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REPUBLIC NATIONAL LIFE INSURANCE COMPANY
0001 011111 • Mt N. tICIaI 9MIi1N0Y • tAM$, Tlia/
(Herein called the Company)
In Comid;ntion of the application for this Policy nude by
...............................................................011 ..v P QI.a. T.E AA..........................................................................
(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 Wividual or individuals entitled thereto, subject to the provisiats and
conditions of this Policy.
The initial premium is due on the date of issue hereof and subsequent premiums shall be due..... mahaH..X
on ....MAY...I........................, 19..69...a.-d on the same day of each........... st4 H........................thereafter.
Policy amnivesaries shall be A.f Wt...ts-.197Q...............................and the same day of each year thereafter.
The provisions and conditions set forth on the follcming pages hereof are a pan of this Policy u fully as if recited
over the signatures hereto affixed.
In Witness Whereof, the Republic National Life Insurance Cmpany lus by its President and Secretary signed, and
by in Registrar countersigned, this Policy at its Home Office in Dallas, Tues. this, 1.JT .........day Of....... Arx i
19.68.., which is the date of issue hereof.
4 "64
Suss PrrridsstJ
Countersigned ............................................................Registrar
GROUP ACCIDENT AND SICKNESS INSURANCE POLICY
GROUP POLICY NO. GA....... 1157Z........ NON-PARTICIPATING
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REPUBLIC NATIONAL LIFE INSURANCE COMPANY
DALLAS, TEXAS
ENDORSEMENT TO BE ATTACHED TO AND MADE A PART OF THIB CERTIFICATE.
THE MAJOR MEDICAL EXPENSE BENEFIT IS HEREBY AMENDED TO INCLUDE THIS
PROVISIONS
AUTOMATIC ANNUAL REINSTAT:MENT OF MAJOR MEDICAL BENEFITS -
ON JANUARY IST OF EACH YEAR THERE SHALL BE AN AUTOMATIC RE-
INSTATEMENT FOR EACH INSURED INDIVIDUAL WHOSE 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 #10000.00, BUT IN NO EVENT SHALL THE MAJOR
MEDICAL MAXIMUM FOR THE INSURED INDIVIDUAL EXCEED THE ORIG-
INAL MAJOR MEDICAL MAXIMUM SPECIFIED BY THC PLAN.
EXCEPT AS STATED IN THIS ENDORSEMENT, NOTHING CONTAINED HEREIN S(.ALL
BE HELD TO ALTER OR AFFECT ANY OF THE PROVISIONS OP THE POLICY,
REPUBLIC NATIONAL LIFE INSURANCE COMPANY
6EORIi
YICE-PRE (DENT
ATTEST:
4 aa.,
VICE P D
ASSISTANT SECRETARY
GC-1165-%8
SECTION 11 A NON-DUPLICATION PROVISIONS
The provisions of this Section (herein called these provisions) are for co-ocdinstion of benefits under th;s Policy with
other benefits. The following Sections of this Policy are subject to these ,provisions:
Section 16 Section 19 Section 22
Section 17 Section 20 Section 13
Section 18 Section 21 Section 24
DEFINITION OF WORDS AND TERMS USED IN THIS SECTION. The word "P1aa" means any plan pro-
viding benefits or services for or by reason of medical or dental cue or treatment, which benefits or services are provided by
(a) any group, franchise, hospital, medical or other service. prepayment or ocher coverage arranged through any
employer, tru7ee, union, employee benefit or ocher association; of
(b) any coverage under governmental programs, and any coverage required or provided by any statute; or
(c) any coverage sponsored by, or provided through, it school or ocher educational institution.
the word "Plan" shall be construed separately with respect to each policy, contract, or other arnngemene for benefits or
services and separately with respect to that portion of any such policy, contract, or other arrangement which reserves the
right to take the benefit a services of ocher Plans into consideration in determining its benefits and that poctloa which
dues not, • , , , ,
t The'dMit Othls Plah`r i AzJ thole Sectiod'of this Pb y which provide the beoeLrcs that Wv sublet' to thee' ptovitioat.'
The term "Allowable Expense" means any necessary, reasonable, and customary item of e%prase at least a portion
of which is covered under at least one 0 the Plans covering the individual for whom claim is made, When a Plan pcov},des
benefits in the form of services ratbef. than, ash payments, clot, reaaooabk cash vales of etch sexy' jep~er
&eawd oo be both as Allowable. pease a 404 paid. ~
f, TM trtin i"ClalsWDd*mifttion Period'' means, for scary individwil, the portion of a cakWu year during vtW& be
would be eligible to receive benefits under this Policy in the absence of this Section t I.A.
EFFECT ON ZF.NEFrrS:, The* ltiro Wons shall apply in determining the benefits as to art individuo ootered tinder,
this Ptah' for wy trim Dewihination Period if, for the Allowable Expense uttered is to mch ttsdividual during saKh
petusd,` tlae Alm bf
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t ll)` i;e UeL4 4 &t,WoW 6PrYAt 'under this Plan in the absence of these pmvlsloas, ash
s (b) the benefits duc,woald be paysble'unda all other Plata in the absence therein of provWons of si~alar purpose
CO tlleae pr011ti0n1'
would exceed such Allowable Expeaki ` .
As W any Claim DfWminstion Period with respect to which these trovisions are ~gptigly~e! the benefits that !would
pa k j fP1ut t~ Te a~,t,~ e, Q~ t} e ~ a `(oc~s fpc ~ the ~l ~rnt~a1?leEr Ic~cttcfed u ~o such tndiv,du
wring such tm nacan P~en~ stiaU be redutid o the rsrtht'acree y so that the neat of such rcducei "6
and a* ebe benefits payable for such AlJpwabk lacpetssa utsdec all rstha Plains, except as provided ip the ac3q gr}Pk
shall not exceed the tool of sash AWwabk Expensta..Berufits pay" undec pother Plot includes„thG,beoe t t
have Oven payable had cWw bm duly Spade thetefpc• ,1 ^ f
if
(a) ahocW Piuf which is invbtved'hn the homing paragraph and which oooains a provisho Co4dinadng
it/ behtfits with dense of tl;ht Plan would, ouvrding to its'ruks, deatmine its beoefia after the benefits of this
Platt biv# beet' detexm(ned; tad ; ' ,
(b) the rules Jet f&th in the neic paragraph would require this Plan to determine its benefits before such other
Pkn
then the benefirs of such othci Plan will be ignored for tl a purposes of decette;ning the bertAts atilt' this 'Plati,
GENERAL PROVIKONS ;
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SECTION I IA - NON-DUPLICATION PROVISIONS (Continis")
y' For the purposes of these :woviskxu the rules establishing the .vdct of benefit determination ut.
(a) the benefits of s plan which tsp►>r4+4 jratilrvidpy~, ~g iy}y~. qx
pgeses claim is breed otf,es dun a a dependent
shall be determined before the benefits of s Plan which covers such individual as a depezI
'"(b) the bealfits of a plan whkh covcn'tlie`individual oo whose expenses dsihi Is based ii i'dep`e &nt of a mak
individual shall be determined before the benefits of a Plan which covers such individual as a dependent of a
female hsdividtul;
(c) when !ales (a) and (b) in this Paragraph do toot establish an order of benefit determirutwo. the benefits
of s Plus which has covered the individual on whose espectses claim is based for the longer period of time
shall be determined before the benefits of a Ptah which has coveted suds itdivfdtsal the shorter periob of
time.
Whets these provisions operate to reduct,the. total amount of benefits otherwise payable as to an individual covered
utxier this Plan during apy Claim Detetmioation Period, each benefit that would be payable in else absence of tbm provisions
shall, be tedtlccd proportknw. , :nd suds reduced amount shall be charged agxlnst any applicab,I,e, benefit lime of this PIW
RIGHT TO 'tECE1VE AND RELEASE NECESSARY INFORMATION. for the purposes of determining the
rpplicabaity of and implementing the terms of these provisions under this Plan or any provision of similar purpose of an
other Plan, the Company may, without the consent of or notice to any individual, release to~bt &toiti frets any other
once company,or other orgusizatiod'or individual any information, with respect to any individual, which the Company
deems to be nacssary for such purposes. Any individual claiming benefits under this Plan shall fur,iisb to the Company
such W( matim as may be neoewry to implement mete prpvidotst .
PACILi* OP 'PAYMEN'T; ' WheneI* psymenti which shocid Have bm made under this Plan in accoedarsce with
do* provisions have been made under any other Plans, the Company shall have the right, exercisable aloe arsd in its
sole dUrMon, to p# ovdr'to atiy otgenitations nuking such other payw6n; any animets it shall derv ;p* to fit. wterassted
4 insdidd t& astlify't* hint tt bf'these pmvislons, oind'stootusts so paid "li be deemed to be bene6p paid under this PA so
and, to the extent of such payments, the Company shall be fully discharged from liability under this Plan.
RIGHT OF REOOVBRY. Whcnedcr payments have been made by the Company with resp9a to^Altowable Expenon
io a "ol 4mount; a arty timer ig comets of the, maUrimum mount of payment necessary at that time to s:,tisfy the intent of
fleas provi~itins, the ~oa►paisy shall, Inave tale right ro recover. such ppytssetus, to the e><teat of sash exptss, frot>3~ arfs4ag
pane or more of the Jp*wing, as the Company shall dFtumine: any Wividutts to or for or,,W~h,,fem= to, wb=-Rxb
psyr"ats -were qude. s r other iuuurvipe companies, any other organizations ,
INDY'{iISSYlA,tr' ~OtiICi>~' P1i j'ra'tnts idt"iidsktidt>3 'it1''' ps~td'Mt~''ifi4de' u'ttdet'i}ib ¢FOrfeioiii of dtTi Sltcioit"off i:fk' Pdlty
dull not affect nor be affected by payments made lender any Individual policy.
Iit,1:lY.'ifC1f X31 Irt)Y.llt Y ~1: liftYn~ f : { I;/' Iill? rf;t! 1t~r, is ,i, GENERAL PROVISIONS
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TABLE OF CON'T'ENTS
General Proviaioee Section
Contact 2
Eligibility 3
Individual Effective Dates 4
Individual Terminations
Individual Reinstatenwats b
Premiums 7
Grace Period
Renewal of Policy 9
Notice and Proof of Claim 10
Payment of Benefits 11
Facility of Payment 12
Gonversion 12A 1
Schedule of Insurance 13
i
Insurance Provialow
ACCIOENTtL DEATH AND DISMEMSCRMENT 14
HOSPITAL . . . 16
SURGICAL . . . . . . . . . . . . . 17
'REGNANCY . . . . . . . . . . , . . . . . . . . 18
PHYSICIAN VISITS . . . . . . . . . . 19
SUPPLEMENTARY ACCIDENT 21
MAJOR MEDICAL . 23
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OA 10MI61 TAKE Of CONTlMT3
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SECTION 1 DEFINITION OF WORDS AND TERMS USED IN THIS POLICY
The word "Perim" means any individual WHO IS A FULL-TIME EMPLOYEE WORKING A MINIMUM OF
THIRTY HOURS A WEEK WITH THE GROUP POLICYHOLDER.
