Dependent shall cease on the date such individual ceasts to be a
Dependent as defined in this Policy- The Dependents Insurance with respect to all Dependents of a Person shall cease on
the date his Personal Insurance terminates, either by such Person's death or as outlined above.
SECTION 6 -INDIVIDUAL REINSTATEMENTS
Insurance terminated with respect to Persons formerly insured, other than insurance terminated at any such Person's
request, may be reinstated if mutually agreed upon in writing bctm,een the Group Policyholder and the Company. Insurance
reinstated in accordance with any such written agre:mertt shall be treated as if the insurance first became Effective on the
date of the reinstatement, unless the agreement expliarly provides othcrv:ise.
GENERAL PROVISIONS
OA IOOOH161 SECTIONS 3 AND 6-INDIVIDUAL TERMINATIONS AND REINSTATEMENTS
SECTION 7 - PREMIUMS
The initial premium due and each premium due tlicreaftcr ,hall be the sum of
(a) the number of Persons then insured for Personal Insurance in each classifitation multiplied by the applicable
Rate Per Person; and
(b) the number of Persons then inured for Ikpendents Insurance, if any, in Bath classification multiplied by the
applicable Additional Rate Per Person;
based on the classifications as determined by Section 13---Schedule of Insurance and the rates in effect on such premium
due (fare.
The Group Policyholder shall be liable for all premiums due during any time this Policy is in force. All premiums
are payable by the Group Policyholder on or before their respective due dates directly to the Company at its flame Office
in Dallas, Texas.
The Company reserves the right to change the rate for any insurance provided under this Policy
(a) on any premium due date that the rare for such insurance has been in effect for at least twelve months by giving
written notice to the Group Policyholder at least one month prior to such premium due date; or
(b) on any date the provisions of this policy arc changed as to the benefits provided or classes of Persons insured.
SECTION 8 GRACE PERIOD
A grace period of thirty-one days, without interest charge, shall be granted to the Group Policyholder for the payment
of every premium, after the first, during which period this Policy shall continue in force, provided the Grmp Policyholder
has not previously given written notice to the Company that this Policy is to be discontinued.
If any premium be not paid within the grace period, this Policy shall thereupon be discontinued, but the Group
Palicyholler shall, nevertheless, be liable to the Company for the payment of all premiums then unpaid, together with
rte premiums for the days of grace. If, however, written notice is given by the Group Policyholder to the Company, during
the grace period, that this Policy is to be discontinued, this Policy shall hen be discontinued on the date of receipt by the
Company of such written notice, bur the Group PoJkyliolder shall, nevertheless, be liable to the Comrony for the payment
of all premiums then unpaid, together with a pr•ra a l,r.mium for the period commenting with the date on which the
last premium became due and ending with the t.'at: rcccil P ,f such written notice by the Company.
SECTIOI`< 9 RENEWAL OF POLICY
This Policy may be rene,sed by the Groh) Policyholder on any premium due date by payment of the required premium
provided the number of Persons then insured is not less than 100 per cent of the number eligible, and also
provided the number of Persons then insured is not less thaq 25
GENERAL PROVISIONS
OA 10001161 SECTIONS 7, 8 AND 9-PREMIUMS, GRACE AND RENEWAL
SECTION 10 - NOTICE AND PROOF OF CLA i V
Written notice of claim must be given to Company within twenty -says •rfter the oc:urrence or commeneetnent
of any loss urvt!•ed by this Policy. Notice given by or on behalf of the claimant to the coroptny at its Home Oficr in
Uaffas, 'f'exas, with information sufficient to iden,ify the individual whose injury or sickness is the basis of claim shall
be deemed ne.xe to the Cwnpany. lh: Cornpau), , ,Isom receipt of such notice, will f;voklt farms for filing proof of loss.
If such form, are not furnished within fifteen daJs after the receipt of such ne,tice, rh, claimant shall be deenacd to have
complied widt the requirements of this Policy as of prcvd ref loss u}N)n submitting wriutu proof of such loss in accordance
with the provisions of the nc%c succeccling paragraph.
Written proof covering the occurrence, eharacret and extent of the loss for which claim is made must be given to
the G)mpany within ninety days after the termination of the pericxl for which the Gjr opany is liable with respeu to any
loss for which this Policy provides payments contingent upon continuing In<.s; o[f•.erwtse, within ninety day's after the
date of the loss for which claim is made. f'zifure to furnisl: notice or proof within the time fixed in this Policy will not
invalidate or reduce any claim if it shall be shown that it was not reasonably rsstble to furnish such notice or proof on
time and that it was furnished as soon as was reasonably possible.
No action at law or in equity shall be brought to recos,cr on this Polity prior to the expira;ion of sixty days after
proof of loss has been filed it accordance with the requirements of this Policy, nor shall sue.. action be brought: at all unless
brought within three years from the expiration of the time within which proof of lass is required by this Policy.
The Company shall have the right and opportunity to have a physician it dcsignltes examine the individual whose
injury or sickness is the basis of claim when and so often as it may reasonably require during the pendency of claim hereunder.
If any time (imitation of this Section of the Policy is less than that permitwd t? ,.he law of the state in which
the person resides at the time he bcYomes insured, such limitation is hereby extended to agree with the minimum permitted
by such law.
SECTION I I - PAYMENT OF BENEFITS
Benefits are payable to the Person insured whose injury or sickness or whose i)tpendent's injury or sickness is the
basis of claim under this Policy; except that if benefits for loss of life are payable in accordance with the Accidental Death
and Di>memberment provisions, such benefits shall be payable to the beneficiary designated by the Person insured. Benefits
payable for any loss other than that for which this Policy provides periodic payments will he paid irmnedately upon receipt
of proof of such loss. Subject to proof of loss, benefits payable for any Ioss for which this Policy provides periodic payrr,ents
will be paid not less than once each month during the continuance of the period for which the Company is liable and any
balance remaining unt aid upon the termination of the Company's liability will be paid immedietely ui,on receipt of proof.
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GENERAL PROVISIONS
OA }0001161 SECTIONS 10 AND It -CLAIMS AND PAYMENTS
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SECTION 12 -FACILITY OF PAYMENT
If any Person insured is, in the opinion of the Company, legally incapable of giving a valid receipt for any payment
due him and no guardian has been appointed, the Company may, at its option, make such payment to the individual or
indisiduals as have, in the Company's opinion, assumed the care and principal support of such Person. If the Person insured
should die lxwforc all amounts due and payable to him have bccn paid, the Company may, at fhs option, make such payment
to the executor or administrator of his (state or to his surviving wife, husband, mother, father, child or children, or to
any other individual or individuals who, in the Company's opinion, are equitably entitled tbrrew,
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If any beneficiary is, in the opinion of th( Company, legally incapable of giving a valid receipt for any payment due
him and not guard ac has been appointed, the Company may, at its option, make such payrn(nt to the individual or indi•
viduals as have, in the Company's opinion, assumed the care and principal support of such lKncficiary, if no beneficiary is
designated or surviving at the death of the Person insured, the Company may, at its option, make payment to the executor
or administrator of the estate of the Person insured, or to his surviving wife, husband, mother, father, child or children, or '
to any other individual or individuals aho, in the Company's opinion, are equitably entitled thereto,
Any payment made by th- Company in accordance with ti ese provisions shall fully discharge the Company to the
extent of such payment.
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SECTION 12A- CONVERSION PRIVILEGE
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Any Person, within thirty-one days after the date his hospital, surgical and pregnancy insurance under this Policy is
terminated because of termination of employrrcnr or of membership in a class or classes eligible for such insurance, shall
be entitled to have issued to him, without cvldcnce of insurability, an indiAdual policy of hospital •surgical-pr egnancy
insurance provided written application therefor and paymeor of the first premium thereon is made to the Company withir,
said thirty-one days. Any such individual pclicy issued shall cover:
(a) the Person, if the hospital, surgical and pregnancy insurance under this Policy covered the Person only; or
(b) the Person and his Dependents, if the hospital, surgical and pregnancy insurance under this Policy covered the
Person and his dependents,
and shall become effective on the day immediately following the date of termination of such insurance under this Policy.
The form of the individual policy, the coverage thereunder, the premium rates and all other terms and conditions r.tereof
shall be such as is then provided by the Company with resMt to insurance issued pursuant to an application made in
accordance with these provisions.
If a Person's hospital and surgical insurance under this Policy with respect to a Dependent spouse is terminated
because of the death of the Person, such spouse shall be entitled to have issued to hitn an individual policy of hospital.
surgical insurance in the same manner and subject to the same conditions as provided for the Person insured.
If it Person's hospital and surgical insurance under this Policy with respect to a Dependent child is terminated
because of the child's marriage or attainment of the maximum age specified in this Policy for Dependent children, such
child shall be entitled to have issued to him an individual policy of hospital-surgical insurance in the same manner and
subject to the same conditions as provided for the Person insured.
GENERAL PROVISIONS
CIA 1000K161 $ECTION 12 AND 1?A - /AC(LM Of PAYMENT AND CONVERSION PRIVILEGE
SECTION 13 - SCHEDULE OF INSURANCE
This Policy provides Personal Insurance with respect to such and so many of the following Personal Insurance Pro-
visions as are indicated by one or more specific amounts set opposite thereto. A Persim shall be insured for the Personal
Insurance applicable to his classification in this Schedule on the effective date of his Prrsnnal Insurance. THEREAFTER)
ANY CHANGE IN CLASSIFICATION SHALL BECOME EFFECTIVE ON THE OA TL OF SUCH CHANGE
PROVIDED THE PERSON IS ACTIVELY AT WORK ON SUCH DATE; OTHERWISL ON THE DATE THE
PERSON RETURNS TO ACTIVL WORK.
CLASSIFICATIONS AND MONTHLY PREMIUM RATES FOR PERSONS INSURED FOR
PERSONAL INSURANCE.
CLARW It AlION RATES PER PERSON
MONTHLY EARNINGS
A $600.00 AND OVER $8.26
a $450.00 To $600.00 7.89
C LESS THAN $450.00 1.75
PERSONAL INSURANCE PROVISIONS BENEFITS ACCORDING TO CLASSIFICATION
"None" menu no rrch inuorancr a provided for that clsrtifscstion
SECTION 14-ACCIDENTAL DEATH AND DISMEMBERMENT A B C
Principal Sum .......A....... 10 000 5,000. 2 .WO.
