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CIIII'I I I 'A))CIA).

I)I'I ICLR
JEFF ATtVATER
snAI Ii oli I I OR) t&A
14-073149
RICHARD KOCOT,
PLA INTIFF(S),
VS,
CASE JJ; 502014CA 007311 XXXXMB
COURT: CIRCUIT COURT
COUNTY: PALM BEACH
DFS-SOP{{1;14-073149
FLORIDA COMBINED LIFE INSURANCE COMPANY
DFFENDANT(S),
CIVIL ACTION SUMMONS, COMPLAINT, EXI-II BITS
NOTICE OF SERVICE OF PROCESS
NOTICE IS HFREIBY GIVEN of acceptance of Service of Process
by
the Chief Financial
Officer of the State of Florida, Said process was received in my
office
by
PROCESS SERVER
on the 23rd day of June, 2014 and a copy
was forwarded
by
Electronic Delivery on the 30th day
of June, 2014 to the designated agent for the named entity as shown below.
FLORIDA COIVIBINED LIFE INSURANCE COMPANY
LYNETTE COLEMAN
CORPORATION SERVICE COM PANY
1201 HAYS STREET
TALLAHASSEE, FL 32301
*
Our office cvill only serve the initial process (Summons and Complaint) or Subpoena and is not responsible for transmittal of any
subsctiuent fiiings, pleadings or documents unless othcmvisc ortlcrcd by the Court pursuant to Florida Rules of Civil procedure, Rulc gl.{)go.
Jeff Atwater
Chief Financial Officer
ec to, Plaintiffs Representative for liling in appropriate court,
MATTHEW T, RAMENDA
505 SOUTH FLAGLER DRIVE,
STE. 1100
WEST PALM BEACH FL 33401
TMB
EXHIBIT
"1"
Dividion of Legal Services - Service ol'Process Section
200 East Gsines Strcct ~ PQ Itov 6200 ~ Tails))asses, Flotlda 323{46200
~ {810)413%200 -
Fax {850)922 2544
Case 9:14-cv-80945-KAM Document 1-1 Entered on FLSD Docket 07/16/2014 Page 1 of 43
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CIVIL ACTION SUMMONS("
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& I','-.,IN
THE CIRCUIT COURT OF THE 15TH
iC. JiUDICIAL CIRCUIT IN AND FOR PALM
BEACH COUNTY, FLORIDA
CASE NO. 502014CA007311XXXXlvIB
RICHARD KOCOT,
Plaintiff,
FLORIDA COMBINED LI FE
INSURANCE, INC.
Deferrdant(s).
Tlm8'y:
THE STATE OF FLORIDA:
To All and Singular the Sheriffs of the State:
YOU ARE COMMANDED to sei ve this Summons aiid a copy
of the
Complaint
in this action orr
Defendant:
Name of corporation
13y serving its Registered Agent.
Address:
Florida Combined Life Insur;incc Company,~
Chief Financial Officer
200 E. Gaines Street
Tallahassee, FL 32399-0000
Each Defendant is required to serve written defenses to the Complaint on Plaintiff's attorney, whose name
and address is:
Matthew T. Ranreiida, Esquire
Jones, Foster, Jolinston 0, Stubbs, I'.h.
505 South Flagler Drive, Suite 1100
West Palm Beach, Florida33401-3475
(561) 659-3000
within 20 days after senicc of this Summons on that Defendant, exclusive of the day ol'service, and to
file the original of the defenses with the Clerk of this Court either before service on Plaintiffs attorney or
immediately thereafter. If a Defendant fails to do so, a default will be entered against that Defendant
for'he
relict demanded in the Complaint,
DATED this
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Roftdq
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OF
f'HARON
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CI.ERK 8c COMPTROLLER
PALM BF CHCO
Y
By:
~
arrl L~~A~~
De puty Clerk
RObITI Pigdp!-
Case 9:14-cv-80945-KAM Document 1-1 Entered on FLSD Docket 07/16/2014 Page 2 of 43
RICHARD KOCOT,
Plaintiff,
IN THE CIRCUIT COURT OF THE
FIFTEENTH JUDICIAL CIRCUIT IN AND
FOR PALM BEACH COUNTY, FLORIDA
CASE NO, 502014CA007311XXXXMB
Fl ORIDA COMBINED LIFE
INSURANCE COMPANY, INC.,
a Florida corporation,
Defendant.
COMPLAINT
COMES NOW Plaintiff Richard Kocot to sue Defendant Florida Combined Life
Insurance Company, Inc., and alleges as follows..
PARTIES
Richard Kocot
("
Mr. Kocot"), a natural person, is the beneficiary of the life
insurance policy issued by
Defendant.
2. Florida Combined Life Insurance
Company,
Inc.
("
Florida Combined Life"
)
is an active Florida corporation with a principal place of business located at the following
street address, 4800 Deerwood Campus Parkway, Building 200, Suite 600,
Jacksonville, FL 32246.
JURISDICTION 8 VENUE
3. This is an action for damages in excess of $15,000.00 exclusive of
interest, attorney's fees and costs
. 4. This Court has jurisdiction of this action pursuant to
g
26.012, Fla. Stat.
Case 9:14-cv-80945-KAM Document 1-1 Entered on FLSD Docket 07/16/2014 Page 3 of 43
Kocot v. Florida Combined Life ins. Co,
Case No.
Complaint
Page 2of 5
5. Venue is proper in Palm Beach County, Florida pursuant to
H
47,011 8
47.051, Fla, Stat., in that: (1)
the contract was breached in Palm Beach County,
Florida, and
(2)
the Certificate of Insurance was issued in Palm Beach County,
GENERAL ALLEGATIONS
6. In December of 2010, Dawn Mi. Kocot ("Ms, Kocot") applied for group term
life insurance through her employer, Comprehensive Pain Management.
7. Also in December of 2010, F'iorida Combined Life delivered to Ms, Kocot
in Palm Beach County, Florida, a 19-page document executed by
the President and
Secretary of Florida Combined Life entitled "Certificate for Group Life and Short Term
Disability
Insurance" (the
"Certificate of Insurance," attached hereto as Exhibit 1).
8. The cover page
of the Certificate of Insurance provides the following:
"Policy: We haveissued the group policy lo the policyholder. The policy
is a contract ofinsurance
1. between your policyholder and us; and
2. fhrough which vou are insured."
See Certificate of Insurance, p. 1 (emphasis supplied).
9.
Page'3 of the Certificate of Insurance provides the following specific and
unambiguous
information relating to the insurance coverage Florida Combined Life
provided to Ms. Kocot:
POLICYHOLDER
COMPREHENSIVE PAIN MANAGEIIENT
GROUP POLICY NUMBER 85244003
CERTIFICATE HOLDER
See Certificate of Insurance, p,
3.
DAWN M. KOCOT
Case 9:14-cv-80945-KAM Document 1-1 Entered on FLSD Docket 07/16/2014 Page 4 of 43
Kocot v. Florida Combined Life ins. Co.
Case No,
Complaint
Page 3 of 5
10. Page 3 of the Certificate of Insurance further provides that "Effective
02/01/11" the benefit amount on the Insured's term life insurance is
"$
25,000.00."
11, In addition to the information contained on Page 3 of the Certificate of
Insurance which indicates that coverage commenced effective on February 1, 2011, the
"DEFINITIONS" section contained within the Certificate of Insurance provides the
following definition:
"'Effective date' the date the policy is put in force, it is shown on page
three of the certificate."
See Certificate of Insurance, p. 5.
12. The Certificate of Insurance, which indicated that coverage was effective
on February 1, 2011, was the oniy document pertaining to the effective date of
insurance coverage received by Ms, Kocot from Florida Combined Life.
13. Ms. Kocot received no written communication of any kind from Florida
Combined Life, either before or after February 1, 2011, indicating that the insured's term
life insurance would not or did not become effective on February 1, 2011,
14. When Ms. Kocot passed away on January 14, 2013, Ms. Kocot was
covered by the term life insurance provided by Florida Combined Life.
15. On March 6, 2013, the Employee Death Claim Statement (the
"Claim
Statement," attached hereto as Exhibit 2) was properly submitted to Florida Combined
Life.
16. Florida Combined
Lif'e
has refused to
pay
Mr. Kocot the $25,000 death
benefit to which he is entitled.
Case 9:14-cv-80945-KAM Document 1-1 Entered on FLSD Docket 07/16/2014 Page 5 of 43
Kocot v Florida Combined Life Ins, Co,
Case No.
Complaint
Page4of5
COUNT I
BREACH OF CONTRACT
17, Mr. Kocot realleges the allegations contained in Paragraphs 1 through 16
and fully incorporates each and every one of those paragraphs into Count I.
18. Mr. Kocot is the beneficiary of a life insurance contract which is'evidenced
by
the Certificate of Service.
19. Pursuant to the terms of the life insurance contract, Mr. Kocot is entitled to
receive $25,000 as the beneficiary.
20, Florida Combined
Lif'e has materially breached the life insurance contract
by failing to pay
Mr. Kocot the $25,000 death benefit to which he, as the beneficiary, is
entitled.
21, Mr. Kocot has been monetarily damaged as a direct result of Florida
Combined
Life's material breach.
WHEREFORE, Mr. Kocot respectfully requests this Court enter judgment in favor
of Mr. Kocot and against Florida Combined Life:
(1)
providing for damages in the
amount of
$
25,000,00, (2)
awarding attorney's fees and costs in favor of Mr. Kocot and
to be paid by
Florida Combined Life pursuant to
g
627.428, Fla. Stat. and
g
57.041, Fla.
Stat,, and
(3)
providing such other and further relief in favor of Mr. Kocot as the Court
deems just and proper.
I
r
h
Case 9:14-cv-80945-KAM Document 1-1 Entered on FLSD Docket 07/16/2014 Page 6 of 43
Kocot v. Florida Combined Life Ins. Co,
gase No.
Complaint
Page 5 of 5
DEMAND FOR JURY TRIAL
Plaintiff demands a trial by jury on all claims and issues so triable,
Dated this 16th day of June, 2014.
JONES, FOSTER, JOHNSTON 5 STUBBS, P,A.