The wad "Dependent" means only a Person's if not legally separsted, and each ~
unmutied ........but less than nineteen years of age, provided such individual Is not eligible under
this Policy for Personal Insurance as hereinafter dcfined and is not in the Armed Forces of any country. In addition to any
natural born child of the Perron, 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 Perim for his principal support and maintenance.
THE WORD BDEPENDENT of SHALL ALSO INCLUDE THE UNMARRIED CHILDREN UP TO TWENTY-FOUR
YEARS OF AGE WHO ARE REGULARLY ATTENDING AN ACCREDITED COLLEGE OR UNIVERSITY.
The term "actuai coat" means those chug" for any services, treatment or supplies not in excess of the usual and
customary charges thenefor, or not in cutest of such charges as would have been made in the absence of this insurance.
;lx term "Persona! Insurance" means the insurance provided under this Policy with respect to a Person insured.
Ilse term ' Dependents Insurance" means the inswor_ce provided under this Policy with respect to a Dependent of a
Person Insured for Dependents Insurance. Any reference hereinafter trade to a Person's Dependent being insured under
say Insurance Provision of this Policy shall mean a Dependent with respect to whom such Person 6 insured thereunder
for Dependents Insttwu.
The word "physician" axons only a legally licensed Doctor of Medicine or Osteopathy.
The term "Hospital" wherever used herein shell mean a l Awfully constituted hospital, ilcensed by the state in whkb
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-nigbt care of patients with a registered graduate nurse (RN) in attendance twenty-four hours a day, with a
physician on call, and with provisions within the hospital for feeding of patients and facilities for major opetatkaa and for
x-ray and laboratory tears. The word "Hospital" does not include clinics or rest bones unless they qualify under the
above definition. An institution meeting all the preceding requirements for qualifications as a "hospital", except those
relating to facilirks for major operations and x-ray mind laborstory tests, which Is constituted primarily for the are and
treatment of mental or tuberculosis patients st mill be deemed a "Mentrl" or 'Tuberculosis" hospital. Amounts payable for
confinement in such a bospital shall be limited to daily room and board only.
The term "insurance month" means that period of time beginning at 11:01 axL on the first day of any calendar
month and ending at 12 midnight on the last day of the same calendar month.
GA iNK161 SECTION 1-ONINITIONIS
SECTION 2 - CONTRACT
ENTIRE POLICY. This Policy, the application col tl.e Group Policyholder (a copy of which is attached hereto)
and the individual applications, if any, of Persons insured shall constitute the entire contract between the parties. Ali
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 in Officer of the Company has authority to make or modify this Policy or extend
the time for payment of any premium.
No change in this Policy shall be vapid unless made by endorsemeat hereon, or by amendment signed by the Group
Policyholder and an Officer of the Company. Any change so made shall be binding on each 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 femirine Sender unless the cootex_
indicates otherwise.
INCONTESTABILITY. No statement made by any Person insured under this Policy relating to his or his Depeadeata
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 one year during such Perna 's lifetia.e nor unless it is
contained in a written instrument signed by the Person.
POLICY NON-PARTICIPATING--EXPERIENCE RATING PLAN. This Policy is not entitled to share in the
surplus earnings of the Company.
At the enel of each policy year after the first, this Policy shall be subject to experience rating in accordance with the
Company's esperiatsce rating plea then in use, which experience ratir_g pan 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 :he Company by the Group Policybolde-, may be applied
by the Group Policyholder toward payment of the premiums next felting due under this Pol:cy.
INFORMATION TO BE FURNISHED. The Group Policyholder shahs furnish such information as is necessary
to administer this Policy whenever required by the Gornlvny. Clerical error on the part of the Group Policy: older in
furnishing such information shall not invalidate insuranct 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 Policyholder and Participating Units, if any, which relate to this Policy may be iropected 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 Person's insurance and to whum the benefits
are payable.
FR" CHOICE OF PHYSICIAN. The Person irm;red shall have free choice of any physician. The Company
shall in no way disturb the physician-patient relationship.
WORKMEN'S COMPENSATIC, V NOT AFFECTED. This Policy is not in lieu of and does not affect any
requirements for coverage by Wommen s Compensation Insurance.
GENERAL PROVISIONS
OA IOOO0161 SECTION 2-CONTRACT
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SECTION 3 - ELIGIBILITY
PERSONAL INSURANCE. Each Pena becomes eligible for the Personal Ins wamce applicable to his classification
on:
(A) THE DATE OF ISSUE OF THIS POLICY IF A FULL-TIME EMPLOYEE WORKING A
MINIMUM OF THIRTY HOURS A WEEK WITH THE GROUP POLICYHOLDER ON T;"i.T
DATE; OR
(B) THE DATE OF FULL-TIME EMPLOYMENT WITH THE GROUP POLICYHOLDER, IF
SUCH DATE IS SUBSEQUENT TO THE DATE OF ISSUE OF THIS POLICY.
DEPENDENTS INSURANCE. EiLb Penn becomes eligible for the Dependents imwLwe applicable to bb
classi6cst?on on the latest of the following dates:
(a) the dace of issue of this Policy; or
(b) the date he is eligible foe Personal Insurance; a
(c) the effective date of Dependents Inswance under this Policy; or
(d) the date he first squires a Dependent.
GENERAL PROVISIONS
OA TsfW161 SICTION S - ILIOIMUTY
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Yom`" SECTION f -INDIVIDUAL TERMINATIONS
ti The insurance of arty Person insured under this Policy shJl cease on the earliest of the following data:
(a) the dare of termination of this Policy; or
(b) the date ending the insursoce month as of which he requests that his insurance be terminated, but in no event
prior to the date of such request; or
(c) the date ending the insurawe month for which the last premium payment is made on account of his insurance; or
(d) the date of termination of his membership in the class or cla3ws eligible for insurance under the Policy; or
(e) the date he enters the Armed Forces of any country; or
.DAY T.HAT
(f) X±1L.N&T...NE%T,.FOLLOk I HG THE
termination of his employrrrcnt occurs. Cessation of active work shall be deemed termination of employment,
except that
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(1) 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
3
(2) if cessation of active wcrk is due to temporary lay-off or approved leave of absence, 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 cork occurs. However, this continuance in the event of temporary lay-off or
approved leave of absence shall rot apply to Weekly Income for Disability insurance benefits. Such benefits
shall cease on the date of the layoff or leave of absence.
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The Dependents Insurance with respect to each Dependent shall cease on the date such individual ceasm to be a
Dependent u defined in this Policy. The Dependents Insurance with respect to all Dependents of a Person shall cease on
the date his Personal Insurance terminates, eithx by such Persons 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 between the Group Policyholder and the Company. Insurance
reinstated in accord= with any such written agreement shall be treated as if the itmitarxe first became effective on the
due of the reinstatement, unless the agreement explicitly provides otherwise.
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GENERAL PROVISIONS
GA ICOOM161 SECTIONS 3 AND 6- INDIVIDUAL TERMINATIONS AND REINSTATEMENTS
IF 2L_
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SECTION 7 -PREMIUMS
The initial premium due and each premium due thereafter dull be the sum of
(a) the number of Persons then insured for Personal Insurance in each classification multiplied by the applicable
Rate Pet Person; and
(b) the number of Persons then insured for Dependents Insurance. if any, in each classification multiplied by the
applicable Additional Rue Per Person;
based on the classifications as determined by Section 13 -Schedule of Insurance and the rates in effect on such premium
due due.
The Group Policyholder shall be liable for all premiums due during any turn 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 Home Office
in Dallas, Teas.
The Ccmpany reserves the right to change the rate for any insurance provided under this Policy
(a) on any premium due dace that the rate for such insurance has been in effety for at least twelve months by giving
written notice to the Group Policyholder at lea- one month prior to such premium due date; or
(b) on any date the provLk4nss of this Policy are changed as to the benefits provided a clasp of Perim instved.
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 fuse, during which period this Policy shall continue in force, provided the Group Policyholder
has not previously given written notice to the Company that this Policy is to be discontinued.
If any pttmium be not paid within the grace period, this Policy shall thereupon be 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 grace. If, however, written notice is given by the Group Policyholder to the Computy, during
the grace period, that 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 prorsta premium for the period commencing with the date on which 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 coot of the number eligible, and also
provided the number of Persons then insured is not Ins than 25
GENERAL PROVISIONS
GA !0001161 SECTIONS 7, a AND 9 - ►REMIUMS, GRACE AND RENEWAL
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SECTION 10 --NOTICE AND PROOF OF CLAIM
Written. noti a of claim must be given to the Company within twenty days after the occurrence or ccuanencement
of tiny loss covered by this Policy. Notice given by or on bebc:f of the claimant to the Company at its Home Office in
Dallas, Texas, with information sudlcient to Identify the individual whose injury or sickness is the basis of claim shall
be deemed notice to the Company. The Company, upon receipt of +uch rat ;ice, will furnish forms for filing proof of loss.
If such fortes are mt furnished within fifteen days after the receipt of such notice, the claimant shall be deemed to have
complied with the requirements of this Policy as to proof of loss upon submitting written proof of such loss in accordance
with the provisions of the next succeafing psragnph.
Written proof covering the occurrence, character and extent of the loss for which claim is made must be given to
the Company within ninerf days after the termination of the period for which the Company is liable with respect to any
loss for which this Policy provides payments contingent upon continuing lass; otherwise, within cinety days after the
date of the loss for which claim is trade. Failure to furnish notice or proof within the time feed in this Policy will not
invalidate or reduce any claim if :t shall be shown that it was not reasonably possible to furnish such notice or proof on
time and that it was furnished a soon as was reasonably possible.
No action at law a ;a equity sh.11 be brought to recovttr out this Policy prior to the expiration of sixty days after
proof of loss has been filed in occurrance with the requirements of rho Policy, not shall such action be brought at all unless
brought within three years from the expiration of the time witf,:n which proof of loss is required by this Policy.
The Company shall have the right and opportunity to have a physician it designates 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 limitation of this Section of the Policy is less than that permiaed by the law of the sate in which
the Person resides at the time he berxmes 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 Dependents 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 Dismemberment provisions, such benefits shall be payable to the beneficiary designated by the Person Insured. Benefits
payable for any joss other than that for which this Policy provides periodic payments will be paid immediately upon receipt
of proof of such loss. Subject to proof of lass, benefits payable for any loss for which this Policy provides periodic psyrnena
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 unpaid upon the termination of the Company's liability will be paid immediately upon receipt of proof.
GENERAL PROVISIONS
GA 10001161 SECTIONS 10 AMC 11 -CLAIMS AND PAYMENTS
s F - " - a - a,w
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SECTION 12 - FACILITY OF PAYMENT
If any Person insured is, in the opinion of the Company, legally incapable of gr,ring 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 and prir.-'pal support of such Person. If the Person insured
should die before all amounts due and payable to him have been paid, the Company may, at its option, make such payment
to the executor or adminisuator of his estate 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 thereto.
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 indn•
viduals as have, in the Company's opinion, assumed the cue and principal support of such beneficiary. 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, a '
to any other individual or individuals who, in the Company's opinion, are equitably entitled thereto.
Any payment made by the Company in accordance with these provisions shall fully discharge the Company to the
extent of such payment.