SECTION 1S - WEEKLY INCOME FOR DISARIIIATY
Weekly Income.......................................................................... NONE NONE NONE
Maximum Benefit Period........ wits. (Maternity- )
Day Benefits Begin Accident
(days disabled) Sickness
SECTION 16-HOSPITAL (See Parts I alt 11)
Daily limit (room and board) 25. 25. 25.
Aggregate limit (room and board) a*tI* **IF It
Miscellaneous Limit ***sta *st*** it iE iF lt*
DEDUCTIBLE EACH CONFINEMENT 25. 25. 25.
SECTION 11-SURGICAL. Svrgical Aggregate limit 400. 400. 400.
SECTION 18-PREGNANCY
Hospital Confinement Limit 100. 100. 100.
Obstetrical Maximum Payment SEE SECTION 18 - PREGNANCY INSURANCE
SECTION 19-PHYSICIAN VISITS. The earliest visit speci-
fied below for Accident S~kkness is the visit benefits begin,
Hospital .57...... .-Single visit Limit..... 5. 5• 5.
Home visit---Single Visit limit..... NONE NONE NONE
Elsewhere .....................-..visit-Single Visit I.imit..... NONE NONE NONE
Aggregate Visit Limit 600. 600. 600.
SECTION 20 - DIAGNOSTIC X-RAY AND LABORATORY
Accident Limit . NONE NOME NONE
Sickness Limit................. NONE NONE NONE
SECTION 2l-SUPPLEMENTARY ACCIDENT. Max. Pay'L...... 300. 300. 300.
SECTION 22-- Maximum Payment.......... NONE NONE NONE
SECTION 23-MAJOR MEDICAL.Maximum Payment........... 10,000 10 000. 30 000.
SECTION 24- Maximum Payment........... NONE NONE NONE
*REDUCES 50% AT ATTAINMENT OF AGE 65
Contributions for Personal Insurance......... ARE_NQ7 ..............required from Persons insured,
****120 DAY PERIOD
*****UNLIMITED
PERSONAL INSURANCE SCHEDULE
OA 10MI61 SECTION 13-SCHEDULE OF INSURANCE
77771
SECTION 13 SCHEDULE OF INSURANCE (CONTINUED)
This Policy provides I)vpendenes insurance with respect In such and so many of the following Dependents Insurance
Provisions as ar,r indicated by one or more specific amounts set oplxosite ihcrLuv A Person shill Ix insured for the Dependents
Insurance applicable to his classification ;ind m his DclxOtnt status in This Schedule on the elfective date of his Ihpendcnis
Insurance.
CLASSIFICATIONS AND MONT 1LY PREMIUM RATES FOR PERSONS INSURED FOR
DEPENDENTS INSURANCE.
CLASSIFY At ION x x x AiomoNAI. RATr: PI R PIRSON LNWRED l1'1111 Rrsrl<. r 'ro:
Nanrrric,d,oiler
indicateDependenr No ADULT CHILD FAMILY
rtatwr Dependents
N
ALL o $10.61 $5.84 $16.45
N
F:
DEPENDENTS INSURANCE PROVISIONS BENEFITS ACCORDING TO CLASSIFICATIG,V
"Nonr" meant no rurh iRlarance is prodded for that clal ifcwiom.
SECTION 14-ACCIi)ENTAL DEATH AND DISMEMBERMENT ALL
Principal Sum_ NONE j
SECTION 16-VIOSPIfAL (See Parts 1 & 11)
Daily Limit (room an! 1=.:r,?....__,,......_.__,........ 25.
Aggtegate Limit (room and bcatd).._...,........... .
Miscellaneous Limit
DEDUCTIBLE EACH CONFINEMENT 25.
SECTION S 7 - SURGICAL. Surgical Aggregate Limit 400.
SECTION IS - PRL6NANCY j
Hospital Confinement Limit 100.
Obstetrical Maximum PAymenr_ SEE SECTION 18 - PREGNANCY INSURANCE
SECTION 19- PnM, CAN V;SITS, The earliest visit speci•
bed below for ccident Sickness is the visit benefits begin,
I{ospital .1-ST_._..1.ST.. visit-Single Visit Limit..... 5•
Home _ ...visit-Single Visit Limit..... NONE
Elsew}irre ................_._....,..,.visit-Single Visic Limit..... 110 NE
Aggregate Visit Limit........ 600.
SECTION 20 - DIAGNOSTIC X•RAY AND LABORATORY
Accident Limit......... _ . NONE
Sickness Limit NONE
SECTION 21 -SUPPLF6ILN'rARY ACCIDEN'1'• Max. PAy't._. 300.
SECTION 22- Iclaximum Payment......,.. NONE
SECTION 23--MAJOR MFFWAL.Maximum Paymcnt...... 10 000
SECTSON 24 - Maximum Payment NONE I
i
Contributions for Dependents Insurance............. A f?E....._........_...required from Persons insured,
****120 DAY PERIOD
*****UNLIMITED
DEPENDENTS INSURANCE SCHEDULE
GA 1000M161 SECTION 13-SCHEDULE Of INSURANCE (Continued)
SECTION 14 - ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE
BENEFITS PAYABLE, If a Person, while insured under this Section of the Policy, sustains an injury effected solely
through exter.tal, violent and accidental means and as a result thereof, directly and indepetnienrly of all other causes, suffers
a loss specif;td below within ninety days following the date of such injury, the Company, wbicct at all provisions of this
Policy, will pay
(a) the Principal Sum for loss of life; or
(b) one-half the Principal Sum for lass of uric hand by severance at or aTNtvc the writ, •r loss of one frxn by scsrrar,,,
at or above the ankle, or irrecucerab!c loss of the sight of one eye, or
(e) the Principal Sum for loss of more than one of the members enumerated in para};ral h (b) above;
but the total payment for all such hoses resulting from injuries due to the same accident shall not exceed the Principal
Sum. If benefits are payable for loss of life, the Company shall have the right and opportunity to have an autopsy made
when it is not forbidden by law.
The Principal Sum shall be determined for a Person by his Personal Insurance classift<ation as shown in Section 13 -
Schedule of Insurance.
BENEFICIARY. The beneficiary shall be the individual or individuals to whom benefits for loss of life are payable
as designated in writing by the Person insured. Any Person may change his beneficiary by executing and filing a written
notice to that effect with the Company but such change will not be effective until recordcf by the Company. The change,
when teccorded, will be effective as of the date such notice was executed; but any payment made by the Company prior
to receipt of such notice shall fully discharge the Company to the extent of such payment.
If any beneficiary dies before the Person insured, any sum which would have become payable to such beneficiary, if
living, shall be payable equally to the beneficiary or beneficiaries surviving the Person insured, unless otherwise provided.
If any beneficiary dies either simultaneously with the Person insured or within fifteen days after the Person insured but
before written proof of the death of the Person insured has been received by the Company at its (lane Office in Dallas, 'T'exas,
payment shall be made as if the Person insured had survived such beneficiary, unless otherwise provided.
If a Person's Accidental Death and Dismemberment insurance is reinstated in accordance with the provisions of
Section h-Individual Reinstatements, the beneficiary shall be the beneficiary of record as of the date of termination of
such insurance unless written notice of change has been filed and recorded as herein provided.
ASSIGNMENT. No assignment of any Person's insurance under this Section shall be valid.
LIMITATIONS APPLICABLE TO ACCIDENTAL DBA T H AND DISMEMBERMENT INSURANCE.
Benefits shall not he vayable for any loss to which a contributing cause is
(a) self-inflicted injury or self-destruction while sane or insane; or
(b) disease, bodily or mental infirmity, or medical or surgical treatment thereof; or
(c) insurrection, participation in a riot, police duty as a member of any military, naval or air organization,
war or any act of war declared or undeclared; or
(d) travel or flight in any aircraft, except as a fare paying passenger on a licensed passenger airero!ft
provided by a licensed passenger carrier on a regularly scheduled flight between established airports,
(t) participation in or as the result of the commission of a felonious act.
GA 10040-161 SECTION 14-ACCIDENTAL DEATH A DISMEMMIMENT (OCCUPATIONAL) PERSONAL
i at, { ti r•.~p» ~e ~7M ,i. rt t!.'+'T~t. °+yfi,',~mn~1•. '''~'~b' r Kiy-rir-.r e1~!7n .n ryF a..,
v
SECTION 16 -HOSPI'T'AL INSURANCE (PART I)
BENEPM PAYABLE. If a Person or his Dependent, while insured under this Section of the Policy, is confined to a
hospital for a period of at least fifteen consecutive hours because of injury or sickness, the Company, subject to all provisions
of this Policy, will pay for such confinement
(a) the actual cost charged to him by the hospital for room and board (including general nursing care) up to the Wy
Limit for each day of such confinement; but the total payment for all such charges for one period of hospital
confinement shall not exceed the Aggregate Limit (room and board); and
(b) the actual cost charged to him in excess of the Hospital Deductible Amount up to the stated amount of
the miscellaneous limit 0")M">'dfxdk2fxiitKANVOWXdblf/gltdMexb''4_4(4XY&11r1t Xdxaftuadd< xant um
(1) by the hospital for services other than room and board which are required for pJrposes of treatment during
such confinement while room and board benefice are }rayable; and
(2) by the hospital or by a licensed ambulance service to $25.00 for cecessary transportation by ambulance
to and from the hospital;
but the total payment for all charges (including any charges resulting from the ume or a related injury or sickwu
for which benefits are paysbie under Pan 11 of this Section) for one period of hospital confinement shall 'hoc
exceed the Miscellaneous Limit
Two or mbar periods of hospitai confinement shall be considered one period of hospital confinement with respect to the
person, Wks . etparssed, by the Penoa't return to the full-time duties of his regular occupation for t period of `at least
tot weals or unW vhe subaegtuat confinement is due to caws entirely unrelated to the anion of tine pserioaa confinement
04 y.kh tesprct.ep Cht aftasdeat, unless ,separated , by toree taonde or unless the sulsesgwot confinemient is 'due a rinses
«!th* unrelated ul the attaes of the pr4rsous oofio oameot. , . . ~ . . , { , .
. ,
The Daily Limit, the Aggregate Limit (room and board), the Miscellaneow Limit and the Hospital Deductible Amount
shelf be determined for a Person by his Personal Insurance classification or for it Dependent f.- the Ikpendenr Insurance
claselficwion as shown in Section 13 Schedule of Insurance.
fCR PERSp~•9 QNIYs_IF PAYMENTS BECOME DUE UNDER THE tERMS OF THIS BENEFIT DUE TO
LOSS CAUSItO BY AN OCCUPATIONAL INJURY OR SICKNESS, THE PROVISION OF LIMITATIONS
APPL.'CABLE TO HOSPITAL INSURANCE. (B) SHALL NOT APPLY.
