Group Accident Insurance Certificate


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Group Accident Insurance Certificate
University of Richmond

Life Insurance Company of North America
1601 Chestnut Street, Philadelphia, Pennsylvania 19192-2235 A Stock Insurance Company
GROUP ACCIDENT CERTIFICATE
THIS CERTIFICATE PROVIDES LIMITED COVERAGE. PLEASE READ YOUR CERTIFICATE CAREFULLY.
We, the Life Insurance Company of North America, have issued a Group Policy, OK 963781 to Trustee of the Group Insurance Trust for Employers in the Services Industry. We certify that we insure all eligible persons who are enrolled according to the terms of the Group Policy. Your coverage will begin according to the terms set forth in the Eligibility and Effective Date provision. This Certificate describes the benefits and basic provisions of your coverage. It is not the insurance contract and does not waive or alter any terms of the Policy. If questions arise, the Policy language will govern. You may examine the Policy at the office of the Subscriber. This Certificate replaces all prior Certificates issued to you under the Group Policy.
William J. Smith, President
THIS CERTIFICATE IS ISSUED UNDER AN ACCIDENT ONLY POLICY. IT DOES NOT PAY BENEFITS FOR LOSS CAUSED BY SICKNESS. GA-00-CE1000.00

TABLE OF CONTENTS

SECTION

PAGE NUMBER

SCHEDULE OF BENEFITS ................................................................................................................................. 1

GENERAL DEFINITIONS ................................................................................................................................... 4

ELIGIBILITY AND EFFECTIVE DATE PROVISIONS ..................................................................................... 7

COMMON EXCLUSIONS.................................................................................................................................... 8

CLAIM PROVISIONS........................................................................................................................................... 9

ADMINISTRATIVE PROVISIONS ................................................................................................................... 11

GENERAL PROVISIONS................................................................................................................................... 12

ACCIDENTAL DEATH AND DISMEMBERMENT COVERAGE .................................................................. 13

EXPOSURE AND DISAPPEARANCE COVERAGE........................................................................................ 14

SEATBELT AND AIRBAG BENEFIT............................................................................................................... 14

GA-00-CE1000.00

SCHEDULE OF BENEFITS

This Certificate is intended to be read in its entirety. In order to understand all the conditions, exclusions and limitations applicable to its benefits, please read all the provisions carefully.

The Schedule of Benefits provides a brief outline of your coverage and benefits. Please read the Description of Coverages and Benefits Section for full details.

Subscriber: University of Richmond

Effective Date of Subscriber Participation:

January 1, 2008

Certificate Effective Date:

February 1, 2020

Covered Class:

Class 1 - All active, full-time Employees of the Employer who are regularly working in the United States and regular scheduled to work at least 1,511 hours annually or Faculty who are enrolled in the Faculty Phased Retirement Program and regularly residing in the United States and who are United States citizens or permanent resident aliens lawfully working and residing in the United States under an appropriate visa or work authorization, excluding Employees who are citizens of jurisdictions subject to active U.S. – OFAC sanctions programs.

SCHEDULE OF BENEFITS

This Schedule of Benefits shows maximums, benefit periods and any limitations applicable to benefits provided for each Covered Person unless otherwise indicated. Principal Sum, when referred to in this Schedule, means the Employee’s Principal Sum in effect on the date of the Covered Accident causing the Covered Injury or Covered Loss unless otherwise specified.

Eligibility Waiting Period The Eligibility Waiting Period is the period of time the Employee must be in a Covered Class to be eligible for coverage.

For Employees hired on or before the Policy Effective Date:

No Waiting Period

For Employees hired after the Policy Effective Date:

No Waiting Period

Time Period for Loss: Any Covered Loss must occur within:

365 days of the Covered Accident

Maximum Age for Insurance:

None

BASIC ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS

Employee Principal Sum:

2 times Annual Compensation rounded to the next higher $1,000, if not already a multiple thereof, subject to a maximum of $100,000.

Changes in the Covered Person's amount of insurance resulting from a change in the Employee's amount of Annual Compensation take effect, subject to any Active Service requirement, on the first day of the month following the change in Annual Compensation.