SECTION 12A- CONVERSION PRIVILEGE
Any Person, within thirty-one days after the date his hospital, surgical and pregnancy insurance under this Policy Is
terminated bemuse of termination of employment or of membership in a class or clasees eligible for such insurance, shall
be entitled to have issued to him, without evidence of insurability, an individual policy of hospital-wrgial-pregnancy
insurance provided written application therefor and payment of the first premium therenn is made to the Company within
said thirty-one days. Any such individual policy 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 Polcy Covered the
Person and his dependents,
god 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 thereof
shall be such as is then provided by the Company with respect 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 it Dependent spouse is terminated
because of the death of the Person, such spouse 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 fa the Person insured.
If a Persons huspiral and surgical insurance under this Policy with respect to a Dependent child is terminated
bemuse 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 tune conditions as provided for the Person insured.
GENERAL PROVISIONS
13A IOODK161 SECTION 12 AND 12A-FACILITY OF PAYMENT AND CONVEISION PRIVILEGE
SECTION 1) - SCHEDULE OF INSURANCE
This 1Iolicy provides Pemxul insurance with respect to such Pad so many of the following Personal Insurance Pro.
visions as Are indicated by one or more speci6: amounts set opposite thereto. A Person shall be insured for the PetsosW
Insumice a to his c]~~ moo in this Schedule on the effective date of his Personal Insurance. THEREAFTER,
ANY LHA IN CLASSIFICATION SHALL BECOME EFFECTIVE ON THE DATE OF SUCH CHANGE
PROV DED THE PERSON IS ACTIVELY AT WORK ON SUCH DATE; OTHERWISE ON THE DATE THI
PERSON RETURNS TO ACTIVE WORK.
CLASSIFIC,.TIONS AND»_s~loxTaiE Y._. PREMIUM RATES FOR PERSONS INSURED FOR
PERSONAL INSURANCE.
CtAMFWAMN RATas Pea PRasm
MI%NTHLY EARNINGS
A 6W .00 AND OVER f8.29
e 450.00 TO $600.00 7.89
C LESS THAN $450.00 7,75
PERSONAL INSURANCE PROVISIONS BENEFITS ACDORDINS TO CLASSL4ICAT10"
"Noire saw me sub rravwra it pm&&W for alias dwitAm*o
83C11M 14 ACCIDENTAL DRATH AND DUMOn hONT A B C
Priodpal Som.»..........».»_»»..».».....R............ 10 5000. 2
SWIM 15-WNULY INCOUE NA DnAllMnY
Ws&ly lacmo_.».....»......... NONE NONE NONE
Morimstn BmAt Period...--wks. (Maunder )
Day Benda Besio . Aaldeot
(days dLablad) » ..»......»......»...Sk lcnoa
SHG CfON 16- HdMrAL (See Pans I do 11)
Daily Umit (room and bard) . 25. 250 25.
AW*pat umtr (room mad board) a1*** ***r
MbodlaaewtS omit.....
DEDUCTIBLE EACH CONFINEMENT 25. 25. 25.
SflCI10N I1-SmGwAL. Sttrsial Antepte unite..».._... 400. 400. 400.
SBCTION 18 - PS MANCY
l:loapital Coofin ment 100. 100. 100.
Obaatriat Matimum Psymeot......» » SEE SECTION 18 - PREGNANCY INSURANCE
SSCITON 19-PHYSICIAN V1slrs. The earliest visit sped-
F ; .bed below for ~}ccldmt S L the visit beads beSia
gJ _ BT visit-Siaate visit I3mit». 5. 5. 5.
~w
S ».»..vWt-S[aak Visit umlt NONE NONE NONE
Ilhewhen ............visit-Sinak Visit Limit.... NONE NONE NONE
Vi6t L'mit 600. 600. 600.
if 20---DUXNOnX X•I AY AND LAWRATORY
Limic.._.........._.»...»» NONE NONE NONE
Limit»»...».... NONE NONE NONE
SBCf1031 21- SurpusmpmAaY AOCIDENT. Ma:. Paj t.._. 300. 300. 300 .
ZWn0N 22- MaAmam Paymeat....»».. NONE NONE NONE
SBCnON 23--MAJOL X8DXALMU1mtua Payment»._.._.. 10 000 10 000. 10 000
SECnON 24- MaAmum Pa!ment.. NONE NONE NO N£
*RE4UCES ` AT ATTAINMENT OF AGE 65
Comtributlons foe Personal Ituumac.•........ .A&E..1N07 ...............required front: Persons insured
****120 DAY PERIOD
*****UNLIMITED
PERSONAL INSURANCE SCHEDULE
OA IOM161 UCTKW 13 - SCHMM Of IMSLRAMCI
r
SECTION 1 3 -SCHEDULE OF INSURANCE (CONTINUED)
This Policy Provides Dependents Insurance with respect to such and so many of the following Dependents Insurance
Provisions as are indicated by one or snore specific amounts set opposite thereto. A Person shall be insured for the Dependents
Insurance applicable to his classification and to his Dependent status in this Schedule on the effective date of his Dependents
Insurance.
CLASSIFICATIONS AND....... MoNTIiLY .......PREMIUM RATES FOR PERSONS INSURED FOR
DEPENDENTS INSURANCE.
CLASSIFICATION X X X ADDITIONAL RATL PER PERSON INSURED WITH RssrKT To:
Nrwirirad role
Wit&&DdW"Jew No ADULT CHILD FAMILY
Odor Dependents
N
ALL 0 $10.61 $5.84 $16.45
E
DEPENDENTS INSURANCE PROVISIONS BPMFITS ACCORDING TO CLASSIFICATION
"Nary" waor wro rub iaiurorce it p►oodod /w Oar ApnifirwWm
SECTION id - ACCUDINTAL DEATH AND Dt"MUNIKAUJINT ALL
Principal Sum, - - - [NONE
SECTION 16-HOSPITAL (See Para I at 11)
Daily Limit (rood and board) 25.
AggeSm Limit (room mW board)
Miscellaneous Limit IL**IFII
DEDUCTIBLE EACH CONFINEMENT 25.
SECTION 17-SURGICAL. Surgical Aggregae Limit
SECTION 18 - PREGNANCY
Hospital Confirement UrAi....................................................... 100.
obstetrical Maximum Payc:.at SEE SE! T I ON 18 - PREGNANCY INSURANCE
SECTION 14--PHYSIC...; YIsrm The earliest visit gpeci-
W below for Accident ickness is the visit benefits begin,
Hospital ....d X.... !A!.... visit-Single Visit limit.._. 5•
Home .......visit-Singk Visit Limit..... NON£
Elsewhere . visit -Single V(.at Limit..... NONE
Aggregate Visit Limit............................. 600.
SECTION 20-DIAGNOSTX X-RAY AND WoRATORY
Accident Limit NONE
Sickness Limit.... NONE
SECTION 21-SUPPLEMENTARY ACCIDENT. Max. Pajt....... 3Q,
SECTION 22 - Maximum Payment . NONE
SECTION 29-MA,roa MEDICAL. Maximum Payment.......... 10 000
S.CTION 24- Maximum Payment........... NONE
Conrributiots for Dependents Insurance CAH ...................xtquifed from Persons insured.
****120 DAY PERIOD
*****UNLIMITED
DEPENDENTS INSURANCE SCHEDULE
OA IOWMI&1 SECTION 17-SCHEDULE OF INSURANCE (CeMiwo*A)
SECTION 14 - ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE
BENEFITS PAYABLE. If a Person, whue insured under this Section of the Policy, sustains an injury effected solely
through external, violent and accidental means and as a result thereof, directly and independently of all other causes, suffers
a Ion specified below within ninety days following the date of such injury, the Compaq, subject to all provisions of this
Policy, will pay
(a) the Principal Sum for loss of lifc; ac
(b) one-half the Principal Sum for loss of one hand by severance at or above the wrist, or loss of one foot by severance
at or above the ankle, or irrecoverab fe loss of the sight of one eye; or
(c) the Principe. Sum for loss of more than one of the members enumerated in paragraph (b) above;
but the total payment for all such Iowa resulting arum injuries due to the same accident shall not exceed the Principal
Sum. If benefits ate payable for loss of life, the Company shall have the right and opportunity to have an autopsy made
when it is tot forbidden by law.
The Principal Sum shaft be determined for a Person by his Personal Insurance classification as abown in Section 13 - -
Scbedule of Insurance.
BENEFICIARY. The beneficlary sbatl be the Individual or Wividuab to wboLL 6enefin for loo of We are payable
as designated in wilting by the Person insured. Any Person may change his beneficiat, by executing and filing a written
notloe to that effect with the Company but such change will not be effective until tecordod by the Company. The change,
when recorded, will be c&ective as of the date such notice was executed; but any payment made by the Company prior
to ttaipt 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, oaks otherwise provided.
If any beneficiary dies either simultaneously with the Person insured or within fi.'ceen 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 mode as if the Person insured had survived such beneficiary, unless otherwise provided.
If a Person's Accidental D-sth and Dismemberment insurance is reinstated in accordance with the provisions of
Section 6-Individual Reitstarements, 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 DEATH AND DISMEMBERMENT INSURANCE.
Benefits shall not be payable 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 aircraft
provided by a licensed passenger carrier on a regularly scheduled flight between established airports.
(a) participation in or as the result of the commission of a felonious act.
GA 10000.161 SECTION M-.KCIDEWAL DEATH i t43MEMULWNT (OCCUPATIONAL) FUSONAL
r, fir, err AY' .w'
SECTION 16 -HOSPITAL INSURANCE (PART 1)
BENEFITS PAYABLE. If a Person or his Dependent, while insured under this Seniors of the Policy, is confined to it
hospital for a period of at lost fifteen consecutive hours because of injury or sickness, the Compacy, subject to all pmvbxxn
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 ate) up to the Daily
Limit for each day of such confinement; but the total payment for all such clarps for one period of hospital
confinement shall nee exceed the Aggregate limit (room and board); and
(61 the wual cost charged to him in excess of the Hospital Deductible Amount up to the stated amount of
the misr lsocous limit )MW ydf xIW xalNtiilt "W xdWW xrg x%W"* thews ~0[ iMn~c xtMtst)c Iowa
(1) by the hospital fa setvices other than room and board which are required for purposes of treatment during
such confinement while roan and board benefits are payable; and
(2) by the hospital or by a licensed ambuLace service to $25-00 fat necearvy trampornrioa by ambulance
to and from the hospital;
but the total payment for all chaff (Including any charges resulting from the tame at a related injury or akkness
for which braefite are payable under Part if of this 3ealoa) for arse period of hmpial confinement shall not
emceed the Misodlaneous LimiL
Two or mve petiods of hospital confinement doll be considered one period of hospital confinement with respect to the
Person, unless w,4rsttd by the Person's return to the full-time duties of tees regular occupation for a period of at kart
am week or unless the subsequent confinement is due to causes entirely +Awelated to the causes of the previous confinement
or, with tapect to the Dependent, unless separated by three months or unless the subsequm confinement Is due to awes
entirely unrelated to the aura of the previotu C"De neaL
The Daily limit, the Aggregate Limit (taom cod board), the Miscellaneous Umh sad the Hospital Deductible Amount
shall be determined for a Person by his personal Insurance classification or for a Dependent by the Dependent Insurance
classification as shown in Section 1) --Schedule of Insurance.