Counsel for l lainfiff
505 South Flagler Drive, Suite 1100
West Palm Beach, Florida 33401
Telephone: (561)
659-3000
+Elec Ionic
Mail:
mragmen
a~ja
eeioeier.corn
r
., jnW
Fla. Bar No, 863076
Case 9:14-cv-80945-KAM Document 1-1 Entered on FLSD Docket 07/16/2014 Page 7 of 43
F(orlda Cosnbined Lite Insurance Company, Inc, ATTN; Group Claims Dopa&trner&t
P.O. EIox 45132
10 receive claims assistance, please
Jacksonv(l(e, Florida
32232-61'32 cz&(i 1-800-696-()552,
EMPLOYEE DEATH CLAIM STATEMEh)T
If you are making claim for a deceased INSURED DEPENDENT,
complete
Page 2 only.
BENEFiCIARY REPORT OF CLAIM
1. Fait legalneme O1deoeaeed emPIOyee;
'2.
DateOfblith t&E&fL/Oy/Yr): )3. D~te OfdePth(&/&cp/Day/Yr);
)4
EmPIOyee SCClal ~S'umber;
Dj&r
tern VV//7 vyd/0.
~f/" I +-( Y-~op
5. Causa of employee's death; 5, VVneh O&O ceoeaaed emplOyee'S hea(lh grat be00ma (7, VVffcrr uru
.d emplOyea flret
///&7."
Irnpairad7 (/42&/Defy/Yr): A &

/ o consulf a physlclan7 (Mrf/027/Yr);


/&7&Cffshv &C C.X7du~ cA I ( Cme
I&- 2&i(
5 Benellclary 1ull legal name: 9, B~netictary slgrature: 10, Relationship to deceased employee:
~Rf c
fu&
c'.
&co rT .
'Id
~ c &&~T'aTppd ri
'I 1 nr12 ii lm
Cltv: 12, Senegoia&y phone number.
13. Beneficiary Social Security number )14: Ben&&flc&ery Date of btrth'tMrf/Ooy/Yr),
"Nofe: F'r
an employee /q DfsD c/alm, sf/ac/7 copies a(any po/ico invest/get/on rapotLs and, //hvai/able, fhe autopsy report.
AUTHORIZATION TO.OBTAIN / RELEASE INFORMATION
I authorize persons or entitles thai have any records or knowledge of me or my haallh to release such inforrnailon lo Florida combined Ll(s k&sucsnce
Co/nceny, inc, (FCL), and its Insurance affiliates, reinsure&s, and aulhorized representatives, Thaso persons or enblies include any licensed physician,
medical prscillloner, hospital, clinic or other medical or medically-related provider, employer, Medical insurance Bureau {I)/&IB), consumer repcrilj agency,
'or
insurance company, These releases include, but are nct limited to, release 0( eny and 0'I medical records and information about, associated,v/Ilh, oi v&1th
rofcrence lo cert~in condigons. fhcse conditions Indude, bul alc not limiled lo;
{a)
I leman )mmunodcficiency Virus (HIV) test resultsp (b)
AIDS.Rolated
Complex (ARC}, (c)
Acquirc:d immune Defldcncy Syndrome (AIDS), (d)
aicohol ur drug abuse or'0) mun&al illness, 7)&ls Information villi be used lo
evaluate this request for cfaims proceeds. To fac&litate rapid submission of such Information, I aut(&or)ze all said sources to give such records or knowledge
to any. agency employed by FCL to co!lect and transmit such lnlcrmaticn,
( also authodze FCL to release any information described above to; {1&
I'CL's
(a} auditors, (b)
insurance rifi'isles
(c) remsurere, (d)
authorized
rapmseslalives and (e) vendors; and (2) with the exception of In(orms(icn a(&out, associated v(lh, or is(th referenco to H!)j teel results ARC ced/cr AIDS,
Iho kfttg cnd other irfsurance came&s, io edmtrf later and pay
claims under any insurance coverage lssubd to mo by FCL, This claims {nfonnatlcn incfudes
specific medical Infcrrnailon on me, A photocopy of ibis auihorlzatlcn shall be as valid as the original.
I hcrebycerlifv that the state&nants cn ihh Corm, Ii'chiding sny sgechmsnt lc it are huo andiumplele lo lhe best of my knowledge a&id belief. I unders(and
und ag~ee lhat any misslatemenls may result In bonefil denial.
FRAUD NOTiCE: Any person whc knowingly, und with lntvnt to in]ure, or deceive nny ir&surer, flips atatemont of clsiin or an
applicatfon containing any false, incomplete, or misleading lnfovmaliun is guilty of a felony of the third dogrce.
NarnOOf deCeaeed'S neX! Of kin Cr authcrlZed rCPreSChiatiVe (Pleaee Prihtc) Signature (Signer muSt be oflegai age)
Relationship tc deceased (Please print )
Date
EMPLOYER'S REPORT OF CLAIM I,
1. Emcloyee's full legal name.
La-nm&o nf mrth is&n/rf ~&; )~n&w.d:r cs&ritv numbec (4. Insurancx& class.
j)7 ~e JC~O ~rodp c
5. Date Cf hire f&f&fr/Omy/Yr) 6, past aqtfvety worked ob fitlp:
P
insurance Effective date (&d&c/os//fr); (0. currenl annual earnings:
0~A Z- Q~lz)
M//iC'6'a.L/ifs
'/'4/
O
-'C& -
J
I &I, /7VD
s. Date of iaaf earnings change 10, Date employsa &a tac&lveiy worked: 11. Re~son for c'essincf active
einplcymant.'Mcr/0
ay/Yr)
'=u&i-time (Mcf&DEY/Yr)', ~pa. -lime (Mrf/DEY/vr)i
Lt yh(E/ q&fjxrp
gg-
(Cp- &c/ (
~O~2.

go
tz
12 Employee Coverage: Amount Claimed: Mnnih&v Premiun&'aid Thro&/ah t&/&c[02y/Yr):1
Q Term Life
gee@
$
~
DOz, On
'&Uyv
tpv&fJlkI~& ( ~grh7 (zy/ZCQ
O Supplemental Term Life $
C3 Voluntary Tenn Life $
LI Group Universal Life $
$
Q
Supplemental AD&SD"
$
13,'es eppilcatlcn subnutted peer tc crnpioyee's death fcr7
I
14. VVas deceeeod employee rcceiv&ng disability ber&slits prior to
Life &nsuiance congnuaiion during disability Q
Yes Q No
I
death7tg Yas g No
Acceferated living benefits C] Yes h( No
15. Use for comments or exp&&nsion oi'nswers above, (At&ech additional sheet of paper, If necessary. Sign and date ft
);
16, Benetalary full legal name (a listed:0 amo&oyer's records): 17, Reif&&&unship of beneficiary tc Insurodi
111. cmol rel' foll& n om
fpolkrn lde,If/ill nli 19. Eroopzoroo: )25.5lolfl ~rill:
C~O/fCEEO
2
fm 2'm, 2'nfd d dffnM.~
'Ci
V'ns
'Rniu'1.xfdomn
9 . '2.5
I 9: 29.5 ll dd
c&fcr&monernrre
ld I&EEET/,
omC
2d. Emmmeondm
" ~.1CitV' 5'&m&e;
Sip Code
25. Emp&Epycf eumOnZed gr up benetlta adrpiniStratcr:
mdrnfrerc~nnminf ee nmm
EXHiBIT
50035-040sn &CTx (Rev 1/10)
Page 1
I
2
I
Case 9:14-cv-80945-KAM Document 1-1 Entered on FLSD Docket 07/16/2014 Page 8 of 43
FLORIDA COIMEI(NEO LIFE tNSURANCE COMPANY, )NC,
P.O. BOX45132
JACKSONVILLE, FLORIDA 32232-5132
Certiftcate: This is your certificate, which
1. is a
summary
of your insurance under the group policy;
2. is not a contract of insurance;
3. is subject to the terms of tiie group policy, and
4. voids and replaces any prior certiticates issued under the group policy number
shown on page
three.
Po~tic: We have issued the group policy to the policyholder, The policy is a contract of
insurance
1. between your policyholder and us; and
2. through v,hich you are insured,
To present inquiries or to obtain information aboui coverage, please call us at 1-800-
333-3256. To receive claims assistance, please call us at 1-B00-696-8562.
Signed for the Florida Combined Life insurance Company, inc,, at Jacksonville, Florida,
on the insured's effective date,
I N&u4&
SECRETARY
PRESIDENT
Certificate for Group Life and Short Term Disability insurance
Florida Combined IIfe Insurance Company, Inc., andils parent, Slue CIOSS end Blue Shield of Florida, Inc., are
lndepr;ndent licensees of the Blue Cross and Slue Shield Associaii'on,
50005-588
EXHIEIIT
ga
2
Case 9:14-cv-80945-KAM Document 1-1 Entered on FLSD Docket 07/16/2014 Page 9 of 43
TABLE OF CONTENTS
Page1-
Page
2-
Page
3-
Page
4-
Page
5-
Page
6-
Page
7-
Page8-
Pageg-
Page 10-
Page11-
FACE PAGE PROVISIONS
TABLE OF CONTENTS
SCHEDULE OF BENEFITS
DEFiNITIONS
DEFINITIONS (continued)
DEFINITIONS (continuecl)
DEFINITIONS (conilriued)
BENEFIT AND BENEFICIARY
PROVISIONS
Benefit
Beneficiary
Change of Beneficiary
INSURING PROVISIONS
Eligibility
Evidence of insurability
insured's effective date
Deferred effective date
Termination af employee's
Insurance
Incontestability
Misstatement of age or class
Physical exams and autopsy
Time of payment of claims
Other insurance
Assignment
GENERAL PROVtSIONS
ACCIDENT AND HEALTH ONLY
Legal Proceedings
Notice of claim
Claim forms
Proof of loss
Page 12-
Page 14-
Page 15-
Page 16-
Pago 17-
Page 18-
Coverage
'I -
Terra L.ife Insurance
(if provided)
Term life benefit
Term life proceeds
Facility of paymerit
Optional inodes of settlement
Other modes of settlement
Extension of employe'e life
insurance during total
disability
Conversion
Coverage 2-Accidental Death,
Dismemberment, and Loss of
Sight Insurance (if provided)
Benefit
Exclusions
Coverage 3

Short Term Disability
Insurance (if provided)
Short term disability benefit
Disability proceeds
tiuith pregnancy benefits
Coverage 4- Dependent Life
Insurance (if provided)
De pendent life benefit
Dependent life proceeds
Beneficiary
Deferred effective date
Termination of employee's
dependent insurance
Conversion
50005-588
Case 9:14-cv-80945-KAM Document 1-1 Entered on FLSD Docket 07/16/2014 Page 10 of 43
12/21/10
SCHEDULE OF BENEFITS
66RBM
TERM LIFE INSURANCE (EFFECTIVE 02/01/11)
BENEFIT AMOUNT:
$
25
(
000. 00
BENEFIT REDUCES 35% AT AGE 65( TO 50% AT AGE 70 AND
TO 254 AT AGE 75.