9k Tl #TftD AENfislrrCS. If a PeisM & his tX*, idedt, ivithlri three 6" after his insurance uridet this' SectioLn of the
Policy tormisnsas,' is congaed In is hospital fetr'a period of at lew fifteen consecutive hours because of Injury or sickness
which out og the there of ct rmtaaciat Of, Luc i nstrf f andif 4e ! .b 4,t y disabled from
tbs dqe. b4 Jq%,W,uK
u + t r„ 1 1
termtmoe4 to ~ dru Bch ho}pt~l o f cQgnlneacgt, the Cou°ptaY, aubJea co all Provisions of fAia Roticy,' dill PsY
the~bettebby~ ro~vIidcd fa this Section the same is though the hospital confinement hid waunetsced,before the termination
of W4yI ifWi1~. 1 -17 i, t a I l r
CJ ri~ ! "Yip I j•~. rl r X` sqiI ✓r ! ._,p y. ;.f , 1':: i. 41.•f. tYY 7
LIVIITA"f pt m HOS,,P--I,,TAL ><rrSMl1NCE (PART x). Beaefite AA not be payable for
1~~•~ a t . .lI7:.f. K-fi~r#0a_"JpnI of,
.W~~v~. Apt ,~~;a}!yi.: [_pr,.i~
(b)
4 T p
.'-TIF.~ fl+^/~r"""=tl
C-1,
I
iWI at' tae to Injury s risini out of or is the course of any uapLiy "t for wage or profit; or
(o) hospital confianrmt, surpry or medlcel taro or service dtariaS coadoess"t within any facility can.
traeted for or operated by the United Sates Goveranseat or any other Severaeost uni : for we&&I
care or treatauat; or
(d) say charges for the services of a physician or any charps for the services of a special surso; or
(e) any coniftia wnt which is cawed by or results from pregnancy or complicatieae therefrom.
I
w t~tnw sNeNe►r a ~1~',INiRr t t{~ 1rI~'d~wlH :
SECTION 17 - SURGICAL INSURANCE
BENEFITS PAYABLE. If a Person or his Dependent, while insured under this 'Scullin of the Policy, undergoes a
surgical operation specified in the Schedule of Operations in this Se(rion because of injury r,r sickness, the Company, subject
to all provisions of this Policy, will pay for such operation the actual cost charge; to him by the physician for performing the
operation up to the Maximum Payment specified for the jimation in the Schedule t,f 01Krarions.
If two or more operations are performed during one period in the olxvating morn, Ibc amount payable, unless otherwise
specified in the Schedule of Operations, shall not Lxccol the Maximum Payment slxe ificd for the principal operation
performed plus 501', of the Maximum Payment specified for each of the other operations performed; but if two or more
such operations are performed through the same incision, payment shall be made only for the one operation for which the
largest amount is payable.
711e total payment for all operations performed on a Parson after lie leaves active work and before he returns to the
full-time duties of his regular occupation or on his dependent within a period of thrte months, vnless due to entirely
unrelated causes, shall not exceed the Surgical Aggregate Limit.
The Surgical Aggregate Limit shall be determined for a Person by his Personal Insurance classification or for a
Dependent by the Dependent Insurance classification as shown in Section 13-Schedule of Insurance.
I
FOR PERSONS ONLY, Ii PAYMENTS BECOME DUE UNDER THE TERMS OF THIS BENEFIT DUE TO LOSS
CAUSED BY AN OCCUPATIONAL INJURY OR SICKNESS, THE PROVISION OF LIMITATIONS APPLICABLE
TO SURGICAL INSURANCE (B) SHALL NOT APPLY.
EXTENDED BENEFITS. If a Person or his Dependent, within three months after his insurance under this Section of
the Policy terminates, undergoes a surgical operation specified in .te Schedule of Operations of this Section because of injury
or sickness which existed on the date of termination of such insurance and if he bas bt zn totally disabled from the date his
insurance terminated to the dare of such operation, the Company, subject to all provisions of this Policy, will pay the benefits
provided in this Section the some as though the operation had been performed before the termination of such insurance.
LIMITATIONS APPLICABLE TO SURGICAL INSURANCE. Benefits shall not be payable for
(a) any operation not recommended and performed by a physician; or
(b) any operation due to sickness which is covered by a Workmen's Compensation Act or other similar
legislation, or due to injury arising out of or in the course of any employment for wage or profit; or
(c) hospital confinement, surgery or medical care or service during confinement within any facility con-
tracted for or operated by the United States Government or any other government unit for medics[
care or treatment; or
(d) any charges for cosmetic or dental surgery, except to the extent necessary to repair injury; or
(e) any operation which is caused by or results from pregnancy or complications therefrom.
OA MOY161 SECTION 17 - SUAOICAL
SCHEDULE OF SURGICAL OPERATIONS
SURGICAL EXPENSE BENEFITS
The maximum amount payable for any procedure will be 200 r of the amount shown in the following ! :hedule.
Maximum Maximum
Payment Payment
Abdomen Esophagus, resccrion of 200.00
Appendectomy 5100.00 laryngcowny, ui,l.o vt neck disse(tion...._._... 160.00
Gall bladder, removal of... _ 110.00 Tonsillectomy, with or without adenoideetomy... 30.00
Gastrotomy 80.00 Tracheotomy (independcnt procedure) 40.00
l,aparotomy, exploratory . 70.00
Stomach, total resection of 200.00 Eye
Cararaet, operation for intracapsular or
Amputations extracapsular, unilateral 140.00
Arm, upper, forearm, entire hand or Lx,r 60,00 D^tached retina, operation for.............................. 100.00
ringer, one 25.00 Eyeball, removal of 60.00
Hip 160.00
Leg, through tibia and fibula.....,.. 80.00 Fracture, Treatment of
Thigh 100.00 Ankle, simple closed
20.00 40.00
Tex, one .
Finger
10.00
Band 14.00
Breast Nose, simple, closed 10.00
Amputation - Simple (0.00 Radius and ulna, simple-closed reduction............ 30.00
Radical 120.00 open reduction 90.00
Benign tumor or cyst, removal of requiring Ribs, simple, strapping 4.00
hospital' confinement 30.00 Tibia and fibula, simple-closed reduction........ 40.00
open reduction 100.00
chest
Artihc!,ol pneumothorax, induction of, initial...... 10.00 Genito-Urinary Tract
Refills, each 4.00 Cervix amputation 30.00
Bronchoscopy, esophagoscopy 30.00 Circumcision-Ncw born 6,00
Lung, removal of or portion of 200.00 Under age 10.............................. 10.00
Valvulotomy or commissurutomy 200.00 Age 10 or ove:................... 16.00
Cystoscopy (diagnostic) 10.00
Dirb,,Redtao ( Dilation and curettage (non•puerperal).............. 20.00
Ankle 1 , knee joint Patails excepted) 20.00 Hysterectomy 100.00
Clavicle 20.00 Kidney Fixation of 120.00
MOW 16.00 Removal of 140.00
Hip 30.00 Tumors or stones in ureter or bladder,
Lower jaw or patella 10.00 Removal of by cutting operation............, 120.00
Shoulder, single, closed 10.00 by endoscopic means.._. 40.00
Wrist 14.00 Prostate, removal of by
Open operation (subtotal) 140.00
Excision or Fixation by Cutting Endoscoplc means (complete)........... 140.00
Vartocaion
Ankle joint 80.00
Bone, removal of ilea Silagtle . _ 90`60
Femur,
sad portion of- C stoxclc,o~^aaor► for 60.00
1pltbot'or .tibia,
bi.s humerus, radius or . fibula t8020.00.00 Y Rectocae, operation for.... 50.00
Hip joint 160.00
Knee joint 100,00 Rectocele and cystocefe.._ . 80.00
Lesser bones 4000
Goitre
Ear, Note and Throat Adenoma of benign tumor of thyroid,
15 6Cstiation 200.00 excision of 80.00
Mastoidectomy-Simple 80.00 ThYroid, excision of, sabtotal........... 100.00
Radical 120.00
Stapes mobilization'! 120.00 Hernia
Adenoidectomy (independent procedure) . 20.00 fn'guinal-Unilateral 60.00
i
Sjnusc y, frontal, tal external simple/ 40.00 US : Il3ilateral.........,..,........... (400,
Sum CPa Us resection of nasal se wn Umbilical GO.q(1;
Sep tectom 60, ntral 80,00
(Over)
OA-1000•YSS• 1161
Maximum Maximum
Payment Payment
Ligaments Skukl
Tendon, lengthening or shortening 40.00 Osteoplastic cranirxomy (other than
Ttndon,repair and suture of single. 20.00 operation for brain tumor)............................... 200.00
Transplant, single 60.00 Trephine 70.00
Spine or Spinal Cord
Pilonidal Cyst or Sinus Iaminectomy 160.00
Removal of 40.00 Spinal cord tumor, operation for.... . 200.00
Tumor
Rectum Benign
Fissure, cutting operation for s
scc or sscs ` S su ritugea1cl . ..sts or
(Independent procedure) . 30-W tumors an c
. . 6.00
Fistuiotomy or fistulectomy- Malignant tumors of face, lip or skin 30.00
Simple _ 40.00
Multiple 75.00 Varicose Veins
Hemorrhoidectorny -External 10.00 Saphenous veins, ligation and division and
Internal 50.00 complete stripping of:
Internal and Fxternal 50.00 Long or Short.................................................. 50.00
Hemorrhoidectomy and fistulotomy Long and Short 70.00
or fistule<tomy 60.00 Sclerosing solutions, injection of into
Papillectomy, single or multiple veinofleg- Initial 2.00
(Independent procedure) 10.00 Subsequent 2.00
For surgical procedures not showa on this schedule, and which arc not expressly excluded by the terms of the Group policy,
the Company will deiermine the amount payable for the operation. An operation of equal gravity ird severity will be u,-_J
as a basis for the Company's determination.