FOR PERSONS ONLY IF PAIMENTS 3ECOME DUE UNDER THE TERMS OF THIS BENEFIT CUE TO
LOSS CAUSED BY AN OCCUPATIONAL INJURY OR SICKNESSS THE PROVISION OF LIMITATIONS
APPLICABLE TO HOSPITAL INSURAPICE (8) SHALL NOT APPLY.
EXTENDED BENEFITS. If it Person a his Dependent, within three months after his Ltsuraace under this Section of the
Policy terminates, is confined In a hospital for a period of at least fifteen consecutive hours bemuse of injnq or sickness
which existed on the date of termination of such insttan oe sad if be has been totally disabled from the date bls insurance
terminated to the date such hospital confinement commences, the Company, subject to all provisions of this policy, will pay
the benefits provided In this Section the seas as though the hospital confinement had commenced before the termination
of such insurance.
LIMITATIONS APPLICABLE TO HOSPITAL INSURANCE (PART 1). Benefits shall not be payable for
(a) any confinement not recomasended by a physician; or
(b) any eoniinanent due to sickness which Is covered by a Workmen's Compensation Act or other similar
kgblation, or due to Injury arising out of or in the course of any employment for wage or prodel or
(c) hospital con5measent, surgery or trmi,4Ical cars or service dwing coofinensent withim may facility con•
truted for or operated by the United States Government or any other government unit for towiied
care or treatment; or
(d) any charges for the services of a physician or any charges for the services of a special aura; or
(e) any confinement which Is caused by or molts from pregnancy or complkadoas therefrom.
tiA 160OW42 KCn0N ,a - ~TAL (PART I 'tRis>Rlt llsw DoWnelq
r
SECTION 16 - HOSPITAL INSURANCE (PART II)
BENEFITS PAYABLE. If a person or his Dependent, while insured under this Section of the Polley, is confined in a
hapitd for a period of lea than fifteen consecutive bouts while receiving emergency care at a result of and within
twenty-four hours after an accident or while undergoing a surgical operation, 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 Lad board (including general nursing care) up to the
Deify Limit for such confinement; and
(b) the actual cat :narged to him in excea of the Hospital lkduaibk Amount up W the stated amount of
the miscellaneous limit )tlott*g*)DfxtftexncnMxsatzoftteged)=xkiagotmutacrofxsatUcltoattdtmemw
(1) by the hospital for services other than room and board which are required for purposes of treatment during
such coofinement; and
(2) by the hospital or by a licensed ambulance service up to $25.00 for necessary transportation by ambulance
to and iron the hoopiad;
but the total payment for all such charges for one period of hospital confinement shall act emceed the kbodlaaeoue Limit.
'ne Do* Limit, the Miscellaneous Liauh and the Hospital Deductible Amount shall be dearmiod foe a Person by his
Personal Instlrslnoe clawi5otrion or for a Dependent by the Dependent laaucanoe classibadw M shown in Section 13
Schedule of Insurance.
If a person or his Depend re, while insured under this Section of the Policy, undergoes a tonsillectomy or sdenaidectomy
performed in a place ocher than a hospital, the Company, subject to all provisiors of this Polity, wltl pay the actual cost
dwz d to him by the OVsklan for drugs, dressiW operatics room fee and admiabaxtim of weet6att; but the tool
payment for all such charges for one sucb operation, or both if performed on the some day, shall not acted $15DO.
FOR PERSONS ONLY) IF PAYMENTS BECOME DUE UNDER THE TERMS OF THIS BENEFIT DUE TO
LOSS CAUSED BY AN OCCUPATIONAL INJURY OR SICKNESS) THE PROVISION Of LIMITATIONS
APPLICABLE TO HOSPITAL INSURANCE (8) SHALL NOT APPLY.
LIMITATIONS APPLICABLE TO HOSMAL INSURANCE (PART 11). Benefits shall not be payable for
(a) any renfineaaset not recommets" by a physician; or
(b) any confinement due to sickness which is covered by a Workmen's Compea:atba Act or other sbailar
bsklatioe, or due to injury arising ont of or in the coarse of any employmeat for wage or profit; or
(o) hospital eoa6asmeat, wrjery or medical care or service darias caalneeseat withla any fealty con-
tracted for or operated by the United States Gove numt or any other government unit foe medical
care or trestatentf or
(d) any charges for the services of a physician or any charg« for the services of a special narml or
(o) any confinesaeat which is cawed by or results frost, preSasacy or complieatioos therefrom.
OA loom" SWOON 16 -HO$WAt (PART 11 k11i1th AN DeotltI KI)
r _
SECTION 17 -SURGICAL INSURANCE
BENEFITS PAYABLE. If a Person or his Dependent, while insured under this Section of the Policy, undergoes a
surgical operation specified in the Schedule of Operations in this Section because of injury or siclwess, the Company, subject
to all provisions of this Policy, will pay for such operation the actual cost charged to him by the physician for performing the
operation up to the Maximum Payment specified for the operation in the Schedule of Operations.
If two or more operations ate performed during one period in the operating room, the amount payable, unless otherwise
specified in the Schedule of Operations, shall not exceed the Maximum Payment specified for the ptincipal operation
performed plus 50% 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 trade only for the one operation for which the
largest amount is payable.
The total payment for all operations performed on a Person after he leaves active work and before he returns to the
full-time duties of his regular occupation or on his Dependent within a period of three months, unless due to entirely
unrelated ceuses, shall not exceed the-Surgical Aggregate Limit.
The Surf#al Aggregate Limit shall be determined for a Person by his Personal Insurance classification or for it
Dependent by the Dependent Insurance classification as dmn in Section 13 -Schedule of Insurance.
FOR ItCRgONS ONLY, IF PAYMENTS BECOME DUE UNDER THE TERMS OF THI3 BENEFIT DUE TO x.033
CAUSED BY AN OCCUPATIONAL INJURY OR StCKNESS, THE PROVISION OF LIMITATIONS APPLI1:AELC
TO SURGICAL IN,IURANCE (B) SHALL NOT APPLY.
EXTENDED BENEFITS. If a Person or his Dependent, within three months after his imurance under this Section of
the Policy terminates, undergoes a surgical operation specified In the Schedule of Opmrions of this Section because of injury
or sickness which existed on the due of termination of such insurance and if he has teen totally disabled from the date his
imuracce terminated to the date of such operation, the Company, sub;cct to all provisions of this Policy, will pay the benefits
provided in this Section k.e same as though the operation had been performed iv4ore 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 physicians or
(b) any operation dvc to sickness which is covered by a Workmen's Compensation Act or other similar
legislatioa, or due to injury arising out of or in the course of any employment for wage or profits or
(c) hospital confinement, surgery or medical care or service during confinement within any facility can.
tracted for or operated by the United States Government or any other government unit for medical
cart or treatment) or
(d) any charges for cosmetic or dental surgery, except to the extent necessary to repair injury{ or
(a) any operation which Is caused by or results from pregnancy or complications therefrom.
GA tMY161 SKTION I? - SURO"
SCHEDULE OF SURGICAL OPERATIONS
SURGICAL EXPENSE BENEFITS
The maximum amount payable fa any procedure will be 200 % of the amount shown in the following schedule.
Maximum Maximum
Payment Payment
Abdomen Esophagus, resection of 200.00
Appendcccomy $100.00 Wyngectomy, without neck dissection............... 160.00
Gail bladder, removal of........ _ 110.00 Tonsillectomy, with or without adenoidecminy.... 30.00
Gascrotomy 80.00 Tracheotomy (independent procedure) 40.00
Laparotomy, exploratory 70.00
Srotruch, total rews ction of 200.00 Eye
Amputations Cataract, operation for intraapsulat or
extraapsular, unilateral 140.00
Arum upper, forearm, entire hand or foot............ rreflasl of for
160.00 yeba% itu, operation fa._......................_... 160.00
60.00
Finger, one
25.00
Ht
Leg, through tibia and fibula 80.00 Fracture, Treatment of
't'high 100.00 Ankle, simple closed 40.00
Toe, one 20.00 10,00
Bract Now, simple, le, closed _ 14.00
» 10.00
Amputation -Simple 60.00 Radius and ulna, simple4osed reduction 30.00
Radical 120.00 open reduction -1....... 90.00
Benign tumor or cyst, removal of requiring Ribs, simple, strapfin&.._....... _ 4.00
hwphal'coofutement 30.00 Tibia and fibula, simple-closed reduction........ 40.00
open reduction 100.00
Chat
ArtificW pneumothorax, Induction of, initial...... 10.00 Gonito-Urinary Tract
Refills, each 4.00 Cervix 0mnputstioa
Broachoacopy, esophagoscopy 30.00 Circamcisnon-New boat 6.00
Lung, removal of or portion of 200.00
Under age 10 10.00
Valvulotomy or con missurotomy 200.00 Age 10 or over........................... 16.00
Cystoscopy (disr'"tic) 10.00
i?ialoc#ti Reduction Dilation and curettage noo• n1) ..J...M..M...._ . 20.00
Aakle,{osioins, knee }olat of (patella excepted) 20.00 Hyscerixtiomy ..t........~~ 100.00 ,
Clavicle 20.00 Kidney--Fixation of 120.00
FI40W .,4rl:.. u.+,.... 16.00 Removal of 140.00
: Hip 30.00 Tumdaa oc stoop la areter or bladder, , r { ,
f' Lowet, (ar Of pt'all . . 1000 Resnoral of by cutciag 120.00
tko
r ng , ckaed 10.00 by endoscopic means 40.00
Wr sr L 14,OQ Prostate, remova(,of byaal , ,
.
Open oper is ation (aubt ) 140
caw ,
144
Excision or Fixation by Cutting E~ m" pla e,~..... .
y~l
BA
o44erenoov~ai of -di~owd or i I n fibula 80 OC Fxc sioq of ingk 6b of - ~ )9W humerus, 80.00, Bilateral
Eibotr Femur, , .....s 120.00 CY~+ operation 66. rattbn for......._.........................._... 50.00
Hip, joitic 1!.00 k"` Knee joint ~ 100.00 Rectocele cystocele 80.00
Lessex boon . I. J r :U Ili
40.00
Goitre
4del or , of beolgn tumor of thyroid
Eat; Nese'iitd ~'A!'btt'
kNlt'lstiation ~
Si . 200.00 ~ hii- Mbuid,wu of excision of, su _ btotaL_...._ . 10080.00
.00
Mastoideccomy -Simple 80.00
Radial 12000
l Stapes tnobiliudaa _ 120.00 Mrai#
Aaenoidectomy (Independent procedure) 20.00 '`In'gtittiat ''UtiilatlrsEl 60.00
Sinusotatay, frontal, external simple 40.OQ, Bilateral
80.
Spbmucoys resection, Q( rasa septum OR:
(sepcpcofcYj 60.00, YS sl ~a~Y..,4.1..J .,~.•N ~,.u~~,~ 8a.