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SCHEDULE OF COVERED LOSSES

Covered Loss Loss of Life Loss of Two or More Hands or Feet Loss of Sight of Both Eyes Loss of One Hand or One Foot and Sight in One Eye Loss of Speech and Hearing (in both ears) Quadriplegia Paraplegia Hemiplegia Uniplegia Coma
Monthly Benefit Number of Monthly Benefits Lump Sum Benefit When Payable Loss of One Hand or Foot Loss of Sight in One Eye Loss of Speech Loss of Hearing (in both ears) Loss of all Four Fingers of the Same Hand Loss of Thumb and Index Finger of the Same Hand Loss of all the Toes of the Same Foot

Benefit 100% of the Principal Sum 100% of the Principal Sum 100% of the Principal Sum
100% of the Principal Sum
100% of the Principal Sum 100% of the Principal Sum 50% of the Principal Sum 50% of the Principal Sum 25% of the Principal Sum
1% of the Principal Sum 11 100% of the Principal Sum Beginning of the 12th month 50% of the Principal Sum 50% of the Principal Sum 50% of the Principal Sum 50% of the Principal Sum
25% of the Principal Sum
25% of the Principal Sum
25% of the Principal Sum

Age Reductions

A Covered Person's Principal Sum will be reduced to the percentage of his Principal Sum in effect on the date

preceding the first reduction, as shown below.

Age

Percentage of Benefit Amount

65 but less than 70

65%

70 but less than 75

45%

75 but less than 80

30%

80 or over

20%

ADDITIONAL ACCIDENTAL DEATH AND DISMEMBERMENT COVERAGES Accidental Death and Dismemberment benefits are provided under the following coverages. Any benefits payable under them are as shown in the Schedule of Covered Losses and are not paid in addition to any other Accidental Death and Dismemberment benefits.
EXPOSURE AND DISAPPEARANCE COVERAGE provides the Principal Sum multiplied by the percentage applicable to the Covered Loss, as shown in the Schedule of Covered Losses.

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ADDITIONAL ACCIDENT BENEFITS Any benefits payable under these Additional Accident Benefits shown below are paid in addition to any other Accidental Death and Dismemberment benefits payable.

SEATBELT AND AIRBAG BENEFIT Seatbelt Benefit
Airbag Benefit
Default Benefit

10% of the Principal Sum subject to a Maximum Benefit of $10,000 5% of the Principal Sum subject to a Maximum Benefit of $5,000 $1,000

GA-00-1100.00

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GENERAL DEFINITIONS
Please note that certain words used in this Certificate have specific meanings. The words defined below and capitalized within the text of this Certificate have the meanings set forth below.
Active Service An Employee will be considered in Active Service with the Employer on any day that is either of the following: 1. one of the Employer’s scheduled work days on which the Employee is performing his regular duties on a full-time
basis, either at one of the Employer’s usual places of business or at some other location to which the Employer’s business requires the Employee to travel; 2. a scheduled holiday, vacation day or period of Employer-approved paid leave of absence, other than sick leave, only if the Employee was in Active Service on the preceding scheduled workday.
Age A Covered Person’s Age, for purposes of initial premium calculations, is his Age attained on the date coverage becomes effective for him under this Policy. Thereafter, it is his Age attained on his last birthday.
Aircraft A vehicle which: 1. has a valid certificate of airworthiness; and 2. is being flown by a pilot with a valid license to operate the Aircraft.
Annual Compensation An Employee's annual earnings for normal work established by the Subscriber for his job classification, excluding commissions, bonuses or overtime.
Covered Accident A sudden, unforeseeable, external event that results, directly and independently of all other causes, in a Covered Injury or Covered Loss and meets all of the following conditions: 1. occurs while the Covered Person is insured under this Policy; 2. is not contributed to by disease, Sickness, mental or bodily infirmity; 3. is not otherwise excluded under the terms of this Policy.
Covered Injury Any bodily harm that results directly and independently of all other causes from a Covered Accident.
Covered Loss A loss that is all of the following: 1. the result, directly and independently of all other causes, of a Covered Accident; 2. one of the Covered Losses specified in the Schedule of Covered Losses; 3. suffered by the Covered Person within the applicable time period specified in the Schedule of Benefits.
Covered Person An eligible person, as defined in the Schedule of Benefits, for whom required premium has been paid when due and for whom coverage under this Policy remains in force.
Employee For eligibility purposes, an Employee of the Employer who is in one of the Covered Classes.
Employer The Subscriber and any affiliates, subsidiaries or divisions shown in the Schedule of Covered Affiliates and which are covered under this Policy on the date of issue or subsequently agreed to by Us.
He, His, Him Refers to any individual, male or female.
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Group Accident Insurance Certificate