ACCELERATED LIVING BENEFIT AMOUNT IS 50% OF THE TERM
LIFE INSURANCE IN FORCE TO A MAXIMUM OF
$
50(000.
ADMINISTRATIVF. FE ~ : 64 OF THE LIVING BENEFIT AMOUNT
IS DEDUCTED PRIOR TO PAYMENT OF THIS BENEFIT.
ACCIDENTAL DEATH AND DISMEMBERMENT (EFFECTIVE 02/01/11)
BENEFIT AMOUNT: )25(000.00
BENEFIT REDUCES 354 AT AGE 65, TO 50% AT AGE 70 AND
TO 25& AT AGE 75.
24 HOUR COVERAGE.
POLICYHOLDER COMPREHENSIVE PAI N MANAGEMENT
2051 45TH ST STE 108
WEST PALM BEACH FL 33407
GROUP POLICY NUMBER
CERTIFICATE HOLDER
85244003
DAWN M, KOCOT
50005-588E
Case 9:14-cv-80945-KAM Document 1-1 Entered on FLSD Docket 07/16/2014 Page 11 of 43
DEFl NIT t D NS
"Actively at work" or "active work" -
you are working for your employer.
in the usual course of your employer's business;
2. full time at the principal place of employment; and
3. for at least the greater of:
a. the number of hours per week your employer stated in his application as the normal work
week; or
b. 20 hours per week.
"Aqe" -
the age at your last birthday,
"Am u
t" -
the amount of'nsurance.
o n
"5Ieneftciorv"
-
the person(s) lo whom we will pay the proceeds.
"Certificate"
-
a document given to you as proof of your coverage under the policy. It is nct part of the
entire contract of insurance. It contains all statements required by law,
"Children"
this term Includes your.
natural child; or
2, legally adopted child; or
3. siepchild or foster oh&id,
Each child must depend on you fcr support and either:
1, live with you; or
2. be a full-time student.
Each child must also be;
unmarried; and
2. under the age(s) shown in the policy schedule.
"Class" -
a grouping ofinsureds:
1. based on their job positions; and
2. determined by thc policyholder.
"Contributorv insurance" (if required) you must pay
a part of the premiums Ali such paymunts are;
made directly to the policyholder; and
2, forwarded tc us.
"Conversion" -
you may exchange your rights under the policy for an individual policy, This only
applies to; 1)
term fife insrance; or 2)
dependent life insurance,
50005-588 Page 4
Case 9:14-cv-80945-KAM Document 1-1 Entered on FLSD Docket 07/16/2014 Page 12 of 43
DEFfNIT JONS (contfnuecf)
"Coverage" ~
all the terms and provisions appearing uitder one of lhe following captions of the policy,
lf provided: 1)
Term Life Insurance; or 2) Accidental Death, Dismemberment, and Loss of Sighi
Insurance; or 3) Dependent Life Insurance; or 4) Shori Term Disabihty Insurance; or 5) other benefit
riders.
"Covered" -
you are insured under the policy.
"Date of death" -
the date of ihe insured's death.
"Dependenl" -
your spouse and children who are not:
Insured employees themselves under the policy; or
2, in tull-time military aeNice.
A dependent can only bs insured:
under one Insured employee; and
2, for contributory insurance- if the eligible employee has made a wdNen requesl for
depeiident's Insurance
"Earninqs"
-
wage, This term does not include.
'i. overtime pay; or
2. bonuses; or
8. any other form of extra compensation,
Except for cominissioned salespersons, the rate of earnings is that in e(feel prior to when the disability
starts.
For commissioned salespersons:
1. durinq the first 12 months of coverage
-
earnings
exclude commissions; or
2. afterthefirst 'l2rnonthscfcovei~ae
-
earnings tnctudetheaverageweeklyormontlily
commissions cerned during the iwelvo montlis )ust prior to when the disability began.
"Effective dale" -
the date the policy is put in force. !t is shown on page three of the certificate.
"Eliqible e~mlo~ee"
-
a person who:
is a inember of the eligible classes shown In the policy schedule of the employer"s masier
policy;
2. has sallsfied any waiting period shown in your employer"s application', and
B. is actively at work onlhe insured's effective date. If the employee is not actively at wort& on
the date he would otherwise be eliglblo, soe "Deferred effective date," found under "insuring
Provisions,"
"Evidence of insurability"
-
evidence of good health accoptable to us,
50005-588 Page 5
Case 9:14-cv-80945-KAM Document 1-1 Entered on FLSD Docket 07/16/2014 Page 13 of 43
DEFINITIONS (continued)
"He," ehis,e and
"him" -
refer to,both genders.
"Illness" -
a disease process that:
causes the abnormal function of: a) an organ; b) s system of the body; ore) the whole body;
and
2. is caused by: a) a pathogenlcchange;orb) a psychological disturbance.
"In force" -
the policy is in etfect, Premiums are paid and alt insuring conditions are met.
p~ln'u
"
-
bodllyinJurywhich:
results directly and independently of all other causes from an accident;
2, occurs after the effective date of coverage for such iniury; and
results In: a) disability; b) death; ore) dismemberment,
"Insured"
-
person who:
is an eligible employee;
2. has fulfilled all conditions under the policy to become insured; and
3, has insurance In force under the policy.
"Insured's scnlicatlong
-
includes:
1, the insured's enroliment form or card; and
2, any evidence of insurability,
elnSured'S effeCtiVe date" - the date yOu beCOme inSured under the pOliCy, It iS ShOWn On yOur
schedule of benefits on page three.
eNoncontributory insurance"
-
you are not required tc pay any part of the premiums,
"Notice" -
written notice in a form satisfactory to us for that purpose.
"Perscne -
is used in the singular, There
may
be more than one person
-
natural or legal,
"~ph sician" a licensed physician practicing rdthtn the scape cihis license.
nPreqnancy" -
Includes; a) childbidh; b) normalmiscanlage; c) elective abortion; d) Caesarean
section; and o) complications from these,
"Proceeds" -
the amount of insurance we will pay.as a benefit. This amount is;
1. shown in the schedule of benefits; and
2. sub)ect to the amount thatyou are eiigible For asshownin the einployer'sinasler policy
schedule for your class.
50005-588 Page 6
Case 9:14-cv-80945-KAM Document 1-1 Entered on FLSD Docket 07/16/2014 Page 14 of 43
DEFINITIONS (Coft tinued)
"Proof" -
a properly completed claim form, plus:
1, for life insurance
-
a) a certified copy of the death certificate; or b) death decreed by a court
order; or
2. for disability or accidental death and dismemberment insurance
-
written proof acceptable to
us,
"~Souse" -
your legal husband or wife.
'Vfe,
"
"us,"
and
"our" -
Florida Combined Life Insurance Company, Inc.
"You"
and
"your" -
Insured employee.
50005-588 Page 7
Case 9:14-cv-80945-KAM Document 1-1 Entered on FLSD Docket 07/16/2014 Page 15 of 43
BENEFIT AND BENEFICIARY P RGVISIONS
Benefit: We will pay tho proceeds to the beneficiary:
when we receive proof of your: a) disability; and/or b)
death;
2. if coverage Insuring the type
of'loss has boon selocted: a) in tho policy; and b) for your class;
3, it the
premiums
have been paid for that coverage; and
4, subject to all policy provisions,
Bcneficlarar: Your onrollmcni form or card lists your choice ofbeneficicry.
Proceeds will be paid;
to you
-
for proceeds paid during your lifetime; or
2. to the beneficiary (as defined); or
S. to your estate
-
if no bonoficianes sun/ive you; or
4. according to tho "Facility of payment" provision for term life insurance.
Number 4 applies tc the life coverage only,
Change of beneficiary; During your lifetime, you may change tho beneficiary, Nalico oflhe chango:
must be sig!wd and doled by you; and
2. should be given to the policyholder. He will sendiiio us,
The change takes effect on the date it is signed We are not liable for any action we take before we
receive the notice at aur home office,
INSURING PROVISIONS
Eligibility: See definition, "Eligible employee."
Evidence of insurability: Evidence of insurability:
1, may be required by us if the amount of insurance exceeds aur underwriting limitalion; and
2. must be sent to us if:
a. your enrollment is made more than 31 days after you ar your dependent was first eligible;
Gr
b, you or your dependon( has converted insurance under tho policy:
1) from prior employment; and
2) to an indivtdua! policy which is in force. You must submit evidence befare you and
your dependent are eligible after Ihe ieomplayment,
Evidence of insurability, if required;
1. will bo al your expanse; and
2. delays the effective date until wo approve the evidence.
50005-588 Pago 8
Case 9:14-cv-80945-KAM Document 1-1 Entered on FLSD Docket 07/16/2014 Page 16 of 43
lnSured'S effeCtiVe date; Bubjeat tO tiie wDeferred effeCliVe date," yOu beCOme inaured;
1. for noncontributory insurance
-
when you become an eligible
employee;
or
2, for contributorv Insurance;
a, ~ir on enrell orl orgriorlo being an eligible emnlovee
.
when ye become an eligibl
employee; or
b, ~ri avenroll iihinar day Il rv b
cornea~nay
ibleemolovee
-
whenyoo enroll or
c. if you enroll more than 31 days aiter you become an eligible employee
-
when we
accept evidence of Insurability.
The date you enroll is deemed to be when:
1, you completed the enrollment form or card lo our satisfaction and signed it; and
2. you gave the form ar card ta the Itolioyholder.
if you do not give evidence of insurabilily as required;
1, your eligibility ends; and
2. you will be subject to the same requirements If you become eligible at a later date.
Deferred effective date; Your effective dale or an increase in coverage will be deferred
1. if on the dale you would otherwise become insured ar receive the Increase in coverage,
a. you are absent from active work; and
b, your absence Is caused by an injury or Illness, and
2. until the date you return to active work.
Termination of e~mloyee's insurance: Your i:overage ends when;
1. this policy terminates; or
2. you stop paying required premiums
-
for contrlbulory insuranre; ar
3. the employer does not remil premiums
-
for noncontributory insurance; or
4 you cease to be ln an eligible class; or
5. you cease ta be an employee; or
6. you enter military service
-
except temporaiy duty ot less than 30 days.