(Over) r
GA•1t104YlSI t61
r`%
ROW
Maximum Masanasm a
_p Paymen` Slttill Ft+ymarre
x
,,tep+ss And sature of sit & _ .00 opes~tlon x brain tumor) ZQQ QQ
TrwpWtt, sigjk. 600 Trtphute _ 70JY~v
(Pike al cyst " Sinus 40. spUm°r .y core
s blectomy 160.00 •
Removal of W Spinal cord rumor, operation for. 200.00
Tumor
Rectum Benign or superbciAl turners and cysts or
Fissure, cutth* operation for abscesses Single 6.00
(Independent procedure) 30.00 Multiple
8.00
Fi Simple. .ct ctnmy-- Malignant tumors fact, lip Or in . 30.00
Simple 40.00
Multiple 75.00 Varicose Vsim
Hensorrhoidectomy-E:rernal 10.00 Saphenous veins, ligulon and division and
Internal . 50.00 complete srrippLIg of:
Internal and External. 50.00 Long or Short 5040 j
Hemorrhoidettomy and ftstulotomy Lon& and Short 7U6.00
cc bsn+lccausay , _ 60.00 Sclei rag sdutiont, in)eUM of into
Papillectomy, shy& or andtiple vent' of !t8 Initial 2.00
(Independent procedure) 10.00 &Itwgtwm 2.00
Foi WSW psoglk~ea nos Am"" on this schedule, apd which are ties wwes~ y Vi cbmw by At oaeara of the Group Pat
dsc, Company ' vili determine the Unowl. psyable for the Operation. An %perastost of equal gravity P; sevesity v, s be ttse~
as,& basis for the CompanYs determination
MAXIMUM PAYMENT FORIANESTMETIC ADMINISTERED BY,A OOCTOR OF MEDICINE OR OSTEOPATHY WILL
¢-;2b9.1CIIt0p4UR0ICAL ALLOWANCE.
r,< 7 r~ . f ~ •va.. r, ,
i
i
:
IIA101-1 rl 1.:J
ref+i:!
sE
1 l r.
OAaoOaYas.ui4 ri;Illlll'f'l t)l. r~itt'1(:I) til~::i!`f,?.i('.`2
SECTION 18 PERSON'S PREGNANCY INSURANCE
BENEFITS PAYABLE. If R Person, while insured under this Section of the Policy, is cixlfined in a hospital or under-
goes an obstetrical procedure specified in this Section because of pregnancy or complications therefrom, and if
(a) such pregnancy commenced while she was so insured; or
(b) she became so insured within thirty-one days after the effective date of this Section;
the Company, subject to all provisions of this Policy, wiA pay for such confinement or such obstetrical procedure the actual
cost charged to ter
(a) by tie hospital for service; which are required for purposes of treatment 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 4 child or children. - 100.00
Caesarean Section. - . ............................200.00
Abdominal operation for eanwerine pregnancy........ 200.00
Misurr i age 50.00
All periods of hospital confinement dve to the same pregnancy or complications therefrom shall be considered one
period of hospital confinement.
The Hospital Cone tmeut Limit shall be derv mined for a Person by leer Personal Irauraoce classifiatioa as shown
in Section 13-Schedule of Insurance
if childbirth or miscarriage occurs In a place ocher than a hospital with respect to it Person who would otherwise
over the requirement for hospital benefits either as act forth above or as set forth under Extended BeceLts, the Company,
subject to all provisions of this Policy, will pay the actual cost charged to her for drugs, dressings and services of a re8is-
tered nurse; but the total payment for all such charges due to the same pregnancy shall not exceed 50% of the Hospital
Confinement Limit
A PERSON IS ELIGIBLE FOR THESE BENEFITS ONLY IF SHE IS INSURED HEREUNDER NITH.RESPECT
TO HER HUSBAND.
EXTENDED BENEFITS. If a person, within nice months after her insurance under this Section of the Policy termi-
tntes due to termination of employment only, is ctcfined in a hospital or undergoes an obstetrical procedure specified
in this Section because of pregnancy or complic tium therefrom, and if
(a) she had been insured under this Section for nine months prior to the date of ternikition of such insurance and
PA pregnancy commenced while sbe was so insured; or
(b) she became insured under this Section within thirty-one days after the effective date thetrof;
the Company, subject to a1) provisions of this Policy, wifl pay the applicable benefits provided in this Section the same as
though the hospital confinement had commenced or the obstetrical procedure had been performed before the terminatioo
of such insurance
LVATATIONS 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 it physkian; or
(c) hospital confinement, Surgery or medical care or service during confinement within any facility eon.
tracted for or operated by the United Sato Government or any other government unit for medical
cars or tnaatmeat.
OA 100W 141 SECTION 10 - ►RLONANCT (1101WITAt AMU SUaOICAI) IMMEDIATE-10E4;ONA1.
SECTION 1 a DEPENDEN'T'S PREGNANCY INSURANCE
RENEWS PAYABLE. If a Periods Dependent W ff yihkjpMJ under this Section of the policy, is confined in a
hospital a undergoes an cbaecrial procedure specified in this eause of pregnancy or complications therefrom,
and if
(a) such pregnancy commenced while she was so insured; or
(b) she became so insured v<ithin thirty-one days after the effective date of this SectidW;
the Company, subject to all provisions of this Policy, will pay for such confinement a wch obstetrical Pcooedute the actual
cost charged to the Person
(a) by the hospital for services which are required for purposes of treatment during such confiwmw, but the total
payment for all such cfnrgp for one period of hospital confinement shelf not ecmvd the Hospital Confinement
Limit; and
(b) by a physician for performing the obstetrical procedure up to the applicable maximum payment shown below:
Obswrical Protnds" maximum Payment
Delivery of child or children. 100.00
Caaareaa section.. 200.00
Abdominal {
oprettion for occraaoaine pregosa~ 200.00
. 50.00 l
periods Ali of hospital t due to the same ptrgmncy or complications therefrom shall be caaaidered one
pct hospital confinement
The Hospital Confinement Limit shall be determined for a Dependent Wife by the Dependent Insurance cl nifiatioo
a: shown in Section 13 -Schedule of Imturnce.
If childbirth or miscarrtage occurs in a place other than a hospital with respect to a Person's Dependent Wife who
would otherwise meet the requirements for hospital benefits as set forth above, the Company, subject to all provisions of
this Policy, will pay the smW cost charged to the person fa 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% of the Hospital Confinement Limit
LIMITATIONS APPLICABLE TO PREGNANCY INSURANCL Bensits shall not be payable foe
(a) medical feet or special nursing feet except as speciical2y provided for above; or
(b) any confinament ant recommended by a physician or any %oStetrical procedure not recommended and
performed by a physiciaa; or
(c) haspitd coainemsat, surgery or medical can at service daring cooiaasaeat whitis any facili y cen.
tracted for or operated by the United States Government or any other government unit for medical
care or treatment.
OA WOMIN SK"M t1- MSONAMCr ("OAMtAt AND SMICAL) IMMMAn-DOOMW
F,ttSS .Y,~
f
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SECTION 19 -PHYSICIAN VISIT'S INSURANCE
BENEFITS PAYABLE. If a Iverson or his Dependent, while insured under this Section of the policy, undergoes treat-
agent by a physician during a period of hospital confinement of at least fifteen consecutive hours because of injury of sicknett,
the Company, subject to all provisions of this Policy, will pay for such treatment the actual coat chuged to hits by the
physician up to the Single Visit Limit for each visit required for such treatment In determining the number of visits not
more than one visit each day shall be considered. The total payment for all such chuges for visits made during cue period
of hospital confinement shall not exceed the Aggregate Visit limit.
The word "visit" as used in this Section trans a personal interview between the Person or his Dependent and a
physician and does not include telephone calls or interviews in which the physician does not we the Perim or his Dependent
for treatment.
Two or more periods of hospital confinement shall be considered one period of hospital confinement unless separates:
by the Person's return to the full-time duties of his regular occupation for it period of at least one week, or unless the subse-
quent confinement is due to causes entirely unrelated to the causes of the previous confinenent or, with respect to the
Dependent, unless separated by three months a unless the subsequent confinement is due to causes entirely unrelated to the
Conn of the previous confinement.
The Single Vuk Limit and the Aggregate Visit Limit shall be determined for a Perinea by his Persona! Iawrs uce
classification or fox a Dependent by dw Dependent Insetuce classification as shown in Section 13 Schedule of Insurance.
FOR PERSONS ONLYs IF PAYMENT$ BECOME DUE UNDER THE TERMS OF THIS BENEFIT DUE i0 LOSS
CAUSED OY AN OCCUPATIONAL INJURY OR SICKNESSS THE PROVISION OF LIMITATIONS APPLICABLE
TO PHYSICIAN VISITS INSURANCE (B) SHALL NOT APPLY.
LIMITATIONS APPLICABLE TO PHYSICIAN VISITS INSURANCE. Benefits dull slot be payable for
(a) any Visit made an or within ninety days after the data of a surgical operation osceopt a visit me&
because of an injury or sickness which is entirely unrelated to the injury or sickness requiring suety
oyeratiaa; or
(b) any visit due to sickness which is covered by a Workman's Compensation Act or other similar legis-
lation, 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
sovernmental unit; or
(d) may charges for the services of a dentist or dental surgeon, eye earsminations for the correction of
vision or fitting of glasses, x-rays; or
(e) any visit due to pregnancy or complications therefrom.
OA 100"141 atcTrON 19-PHYSICIAN VISM (IN HOSMtAq
SECTION 21 -SUPPLEMENTARY ACCIDENT INSURANCE
BENEFITS PAYABLE. If a person, of his Dependent, while insured under this Section of the Policy, swtaim an injury
effected solely through external, violent and accidental means and as a result thereof, directly and independently or all
other causes, undergoes any treatment or receive any service specified below commencing within thirty days after the date
such accident occur, the Company, subject to all provisions of this Policy, will per for such traunent or service the actual
cost charged to him
(a) by a hospital for room and board and other services required for purposes of trearmear, and
(b) by it physician for professional services; and
(c) for the services of a graduate registered nurse (R4N.); and
(d) for drugs and dressings; and
(e) for braces, crutches, artificial limbs, Anificial eyes or for rental of a wheel chair, hospital-type bed, or an artificial
respirator; and
(f) for X-ray or laboratory exam4046006; and
(g) for oeassary transportation by ambulance to and from a hospital;
to the extent that such charges exceed the sum of bendta, if any, payable for such injury under Seaiora 16 through 20
of the Insurance Provisions of this Polley; but benefits stall not be payable for may treatment or service received mote
than 90 days after the dam rise accident omm, The total payment for all suds exce" dnarge due to injuries resulting from
the tame accident shall not exceed the Supplementary Accident Maximum Payment.
The Supplementary Accident Maximum Payment shall be determined foe a Person by his Personal Insurance clawhatsoo
or for it Dependent by the Dependent I==nce classification as shown in Section 13--Schedule of Insurance,
FOR PERSONS ONLY$ IF PAYMENTS BECOME DUE UhD£R THE TERMS OF THIS BENEFIT DUE TO LOSS
CAUSED BY AN OCCUPATIONAL INJURY OR SICKNESSp 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 phy"an; or
(b) any treatment or service due to injury arising out of or In the course of any employment fn wage or
profit; or
(c) any treatment or service which Is compensated for or furnished by the United State 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 vi.ion or fitting of Slum; or
(a) any treatment or service due to pregnancy or complications therefrom.