MAXIMUM PAYMENT FOR 'ANESTHETIC ADMINISTERED BY A DOCTOR OF MEDICINE OR OSTEOPATHY WILL
PE ,ZO OF THE SURGICAL ALLOWANCE.
t
r f,~''k~ ~i i •S .'1 r - I
0A•t0oo-Y5S-1161 , , f I t x
SECTION IS - PE KSON'S PREGNANCY INSURANCE
BENEFITS PAYABLE. If a Person, while insured under this Sc(tion of the Polity, is confined in a hospital or under
goes an obstetrical proeedure sMified in this Section because of pregnant) or ara;plications therefrom, and if
(a) such pregnancy commenced while she was so insured; or
(b) she became so insured within thirty-ore days after the effective date of this Section;
the Company, subjccr to all provisions of this Polity, will pay for such confinement or such obstetrical procedure the actual
cosy charged to tier
(a) by the hospital for services which are r.-quired for purposes of treatment during such confinement; but the total
payment for all such charges for one period of hospira, confinement shall not exceed the Hospital Confinement
limit; and
(b) by a physician for performing the obstrrrical procedure up to the applicable maximum payment shown below:
Obstetrical Procedure Maximum Payment
fklivery of child or children....... . 100.00
Caesarean Section 200.00
Abdominal operation for extrauterine pregnancy......... 200.00
Miscarriage- 50.00
All periods of hospital confinement due to tie same pregnancy or complications therefrom shall be considered one
period of hospital confinement.
The Hospital Confinement Limit shall be determined for a Person by her personal Insurance classification as shown
in Section 13-Schedule of Insurance
if childbirth or miscarriage occurs in a placc other than a hospital with respect to a Person who would otherwise
meet the requitement for hospital benefits either as set forth above or as set forth under Extended Benefits, the Company,
subject to all provisions of this Polity, will pay the actual cost charged to her for drugs, dressings and services of a regis-
tered nurse; but the total payment for all such ch,,xges due to the same pregnancy shall not exceed 50% of the Hospital
Confinement Limit
A PERSON 1S ELIGIBLE FOR THESE BENEFITS ONLY IF SHE IS INSURED HEREUNDER W,TH RESPECT
TO HER HUSBAND.
EXTENDED BENEFITS. If a Person, within nine months after her insurance under this Section of the Policy termi-
nates due to termination of employment only, is confined in a hospital or undergoes an obstetrical procedure specified
in this Section because of pregnancy or complications therefrom, and if
(a) she had been insured under this Section for nine months prior to the date of termination of such insurance and
such pregnancy commenced while she was so insured; or
(b) she became insured under this Section within thirty-one days after the effective date thereof;
the Company, subject to all provisions of this Policy, will pay the applicable bcnefiu provided in this Section the same as
though the hospital confinement had commenced or the obstetrical procedure had been performed before the termination
of such insurance
LIMITATIONS APPLICABLE TO PREGNANCY INSURANCE. Benefits shall not be payable for
(a) medical fees or special nursing fees except as specifically provided for above; or
(b) any confinement not recommended by a physician or any obstetrical procedure not recommended and
performed by a physician; or
(c) hospital confinement, surgery or medical care or service during confinement within any facility con-
tracted for or operated by the United States Government cr any other government unit for medical
can or treatment.
OA 100A0161 SECTION 10 - PaEONANCT (HOSPITAL AND SUaOICALI IMMEDIATE-►ESSONAI
SECTION IS DEPENDENT'S PREGNANCY INSURANCE
BENEFITS PA; ABLE. If a Person's Dependent Wife, whi insured under this Section of the Polity, is confined in a
hospital or undergoes an obstetrical procedure specified in this non because of pregnancy or complications therefrom,
and if
(a) such pregnancy commenced while she was so insured; or
(b) she became so insured within tnirry-one days after the effective date of this Section;
the Company, subject to all provisions of this Polity, will pay for such confinement ar such obstetrical procedure the actual
cost charged to the Person
(a) by the hospital for services which are required for purposes of treltment during such confinement; but the total
payment for all such charges for one period of hospital confinement shall not exceed the Hospital Confinement
Limit; and
(b) by a physician for performing the obstetrical procedure up to the applicable maximum payment shown below;
Obstetrical Procedure Maximum Payment
Delivery of child or children. 100.00
Caesarean Section
Abdominal operation for extrauterine pregnancy 200.00
Miscarriage 50.00
Alf periods of hospital confinement due to the same pregnancy or complications therefrom shall be considered one
period of hospital confinement.
The Hospital Confinement Limit shall be determined for a Dependent Wife by the Dependent Insurance classification
as shown in Section 13 -Schedule of Insurance.
If childbirth or miscarriage occurs in a place other than a hospital with respect to a Persons Dependent Wife who
would otherty.^e meet cf.! requirements for hospital benefits as set forth above, the Company, subject to all provisions of
this Policy, will pay the actual cost charged to the Person for drugs, dressings and services of a registered nurse; but the
total payment for all such charges due to the same pregnancy shall not exceed 50% U the Hospital Confinement Limit.
LIMITATIONS APPLICABLE TO PREGNANCY INSURANCE. P:nwfits sl{all not be payable for
(a) medical feet or special nursing fees except as specifically provided for above; or
(b) any confinement not recommended by a physician or any obstetrical procedure not recommended and
performed by a physicians; or
(c) hospital confinement, surgery or medical care or service during coafineaaent within any facility con.
tracted for or operated by the United States Government or any other government unit for medical
can or treatment.
OA IOMM140 WOON 11- POIGNANCY (HOSPITAL AND SURGICAV 1AW101ATI-DI►INDINT
SECTION 19 -PHYSICIAN VISITS INSURANCE
BENEFITS PAYABLE. If a Person or his Dependent, while insured under this yecrion of the Policy, undergoes treat-
ment by a physician during a period of hospital confinement of at Ieasr fifteen consecutive liours because of injury or sickness,
the Company, subject to ,!I provisions of this Policy, will pay for such treatment tltc aetuA cost charged to him by the
physician up to the Single Visit Limit fur each visit required for such treatment. In dctetminin¢ the number of visits not
m: re than one visit each day shall be considered. The total payment for all such ch.trgvs for visits made during one period
of hospital confinemenr shall nor exceed the Aggregate Visit Limit.
The word "visit" as used in this Section means a personal interview between the Person or his Dependent and a
physician and does not include teleplwne calls or interviews in which the physician dons not see the Person or his Dependent
for treatment.
Two or more periods of hospital confinement shall be considered one period of hospital confinement unless separated
by the Person's return to the full-time duties of his regular occupation for a pe,tod of at least one week, or unless the subse-
quenc confinement is due to causes entirely unrelated to the causes of the previous confincment or, with respect to the
Dependent, unless separated by thr•:e months or unless the subsequent confinement is due to causes Lntirely unrelated to the
causes of the previous confinement.
The Single Visit Limit and the Aggregate Visit limit shall be determined f(,r a Person by his Personal Insurance
classification or for a Dependent by the Dependent Insurance classification as shown in Section 13-Schedule of Insurance.
FOR PERSONS ONLY, IF PAYMENTS BECOME DUE UNDER THE TERMS OF THIS BENEFIT DUE TO LOSS
CAUSED BY AN OCCUPATIONAL INJURY OR SICKNESS) THE PROVISION OF LIMITATIONS APPLICABLE
TO PHYSICIAN VISITS INSURANCE (B) SHALL NOT APPLY.
LIMITATIONS APPLICABLE TO PHYSICIAN VISITS INSURANCE. Benefits shall not be payable for
(a) any visit made on or within ninety days after the date of a surgical operation except a visit made
because of an injury or sickness which is entirely unrelated to the injury or sickness requiring such
operation; or
(b) any visit due to sickness which is covered by a Workmen's Compensation Act or other similar legis-
lotion, or due to injury arising out of or in the course of any employment for wage or profit) or
(c) any visit which is compensated for or furnished by the United States Government or any other
governmental unit) or
(d) any charges for the services of a dentist or dental surgeon, eye examinations for the correction of
vision or fitting of glasses, x-rays; or
(e) any visit due to pregnancy or complications therefrom.
OA IOOOAE161 SECTION 1!-PHYSICIAN VISITS (IN HOSPITAL)
SECTION 21 -SUPPLEMENTARY ACCIDENT INSURANCE
BENEFITS PAYABLE. If a Pers-3n, or his Dependent, while insured under this Section of the Policy, sustains an injury
effected v)lcly through external, violent and accidental means and as a result thereof, directly and independently of all
other causes, undergoes any treatment or rcce;ves any service specified below commencing within thirty days after the date
such accident occurs, the Company, subject to all provisions of this Policy, will pay for such treatment or service the actual
cost charged to him
(a) by a hospital for room and board and other services required for purposes of treatment; and
(b) by a physician for professional services; and
(c) for the services of a graduate registered nurse (R.N.); and
(d) for drugs and dressings; and
(e) for braces, crutches, artificial limbs, artificial eyes or for rental of a wheel chair, hospitsl•type bed, or an artificial
respirator; and
(f) for X-ray or laboratory examinations; and
(g) for necessary transportation by ambulance to and from a hospital;
to the extent that such charges exceed the sum of benefits, if any, payable for such injury under Sections 16 through 20
of the Insurance Provisions of this Policy; but benefits shall not be payable for any treatment or service received more
than 90 days after the date the accident occurs. The total payment for all such excess charges due to injuries resulting from
the sarre accident shall not exceed the Supplementary Accident Maximum Payment.
The Supplementary Accident Maximum Payment shall be determined for a Person by his Personal Insurance classification
or for a Dependent by the Dependent Insurance classification as shown in Section 13 -.Schedule of Insurance.
FOR PERSONS ONLYr IF PAYMENTS BECOME DUE UNDER THE TERMS OF THIS BENEFIT DUE TO LOSS
CAUSED JY AN OCCUPATIONAL INJURY OR SICKNESS, THE PROVISION OF LIMITATIONS APPLICABLE
TO SUPPLEMENTARY ACCIDENT INSURANCE (B) SHALL NOT APPLY.
LIMITATIONS APPLICABLE TO SUPPLEMENTARY ACCIDENT INSURANCE, Benefits shall not be pay-
able for
(a) any treatment or service not prescribed by a physician; oe
(b) any treatment or service due to injury arising out of or in the course of any employment for wage or
profit; or
(c) any treatment or service which is compensated for or furnished by the United States Government or
any other governmental unit; or
(d) any charges for the services of a dentist or dental surgeon, or eye examinations for the correction
of vision or fitting of glasses; or
(e) any treatment or service due to pregnancy or complications therefrom.