Discontinuance of the policy during disability shall have no e11ect on benefits payable for tiiat
disability,
Incontestability: Na statement made by you about you or your dependents'nsurability wiil be used to
contest the vaiidity af your insurance, unless:
the cove~age has been in force prior to the contest for Jess than two years during:
a. far the insured's coverage
-
your lifetime; or
b. for your dependent's coverage
-
your dependent's lifetime,
2. il is in the Jnsured's application signed by you; and
3. a oopy ofthe insured's application is or has been given to;
a, you; or
b. the beneficiary.
50005-588 Page 9
Case 9:14-cv-80945-KAM Document 1-1 Entered on FLSD Docket 07/16/2014 Page 17 of 43
Misstatement of age or class: We will pay based on the amount of insurance:
1. ~if
our aae or class is misslated
-
that you are entitled ta at your true age or class; or
2, if your d~eendent's aae is iiiisstated
-
that your dependent is entitled tc at his true age,
Physical exams and autopsy: We will have lhe right and opporti!nily
t'o
examine you:
1, by a physician of our choice;
2, at our own expense;
3. while a claim is pending ar being paid; and
4. as often as we may reascnabty require,
We also have the right to make an autopsy:
1. in case af death;
2. where it is allowed by law; and
3. at our expense.
This provision also applies lo dependents
-
if dependent life insurance is included,
Time of payment
of claims; We will pay the proceeds for insured losses as soon as we receive proof,
Other insurance: This insurance is not in lieu of workers'ompensation; it does nat affect any
requirement
for workers'ompensation coverage.
Ass!qnrnent: Yau may asslgil any of yaui'rights. We are not liable for the assignmenl's;
1) validity;
or 2) sufficiency. We are nct bound bythe assignment uritil we receive it.
GENERAL PROVISIONS
ACCIDENT AND HEALTH ONLY
~eceaal proceedings: A claimant may not file suit unless:
1. proofs af loss are filed within three years of the time required by this policy; and
2, at least 60 days have passed since the required praofs of(oss are filed.
Notice of claim: Written notice of claim must ba given to us:
1, within 60 days after the date of loss co'vered
by this policy; or
2, as soon thereafter as reasonably possible,
Claims forms: We will furnish the claimant with forms for fiillng proof of loss within 15 days after we
receive notice of the claim. if we do not do so, the claimant can comply with the requirements far filing
proof of loss by giving us this proof:
1, within the tenn fixed in the "Proof of loss"
provision; and
2, covering the loss's
a) occurrence; b) character, and c) extent,
50005-586 Page 10
Case 9:14-cv-80945-KAM Document 1-1 Entered on FLSD Docket 07/16/2014 Page 18 of 43
Proof of loss; Written proof of loss:
must be furnished to us at our home office; and
2. should be furnished within 90 days aRer the period for which we are liable.
In case of a claim for any other loss, the proof must be provided within 90 days aRer the date cf loss.
Failure to furnish the proof within these times wi(l not invalidate nor reduce the claim If proof is furnished
as soon as is reasonable possible,
Coveraqe 1
-
Term Life Jnsttrance
(only available to employees)
Term life benefit: We will pay the proceeds to the beneficiary:
1, If this coverage has been selected;
a. in the policy;
b. for your class, and
c. as shown in the policy schedule;
2, if the
premiums
have been paid for this coverage;
3, subject to all policy provisions; and
4, when we receive proof of your death,
Term life proceeds: The proceeds we will pay is tho amount that your'life is iiisiiied for at the date of
death.
Facility of pa~ment: We have the option to pay
the proceeds to any one or more of your surviving
relatives:
1. Instead of paying your estate; and
2. these relatives includo your. a) spouse; or b) parent; or c) brother; or d) sister,
WB have the option to pay up to $2,000 of the proceeds:
1, If allowed by law; and
2, io any person who appears to us as having incurred costs from your. a) test illness; or
b) death, ore) funeral,
If the beneficiary Is a minor or nol competent, we have the optioii;
1. to
pay up to $2,000 to the person or institution whc appears to us to havo assumed tho
beneficiary's. a) custody; and b) principal supporl; and
2, unless or until a formal claim is made by a legal representative of ihe beneficiary,
Our liability for the payment ends if we make It ln good faith,
Optional modes of settlement'The proceeds inay be paid on a monthly basis for a fixed term of
years:
1. if you send us your written request;
2. Ifwe agree; and
3. if each payment will be at toast
$25,00.
50005-588 Page 11
Case 9:14-cv-80945-KAM Document 1-1 Entered on FLSD Docket 07/16/2014 Page 19 of 43
The amount of the payments Is figured from this table,
TABLE OF MONTHLY PAYMENTS PER $1,000 OF PROCEEDS
Years Payable Monthly Payments Years Payabie Monthly Payments
1
2
3
$84,28
42,66
28.79
2'l.86
5
10
15
20
$17.70
9,39
6.84
5.27
Thoso payments are based on an Interest rate;
1, of 2 1)2% per year, and
2. compounded yearly.
We will also pay any excess interest that we may declare from year to year,
The first payment will be paid;
1, on the date the proceeds would have been paid in one sum,'r
2, on tho date you request.
If all beneficiaries under this mode die, we will',
1,
pay
the unpaid proceeds pius lho earned interest In one sum; and
2, pay this one sum to:
a. the beneficiary's estate; or (at our option)
b. to one or more of the boneficiary's surviving relatives.
Other modes of setttement: Other modes of settlement may be arranged if you and wc agree, We will
furnish data on these modes upon reques!.
Extension of
employee
life insurance during total disability
(accidental death and dismemberment, sl;oit term disability,
and dependent lite benefits aro not Included)
Definition (for this provision only)
'yolalfydtnabted" ar ~total dlnabtltt" -
you are unable to work el youremploymanl orna
ap tl ~ n due
to dlsabiiiiy causod by injury or illness. However, atter the first 24 months of disability, you must also bo
unable to engage ln any employment or occupation for which you aro or become qualified by roason of
education, training, or experience.
50005-588 Pago 12
Case 9:14-cv-80945-KAM Document 1-1 Entered on FLSD Docket 07/16/2014 Page 20 of 43
Your life insurance will exlend beyond when il would otherwise end:
1. if you become totally disabled prior to age 60, while you are insured under this policy;
2. ifthe required life premiums have been paid For the first six months of total disability;
3, while your total disability fs continuous;
4. if you give us written notice of your total disability wllhin one year from the date it started; and
5. if you give us proof of your continuous total disability:
a, first proof
-
between the sixth and twelfth month after the date the total disability began;
and
b. subsequent proof
-
during the last three months of each subsequent 12-month term
atter the first.
lf nolice of proof of'your continuous total disability cannot be given witfiin these times;
it musl be given as soon as ls reasonably possible; and
2, it rnusl be given within three months after the time it is otherwise required.
When we are satisfied with the proof, life insurance will be extended,
without fujther preiniums after the first six months is paid; and
2. while your total disability continues.
We will still pay
the life proceeds even thouqh ycu become disabled after age 80 or do not give us the first
proof if;
1. you die prior to age 71 and within one yearofthe date that the premium payments stop; and
2. we are given proof of:
a, your continuous total disabiliiy irom the day it began; and
b. your death.
The amount of life insurance extended wi8 be lhe lesser of;
the amount shown in the schediile; or
2, ihe amount in force on the last dayof active work,
These provisions apply if they are!n effect on the last day of active work:
1. reductions provisions;
2. termination provisions; and
3. retirement provisions,
Extended life insurance will end at the sooner of the date you:
1, are no longer totally disabled; or
2, fail to give us the roquired proof of continuous total disability; or
3. refuse to be examined as required; or
4. retire at the normal age according to each company's requirements
-
unless retiree
coverage is provided.
60006-588 Page 13
Case 9:14-cv-80945-KAM Document 1-1 Entered on FLSD Docket 07/16/2014 Page 21 of 43
If extended )ife insurance ends because you retire, you become entitled to the rights under
"Conversion,"
unicssI'.
you return to work; and
2. you are insured again under the policy,
We are not liable for a death claim under this coverage, unless we receive proof;
of your death, and
2. within 12 months after tho date of death.
Conversion
You may convert aH or part of the insurance under this coverage without evidence of insurability to an
individual life policy:
1. if insurance ends because;
a. of termination of your. 1) employment; or 2) membership In an eligible class; or
b. of your retirement; ar
c, you reach a specified age, or
d, of a policy change affecting your class; or
e. the poHcy or the employer's participation ends oi Is amended; and
2. if within
3'I
days after termination you:
a. give us a written request to converl; and
b, pay
the first.
premium
un the new policy,
The new policy may be on any plan of life insurance, except term, issued by us;
1, at the age and for the amount applied for; and
2. without dfsabiiity or other supplemental benefits,
The new policy:
1. face amount may not exceed:
a, ihe amount of insuiance in force on the convcisii&n date; or
b. Ior
"1.e."
above
-
the lesser of:
1) the amount which terminated
-
less the amoiint of any life insurance for which you
are or become eligible under any group policy.issued or reinstated;
a) by us or by any company; and
b) within 31 days after the terminagon of your coverage; or
2) $10,00D.OO;
2.
premium
rate will be based on:
a, your age on its effective dato;
b, the rates then in use by us; and
3, effective date will begin at the end of the 31-day term to convert after termination,
If you die during the 31-day term to convert, the proceeds we will pay:
1, will be paid under the group policy; and
2, will be the maximum amount which could have been converted, whether or not:
a, the application to convert was made; or
b. the first prerniurn was paid
Any life conversion policy must be surrendered without claim. We will refund any premium paid for it,
50005-568 Page 14
Case 9:14-cv-80945-KAM Document 1-1 Entered on FLSD Docket 07/16/2014 Page 22 of 43
Coverage 2
-
Accidental Death, Dismemberment, and Loss of
Sight
Insurance
(only available to employees)
Definition (for this coverage only)
"Loss" -
means with regard to:
1. life
-
death;or
2. hands and feet
-
complete severance through or above the wrist or ankle joint; or
3. ~si ht
-
loss ofsight which is'.
a) entire; and 0) irrecoverable.
Benefit: We will pay the proceeds to the beneficiary:
1, if this coverage has been selected;
in the policy;
b, for yo
ur class; and
c. as shown in the policy schedule;
2. if the premiums have been paid for this coverage;
3. subject to all policy provisions;
when we receive proof of your loss stiown betovr,
a. that wes caused by injury while you were Insured under this coverage, and
b. that occurs vjithin 365 days from the rlate of the, injury; and
5. if the loss is not excluded below.