OA 1000AN1&1 SECTION 21 -SUM►EAtIWARY ACCWNIT
N: y
SEC'T'ION 29 --SUPERIMPOSED MAJOR MEDICAL INSURANCE
BENEFI'T'S PAYABLE. If a Person or his Dependent, while insured under this Section of the Policy, undergoes any
treatment Of receives any service specified below because of injury or sickness, the Company, subject to all provisions of
this Policy, will pay for such treatment oe service received during any calendar year and while he is so insured,
80 46 of the Covered Expenses In excess of the Major Medical Ie-ductible Amount in such calendar year.
Covered Expenses are the actual cost charged to a Person with respect to himself or his Dependent but only to due
extent that they shall be deemed reasonable and customary:
(a) by at hospital for room sad board, but not to exceed S 31 .25 per day and other services required for
purpoieas of treatment;, and
(b) by a physician for professional services; and
(c) for services of legally licensed physiotherapists and graduate registered nurses (RN), provided such services
are not rendered by a member of the Persons family; and
(d) if hospital confined, for drugs and medicines purchased under a physicians prescription or, if rtoc hospital con;
fined, for drugs and medicines in excess of S NONE purchased under A physicisn's prescription; and
r
(e) fa btaces, erutcbea, mificid limbs, artificial eyes or for rentcl of a wheel chair, hospital-type bed or an artificial
'mpirator; and
(f) for x-ray sad laboratory examinstions; and
r• -
by a hospital or by a professional licensed ambulance service for necessary transportation by ambulacnce to and
from the bospital; sad
(h) by it dentist or dental surgeon for repair of damage to the jaw and natural teeth as the direct -Conn of an accidtttt.
1 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 diving confinement In a mental bospital.
The percentage sppticable to expenses Incurred, if apt hospital confined, because of nervous or mental disorders shall be
instead of the percentage specified above with a maximum of ¢20.00 to be considered a covered expense for each
outpatient treatment or corsultaolon. Payment will not be made for'mote than SO such outpatient treatments or consulta-
tions during any one CAL-Mae yea
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 Major Medical Deductible Amouu will be applied,
In the calendar year in which the accident occurred and in the next following ca"sz year to the tool Covered Expenses
Incurred In said calendar years for all such injuries combined rather than the CAvered Expenses inured by each individual
separately. The payment of benefits and the satisfaction of the Major Medical Deductible ],mount as described herein will
apply only w those injuries sustilnled In such accident and provided it will result in greater benefits to the Person insured.
Covered Expenses in an amwnt at least equal to the Deductible Amount specified above must be incurred during
A COntinuOw 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
MONTHS AFTER SUCH INSURANCE TERMINATES DUE TO TERMINATION OF EMPLOYMENT BECAUSE Of
PREGNANCY IF SHE'HAD BEEN IIISUREO FOR THE PREVIOUS NINE MONTHS. OR A DEPENDENT WIFE
WHILE INSURED UNDER THIS SECTION UNDERGOES A TREATMENT OR RECEIVES ANY SERVICE SPEC-
IFIED HEREIN IN CONNECTION WITH fOMPLICATIONS OF PREGNANCY ONLY THE COMPANYr SUBJECT
TO ALL PROVISIONS OF THE OLICY WILL PAY 80% OF THE ACTUAL COST CHAPGED WHICH IS IN
EXCESS OF THE GREATER Or W0.66 CR THE BENEFITS PAID UNDER THE PREGNANCY INSURANCE
SECTION OF THE POLtCY. THE TOTAL PAYMENT 13 SUBJECT TO THE OVERALL MAJOR MEDICAL
" MAXIMUM.
FOR PERSONSONLYr IF PAYMENTS BECOME DUE UNDER THE TERMS OF TIi1B BENEFIT DUE TO LOSS
CAUSED BYMtg OC UPATIO tEItit'RY OR SICKNESS 01 THE PROV1311k OF LIMITATIONS APPLICABLE
70 OA 1006A1i17 s«+roa to - •l~yulwyewd Atelor Ateteol (C.1'.j
.m
Ber'taaea inn
p a~ raCtt CQVMod
erns Ydsja ldedtcal Maximum payment, except e„ here ktime of my "YAW lobtred under d& 3octioa ~ttl
naf ter provided
Clot TWO.
Thu Mo4rir Medical Maximum Payment nay be restored to its full amount with respect to futtre benefits, u any time
after benefits paid to an individual insured under this Section equal or exceed $1AWX provided
(a) such individual has furnished (without expense to the Company) such evidence of his insurability as stay be
required by the Company; and
(b) such evidence of insurability has been approved by the Company.
I The Major Medical Maximum Pa,,nent shall be determined for a Person by his Personal Insurance classifcatiat and
for a Dependent by the Dependent Insurance classification as shown in Section 13 -Schedule of Insurance in this Policy.
Expenses specified above with respect to an individual insured under this Section, which are incurred for treatment or
service received on or after October lot in any calendar year and while :he individual Is to insured, may be deemed incurred
in the am following calendar year, instead of the year in which Incurred, if it will result in greater xnefits to such individual
y y and if revert is made to the Company on or before the last day of such next following calendar year.
1 EXTENDED BENEVITS. 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 specified herein because of injury
or sickness which existed on the date of termination of etch insurance and if he has been totally dir%bled from the date his
insurance terminated to the date of such treatment or service, the Company, subject to all provisions of this Policy, will pay
for such treatment or service to the extent provided herein the some as though his insurance was in force with tape" to
such treatment or service on the date it was received.
apRE•EXISTING CONDITIONS. No benefits shall be paid to a Person in connection with the same or related c.iuse
3?
for which the Person or his Dependent received any medical cue or services within the three-month period i iarey
before becoming insured, until the earliest of (a) the end of a period of three consecutive months during which the Pe:%on
of Depentent has not received any medial cue or service for such or a related cause, or (b) the end of a p.: od of six
ti consecutive months during which the Person has beer, continuously insured under this Pdlcy and condraauly at strive
full-time work, or (c) the end of it period of twelve consecutive months during which the Person has Iten continuously
i0suteduadetthisPoliq.*THIS APPLIES ONLY TO PERSONS AND THEIR DEPENDENTS INSURED A+'TEA
APR t L 1, 1969.
LIMITATIONS APPLICABLE TO MAJOR MEDICAL INSURAKCE. No coverage shall be provided for
.(a) any treatment or service for the prevention sr cure of alcoholism or narcotism; or
,4_ o
'(b) bodily injuries caused by war or any act of war, whether war be declared or undeclared; or
.(e) any treatment or service due to Pre8asstY or any ctuaPhatbns resulting from Yc. saneys except
ae as provided is this Section under Pregnancy Benefits; or
(d) benefits paid for or furnished under any other group, franchise, hospital, medical, or other rervice
yr prepayment pion arranged through soy employer, trustees, nnioa, or employee benefit association,
" as reported to the Company by the employer or otherwise, but only to the extent so paid for or fur.
w
nIshedi or
(sj any treatment or service not prescribed by a physician; or
(fj any treatment or service due to sickness which is covered by a Workmen's Compensation Act or other
f; similar legislation, or due to Lalury arising out of or in the course of any employment for wage or
profit; or
($)•any surgery or snedieal care or service furnished by any facility contracted for or operated by At
United Stites Government or any other governmental unit for medical care or treatment; or
(h) any charge for eye examInati;ws for the correction of vision or f tting of glasses.
r
":s OA IOOCAl167 SacRen 23 - Supartmpaied Major N."Ce! (C.Y.)
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APPLICATION FOR GROUP INSURANC.i
Application t ItIPLKILIC NATONAL LIFE INSURANCE COMPANY, Dalas, Texas, for tlse following poky or Policies of Grate
br ~ N OF DENTO
(Nam in which Poliq to to be toyed)
o(_ MUNICIPAL SUILOINtis DENTONs TEXAS 76201
(Group Policybolders Main Office Address Includc ZIP Code)
g) Group Life Insurance Policy 0 Dependent's Group Life Insurance
Group Accident and Sickness Insurance Policy providing Benefits for Persons with respect to:
® 1. Accidental Death and Distnemberment g) S. Phl►sieian s Visits p 9. Es pease
d -2. Weekly Income for Disability Q 6. Pregnanq f1 10. Major Medial Expense
D 3: Hospital Confinement O 7. X•Ray and Laboratory Exams p 1I,
A3 4. Surgical Operations Q 8, Supplementary Accident Expense.
And Benefits foe Dependents with respect to: 13Y,4f,5' , 7 6 9 11 (Circle Numbers Desired) Q None
Persons Eligible ALL, FULL TIME
Total Number 444
Parc-Time and Temporary not Eligible. Oth:is :sac Eligible NONE '
Tots! Numbar_. 2
If there are persrxa in states other than where the Group Policyholder has his Main Office, list the states and the number of persons Ln ea&
ststt N4JL
Coatributions for (a) Personal Insurance O are M are not (b) Dependents Insurance iB are C1 are not required from persons injarer_r.
Premiums shall be payable MO TNLY . Advance payment of $10Q.C0 _ is submitted with this applica:ion to Ee
eAss., aeani•Ann., Qt1f•, 3thtr•)
applied by the Company on premiums for insurance when and if issued.
It is requested that the Insurance bt effective APRIL 1. 1269
U Insurance applied for replace, or is in addition to, any Group or Wholesale insurance now or previously lu fora, give name of ci:r`er to!
'ice frtsnrance was or is to be discontinued BLUE CROSS AND BLUE BNIELO
DISCOIITINUED MARON 91, 1969
(If none, so ial
..tcacd
Address correspondence to MUNICIPAL BUILD 1 NQ, OENTON r TEXAS 76201
IT IS AGREED THAT the insurance applied fx shall not become effective unless (a) this application is received and ap?:,AtJ by
REPUBLIC NATIONAL LIFE INSURANCE COMPANY at its Horne Office in Dallas, Texas, (b) Ilse persons insured are not less than
r in number, and (c) with respect to insurance for which individual contributions are required, at Itasc -Sf of the p:rsocs
eligible for such insurance make written request for the insurance. Acceptance by the Group Policyholder of any Group Policy or P,4jcirs
issued pursuant to this application shall conscitute approval by the Group Policyholder of any corrections, additions, or chanSes spt6fi-'
low in the space entitled "FOR REPUBLIC NATIONAL LIFE INSURANCE COMPANY USE ONLY."
REPUBLIC NATIONAL LIFE INSURANCE COMPANY USE ONLY
R
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red arm DEN ONs T XAS this 67ll-day of_-MASC14 1969
imess + (Full or corpora name of Group Policyholder)
e
ITide-
1"I U
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`4 :M1
_yyY.
- REPUBLIC NATIONAL LIFE INSURANCE COMPANY
100101 OFFICI 0 »i/ 10. Ct101/aL 111/011LWAT • DAMS, TIJAI
(Herein called the Company)
u
In consideration of the application for this Policy made by
r
CITY OF OENTOMs TEXAS
(Herein called the Group policyholder)
r and the payment by the Group Policyholder of all premiums when due as hereinafter -rovided, 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
70
MONTHLY on MAY 1 , 19 69 , recd on the same day of each MONTH thereafter.
Policy anniversaries shall be APRIL 1 r 1970 wd the sane day of each year thereafter.