OA 1000AH161 SECTION 21 SUPPLEMENTARY ACCIDENT
• SECTION 23 --SUPERIMPOSED MAJOR MEDICAL. INSURANCE
BENEFITS PAYABLL. If a Person or his D) IICDA(11, white insured LHAr this Section of the Policy, undergoes any
treatment or receives any service spccificd below bccau(e of injury or sickness, the Grmpany, subject to all provisions of
this Policy, will pay for such tre11111ellt or scrvi(e re(civcd durini; any (alcnd.u )(ar and while he is so insured,
80 % of the Covered I xpcw,cs in excess of the bS:,jor Nkdici l Dolu(riblc Amount in such calendar year.
Covcrol Fxpenses arc the actual co>t ch,'rgc'l ar a I'uson with respect u, hiut"ell or his Dependntt but only to the
extent char they shall be dccmal reason,dole and cus,iojw,uy;
(a) by a hospital for roost and bo.ird, but n(•t ar cacccd $ 31.25 pcr d,ry end other services required for
purposes of trea(mcnt; and
(b) by a physician for professional services; and
(e) for services of legally licensed physiotherapists and graduate registered nurses (RN), provided such scrvi~cs
arc not rendered by a member of the Person's family; and
(d) if hospital confined, for drugs and medicines purchased under a physician's prtscription or, if not hospital eon-
fined, for drugs and medicines in excess of S NONE purchased unacc a physician's prescription; and
(e) for braces, crutches, artificial limbs, artificial eyes or for rental of a wheel chair, hospital type bed or an artificial
respirator; and
(f) for x-ray and laboratory examinations; and
(g) by a hospital or by a professional licensed ambulance service for necessary transportation by ambulance to and
from the hospital; and
(h) by a dentist or dental surgeon for repair of damage to the jaw and natural teeth as the direct result of an accident.
Covered Expenses shall include, for the purposes of and subject to all limitations of this Section of the Policy only,
all charges made by the hospital for treatment of nervous or mental disorders during confinement in a mental hospital.
The percentage applicable to expenses incurred, if not hospital confined, because of nervous or mental disorders shall be
5096 instead of the percentage specified above with a maximum of $20.00 to be consif1cred a covered expense for each
outpatient treatment or consultation. Payrnenr will not be made for-more than 50 such outpatient treatments or eonsulta.
docu during any one calendar year
COMMON ACCIDENT PROVISION. If two or more insured members of a family, composed of a Person and his
Dependents, sustain bodily injuries in the same accident, the applicable btajor Medical Deductible Amount will be applied,
in the calendar year in which the accident occurred and in the next following calendar year to the total Covered Expenses
incurred in said calendar years for all such injuries combined rather than the Cavered Expenses incurred by each individual
separately. The payment of benefits and the satisfaction of the Major Medical Deductible Amount as described bcrein will
apply only to those injuries sustained in such accident and provided it will result in greater benefits to the Parson insured.
Covered Expenses in an amount at least equal to the Deductible Amount: specified above must be incurred during
a continuous period of THREE MONTHS beginning on the day that the first Covered Expense is incurred which
is credited toward the accumulation of the Deductible Amount.
MAJOR MEDICAL DEDUCTIBLE AMOUNT. THE MAJOR MEDICAL DEDUCTIBLE SHALL BE $100.00
IN ADDITION TO ALL AMOUNTS PAYABLE UNDER ANY OTHER BENEFIT PROVISION OF THE POLICY.
PREGNANCY BENEFITS. IF A PERSON, WHILE (INSURED UNDER THIS SECTION OR WITHIN NINE
MOIITES AFTER SUCH INSURANCE TERMINATES DUE TO TERMINATION OF EMPLOYMENT BECAUSE OF
PREGNANCY IF SIZE HAD BEEN INSURED FOR THE PREVIOUS NINE MONTHS, OR A DEPENDENT WIFE,
WHILE INSURED UNDER THIS SECTION, UNDERGOES A TREATMENT OR RECEIVES ANY SERVICE SPEC-
IFIED HEREIN 114 CONNECTION WITH COMPLICATIONS OF PREGNANCY ONLY) THE COMPANY, SUBJECT
TO ALL PROVISIONS OF THE POLICY WILL PAY 80% OF THC ACTUAL COST CHARGED WHICH IS IN
EXCESS OF THE GPEATER OF $300.06 OR T,1E BENEFITS PAID UNDER THE PREGNANCY INSURANCE
SECTION OF THE POLICY. THE TOTAL PAYMENT IS SUBJECT TO THE OVERALL MAJOR MEDICAL
MAXIMUM.
FOR PERSONS ONLY, IF PAYMENTS BECOME DUE UNDER THE TERP45 OF THIS 8ENEFIT DUE. TO LOSS
CAUSED BY AN OCCUPATIONAL I J RY OR SICKNESS, THE PROVISION OF LIMITATIONS APPLICABLE
TO MAJOR MEDICAL INSURANCE ~F SHALL NOT APPLY.
OA I000AtT6T Seaton 23 -Suptrlmpoied Moor Medical (c.Y.)
:7 . R!~,
The total payment of all such Covered Expenses during the lifetime of any individual insured under this Section shall
not exceed the Major Medical Maximum Payment, except as hereinafter provided.
The Major Medical Maximum Payment may be restored to its full amount with respect to fuuilt benefits, at any time
after bcm(Is paid to an individual insured under this Section equal or exceed $1,00000 provided
(a) such individual has furnished (without expense to the Company) such evidence of his insurability as may be
required by the Company; and
(b) such evidence of insurability has hrcn approvc.i by the Company.
The Major Afedic.il bfaximum 11ayuunt shall be determined for a Person by his Persmal Insurance classification and
for a Dependenr by the I)ependenr Insurance classi(106011 as shown in Section 13---Schclule of Insurance in this Policy.
Expense, specified above with respect to an individual insured under this Section, which are incurred for treatment or
service received on or after October Ist in any calendar year and while the individual is so insured, may be deemed incurred
in the next following calendar year, instead of the )car in which incurred, if it will result in gicatcr benefits to such individual
and if request is made to the Company on or before the last day of such next following calendar year.
EXTENDED BENEFITS. If a Person or his Dependent, within two years after the insurance of such Person or such
Dependent under this Section terminates, undergoes any treatment or receives any service spec&d herein because of injury
or sickness which existed on the date of termination of such insurance and if he has been totally disabled from the dare his
insurance terminated to the date of such treatment or service, the Company, subject to all provisions of this Polity, will pay
for such treatment or service to the extent provided herein the same as though his insurance was in force with respect to
such treatment or service on the date it was received.
PRE-EXISTING CONDITIONS. No benefits shall be paid to a Person in connection with the same or related cause
for which the Person or his Dependent received any medical care or services within the three-month period immediately
before becoming insured, until the earliest of (a) die end of a period of three consecutive months during which the Person
or Dependent has not received any medical care or service for such or a related cause, or (b) the end of a period of six
consecutive months during which the Person has been continuuu-!y insured under this Policy and continuously at active
full-time work, or (c) the end of a perioi of twelve consecutive months during which the Person has been continuously
insured under this Policy. *THIS APPLES ONLY TO PERSONS AND THEIR DEPENDENTS INSURED AFTER
APRIL 1, 1969.
LIMITATIONS APPLICABLE TO MAJOR MEDICAL INSURANCE. No coverage shall be provided for
(a) any treatment or service for the prevention or cure of alcoholism or narcotism; or
(b) bodily injuries caused by war or any act of war, whether war be declared or undeclared; or
(c) any treatment or service due to pregnancy or any complications resulting from pregnancy, except
as provided in this Section under Pregnancy Benefits; or
(d) benefits paid for or furnished under any other group, franchise, hospital, medical, or other service
pr prepayment plan arranged through any employer, trustees, union, or employee benefit association,
as reported to the Company by the employer or otherwise, but only to the extent so paid for or fur-
nished; or
(e) any treatment or service not prescribed by a physician; or
(f) any treatment or service due to sickness which is covered by a Workmen's Compensation Act or other
similar legislation, or due to injury arising out of or in the course of any employment for wage or
profit; or
(g) any surgery or medical care or service furnished by any facility contracted for or operated by the
United States Government or any other governmental unit for medical care or treatment; or
(h) any charge for eye examinations for the correction of vision or fitting of glasses.
GA 1000AtI E7 Secoon 23- Superimpoied Major Medical (C.Y.)
'°..,a'F','`?r ',f' T'~".i."~tX.'fT-!7 i" st 3 -s^n~a• ;-•rs
APPLICATION FOR GROUP INSURANCE
Application tu'RF1'URBLIC NATIONAI. LIFE INSURANCE COMPANY, Dallis, Texas, for the following Policy or Policies of Group
Insurance
by_r C I T_Y t)E DE410N__--
(Name in which Policy is to be Issuod)
of__- MUNICIPAL BUILDINC, DENTON, TEXAS 76201
(Group Polic'holder'% Main Office Addrtss - Include 'LIP Code)
® Group Life Insurance Policy ❑ Dependent's Group Life Insurance
Group Accident and Sickness Insurance Policy providing Benefits for Persons with respect to:
® 1. Accidcnral Death and Dismemberment k1 5. Phy'sician's Visits ❑ 9. L t n~
O 2, Weekly Income for Disability ~1 6. Pregnancy 10. Major Medical Exler.<:
Q0 3. Hospital Confinancnt ❑ 7. X•Ray and Laboratory Exams ❑ 11.
LI 4. Surgical Operations 8. Supplementary Accident Expense
And Benefits for Dependents with cespect to: 1 `4~'v 7 L 9 0 11 (Circle Numbers Desired) O None
. r
Persons 71ME
Numbcr il~___
Part-Time and' Temporary not Eligible. Others not Eligiblc-__-NONE
_--Total Numberr a
If there are person, in states ocher than where the Group Policyholder has his Main Office, list the states and the number of pers,,,ns in eac_i
state-___N.QNE
s
Contributions for (a) Personal Insurance O are (ld are not (b) Dependents Insurance IU are ❑ are not required from persons insure-?
Premiums shall be payable-. MONTHLY Advance payment of $_1_00•~ is submitted with this applica.io: co E-e
tAnn., geml-Ann., Qtlr.. Mthly.)
applied by the Company on premiums for insurance when and if issued.