The principal sum that applies to the insured is shown in the policy schedule for loss of',
Life.
Both hands or both feet or sight of both eyes,
One hand and one foot
One hand and sight of one eye
One foci and sight of one eyo
Sight ofone eye..
One hand or one foot..
,.Principal Sum
Principal Sum
,.Principal Sum
..Principal Sum
..Principal Sum
One half of tho Principal Sum
One half of the Principal Sum
50005-588 Page 15
Case 9:14-cv-80945-KAM Document 1-1 Entered on FLSD Docket 07/16/2014 Page 23 of 43
Exclusions: We will not pay the proceeds for any loss resulting from:
1, intentional self-inflicted injury
-
or any attempt to injure oneself while sane; or
2. travel, flight in, or descent from any kind of aircratt
-
unless solely as a fare-paying
passenger:
a, of a cammercia! airline; end
b. without any duties with the airline; or
5. taking part in a riot; or
4. any war or act of war
-
deciared or undeclared; or
5. military service; or
6. taking part in an assault or a felony; or
7. voluntary use of any controlled substance.* This exclusion will i,ot apply it the controlled
substance is prescribed for yau by a physician; or
6. bodily Infirmity or disease from bacterial infectians {except accidentai ingestion of
contaminated foods)
-
other than Infection caused from an injury covered under this
Gavel'age,
"Controlled substance" is defined in Title II of the Comprehensive Drug Abuse Prevention arid Control
Act af 1970 and all amendments.
Coveraqe 3
-
Short Term Disability Insurance
(only available to
employees)
Definition {/or this coverage only)
"Disabled" or "disability" -
you are unable ta do the m%r duties of your occupation due to an:
1) injury;ar2) illness.
Short term disability benefit; We will pay the shart term proceeds to you;
1, if this coverage has been selecled:
a, in the policy;
b, for your class, and
c. as shown in the policy schedule;
2. if the premiums have been paid for this coverage;
5. subject to all policy provisions;
4, while you remain disabled; and
5. When we receive proof that you:
a. became disabled while insured; and
b, have been seeii and treated by a physician for liie disability.
Disability proceeds, The policy schedule shows these data for your class;
the amount of gie short term proceeds;
2, the day we begin paying short lerm proceeds after your disability starts;
8. the maximum term that we will pay the short term proceeds;
a. for any one continuous term of disability
-
whether due to one or more causes; or
b. for all successive terms of disability;
1) due to the same or related causes(s); and
2) which are separated by less than two weeks of continuous active work.
50005-588 Page
'I6
Case 9:14-cv-80945-KAM Document 1-1 Entered on FLSD Docket 07/16/2014 Page 24 of 43
For disability lasting less than one futt week, the proceeds we will
pay wili be ihe ratio of the number of
days of disability divided by the number ofdays in the week.
Any subsequent disability will be deemed to be a new disability:
for the same causes of disability
~
If you retuni to active work for a continuous terin of at
least two weeks; or
2, for diFferent snd unrelated causes ofdisab~itit
-
if the disability is separated by at least one
day of active work,
Your disabihty cannot be caused by.
1. any injury:
a. which results from work; and
b. for which you are entitled to benefits under any workers'ompensation law; or
7, any illness for which you are entitled to benefits under any:
a. workers'ompensation law; or
b. occupational disease law; or
3. intentionally self-inflicted injury,
With preqnancy benefits: Disability caused by your pregnancy is covered:
for any one pregnancy;
2, if you become.disabled while insured; and
3, up to the maximum term shown in the policy schedule,
Coverage 4
-
Dependent Life Insurance
Definition (for this coverage only)
"Dependent's effective dato" -
the date the dependent becomes insured under the policy,
Dependent life benefit; We will pay the proceeds to tho boneticiary:
1. if this coverage lies been selected:
a. in the policy;
b, for yourclass; and
c, es shown in the policy schedule;
2. if the premiums have been paid forthis coverage;
3. subject to all policy prOvisions; and
4. when we receive proof of the dependent's death,
Dependent life proceeds: The procoods we will pay
is tho amount:
that your dependents
ill'e
Is Insured for ai tho date of his death; and
2. shown in the policy schedule for dependents in your class on ihe date of his death.
Beneficiary: We will pay
the proceeds to
1. you
-
if you are living; otherwise
2. your estate, or (at cur option)
3, your spouse
-
if living.
50005-588 Page 17
Case 9:14-cv-80945-KAM Document 1-1 Entered on FLSD Docket 07/16/2014 Page 25 of 43
Oeferred effective date: The dependent's eifecgve date ol'coverage cr an increase therein will be
deferred;
h
1. Ifon such dale he Is confined to home or a hospital because of: a) an injury; orb) an iHness;
and
2. until he is discharged from confinement.
Termination of employee's dependent insurance: A dependent's coverage ends on thc sooner of
the date:
1. the person ceases to be a dependent; or
2, you stop paying premiums
-
if
premiums
are required; or
3, your coverage ceases under the policy; or
4. all dependent coverage ceases underthe policy; or
5. the dependent becomes an insured employee; or
6, the day you are eligible for extended insurance.
Conversion
Your dependent may converl his insurance if:
1, it ends because:
a. Ihe policy terminated; or
b. the policy was amended; or
c. you die
-
your surviving dependent
may conveA
only the insurance un&ler the policythst
would end because of your death; or
d. he ceases to be a qualified dependent, and
2. within 31 days after termination he;
a. gives iis a written request io convert; and
b. pays the first premium on the new policy.
The new converted individual life policy:
1, may be on any form issued by us except term insurance:
a. that has s level: 1) premium; aitd 2) amount of Insurence; and
b. that he selects from among those forms we then issue for: 1) his age; and 2) the amount
applied for;
2. premium rate will be based on:
a, his ege on its effective date; and
b, the rates then in use by us;
3, effective date will begin at the end of the 31-day term to convert', and
4, amount
may
not exceed the lesser of:
a, the amount of his Insurance being terminated
-
less any amount that he is or becomes
eligible for under any group policy issued or reinstated:
1) by us or by any company; and
2) within 31 days after his insurance terminates; or
b. $10,000,00,
50005-588 Page 18
Case 9:14-cv-80945-KAM Document 1-1 Entered on FLSD Docket 07/16/2014 Page 26 of 43
If he dies during the 31-day term Ic convert, the proceeds we will pay:
1, will be paid under the group policy, and
2. will be the maximum amount which could have been converted, whether or not:
a. the application to ronvert was made; or
b. the first preinium was paid,
Any life conversion policy must be surrendered without claim, We will refund any premium paid for it.
50005-588 Page 19
Case 9:14-cv-80945-KAM Document 1-1 Entered on FLSD Docket 07/16/2014 Page 27 of 43
HARTFORD LIFF. AND ACCIDENT INSURANCE COMPANY
Hartford Plaza
Hartford, Connecticut
(A stock insurance company)
Will
pay
benefits according to the conditions of this Policy.
Signed for the Company
Richard G. Costello, Secretary Thomas M. Marra, President
Policyholder Name:
Policvholder Address:
CFE FEDERAL CREDIT UNION
1200 WEBER STREET
ORLANDO, FL 32803
Policv Number:
Place of Deliverv:
Policv Effective Date:
ADD-12205
ORLANDO, FL
March 1, 2006
TABLE OF CONTENTS
Schedule
Contract Provisions
Incorporation Provision
Certificate of Insurance
Riders (if any)
Accepted by:
Policyholder
Form 7582 A2
Printed in U,S,A,
8507443 1
EXHIBIT
2o
Case 9:14-cv-80945-KAM Document 1-1 Entered on FLSD Docket 07/16/2014 Page 28 of 43
SCHEDULE
ELIGIBLE PERSONS;
C1iiss Descrintion
All members of the Policyholder;
a) who are age 18 or over; and
b) who were covered under the Prior Policy's Basic Plan of Accidental Death and
Dismemberment Coverage prior to the Policy Effective Date of this Policy.
All members of the Policyholder;
a) who are age 18 or over; and
b) who were covered under the Prior Policy's Voluntary Plan of Accidental Death and
Dismemberment Coverage prior to the Policy Effective Date of this Policy,
All members of the Policyholder;
a) who are age 18 or over; and
b) for whom We have received a completed Enrollment Form for the Basic Plan of Coverage
under this Policy.
All members of the Policyholder:
a) who are age 18 or over; and
b) for whom We have received a completed Enrollment Form for the Voluntary Plan of
Coverage under this Policy.
Prior Policy means the Accidental Death and Dismemberment Policy issued by
the prior carrier to the Policyholder, This Policv
means the Accidental Death and Dismemberment Policy issued by
Hartford Life and Accident Insurance Company to the Policyholder.
Each Prior Covered Person will be covered for the same Benefit Amounts for which he or she was covered under the Prior Policy on
the day before the Policy Effective Date of This Policy. The Beneficiary Designation under the Prior Policy in effect prior to the
Policy Effective Date of This Policy will be considered to be the Beneficiary Designation under This Policy, subject to the Naming a
Beneficiarv provision. This Policy will not
pay any benefits for a claim in effect before the effective date of This Policy.
ELIGIBLE DEPENDENTS; Eligible Person's Spouse and Child(ren) under the Voluntary Plan Only.
When a husband and wife are both Eligible Persons:
a) coverage may not be duplicated by applying
as dependents of each other; and
b) coverage for an Eligible Dependent Child may be requested by
either the wife or the husband, but not both.
No Eligible Child will be covered unless either the Eligible Person or the Eligible Spouse is covered,
ELIGIBILITY RESTRICTIONS: If an Eligible Person has more than one Certificate under this Policy, the total amount of Voluntary
coverage under all Certificates may not exceed $300,000. If coverage does exceed $300,000, premiums paid for coverage over
$300,000 will be refunded.