The provisions and conditions set forth on the fofkming pages hereof ue a part of this Polity u
fully as if recited over the signatures hereto affixed.
k.' The Policy was applied for and is delivered to the Group Policyholder in the Suwee of TEXAS _
whose laws will Saw-n all questions and lisbilities arising out of this Policy.
In Witoeats Whereof, the Republic National Lift Insurance Company has by its President and Ea
Secretary signed this Policy at its Home Office in Dallas, Texas, this 1ST day of
71
APRIL , 19 69, which is the date of issue hereof.
Seaelay Prtridewtt Ba
GROUP LIFE INSURANCE POLICY
GROUP POLICY NO. G 11572 RENEWABLE TERM - Non-Participating
lI~!(~~I~Illli!(!llllifllillllllllll~f,dl~IIIING~lhllillllllii~~i;hEllE!{Ilflli!I+IIIiIICINII!!~I!411i~1Ii'itflllhll~;~~i~~'l~iihl(~{II{IHIti~',ltl!Ilfil~l431f~1'Slhkll"i~~~!~~;,i!i~ii'111{f{i
llifilfall'f!ilEilllillillliilNli!gilil(IIIfIIII~IIEIi-(r.
1• , , i a,
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TABLE OF CONTENTS
Ge"I'al Provision Section
Definitions 1
Contract 2
Migibility 3
Individual Effective Dates 4
Individual Terminations S
Individual Reinstatemeots 6
Premiutns T
Grace Period 8
Renewal of Policy 9
Beneficiary 10
Facility of Payment 11
Settlement Options 12
i
I
Insurance Provisions
Schedule of Insurance 13
Death Benefit
Tsai D'tubility Benefit 15
Convet"i Privilege 16
i
I
GE-1001.36161 TABLE OF CONTENTS
x
yt .
4 'u
' SECT104N 1 - DEFINITION OIL WORDS AND TERMS USED IN THIS POLICY
11wword "Persmilmamany individual WHO IS A FULL-TIME EMPLOYEE WORKING A MINIMUM OF
THIRTY HOURS A WEEK WITH THE GROUP POLICYHOLDER.
I
I
The term "insurance month" means that period of time beginning at 12:01 Am. on the first day of any calendar
month and ending at 12 midnight on the last day of the same calendar month.
GL1Mt G161 sECTWN l-DVtNrWN3
SECTION 2 CONTRACT
A3 ]ENTIRE POLICY. This policy, the spocirion of the Group Policyholder (a copy of which is attached hereto) and the
-
individual applications, if any, of Persona insured shall constitute the entire contract between the parties. All statements
made by the Group Policyholder or by the Persons insured shall be deemed representarkw 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 make or modify 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 sigr•ad by the Group
Policyholder and an Officer of the Company. Any change so made shall be binding on each 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.
4 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 date of issue. No statement made by any Person insurred 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
tuch insurance has been in force prior to the contest for a pe6od of two yeah during such Periods 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.
a At the end of each policy year after the first, this Policy shall be subject to experitnce rating in accordance with the
C3mpany's experience rating plan then in use, which experience rating plan shall take Into account those reserves which
y: the Company shall determine to b: necessary or advisable. Any refund which develops from the experience rating drill 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 1941
Standard Ordinary Table of Mortality with interest at three per cent per annum.
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 parr of the Group Policyholder in furnishing
such information shall not invalidate insurance otherwise in force, not continue insurance otherwise terminated. Upon
discovery of any such error an equitable adjustment shall be made in the premiums.
x;=
s Records of the Group Polkyholder and Participating Units, if any, which relate to this Policy may be innslected by the
Company at soy reasonable time.
MISSTATEMENT OF AGE. If the age of a Person insured is misstated, an equitable adjustment shall be nude in the
premiums. If the amount of such Person'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 furnish the Group Policyholder an individual certificate for delivery to each Person
insured setting forth, in summary form, the essen6sl 6eatures of such Persons insurance, to whom the benefits are j-4yable
and the Conversion Privilege.
ASSIGNMENT. No assignment of any Person's insurance under this Group Policy shall be valid.
~d
tiw00t.atfs sECrM 2-CONTLWr
T x~x e ~ ` 7.
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Y
S I
IV 77WX
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SECTION 3 ELIGIBILITY
Each Person becomes eligible for the insurance applicable to his classification on:
(A) THE DATE OF ISSUE OF THIS POLICYp IF A FULL-TIME EMPLOYEE WORKING A
MINIMUM OF THIRTY HOURS A WEEK WITH 1HE GROUP POLICYHOLDER ON THAT
DATE] OR
(B) THE DATE OF FULL-TIME EMPLOYMENT WITH THE GROUP POLICYHOLDERr IF
IUCH DATE IS SUBSEQUENT TO THE DATE OF ISSUE OF THIS POLICY.
SECTION 4 -INDIVIDUAL EFFECTIVE DATES
The insurance under this Policy for which a Person is eligible shall became 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 effective, his insurance shall not become effective until the first date thereafter that he is actively at work.
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 requitett, as determined by Section 13 -Scheduk
of Insurance, must be requested by the Person on a form furnished by wpany and delivered to the Group Policyholder.
Such insurance, when so requested, shall became effective on
(a) the date the !'erson is eligible, if the request is nu It on or before that date; or
(b) the date of the request, if it is made after but within thirty-one dare :v'.nwing the dare the Person is eligible;or
(e) the date the Company approves sw evidence of insurability (furnished without expense ro the Company)
m may be required by the Company a the request is made more than thirty-one days following the date the
Person is eligible or after terminaurtn of the insurance as the Persons request.
641001-fdil faCl'1tAV! 3 AND 1- [I,IG1E11JTY AND INDIVIDUAL UfWrrva DATb
3
Y.
a" "M WFM
s.
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SECTION 4 -INDIVIDUAL EFFECTIVE DATES
The insurance under this Policy for which a Person is eligible shall become 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 Personal Insurance would otherwise become effective, his
personal Insurance shall not become effective until the first date thereafter that he is actively at work; and
(b) if a Dependent is confined in a hospital on the date of the Person's Dependents Insurance would otherwise become
effective for that Dependent, the Dependents Insurance for that psrticular depetsAent shall not become effective
until final discharge from the hospital; and
(c) no Dependents Insurance shall becoc-^ effective for a person unless he is insured, or simultaneously becomes
insured, for Personal Insurance;
(d) Dependents Insurance on the first Dependent acquired by a Person previously insured for Personal Insurance
only shall become effective on the date such Dependent is eligible or the date of approval by the Company of
application for insurance on such Dependen• whichever date is later.
♦ i1
1
j
Insurance under this Policy for hkh no Individual contributions are required, as determined by Section 13-
Schedule of Insurance, shall become effective on
the date the Peron is eligible for such insurance.
Insurance under this Policy for which individual contribution are required, as determined by action 13--Schedule
of Insurance, must be requested by the Person on a form furnished by the Company and delivered to the Group Policyholder.
Such insurance, when so requested, shall become effective on
(a) the due 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 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 made more than thirty-one days following the date the
person is eligible or after termination of the insurance at the Person's request
The Dependents Insurance with respect to a Dep•.ndent acquired by a Person while he is insured for Dependents
Insurance shall become effective on the date such Depmient u eligible and thereafter premium payments for such Perm
shall be based on his new dependent status.
GENERAL PROVISIONS
OA 10000101 WON 4-t1 OMDUAL IFFKf VE DATE:
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SEC',70N S - INDIVIDUAL TERMINATIONS
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The insurance of any Person insured under this Policy shall case on the earliest of the following dates:
(a) the date of termination of this Policy; or
41` (b) the date ending the insurance month w of which he requests that his insurance be terminated, but in no event
' prior to the date of such request; or
4r.. (c) the date ending the insurance month for which the last premium payment is made on account of his insurance; or
tke date of termination of his metabership in the class or classy eligible for insurance under the Policy; or
(e) the dare he enters the Armed Forces of any country; or
r' (f) THE DAY NEXT FOLLOWING THE DAY THAT
termination of his employment occurs. Cessation of active work shall be deemed termination of employment,
except that
4*
~.v (1) if cessation of active work is due to illness or injury. his insurance shall be continued until premium paytrn_roa
are discontinued by the Group Policyholder, or
' (2) if cessation of active work is due to temporary layer or approved lave of dmaxe, his insurance shs11
be continued until premium payments ere discontinued by the Group Policyholder but in no case beyond
N' 31 DAYS AFTER THE DAY THAT
his cessation of active work occur.
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SECTION 6 -INDIVIDUAL REINSTATEMENTS
Insurance terminated with tapect to Persons formerly insured, other than insurance terminated at any such Person's
request, may be reinstated if mutually agreed upon in writing between the Group Policyholder and the Company. Insurance
reinstated in sccordance with any such written agreement shall be treated as if the insurance fast became effective on the
date of cnc reinstatement, unless the agreement explicitly provides otherwise.
GL.10010161 119CTIONS f AND 6 - INDMDUAL TERMINATION! AND U[N5TAT2MDM
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SECTION T PPJMUMS
The initial premium due and each premium doe thereafter shall be the amount Jetermined by multiplying the then
eSeaive avenge premium rate per $1,000.00 of insurance by on/ thousandth of the total amount of life insurance then
in force under this Policy. On additional, increased, of terminated insurance the premium will be adjusted as of the first day
of 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 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 Home Office
in Dallas, Texts.
The Group Policyholder or the Company may require a recanputstion of the average monthly premium rate per
$1,000.00 of life Insurance on any policy anniversary or on any date the provisions of this Polio sae changed as to the
amount of insurance or classes of Persons insured.
COMPUTATION OF PREMIUMS. The average monthly premium 1xv $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 thew. in effect, his then nearest birthday, and the amount of ituutance 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 shall be determined on any date
by mukiplying the then effeafve average monthly premium rate by 11.82, 5.936, or 2.985, respectively.
Tike Company reserves the right to change tha rate for any insurance provided under this Policy on any premium due
dare 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 premium due date or on any date the provisions of this Polity are changed
is to the benefits provided or classes of Persons insured.
TABLE OF MONTHLY BASIC PREMIUMS
Attalad Attained Attained Attained Attalad
Ap ltwt{dr Aaa R"tilr Age AWadl► A,r Weekly Ara 14"Wr
K "Mr tick Nearatt s"k Nana axle Nor= little Nearest auk
sin►rar rteatf r ain"ar pleads si,t661 rrtalim sires? Preaiwa sin"Sy treiaw
15 .19 29 .26 43 .58 57 197 71 6.32
16 .20 30 .27 44 .63 58 2.14 72 634
17 .21 31 .27 43 48 59 2.32 73 7.38
18 ,22 32 .28 46 .74 60 2.31 74 70
19 .23 33 .29 47 .81 61 2,72 75 8.56
20 23 34 .30 48 .89 62 2,96 76 9.24
21 24 55 .32 49 .97 63 321 77 i0.00
22 24 36 .34 SO 1.06 64 3.48 78 10.86
23 .25 37 .36 31 1.16 63 3.78 79 11,81
24 25 38 .38 52 116 66 4,11 80 12.33
25 .25 39 Al 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 1.63 69 5.34 83 id.2o
28 26 42 .53 56 1180 70 5.81 84 17.30
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SECTION I - GRACE PERIOD
A grace period of thirty-ow days, without interest charge, shall be graced to the Group Polkyholder for she payment
of every premium, after she first, during which period this Pala shall continue in force, provided the Group Policyholder
has nos previously given written notice to the Company that this Pcitcy is to be discontinued.