It is requested that the Insurance be
U insurance applied for replaces, or is in addition to, any Group or Wholesale insurance now or previously in force, give name of cas:;:r ar.1
_
date insurance -was or is to be discontinued.-_2L11E `ROSS AND BLUE. SHIELD
018CONT_L MAM_ 1969 _ none, so in_ricare
Address correspondence to- MUNICIPAL BUILDING, 1ENTONs-TEXAS 76201
IT IS AGREED THAT the insurance applied for shall not become effective unless (a) this application is received and app:s;.i b:
REPUBLIC NATIONAL LIFE INSURANCE COMPANY at its Home Office in Dallas, Texas, (b) the persons insured are noc :ess dtiau
in number, and (e) with respect to insurance for which individual contributions are required, at least -q of the p:rsoes
eligible for such insurance make written request for the insurance. Acceptance by the Group Policyholder of any Group Policy or P;dicis
issued pursuant to this application shall constitute approval by the Group Policyholder of any corrections. additions, or than8:s st-.-cifit2
below in the space entitled "FOR REPUBLIC NATIONAL LIFE INSURANCE COMPANY USE ONLY,"
FOR REPUBLIC NATIONAL LIFE INSURANCE COMPANY USE ONLY
Dated at-__ EN70Nr TXAS _-this___~2713--day of--139BSH-_- I9~3-
Wirncss_ ~ `ti•d_-_ -
(Full or corporoe name of Group Policyholder)
Agent B 0-s.s L`~`f~-----
(Tit_e.
GA 1002.200
77
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IfllifllSl~N~II(IIjIIn,ilfilllf
REPUBLIC NATIONAL LIFE INSURANCE COMPANY -
ROME Orrl(E • 3916 N. (INTRAt EXPRESSWAY • DALtAt, TEXAS
(1lc•rciu call(til the Comp.tny) -
Jn consideration of the application for this Policy made by
CITY OF DENTON) TEXAS
(Herein called the Group Policyholder)
and the payment by the Group Policyholder of all premiums when due as hereinafter provided, the
Company agrees to make the payments hereinafter provided to the individual or individuals entitled =
- thereto, subject to the provisions and conditions of this Policy.
The initial premium is due on the date of issue hereof and subsequent premiums shall be due
MONTHLY On MAY 1 19 69 , and on the same day of each MONTH thereafter.
Policy anniversaries shall be APRIL 1, 1970 and the same day of each year thereafter.
The provisions and conditions set forth on the following pages hereof are A part of this Policy as _
fully as if recited over the signatures hereto affixed. -
_ The Policy was applied for and is delivered to the Group Policyholder in the State of TEXAS _
whose laws will govern all questions and liabilities arisin3 out of this policy.
fn Witness Whereof, the Republic National Life Insurance Company has by its President and
Secretary signed this Policy at its Home Office in Dallas, Texas, this 15T day of
APRIL , 19 69, which is the date of Sssue hereof.
Secretary Preriderrt
GROUP LIFE INSURANCE POLICY
GROUP POLICY NO. G 11572 RENEWABLE TERM-Non-Participating -
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~lllflll{IlIIfHliiiliili111kIIlRllLllilllllNlllEi!!flilliliifiilllliiilill111111!litlill!ll~ilfllli!ii,l111iifiiNl;filil'~lil9li41!ffilY!II1lI~IH!Ili+i1'ii'.c;41~!I;liif?H~±I'E'I~;~litill'
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♦ 1
TABLE, OF CONTENTS
General Provisions Section
Definitions i
Contract . 2
Eligibility
Individual Effective Dates _ _ A
Individual Tcrminations 5
individual Reinstatements C
Premiums . . 7
Grace Period S
Renewal of Policy 9
Beneficiary
Facility of Payment 11
Settlement Options 12
Insurance Provisions
Schrduie of Insuranc:-..............._..__.... 13
Death Benefit
Total Disability Benefit _ . _ 15
Conversion Privilege
G1.1001-B-16t TABLE OF CONTENTS
s7
SECTION I -DEFINITION OV WORDS AND TERMS USED IN THIS POLICY
The Hord "Person" moans any individuat WHO IS A FULL-T IME EMPLOYEE WORK ING A MI hIMUM OF
THIRTY HOURS A WEEK WiTH THE GROUP POLICYHOLDER.
Ilie term "insurance month" me.uls that Pericd of Tillie hrginning at 1' 01 am. on the f!tst day, of any calendar
month and riding .,t 12 midnight on the last dry of the same calendar u•:nth.
I
I
641001-Gt61 SECTION I-DYFINITIONS
SECTION 2 -CONTRACT
ENTIRE POLICY. This Policy, the application of the Group Policyholder (a copy of which is attached hereto) and the
individual applications, if any, of Persons insured shall constitute the entire crncract between the parties. All statements
made by the Group Policyholder or by the Persons insured shall be deemed representations and not warranties. No statement
made by any Person insured shall be used in any contest unless a copy of the instrument containing the statement is or has
been furnished to such Person or to his beneficiary.
No agent or other individual except an Officer of the Company has authority to ')ake or rnodify this Policy or extend
the time for payment of any premium.
No change in this Policy shall be valid unless made by endorsement hereon, or by amendment signed by the Group
Policyholder and an Officer of the Company. Any change so mode shall be binding on ash Person insured and on any other
individual or individuals referred to in this Policy.
Masculine pronouns used in this Policy shall include both masculine and feminine gender unless the context indicates
otherwise.
INCONTESTABILITY. The validity of this Policy shall not be contested, except for non-payment of premiums, after it
has been in force for one year from its dare of issue. No statement made by any Person insured under this Policy relating
to insurability shall be used in contesting the validity of the insurance with respect to which such statement was made after
such insurance has been in force prior to the contest for a period of two years during such Person's lifetime nor unless it is
contained in a written application signed by the Person.
POLICY NONPARTICIPATING--EXPERIENCE RATING PLAN. This Policy is not entitled to share in the
surplus earnings of the Company.
At the end of each policy year after the first, this Policy shall be subject to experience, rating in accordance with the
Company's experience rating plan then in use, which experience rating plan shall take into account those reserves which
the Company shall determine to be necessary or advisable. Any refund which develops from the experience rating shall be
paid in cash to the Group Policyholder or upon written notice to the Company by the Group Policyholder, may be applied
by the Group Policyholder toward payment of the premiums next falling due under this Policy.
BASIS OF RESERVE. The reserve upon this Policy shall not be less than that computed upon the Commissioners '941
Standard Ordinary Table of Mortality with interest at three per cent per anuurn.
INFORMATION TO BE FURNISHED. The Group Policyholder shall furnish such information as is necessary to
administer this Policy whenever required by the Company. Clerical error on the part of the Group Policyholder in furnishing
such information shall not invalidate insurance otherwise in force, nor continue insurance otherwise terminated. Upon
discovery of any such error an equitable adjustment shall be made in the premiums.
Records of the Group Poilcybolder and Participating Units, if any, which relate to this Policy may be inspected by the
Company at any reasonable time.
MISSTATEMENT OF AGE. If the age of a Person insured is misstated, an equitable adjustment shall be made in the
premiums. If the amount of such Persnn's insurance in accordance with Section 13-Schedule of Insurance is dependent
upon age, the amount of his insurance shall be the amount, if any, to which he would have been entitled at his correct age
and the adjustment in premiums shall be based on the corrected amount of insurance.
CERTIFICATES. The Company will .`urnish the Group Policyholder an individual certificate for delivery to each Person
insured setting forth, in summary form, the essential features of such Person's insurance, to whom the benefits are payable
and the Conversion Privilege.
ASSIGNMENT, No assignment of any Person's insurance under this Group Policy shall be valid. j
Gt.1001-D 161 5F.CrION 7-CONTRACT
SECTION 3 -ELIGIBILITY
Fah Person becomes eligible for the insurance applicable to his classification on:
(A) THE DATE OF ISSUE OF THIS POLICYr IF A FULL-TIME EMPLriYEE WORKIt:G A
MINIMUM OF THIRTY HOURS A WEEK WITH THE GROUP POLICYHOLDER ON THAT
DATE; OR
~D~ THE DATE OF FULL-TIME EMPLOYMENT WITH THE GROUP POLIr,Y'1OLDERr IF
SUCH DATE IS SUBSEQUENT TO THE DATE OF ISSUE OF THI', POLICY.
SECTION 4 -INDIVIDUAL EFFECTIVE DATES
The insurance under this Policy for which a Perum is eligible shall become effective on the date applicable to the
Person as set forth in this Section; however, if the person is not actively at work on the date his insurance would otherwise
become effecrive, his insurance shall not become effective until the first date thereafter that he is actively at work.
I~
Insurance under this Policy for which no individual contributions are required, as determined by Section 13-Schedule
of Insurance, shall become effective on
the date the Person is eligible for such insurance.
Insurance under this Policy for which individual contributions are required, as determined by Section l3-Schedule
of Insurance, must be requested by the Person on a form furnished by the Corr.pany and delivered to the Group Policyholder.
Such insurance, when so requested, shall become effective on
(a) the date the Person is eligible, if the request is made on or before that date; or
(b) the date of the request, if it is made after but within thirty-one days following the date the Person is cligible;or
(c) the date the Company approves such evidence of insurability (furnished without expense to the Company)
as may be required by the Company if the request is made more than thirty-one days following the date the
Person is eligible or after termination of the insurance at the Person's request.
GE-20014.161 SECTIONS 3 AND 4 - FLIGIBILIIY AND INDIVIDUAL F.FEE(TIVE DATES
77 1 77 77 1 i IT
SECTION 4 -INDIVIDUAL EFFECTIVE DATES
'['lie insurance under this Policy for which a Person is eligible shall txcolne effective on the date applicable to the
Person As set forth in this Section; however,
(a) if the Person is not actively at work on the date his Pcr-.onai Insurance woubl otherwise become effective, his
Personal Insurance shall nor become effective until the first date thereafter thht he is actively at work; and
(b) if a Dcpendcnt is confined in a hospital on the date of the Person's Dcpende•nts 1w.urame would otherwise become
efkctive for that Dependent, the IXI,cri enrs Insurance for that particular dej.cndent shall not become effective
unt it final disdharge from the hospital; and
(c) no Dependents Insurance shall become effective for a Person unless he is itsureJ, or simultaneously bceomcs
insured, for Personal Insurance;
(d) Delx•ndents Insurance on the first Dependent acquired by a Person previously insured for Personal Insurance
only shall bcceime effective on the date such Dependent is eligible or the date of approval by the Company of
application for insurance on such Dependent, whichever date is later.
Insurance under this policy for which no individual contributions are required, as determined by Section 13-
Schedule of Insurance, <'.all become effective on
the date the Person is eligible for such insurance.
Insurance under this Policy for which individual contributions are required, as determined by Section 13-Schedule
of Insurance, must be requested by the Person on a form furnished by the Company and delivtred to the Group Policyholder.