Form 7582 B6
8507443 i
SCHEDULE (Elieibilitv)
Case 9:14-cv-80945-KAM Document 1-1 Entered on FLSD Docket 07/16/2014 Page 29 of 43
SCHEDULE
POLICY AGE LIMIT: None
EVIDENCE OF INSURABILITY: None
Form 7582 B7
8507443 1
SCHEDULE (Ave, Insurabilitv and Class)
Case 9:14-cv-80945-KAM Document 1-1 Entered on FLSD Docket 07/16/2014 Page 30 of 43
SCHEDULE
BENEFITS AND AMOUNTS;
Basic Plan of Coverage
-
Classes I and 3:
Accidental Death and Dismemberment Benefit:
Principal Sum for each Insured Person:
Princinal Sum Amount:
$2,000
Voluntary Plan of Coverage
-
Class 2:
Accidental Death and Dismemberment Benefit;
Princioal Sum
The Principal Sum applicable to an Insured Person is the amount for which he or she was covered under the Prior
Policy, provided the required premium is paid, subject to the Minimum and Maximum Amounts stated below.
Princinal Sum Amount:
Minimum Amount: $10,000
Maximum Amount: $300,000
Increments: $5,000
Voluntary Plan of Coverage
-
Class 4:
Accidental Death and Dismemberment Benefit:
Principal Sum
The Principal Sum applicable to an Insured Person is the amount for which:
a) he or she is eligible to request as determined below;
b) he or she has given Us a Written Request; and
c) the required premium is paid.
Princinal Sum Amount:
Minimum Amount: $ 10,000
Maximum Amount: $300,000
Increments: $5,000
Accidental Death and Dismemberment Reduction on and after Age 70 (Applicable to Basic and Voluntary Plan): On the date
an Insured Person attains age 70, his or her amount of Principal Sum will reduce by
50%. An Eligible Person age 70 or over, will not
be eligible for more than 50% of the Principal Sum Amount under the Basic Plan, An Eligible Person age 70 or over, who enrolls
under the Voluntary Plan will not be eligible for more than 50% of the Principal Sum Amount for which he or she enrolls.
Form 7582 B8
8507443 1
SCHEDULE (Benefits and Amounts)
Case 9:14-cv-80945-KAM Document 1-1 Entered on FLSD Docket 07/16/2014 Page 31 of 43
SCHEDULE
Additional Benefit under Basic Plan (Classes I and 3):
Anti-Inflation Benefit
See Benefit
Applicable to Classes 2 and 4

Voluntary Plan of Coverage:
The Principal Sum applicable to each person covered under this Policy as an Insured Person's Dependent
is calculated by applying the percent, determined below, to the Insured Person's Principal Sum,
Insured Person with Covered:*
Spouse, but no covered Child
Spouse and Child(ren)
Child(ren), but no covered Spouse
'"As
determined
Spouse Each Child
60% 0%
50% 20%
0% 25%
on the date of accident
Additional Benefits under Voluntary Plan

Classes 2 and 4:
Common Carrier Benefit
See Benefit
Anti-Inflation Benefit
See Benefit
Education Benefit
See Benefit
Accident Hospital Income Benefit
See Benefit
Dav Care Benefit
See Benefit
Adaptive Home and Vehicle Benefit
See Benefit
Form 7582 B8 (Continued)
8507443 1
SCHEDULE (Benefits and Amounts)
Case 9:14-cv-80945-KAM Document 1-1 Entered on FLSD Docket 07/16/2014 Page 32 of 43
SCHEDULE
INDIVIDUAL PREMIUMS
Classes 1 and 3:
Basic Plan Premium: Premium is paid by the Policyholder as per agreement between the Policyholder and Us.
Classes 2 and 4:
Voluntary Plan Premium; Premiums for each Insured Person are on file at the offices of the Policyholder.
Premiums are based on the Covered Person's Plan and Amount of Insurance. Premiums are mutually agreed upon by
the Policyholder
and Us.
The premium for Insured Persons age 70 and older will be based on the Principal Sum selected prior to reductions due to age,
POLICY PREMIUM; The premium for this Policy is the sum of the Individual Premiums shown above.
PREMIUM DUE DATES; The Policy Premium is payable on the Policy Effective Date and premium cycle thereafter. Each Policy
Premium is due in advance of the date it becomes payable. This Policy terminates on the last day of the period for which premium is
paid unless continued in force during a grace period,
PAYMENT: The Policy Premiums are to be paid to Us by the Policyholder, However, they may be paid to Us by any other person
according to a mutual agreement among the other person, the Policyholder and Us.
CHANGE OF PREMIUMS; We have the right on each Premium Due Date to change the rate at which further premiums will be
calculated. We will give the Policyholder notice of any change at least 30 days before the Due Date on which it is to become effective,
INDIVIDUAL GRACE PERIOD: After the first premium has been paid, an Insured Person will have a 31 day grace period following
the date his or her next premium is due. If the Insured Person's premium has not been received by
Us before the 31 day grace period
ends, the Insured Person's Voluntary coverage under this Policy will terminate in accordance with the Termination provision unless
reinstated as described below,
REINSTATEMENT FOLLOWING TERMINATION; Any coverage which is reinstated will cover only those losses under this Policy
which result from Injury which an Insured Person and his or her Covered Dependents sustained on or after the first day of the period to
which the reinstatement premium payment is applied,
Form 7582 B9
'507443 1
SCHEDULE (Premiums)
Case 9:14-cv-80945-KAM Document 1-1 Entered on FLSD Docket 07/16/2014 Page 33 of 43
CONTRACT PROVISIONS
Entire Contract: The entire contract between the Policyholder and Us consists of this Policy, any individual applications, and any
papers made a part of this Policy at issue.
All statements made in any application will be deemed representations and not warranties. No statement will be used to void insurance
or deny a claim unless:
a) it is in writing, and
b) a copy of it has been given to the person who made it or to his or her beneficiary.
Changes: No agent has authority to change or waive any part of this Policy. To be valid, any change or waiver must be in writing,
approved by one of Our officers and made a part of this Policy.
Time Periods: All periods begin and end at 12;01 A,M., Standard Time at the place where this Policy is delivered.
Certificates: We will give certificates to:
a) the Policyholder; or
b) any other person according to a mutual agreement among the other person, the Policyholder and Us;
for delivery to Insured Persons.
The certificates will state the features of this Policy which are important to Insured Persons.
Data Furnished bv Policvholder: The Policyholder will, upon Our request, give Us,
a) the names of all persons initially eligible;
b) the names of all additional persons who become eligible;
c) the names of all persons whose amount of Principal Sum is to be changed;
d) the names of all persons whose insurance is cancelled; and
e) any data necessary to calculate premiums.
The Policyholder's failure to report a person's termination of insurance does not continue the coverage beyond the date of termination.
The Policyholder, with Our approval, may keep the important insurance records on all Covered Persons, The Policyholder must give
Us information, when and in the manner We ask, to administer the insurance provided by this Policy.
The Policyholder's insurance records will be open for Our inspection at any reasonable time.
Cancellation: This Policy may be cancelled at any time
by
written notice mailed or delivered by Us to the Policyholder or by
the
Policyholder to Us. If We cancel, We will mail or deliver the notice to the Policyholder at its last address shown in Our records.
If We cancel, it becomes effective on the later of:
a) the date stated in the notice; or
b) the
31"
day after We mail or deliver the notice,
If the Policyholder cancels, it becomes effective on the later of:
a) the date We receive the notice; or
b) the date stated in the notice.
In either event:
a) We will promptly return any unearned premium paid; or
b) the Policyholder will promptly pay any earned premium which has not been paid.
Subject to the Cancellation provision under this Policy, cancellation (either by Us or the Policyholder) will not affect any claim for
Loss due to an accident which occurs before the effective date of the cancellation.
Not in Lieu of Workers'ompensation; This Policy does not satisfy any requirement for workers'ompensation insurance,
Form 7582 D 1 Rev.-!
8507443 1
CONTRACT PROVISIONS FL
Case 9:14-cv-80945-KAM Document 1-1 Entered on FLSD Docket 07/16/2014 Page 34 of 43
Privacy Policy and Practices of The Hartford Financial Services Group, Inc. and its Affiliates
(herein called "we, our, and us")
This Privacy Policy applies to our United States Operations
We value your trust. We are committed to the responsible:
a) management;
b) use; and
c) protection;
of Personal Information.
This notice describes how we collect, disclose, and protect
Personal Information,
We may also share Personal Information, only as
aHowed
by law, with unaffiliated third parties including:
a) independent agents;
b) brokerage firms;
c) insurance companies;
d) administrators; and
e) service providers;
who help us serve You and service our business.
We coHect Personal Information to;
a) service your Transactions with us; and
b) support our business functions,
We may obtain Personal Information from:
a) You;
b) your Transactions with us; and
c) third parties such as a consumer-reporting agency.
When aHowed by law, we may share certain Personal
Financial Information with other unaffiliated third parties
who assist us by performing services or functions such as:
a) taking surveys;
b) marketing our products or services; or
c) offering financial products or services under a joint
agreement between us and one or more financial
institutions,
Based on the type of product or service You apply
for or
get from us, Personal Information such as:
a) your name;
b) your address;
c) your income;
d) your payment; or
e) your credit history;
may be gathered from sources such as applications,
Transactions, and consumer reports,
To serve You and service our business, we may share
Certain Personal Information, We will share Personal
Information, only as allowed
by law, with affiliates such
as;
a) our insurance companies;
b) our employee agents;
c) our brokerage firms; and
d) our administrators.
As allowed by law, we may share Personal Financial
Information with our affiliates to:
a) market our products; or
b) market our services;
to You without providing You with an option to prevent
these disclosures.
We will not sell or share your Personal Financial
Information with anyone for purposes unrelated to our
business functions without offering You the opportunity to:
a)
"opt-out;" or
b)
"opt-in;"
as required by law,
We only disclose Personal Health Information with:
a) your proper written authorization; or
b) as otherwise allowed or required by
law,
Our employees have access to Personal Information in the
course of doing their jobs, such as:
a) underwriting policies;
b) paying
claims.
c) developing new products; or
d) advising customers of our products and services.
We use manual and electronic security procedures to
maintain;
a) the confidentiality; and
b) the integrity of;
Persona/ Information that we have. We use these
procedures to guard against unauthorized access,
HPP Revised March 2005
8507443 1
GBD-Affinity
Case 9:14-cv-80945-KAM Document 1-1 Entered on FLSD Docket 07/16/2014 Page 35 of 43
Some techniques we use to protect Personal Information
include:
a) secured files;
b) user authentication;
c) encryption;
d) firewall technology; and
e) the use of detection software.
We are responsible for and must:
a) identify information to be protected;
b) provide an adequate level of protection for that data;
c) grant access to protected data only to those people who
must use it in the performance of their job-related duties,
Employees who violate our Privacy Policy will be subject to
discipline, which may include ending their employment with
us,
Personal Financial Information means financial information
sucll as:
a) credit history;
b) income;
c) financial benefits; or
d) policy or claim information.