If aq premium be not paid within the gran period, this PoBcy shall hereupon be 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 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 loll 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 prorats premium for the period commencing with the dare on which the
last premium became due rod 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 Polkyholder on any prerniurs due date by payment of the requited premium
provided the number of Persons then insured is not less than 100 pct coat of the number eligible, and also
provided the number of Persons then insured is not less than 25
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s SECTION 10 - BENEFICLUY
The bene6cLty shall be the individual or individuate 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, of he
may change a names beneficiary by executing and filing a written designation to that elect with the Company, but each
designation will not be eff, give until received at the Home Office of the Company. The designation, when received at the
Horne 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 shalt fully discharge the Company to the extent of such Paymenr,
If any beneficiary dies before the Peron insured, any sum which would have become payable to such beneficiary, if
living, shall be payable equally to the beneficiary or F.neficiarki surviving the Person insured, unless otherv ire provided.
d' If any beneficiary dies either simultaneously with the Person insured or within fifteen days after the Person insured
but before written of the death of the Perm insured has been received the Company at is Home Offce in Dallas,
Texas, payment shall be made as if the Person insured had survived such beneficiary, unless otherwise provided,
The designation, in an appliation 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 ronsdrute a request for a change of
beneficiary under this Policy to the beaeficiary designated in such application.
If a Person's iasuraoce 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 mcorded v herein provided.
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SECTION 1 l - FACILITY OF PAYMENT
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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 cppointed, the Company may, at its option, make such payment to the individual
r , or individuals as have, in the Company's opinion, assumed the are and principal support of ruch Person or of such
y beneficiary, except that any payment due a minor shall be paid at a rate not exceeding $110.00 per month.
If no beneficiary is designated or surviving at the death of the Person insured, the Company may, at is 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, norther,
father, child or children.
Any payment made by the Company in accordance with these provisions shall fully discharge the Company to the
extent of such payment.
GLltYll•J•le! eecMM 10 AND 11-s>10R MUY AND FAGU7T Of tAYle M
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SECTION 12 SETTLEMENT OPTIONS
' Any Penal insured may elect, by written instructions for settlement delivered to sof approves by the Compsiq at
its Home Office in Dallas, Tess, to have the whole or any part of his life insurance (payable upon his death to any bene.
ficiary who is a sutural person) 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 settlement are in effect at the death of the Peron insured, such beneficiary
may make the election and may designate any individual who is a natural person to receive say 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 folbwing table for each $1,000.00
applied and the first monthly payment shall be due upon receipt of written proof of such Perm's death as provided in
Section 14 - Death Benefit.
Fixed Period
of Yeah Elected 1 2 3 4 5 6 7 8 9 10
1; . Monthly Payment foe
Each $1,000.00 Applied $84.28 42.66 28.79 21.86 17.7 14.93 12.95 11.47 1032 9.39
The Company reserves the right to change the above table on any policy anniversary or on any date the provisions of
this Policy ate 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 boils 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 settlement other than -he one set out above may be arranged if mutually agreed upon bet men 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.
t34lOpt-K•!il secrsoN Ir-srnustWT OPMNs
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SECTION 13 SCIUDLTU OF INSURANCE
a A Person shall be'nsurrd for the Life Inwaace applicable to his dwificstlon in this ScEsedale an the eBectl-i. date
of hls insurance. THEREAFTER, ANY CHANGE IN CLASSIFICATION SHALL BECOME EFFECTIVE ON THE
DATE OF SUCH CHANGES PPOViDED THE PERSON IS ACTIVELY AT YORK ON SUCH DATE; 0rHERWII;E
't. ON THE DATE THE PERSON RETURNS TO ACTIVE YORK.
AMOUM OF
CLASSIFICATION LIFE INSUFANCE
MON1#4LY EARNINGS
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A - $600.00 AND OVER $10,000.00*
B - $450.00 TO $600.00 5s000.00*
C - LESS THAN $450.00 2,90W.00*
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*REDUCES 5O AT ATTAIN'4ENT OF AGE 65
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Contn'butions for insurance ARE NOT required from Persons insured.
SECTION ' -DEATH BENEFI'T'
If a Person dies while insured under this Policy, the Company, upon receipt of writ.cn pro i if suds death And subject
to all provisions of this Policy, will pay to his beneficiary the amount of life insurance in face on f.is Life u of the date
of his cteath. Such amount of insurance shall be determined for it Person by his classification as shown in Section 13. -
Schedule of Insurance.
If the Person dies during the thirty<xwday period within which he is entitled to have an individual policy issued to him,
as provided in Section 16-Con►;rsion Privilege, and before any such policy shalt 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 Peron is
.ntided 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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SECTION IS -TOTAL DISABILITY BENEFIT
If a Person bcoomes funnily disabled prior to the date he is sixty yeah of age and while he is insured under this policy,
then upon termination of his iruurance 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 fora, the Company, upon receipt of
written 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 disability commenced.
Total disability, for the purposes of this Section, is defined as disability resulthig from injury or sickness which com•
m Poly prevents the Person from performing any work or engaging in any occupation for wage or profit.
Initial written proof that toad disability exists and has continued uninterruptedly roust be furnished to the Company
y- within one year after the date of termination of the Person's insurance but not before such disability has continued unimter.
r~. ruptedly for at least nine months. Further written proof that total disability exists and has continued uninterruptedly must be
famished to the Company when and so often m it may reasonably require, but not more often than once each year after
total disability bas 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 Company, further
written proof that total disability continued uninterruptedly until the date of death must be furnished to the Company.
If the Peron dies within oat year after the dace 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 toad disability continued unimxrrupttdly
s, until the date of death must be furnished to the Company within one year after death occur.
The Company, upon receipt of any notice or proof of a Person'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 coal disability has continued uninterruptedly for ar least two years beyond the date the initial
wri nm proof Is received and approved by the Company.
t. If an Individual policy of life insurance has become effective for a totally disabled Person in accordance with the pro-
visions of Section 16-Conversion Privilege, these Total Disability l3enefit provisions shall be applicable to that Person
only if such individual policy is surrendered to the Company without claim thereunder other than for retum of the premiums
paid thereon less any indebtedness.
All rights under time Total Disability Benefit provisions shag 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 uninterrupted existence of such total disability; or
(d) the date of termination of this Policy.
If a death benefit is paid under this Section of the Folicy, it shall be in lieu of all other life insurance benefits provided
in .'tis Policy.
t3Lrtt?I•ar•MI 11MON IS-TOTAL DNANLny Ell wT
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SECTION 16 CONVERSION PRIVILEGE
Any Person with:a thirty-me days after
(a) the date his life insurance under this Policy is terminated because of termination of employment or of member-
ship in a class or classes eligible for such insurance under this Policy; or
(b) the date this Policy is terminated, or is amended to exclude the classifitAtioa of Persons to which he belongs, if he
has been so insured continuously for at least five years immediately prior thereto; or
(c) the date of cessation of txal disability for which he has qualified and been approved by the Company as pro-
vided in Section 13 -T(,,A Disability Benefit unless he spin becomes insured under this Policy within said
thirty-one days;
shall be entitled to have issued to Lim, without evidence of insurability, an individual policy of life insurance without
disability or other supplementary benefits ; -,vided written-. application therefor and payment of the first premium thereon
s , . is made to the Company within said thirty-&. days Any such individual policy issued shall become effective on the thirty-
second day following the applicable date specified in (a), 'b), of (c) above.
If the insurance is terminated as outlined in (a) above, the Person shall have the right to convert the amount of life
insurance in face on his life as of the date of such termination, less any amount of insurance in force on his fife pursuant
to an application for an individual policy previously made in accordance with these provisions.
If the insurance is terminated as outlined in (b) above, the Person shall have the right to convert the stuller of
(a) the amount of !ife insurance in force on his life as of the date of such termination, less any amount for which
he is of be.omes eligible under any group life insurance policy issued or reissued by the Company or any other
insurance carrier within thirty-one days after such termination date; and
y , (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 then belongs. The 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.
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G1s100616.161 ISCT101't 16 00WIRAM MVUAGE
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/ ApPLICATION R GROUP INSURANCE
Ion to REPUBLIC NATIONAL LIFE INSURANCE COMPANY, Was, Texs+s„ for the following PWk7 at pgtkkt of CITY OF DEN ON Gq0jW
(Name in which Policy Is ro be towed)
MUN_I01PAL lUtLOINRO DENTONs TEXAS 76201
(Group Policyboer i lain Offix Address -Include ZIP Code)
10 Group Life Insurance Policy O Dependent's Group Life Insurance
r Gawp Accident and Sickness Insurance Policy providing Benefits for Persons with respect ta:
M 1. Accidental Death and Dismemberment 10 S. Physician's Visits O 9, Expo
O •2, Weekly Income for Disability Q 66 Prepsncy Q 10. Major Medical Expense
10 3. Hospital Confinement O 7. X•Ray and Laboratory Exams 011.
V 4. Surgical Operations Q a Supplementary Accident Expense.
And Benefits for Dependents with respect to: I e4r V 7 6' 9 0 11 (Circle Numbers Desired) O None
Mr Persons Eligible _ALL FULL TIME
't'ad Number 4"4'1'
tt•1`lim and Temporary not Eligible. Others na Eligible NONE t
Total Number 0
there ate persons In states otter than where the Group Policyholder has his Main Office, list the scats and the number of persons in each
NONE
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Contributioni for (a) Personal Insurance O are ® are nor (b) Dependents Insurance tl are O are not required frats persons insured.
Premiums shall be payable MONTHLY Advance pa;ment of S 100,00 is submitted with this application to be
lAaa., a4si.Aaa, tytnr. twtlh.l
applied by the Company on premiums for insurance when arnd if issued.
It is requested that the Insurance be effective APR I L 1 s 1969
1
If insurance applied for replaces, or is In addition to, any Group or Wholesale insurance now or previously in force, give name of carrier and
date insurance was or is to be discontinues BLUE CR098 AND OLLIE SH 1 ELO i
21 SCONJ I NUEU MAg¢H 31 , 1969 _(If none, so indicate)
Address correspondence to MUNICIPAL BU I LD I NF, DENT01112_TCXA9 76201
IT IS AGREED THAT the insurance applied for shall trot berme effective unless 00 this application is received and approved b)'
REPUBLIC NATIONAL LIFE INSURANCE COMPANY at ir, Home Office in Dallas, Texas, (b) the persons insured are not less than
in number, and (c) with respect to insurance for which individual contributions are required, at least.r._„96 of the persons
digible for such insurance make written request for the insurance, Acceptance by the Group Policybolder of any Group Policy or Policies
bsued pursuant to this application shall constitute approval by the Group Policyholder of any corrections, additionm or changes specified
below In the space entitled "FOR REPUBLIC NATIONAL LIFE INSURANCE COMPANY USE ONLY."
FOR REPUBLIC NATIONAL LIFE INSURANCE COMPANY USE ONLY
Dated at DENTON, T XA9 6TH this day of,__MARCH
A ;N or name of Group Polkylwlder)
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or,
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