Such insurance, when so requested, shall become effective on
(a) the date the Person is eligible, if the request is made on or before that date; or
(b) the dare of the ft-quest, if it is made after but within thirty-one days following the date the Person is eligible; or
(c) the date the Company approves such evidence of insurability (furnished without expense to the Company)
as may be required by the Company if the request is rude more than thirty-one days following the date the
person is eligible or after termination of the insurance at the Persons request.
The Dependents Insurance with respect to a Dependent acquired by a Person while he is insured for Dependents
Insurance shall become effective on the date such Dependent is eligible and thereafter premium payments for such Person
shall be based on his new dependent status.
GENERAL PROVISIONS
OA 10006161 SECTION 4-INDIVIDUAL EFFECTIVE DATES
, ,.L. Imo(
rr.
SECTION 5 -INDIVIDUAL TERMINATIONS
The insutance of any Person insured under this Policy shall cease on the earliest of the following dates:
f a 1 (he date of termination of this Policy; or
lb) the dare en,ling the insurance month as (if which he rcyucsts that his insurancc be terminated, but in no event
prior to the date of su.'t request; or
(c) the date ending the insurance month for which the last prerniurn payment is +rnvlc on account of his insurance; or
(d) the date of re'tmination of his membership in the (lass nr classes eligible for insurance under the Policy; or
( e ) the date he enters the Armed Forms of any country; or
(f) TtIE. DAY NEXT FOLLOWING THE DAY THAT
termination of his employment occurs. Cessation of active work shall be deemed termination of employment,
except that
(1) if cessation of active work is due to illness or injury, his nsurance shall be continued until premium payments
are discontinued by the Group Policyholder, or
(1) if cessation of active work is due to temporary lay-off or approved (cave of absence, his insurance shzll
be continued until premium payments are discontinued by the Group Policyholder but in no case beyond
31 DAYS AFTER THE DAY THAT
his cessation of active work occurs.
SECTION 6 -INDIVIDUAL REINSTATEMENTS
Insurance terminated with respect to Perons formerly insured, other than insurance terminated at any such Person's
request, may be reinstated if mutually agreed ujxwn in writing between the Group Policyholder and the Company. Insurance
reinstated in accordance with any such written agreement shall be treated as if the insurance first became effective on the
dare of the reinstatemen!, unless the agreement explicitly provides otherwise.
GL•1001,G.161 SECTIONS 5 AND 6-INDIVIDUAL IFRMINATIONS AND RFINSTATFMFNTS
7 V,
'
SECTION 7 -PREMIUMS
The initial premium due and each premium due thereafter shall be the amount determined by multiplying the then
effective average premium rate per $1,000.00 of insurance by one thousandth of the total amounr of life insurance then
in force under this Policy. On additional, increased, or terminated insurance the premium will h., adjusted as of the first day
cf the insurance month coinciding with or next following the effective date of such change,
The Group Policyholder shall be liable for all premiums due during any time this Polity is in force. All premiums are
payable by the Group Policyholder on or before their respective due dates directly to 0,V Company at its liome Office
in Dallas, Texas.
The Group Policyholder or the (:ompany may require a rccompuration of the a•,crage monthly premium rate per
$1,000.00 of life insurance on any policy anniversary or on any date the provisions of this Policy are changed as to the
amount of insurance or classes of Persons insured.
COMPUTATION OF PREMIUMS. The average monthly premium per $1,000.00 of insurance for each policy year
shall be determined at the beginning of each policy year by computing the Monthly Basic Premium for each person accord-
ing to the table of basic premium rates then in elTect, his then nearest birthday, and the amount of insurance then in force
on his life, and dividing the sum of all such basic premiums plus the Administrative Charge of
NONE
by one thousandth of the total amount of insurance then in force on the Policy, subject to premium adjustment, if any. The
average annual, semi-annual, or quarterly premium rate per $1,000.00 of life insurance shill be determined on any date
by multiplying the then effative average monthly premium rate by 11.82, 5.956, or 2.985, respectively.
The Company reserves the right to change the rate for any insurance provided under this Policy on any premium due
date that the rate for such insurance has been in effect for at least twelve months by giving written notice to the Group
Policyholder at least one month prior to such premiurn d.le date or on any date the provisions of this Policy are changed
as to the benefits provided or classes of Persons insured.
TABLE OF MONTHLY BASIC PREMIUMS
Aneined Atulned Annned AruineJ Attuned
Age Monthly Age M"mthly Ate hranthly Ate Mnnthry Age Monthly
Nearrrt aesic Nturu rlvic Nront 15";c Nrtre.t a..ic Nureet 616e
rllrthd.y Premiutu DVtthd,y Pimium birnhd.y rremlum Iwldar f"owra Eirthdry Prer4m
15 .19 29 .26 43 .58 57 1.97 71 6.32
16 .20 30 .27 44 .63 58 2.14 71 6.84
17 .21 31 .27 45 .68 59 232 73 7.38
18 .22 32 .28 46 .74 60 2.51 74 7.95
19 .23 33 .29 47 .81 61 2.72 75 8.56
20 .23 34 .30 48 .851 62 2.96 76 9.24
21 .24 35 .32 49 .97 63 3.21 77 10.00
22 .24 36 .34 50 1.% 64 3.48 78 10.86
23 .25 37 .36 51 1.16 65 3.78 79 11.81
24 .25 35 .38 52 1.26 66 4,11 80 12.83
25 .25 39 .41 53 1.38 67 4.48 81 13.93
26 .25 40 .45 54 1.51 68 4.89 82 15.07
27 .26 41 .49 55 1.65 X19 5.34 83 1626
28 .26 42 .53 56 1.80 70 5131 84 17.50
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GG1001•N•162 SECTION 7 - PPIMIUMS
SECTION 8 -GRACE PERIOD
A grace period of thirty-one days, without interest charge, shall be granted to the Group Policyholder for the payment
of every premium, after the first, during which pe tiod this Polity shall continue in force, provided the Group Policyholder
has not previously given written notice to the Company that this Policy is to be discontinued.
It any premium be not paid within the grace period, this Policy shall thereupr,n tv discontinued, but the Group
Policyholder shall, nevertheless, be liable to the Company for the payment of all premiums then unpaid, together with
the premiums for the days of gn:c. If, however, written notice is given by the Group Policyholder to the Company, during
the grace period, chat this Policy is to be discontinued, this Policy shall then be discontinued on the date of receipt by the
Company of such written notice, but the Group Policyholder shall, nevertheless, be liable to the Company for the payment
of all premiums then unpaid, together with a prorata premium for the period commencing with the dare on whici, the
last premium became due and ending with the date of receipt of such written notice by the Company.
SECTION 9 -RENEWAL OF POLICY
This Policy may be renewed by the Group Policyholder on any premium due date by payment of the required premium
provided the number of Persons then insured is not less than 100 per cent of the number eligible, and also
provided the number of Persons then insured is not less than 25
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GLd001•Lf6l SEC11ONS 8 AND 9-GRACE AND RENEWAL
SECTION 10 BENEFICIARY
The beneficiary shall be the individual or individuals to whom proceeds are payable upon the death of the Person
insured, subject to the provisions of Section I I -Facility of Payment. A Person insured shall name such beneficiary, or he
may change a named beaeficiary by executing and filing a written designation to that effect with the Company, but such
designation will not be effective until received at the Home Office of the Company. The designation, when received at the
Home Office of the Company, will be effective as of the date it was executed, but any payment made by the Company prior
to receipt of such designation shall fully discharge the Company to the extent of such payment,
if any beneficiary dies before the Person insured, any sum which cvnuld have beYUmr, payable to such beneficiary, if
living, shall be payable equally to the beneficiary or beneficiaries surviviny ,he Person insured, unless otherwise provided.
If any beneficiary dies either simultaneously with the Person insured or within fifteen days after the Person insured
but before written proof of the death of the Person insured has been received by the Company at its Home Office in Dallas,
Texas, payment shall be made as if the Person insured had survived such teneficiary, unless otherwise provided.
The designation, in an application for an individual policy of insurance made in accordance with Section 16-Con-
version Privilege, of a beneficiary other than the beneficiary under this Policy shall constitute a request for a change of
beneficiary under this Policy to the beneficiary designated in such app:ication.
If a Person's insurance is reinstated in accordance with the provisions of Section 6---Individual Reinstatements, the
beneficiary shall be the beneficiary of record as of the date of termination of such insurance unless written notice of change
has been filed and recorded as herein provided.
SECTION 11 -FACILITY OF PAYMENT
If any Person or if any beneficiary is, in the opinion of the Company, legally incapable of giving a valid receipt for any
payment due him and no guardian has been appointed, the (company may, at its option, make such payment to the individual
or individuals as have, in the Company's opinion, assumed the care anal principal support of such Person or of such
beneficiary, except that any payment due a minor shall be paid at a rate not exceeding $190,00 per month.
If no beneficiary is designated or surviving at the death of the Person insured, the Company may, at its option, make
payment in one or both of the following ways:
(a) up to $250.00, to any individual or individuals who, in the Company's opinion, are equitably entitled thereto
by reason of having incurred funeral or other expenses incident to the last illness of the Person insured;
(b) to the executor or administrator of the estate of the Person insured, or to his surviving wife, husband, mother,
father, child ur children.
Any payment made by the Company in accordance with these provisions shall fully discharge the Company to the
extent of such payment.
G4f001.J-161 SECTIONS 10 AND II - lF.NEFICIARY AID FACILITY OF PAYMENT
SECTION 12 -SETTLEMENT OPTIONS
Any Person insured may elect, by written instructions for settlement delivered to and approved by the Company at
its Home Office in D; Ilas, Texas, to have the whet: or any part of his life insurance (payable upon his death to any bene-
ficiary who is a natural perv-n) applied under the Option set out below except that monthly payments of less than $10.00
each shall not be allowed. If no instructions for sev'emcnt are in effect at the death of the Person insured, such beneficiary
may make the election and may designate any in vidual who is a natural person to receive any amounts payable on the
death of such beneficiary.
The specified amount applied under the following Option shall be paid as a monthly income for the fixed period stated
in the instructions for settlement, the monthly payments to be at the rate designated in the following table for each $1,000.00
applied and the first monthly payment shall be due upon receipt of written proof of such Person's death as provided in
Section 14 - Death Benefit.
Fixed Period
of Years Elected 1 2 3 4 5 6 7 8 9 l0
Monthly Payment for
Each $1,000.00 Applied $84.28 42.66 28.79 21.86 17.70 14.91 12.95 11.47 10.32 9.39
The Company rmrves the right to change the above table on any policy anniversary or an any date the provisions of
this Policy are changed as to the amount of insurance or classes of Persons insured, but such new table shall apply only to
instructions for settlement thereafter elected.