Personal Health Information means health information such
as:
a) your medical records; or
b) information about your illness, disability or injury,
Personal Information means information that identifies You
personally and is not otherwise available to the public. It
includes;
a) Personal Financial Information; and
b) Personal Health Information,
At the start of our business relationship, we will give You a
copy of our current Privacy Policy.
We will also give You a copy of our current Privacy Policy
once a year if You maintain a continuing business relationship
with us,
We will continue to follow our Privacy Policy regarding
Personal Information even when a business relationship no
longer exists between us.
As used in this Privacy Notice:
Application means your request for our product or service.
Transactio~ means your business dealings with us, such as:
a) your Application;
b) your request for us to
pay
a claim; and
c) your request for us to take an action on your account.
I'ou means an individual who has given us Personal
Information in conjunction with:
a) asking about;
b) applying for; or
c) obtaining;
a financial product or service from us if the product or service
is used mainly for personal, family, or household purposes.
This Privacy Policy is being provided on behalf of the following affiliates of The Hartford Financial Services Group, Inc.:
American Maturity Life Insurance Company; Capstone Risk Management, LLC; First State Insurance Company; Hart Life Insurance Company;
Hartford Accident & Indemnity Company; Hartford Administrative Services Company; Hartford Casualty Insurance Company; Hartford Equity Sales
Company, Inc.; Htutford Fire Insurance Company; Hartford HLS Series Fund II, Inc.; Hartford Insurance Company of Illinois; Hartford Insurance
Company of the Midwest; Hartford Insurance Company of the Southeast; Hartford International Life Reassurance Corporation; Hartford Investment
Financial Services, LLC; Hartford Investment Management Company; Hartford Life & Accident Insurance Company; Hartford Life and Annuity
Insurance Company, Hartford Life Insurance Company; Hartford Life Group Insurance Company, Hartford Lloyd's Insurance Company; Hartford
Mezzanine Investors I, LLC; Hartford Securities Distribution Company, Inc.; Hartford Series Fund, Inc.; Hartford Specialty Company; Hartford
Specialty Insurance Services of Texas, LLC; Hartford Underwriters Insurance Company; Hartford-Comprehensive Employee Benefit Service
Company; HL Investment Advisors, LLC; Hartford Life Private Placement, LLC; M-CAP Insurance Agency, LLC; New England Insurance
Company; Nutmeg Insurance Agency, Inc.; Nutmeg Insurance Company; Nutmeg Life Insurance Company; Omni General Agency, Inc.; Omni
Indemnity Company; Omiii Insurance Company; P2P Link, LLC; Pacific Insurance Company, Limited; Planco Financial Services, Inc.; Property and
Casualty Insurance Company of Hartford; Sentinel Insurance Company, Ltd.; Servus Life Insurance Company; Specialty Risk Services, Inc.;
The Hartford Income Shares Fund, Inc,; The Hartford Mutual Funds II, Inc.; The Hartford Mutual Funds, Inc.; Trumbull Insurance Company;
Trumbull Services, L,L,C.; Twin City Fire Insurance Company; Woodbury Financial Services, Inc.
HPP Revised March 2005
8507443 1
GBD-Affinity
Case 9:14-cv-80945-KAM Document 1-1 Entered on FLSD Docket 07/16/2014 Page 36 of 43
INCORPORATION PROVISION
The Certificate(s) of Insurance and Riders listed below are attached to, incorporated in and made a part of, this Policy.
Certificate of
Insurance Apnlicable to Certificate Coverage
Effective Date of
Incornoration
Form PA-5427 A2 (12205) Insured Persons Classes 1 &3: Basic Coverage March 1, 2006
Form PA-5427 A2 (12205) Covered Persons Classes 2 & 4: Basic & Voluntary Coverage March 1, 2006
The provisions listed below are shown in the Certificate(s) of Insurance and are hereby incorporated into and made a part of this
Policy.
Definitions
Period of Coverage
Exclusions
Benefits
Claims
Riders (if any)
Form 7582 INC (HLA)
8507443
't
Case 9:14-cv-80945-KAM Document 1-1 Entered on FLSD Docket 07/16/2014 Page 37 of 43
Certificate of Insurance
Hartford Life and Accident Insurance Company
Hartl'ord, Connecticut
Policyholder: CFE FEDERAL CREDIT UNION
Policy Number: ADD-12205
We have issued a Policy to the Policyholder. Our name, the Policyholder name and the Policy Number are shown above. The
provisions of the Policy which are important to You are summarized in this Certificate; consisting of this Certificate and any additional
forms which have been made a part of this Certificate. This Certificate replaces all certificates which may have been given to You
earlier for the Policy, The Policy alone is the only contract under which payment will be made, Any difference between the Policy
and this Certificate will be settled according to the provisions of the Policy.
Richard G. Costello, Secretary Thomas M. Marra, President
30 DAY RIGHT TO EXAMINE CERTIFICATE: We urge You to examine this certificate closely. If You are not satisfied,
return it to Us within 30 days of Your Effective Date. In that event, We will consider it void from the certificate Effective Date
and any premium paid will be refunded. Any claims paid during the initial 30 day period will be deducted from the refund.
Note: Premiums will automatically be [debited from / charged to / added to] Your [account type] the first week of each
[month/quarter] beginning with the effective date indicated above.
Accidental Death and Dismemberment Reduction on and after Age 70: On the date You attain age 70, Your amount of Principal
Sum will reduce
by
50%, If You are age 70 or over You will not be eligible for a Principal Sum Amount that is more than 50% of the
Principal Sum Amount(sl shown above.
APPLICABI.E TO INSURED PERSONS WHO WERF. COVERED UNDER THE PRIOR GROUP ACCIDENTAL DEATH
AND DISMEMBERMENT POLICY ISSUED TO THE POLICYHOLDER: TRANSITION PROVISION: Your designation of
beneficiary under the prior carrier's Accidental Death and Dismemberment Policy issued to the Policyholder named above and in
effect the day before Your Effective Date of this Certificate will be Your beneficiary designation under The Policy named above. It
will take effect on Your Effective Date stated in Your Schedule and is subject to the Naming A Beneficiary provision, The Policy will
not
pay any benefits for a claim in effect before the Effective Date of Your coverage under The Policy. The Policv means the
Accidental Death and Dismemberment Policy issued by Hartford Life and Accident Insurance Company to the Policyholder,
Limitation: If You have more than one Certificate under the Policy's Voluntary Plan, the total Principal Sum Amount of Voluntary
coverage under all Certificates may not exceed the Maximum Amount of $300,000 under the Voluntary Accidental Death and
Dismemberment Benefit, If coverage exceeds the Maximum Amount, premiums paid for coverage over the Maximum Amount will be
refunded.
Customer Assistance; For Customer Assistance/Information call 1-800-860-7182; 7;00 a.m, to 8;00 p,m. Monday through Friday, and
8:30a,m. to 5:00p.m., Saturday, Central Time.
Form PA-5427 A2 (12205)
Printed in U,S,A,
8507443 1
Case 9:14-cv-80945-KAM Document 1-1 Entered on FLSD Docket 07/16/2014 Page 38 of 43
CERTIFICATE MODIFICATIONS: This certificate as issued is amended as follows: (1) Under DEPENDENTS PERIOD OF
COVERAGE, the definition of Child(ren) is deleted and is replaced by the following; Child or Children means Your unmarried
child, stepchild, newborn child from the moment of birth (if a written agreement to adopt such child has been entered into prior to the
birth of the child whether or not the agreement is enforceable), legally adopted child, child in the process of adoption, foster child or
other child in a court-ordered temporary or other custody, from the moment of placement with You who: a) is less than age 21 and
primarily dependent on You for support and maintenance; or b) is at least age 21 but less than age 25 (until the end of the calendar year
in which the child reaches 25) who: 1) regularly attends an institution of learning; and 2) is primarily dependent on You for support
and maintenance, (2) Under DEPFNDENTS PERIOD OF COVERAGE, in the Incapacitated Child provision, the age of a child is
increased to age 25 (until the end of the calendar year in which the child reaches 25). (3) Subject to the Cancellation provision under
the Policy, cancellation (either by Us or the Policyholder) will not affect any claim for Loss due to an accident which occurs before the
effective date of the cancellation; (4) Under CLAIMS, under the Payment of Claims provision, the reference to $1,000 is changed to
be $3,000. (5) Under CLAIMS, under Legal Actions, section b) is deleted and is replaced by the following: b) after the expiration of
the applicable statute of limitations from the time written proof of Loss is required to be given.
Form PA-5427 B10(FL) Rev.-2
DEFINITIONS: We, Us or Our means the insurance company named on the face page, You, Your or Insured Person means an
Eligible Person while he or she is covered under the Policy. Covered Person means You or Your Eligible Dependent while You, he or
she is covered under the Policy. Injury means bodily injury resulting directly from accident and independently of all other causes
which occurs while the Covered Person is covered under the Policy. Loss resulting from; a) sickness or disease, except a pus-forming
infection which occurs through an accidental wound; or b) medical or surgical treatment of a sickness or disease; is not considered as
resulting from injury, Common Carrier means a conveyance operated by a concern, other than the Policyholder, organized and
licensed for the transportation of passengers for hire, with published schedules, and operated by an employee of that concern, On,
when used with reference to any conveyance (land, water or air), means in or on, boarding or alighting from the conveyance. Civil or
Public Aircraft means an aircraft which: a) has a current and valid Airworthiness Certificate; b) is piloted by a person who has a valid
and current certificate of competency of a rating which authorizes him or her to pilot the aircraft; and c) is not operated by the militia
or armed forces of any state, national government or international authority. Airworthiness Certificate means; a) the "Standard"
Airworthiness Certificate issued by the United States Federal Aviation Administration; or b) a foreign equivalent issued by the
governmental authority with jurisdiction over civil aviation in the country of its registry. Military Transport Aircraft means a
transport aircraft operated by: a) the United States Air Mobility Command (AMC); or b) a national military air transport service of any
country. Written Request means any form provided by Us for the particular request.