If any beneficiary dies while receiving monthly payments in accordance with these provisions the remaining payments,
unless otherwise specified in the instructions for settlement, shall be commuted on the basis of compound interest at the rate
of two and one-half per cent per annum and paid in one sum to the executor or administrator of the estate of the beneficiary.
Instructions for %eettement other than the one set out above may be arranged if mutually agreed upon between the
Company and the individual entitled to elect the option.
The Company reserves the right to make payments in one sum whenever the monthly payments to any payee are less
than $10 00 each.
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GL.1001-K-161 SECTION 12 - SETTLEMENT OPTIONS
1
SECTION 13 -SCHEDULE OF INSURANCE
A Person shall be insured for the Life Insurance applicable to his classification in this Schedule on the effective date +
of his insurance. THEREAFTER) ANY CHANGE IN CLASSIFICATION SHALL BECOME EFFECTIVE ON THE
DATE OF SUCH CHANGEj, PROVIDED THE PERSON IS ACTIVELY AT WORK ON SUCH DATE; OTHERWISE
ON THE DATE THE PERSON RCTURNS TO ACTIVE WORK.
CLASSIFICATION LIFEMINSURANCE
MONTHLY EARNINGS
A - $600.00 AND OVER $10,000.00*
B - $450.00 To $600.00 5,000.00*
C - LESS THAN $450.00 2,000.00
*REDUCES 50% AT ATTAINMENT OF AGE 65
Contributions for insurance ARE NOT required from Persons insured.
SECTION 14 -DEATH BENEFIT
If a Person dies while insured under this Policy, the Company, upon receipt of written proof of such death and subject
to all provisions of this Policy, will pay to his beneficiary the amount of life insurance in force on his life as of the date
of his death. Such amount of insurance shall be determined for a Person by his classification as ;hown in Section 13 -
Schedule of Insurance.
if the Person dies during the thirty-one-day period within which he is entitled to have an individual policy issued to him,
as provided in Section 16-Conversion Privilege, and before any such policy shall have become effective, the Company
will pay to the beneficiary, upon receipt of due proof of such death, the amount of life insurance which the Person is
entitled to have issued to him under such individual policy, whether or not application for the individual policy or the
payment of the first premium therefor has been made.
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GI.1001-G161 SECTIONS 13 AND lt - SCkIBDULE OF INSVILANCE AND DEATH BENEFIT
SECTION 15 -TOTAL DISABILITY BENEFIT
If a Person becomes totally disabled prior to the date he is sixty years of age and while he is insured under this policy,
then upon termination of his insurance under this Policy, if such total disability continues uninterruptedly from the date of
such termination to the date of his death, which death occurs while this Policy is in force, the Company, upon receipt of
w=ritten proof as set forth in this Section and subject to all provisions of this Policy, will pay to his beneficiary as a benefit the
amount of life insurance in force on his life as of the date such total disabi!ity commenced.
Total disability, for the purposes of this Section, is dcfincd as disability resulting from injury or sickness which com.
pletely prevents the Person from performing any work or engaging in any occupation for wage or profit.
Initial written proof that total disability exists and has continued uninterruptedly must be furnished to the Company
,vithin one year after the date of termination of the Person's insurance but not bcdore such disability has continued uninter-
ruptedly for at least nine months. further written proof that total disability exists and has continued uninterruptedly must be
furnished to the Company when and so often as it may reasonably require, but not more often than once each year after
total disability has continued uninterruptedly for at least two years beyond the date the initial written proof is received
by the Company.
If the Person dies at any time after initial written proof of total disability has been received by the Companf; further
written proof that total disability continued uninterruptedly until the date of death must be furnished to the rwmpany.
If the Person dies within one year after the date of termination of his insurance under this Policy but before written
proof of total disability has been received by the Company, then written proof that total disability continued uninterruptedly
until the date of death must be furnished to the Company within one year after death occurs.
The Company, upon receipt of any notice or proof of a P^rsori s total disability, shall have the right and opportunity
to have a physician it designates examine such Person when and so often as it may reasonably require, but not more often
than once each year after tcaal disabili; has continued uninterruptedly for at least two years beyond the date the initial
written proof is received and approved by the Company.
i
If an individual policy of life insurance has become effective for a totally disabled Person in accordance with the pro-
visions of Section lb-Conversion Privilege, these Total Disability Benefit provisions shall be applicable to that Person
only if such individual policy is surrendered to the Company without claim thereunder other than for return of the premiurns
paid thereon less any indebtedness.
All :ights under these Total Disability Benefit provisions shad automatically and immediately cease on the earliest
of the following dates:
(a ) the date the Person's total disability no longer exists; or
(b) the date the Person fails to submit to any required medical examination; or
(c) the date the Person fails to submit any required proof of the unintetrupted existence of such total disability; or
(d) the date of termination of this Policy.
If a death benefit is paid under this SCet1Un of the Policy, it shill be in lieu of all other life insurance bcnrfus prop;jed
in this Policy.
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GL•1001•M•161 SECTION 1S-TOTAL DISABILITY BENEFIT
7?VT-M 1,
SECTION 16 - CONVERSION PRIVILEGE
Any Fcrson within thirty-rmc days after
(a) the dare his life insurance under this Polir.y is terminated because of termination of employment or of member-
shit; in a class or classes eligible for such insurance under this Policy; or
(b) the date this Polky is terminated, or is amended to exclude the classification of Pcr%oris to which he belongs, if he
has been so insured continuously for at least twe years immediately prior thc•rcit r; to
cI the dare of c(13ari4n of total disability for which lie has qualified and been pproved by the Company as pro-
vided in Secron 15-Total Disability Benefit unless he again becomes insured under this Policy within said
thirty-one days;
shall be entitled to have issued t) him, without evidence of insurability, an individual Igrlicy of life insurance without
disability or other supplementary benefits provided written application therefor and payment of the first premium thereon
is made to the Company within said thirty-on% days. Any such individual policy issued shall become effeccive on the thirty-
second day following the applicable date specified in (a), (b), of (c) above.
If the insurance is termina-:ecl as outlined in (a) above, the Person shall have t}tc right to convert the amount of life
insurance in force on his life as of the date of such termination, less any amount of insurtocc in force on his life pursuant
to an application for an individual policy previously made in accordance with these provisiw s.
If th,: insurance is terminated as outlined in (b) above.. the Person shall have the right to convert the smaller of
{ the amount of life insurance in force on his life as of the date of such termination, less any amount for which
he i; or becomes eligible under any group life insurance policy issued or reissued by the Company or any other
insurance carrier within dtirty-one days after such termination date; and
(b) $2,000.00.
If the Person ceases to be totally disabled as outlined in (c) above, he shall have the right to convert the amount of
death benefit in force on his life as of the date such total disability ceased.
Any such individual policy issued may be on any one of the forms, except term insurance, then customarily issued by
the Company to the class of risk to which the Persons nccn belongs. I -lie premium for such individual policy shall be at the
Company's then customary rate applicable to the form and amount of the individual policy and to the Person's age attained
on the effective date of the individual policy.
GL1001•N-161 sECrION 16-CONVERSION PRIVILEGE
♦ 77, 7, 777, - V , 1 l 4 a < x.l+ 1\°~'C ''d' a ~.;'.f~. ih'1, •`T"'$~.7, \
l APPLICATION FOR GROUP INSURANCE
Application to REPUBLIC NATIONAL LIFE INSURANCE COMPANY, Dallas, Texas, for the following Policy or Policies of Group
Insurance
(Name in Khi<h Poli<y is to be Issucd)-
MUNICIPAL SUILDINGa DENTON, TEXAS 76201
(Group Pulic)hold<r'j Main Office Address Include ZIP Caic)
® Group Life Insurance Policy O Dependent's Group Life Insurance
Group Accident and Sickness Insurance Policy providing Benefits for Persons with tcspcu to:
M 1, Accidental Death and Dismemberment 5. Physician's Visits ❑ 9• Expense
❑ 2. Weekly Income for Disability 6. Pregnancy $0 10. Major Medical Expense
® 3. Hospital Confinement 0 7• X•Ray and Laboratory Exams ❑ 11.
>U 4. Surgical Operations Q S. Supplementary Accident Expense.
And Benefits for Dependents with respect to: 1 L'v 7 ~8 9 0 11 (Circle Numbers Desired) ❑ None
Persons Eligible___-f+Li
-------Total Number eA
Part•Timc and Temporary not Eligible. Others not
-Total Number 0-
If there are persons in states other than where the Group Policyholder has his Main Office, list the states and the number of persons in each
state-, NONE -
t
Contributions for (a) Personal Insurance O are (2 are not (b) Dependents Insurance IU are ❑ are not required from persons insured.
Premiums shall be payable- MQ1J71I1Y_- Advance payment of S 1_00.00 submitted with this application to be
t Aun., Smi-Ann., Qtly., !At>,'7•I
applied by the Company on premiums for insurance when and if issued.
It is requested that the Insurance be effective APRL4.~:~1c49 - If insurance applied for replaces, or is in addition to, any Group or Whofesale insurance
now or previously in force, give name of carrier and
dare insurance was or is to be discontinued___0Ly1=CROSS ADD BLUE SHIELD
i D I SCON?_I (4UE0 MARCH__ 31 -(If none, so indicate)
I
Address correspondence to MUNICIPAL BU I LDI NGj_DENTON~TEXAS 76201
IT 1S AGREED THAT the insurance applied for shall not become effective unless (a) this application is received and approved by
REPUBLIC NAT10i.AL LIFE iNSUPANCE COMPANY at its Nome Office in Dallas, Texas, (b) the persons insured are not less thin
in number, and (c) with resrwct to insurance for which individual contributions are required, at least---_% of the persons
eligible for such insurance make written request for the insurance. Acceptance by the Group Poticyholdet of any Group Policy or Policies
issued pursuant ':o this application shall constitute approval by the Group Policyholder of any corrections, additions, or changes specified
below in the ,pace entitled "FOR REPUBLIC NATIONAL LIFE INSURANCE COMPANY USE ONLY."
FOR REPUBLIC NATIONAL LIFE INSURANCE COMFANY USE ONLY
Dared atv I IDENTON? XAS --this---. 6111 ---day of_-MARCH _19j9
Wimeu 1 ~a.41- (Full c• corpora name of Croup Policyholder)
Agent
(Tide)
OA itA4•;6a