INSURED PERSON PERIOD OF COVERAGE: Effective Date: Your Effective Date of Coverage is stated in Your Schedule,
Termination: Your coverage under the Basic Plan terminates on the earlier of: a) the date the Policy is terminated; b) the Premium
Due Date on or next following the date You cease to be an active member of the Policyholder; or c) the Premium Due Date on or next
following the date the Policyholder terminates coverage under the Basic Plan of the Policy or ceases to
pay
the required premium,
Your coverage under the Voluntary Plan, if elected, terminates on the earlier of; a) the date the Policy is terminated; b) the first day of
the next premium cycle following receipt of Your request that Your Voluntary Benefits be terminated; c) the Premium Due Date on or
next following the date You cease to be an active member of the Policyholder; or d) the Premium Due Date on which You fail to
pay
any required premium for Voluntary Benefits subject to the Individual Grace Period provision, Request for Cancellation of
Coverage: You may cancel Your coverage at any time. You will be refunded any premium due as a result of such cancellation, You
may cancel by writing to: Plan Administrator, P,O. Box 40606, Nashville, TN 37204 or
by calling Customer Assistance. Request for
Change in Coverage: If You give Us a Written Request for a change in Your coverage, and if You: a) are not eligible for the
coverage requested, the change will not become effective; b) are eligible for the coverage requested, the change will become effective
on the first day of the next premium cycle following receipt of Your request, Individual Grace Period: After the first premium has
been paid, You will have a 31 day grace period following the date Your premium is due. If Your premium has not been received by
Us before the 31 day grace period ends, Your Voluntary coverage under the Policy will terminate in accordance with the Termination
provision unless reinstated. Reinstatement Following Termination: Any coverage which is reinstated will cover only those losses
under this Policy which result from Injury which You and Your Covered Dependents sustained on or after the first day of the period to
which the reinstatement premium payment is applied,
DEPENDENTS PERIOD OF COVERAGE: You are insured with Dependents Coverage if the Family Plan is stated in Your
Schedule under Coverage Type. You are not an Eligible Dependent, Eligible Dependents: 1) Spouse means Your spouse unless You
and Your spouse are legally separated or divorced. 2) Child or Children means Your unmarried child, newborn child, stepchild,
legally adopted child, foster child or child in the process of adoption: a) who is less than age 21 and primarily dependent on You for
support and maintenance; or b) who is at least age 21 but less than age 25 who regularly attends an institution of learning and is
primarily dependent on You for support and maintenance, Effective Date: Each Eligible Dependent will become covered under the
Policy on the later of: a) the date You become an Insured Person; b) the first day of the next premium cycle following receipt of Your
Written Request for coverage of Dependents; or c) the date the person qualifies as an Eligible Dependent. Termination: Coverage of
each Eligible Dependent terminates on the Premium Due Date next following the earlier of: a) the date You cease to be an Insured
8507443 1
Case 9:14-cv-80945-KAM Document 1-1 Entered on FLSD Docket 07/16/2014 Page 39 of 43
Person; or b) the date he or she ceases to qualify as an Eligible Dependent. Incapacitated Child: Coverage of a Child who, on the
date he or she reaches age 21 or 25, is: a) covered under the Policy; b) mentally or physically incapable of earning his or her own
living; and c) unmarried and primarily dependent on You for support and maintenance; will not terminate solely due to age, However,
You must give Us notice of the incapacity within 31 days of the termination date, Coverage will continue as long as: a) the incapacity
continues; and b) the required premium is paid. We may, from time to time, require proof of continued incapacity and dependency,
After the first two years, We cannot require proof more than once each year, Request For Change In Coverage: If You give Us a
Written Request for a change in coverage, and; a) are not eligible for the coverage requested, it will not become effective; or b) are
eligible for the coverage requested, the change will become effective the first day of the next premium cycle following receipt of Your
request.
EXCLUSIONS: The Policy does not cover any Loss resulting from; 1. intentionally self-inflicted Injury, suicide or attempted suicide,
whether sane or insane; 2. war or act of war, whether declared or undeclared; 3, Injury sustained while full-time in the armed forces of
any country or international authority. (Coverage will be provided for Injury resulting from non-military or non-combat activity within
the U,S.); 4. Injury sustained while riding On any aircraft except a Civil or Public Aircraft, or Military Transport Aircraft; 5. Injury
sustained while riding On any aircraft: a) as a pilot, crewmember or student pilot; b) as a flight instructor or examiner; or c) if it is
owned, operated or leased by or on behalf of the Policyholder, or any employer or organization whose eligible persons are covered
under the Policy; 6. Injury sustained while voluntarily taking drugs which federal law prohibits dispensing without a prescription,
including sedatives, narcotics, barbiturates, amphetamines, or hallucinogens, unless the drug is taken as prescribed or administered by
a licensed physician; 7, Injury sustained while committing or attempting to commit a felony; 8, Injury sustained as a result of being
legally intoxicated from the use of alcohol.
ACCIDFNTAL DFATH AND DISMEMBERMFNT BENEFIT (BASIC PLAN

INSURED PERSON ONLY); If Your Injury
results in any of the following losses within 365 days after the date of accident, We will
pay
the sum stated opposite the Loss shown in
the Loss Table, We will not
pay
more than the Principal Sum for all losses due to the same accident. Your amount of the Principal
Sum under the Basic Plan is shown in the Schedule.
ACCIDENTAL DEATH AND DISMEMBERMENT BENEFIT (VOLUNTARY PLAN): If a Covered Person's Injury results in
any of the following losses within 365 days after the date of accident, We will
pay
the sum stated opposite the Loss shown in the Loss
Table, We will not
pay
more than the Principal Sum for all losses due to the same accident. Your amount of the Principal Sum for the
Voluntary Plan, if elected, is shown in the Schedule. The Principal Sum for Your Dependents, if Dependents Coverage is elected, is a
percentage of Your Principal Sum as follows:
You with:* Spouse only
Spouse k Child(ren)
Child(ren), but no Covered Spouse
Spouse
60%
50%
0%
Each Child
0%
20%
25%
'"as
determined on the date of accident
LOSS TABLE
(Basic and Voluntary Plans)
For Loss of:
Life,
Both Hands or Both Feet or Entire Sight of Both Eyes.
One Hand and One Foot,
Speech and Hearing in Both Ears.
Either Hand and Entire Sight of One Eye
Either Foot and Entire Sight of One Eye,,
Either Hand or Foot
Entire Sight of One Eye.,
Speech
Hearing in Both Ears.. ....,..........,
Thumb and Index Finger of Same Hand
100%Principal Sum
100%Principal Sum
100%Principal Sum
100%Principal Sum
100%Principal Sum
100%Principal Sum
50% Principal Sum
50% Principal Sum
50% Principal Sum
50% Principal Sum
25% Principal Sum
Loss means with regard to: a) hands and feet, actual severance through or above the wrist or ankle joints; b) sight, speech or hearing,
entire and irrecoverable Loss thereof; c) thumb and index finger, actual severance through or above the metacarpophalangeal joints.
Fxposure: Exposure to the elements will be presumed to be Injury if: a) it results from the forced landing, stranding, sinking or
wrecking of a conveyance in which the Covered Person was an occupant at the time of the accident; and b) the Policy would have
covered Injury resulting from the accident. Disappearance: A Covered Person will be presumed to have suffered Loss of Life if: a)
his or her body has not been found within one year after the disappearance of a conveyance in which he or she was an occupant at the
8507443 1
Case 9:14-cv-80945-KAM Document 1-1 Entered on FLSD Docket 07/16/2014 Page 40 of 43
time of its disappearance; b) the disappearance of the conveyance was due to its accidental forced landing, stranding, sinking or
wrecking; and c) the Policy would have covered Injury resulting from the accident.
ANTI-INFLATION BENEFIT (BASIC AND VOLUNTARY PLANS): If: a) a Covered Person's Injury results in a Loss; and b) a
Principal Sum is payable under the Voluntary Plan's Accidental Death and Dismemberment Benefit; We will
pay
an inflation
adjustment in addition to the Principal Sum. The Anti-Inflation Benefit will be the amount of the Covered Person's Voluntary Plan's
Principal Sum, at the time of Claim, multiplied by: a) 5%; for b) every two (2) years of continuous coverage the Covered Person had
under the Policy; to a maximum of ten (10) years and subject to a maximum of 125% of the Covered Person's original Principal Sum.
If a Covered Person adds to the coverage, the Anti-Inflation Benefit will be applied separately to each additional amount applied for;
likewise, if coverage is reduced, any
Anti-Inflation Benefit which was increased will be reduced proportionately.
APPLICABI.E TO ANTI-INFLATION BENEFIT (BASIC AND VOLUNTARY PLANS): If the Covered Person's coverage
under the Policy is an uninterrupted continuation of coverage from Your previous policy, the effective date used to calculate this
benefit shall be the effective date of Your coverage under the previous policy. Benefit amounts for Covered Dependents will not be
increased.
ADDITIONAL BENEFITS UNDER THE VOLUNTARY PLAN ONLY
ADAPTIVF. HOME AND VEHICLE BENEFIT (VOLUNTARY PLAN): If a Covered Person's Injury results in a covered Loss,
except of Loss of Life, and a benefit is payable under the Voluntary
Plan's Accidental Death and Dismemberment Benefit, We will
pay
the lesser of: a) 2% of the Principal Sum; b) the actual cost; or c) $2,500; for the one-time cost of alterations incurred within two
years from the date of the accident to the Covered Person':
a) principal residence; and/or b) Private Automobile; to make the
residence accessible and/or the Private Automobile drivable or rideable for the Covered Person. The benefit will be payable only if:
a) such home alterations are: 1) made by a person or persons with experience in such alterations; and 2) recommended by a
recognized organization associated with the Injury; and/or b) such vehicle modifications are: 1) carried out by a person or persons
with experience in such matters; and 2) approved by the Motor Vehicle Department. Private Automobile means a four wheeled:
private passenger car, station wagon, pick-up truck, van, sport utility vehicle or jeep-type automobile which is not being used as a
common carrier, Common Carrier means a conveyance operated by a concern, other than the Policyholder, organized and licensed
for the transportation of passengers for hire and operated by an employee of that concern, Your Principal Sum Amount under the
Voluntary Plan, if elected, is stated in the Schedule. The Principal Sum Amount applicable to Your Covered Dependents, if any, is
shown as a percentage of Your Principal Sum Amount in the Voluntary
Plan's Accidental Death and Dismemberment Benefit,
ACCIDENT HOSPITAL INCOME BENEFIT (VOLUNTARY PLAN): We will
pay
the Monthly Benefit equal to 1% of a
Covered Person's Principal Sum to a Maximum Monthly Amount of $2,500 or a portion thereof when a Covered Person is Confined
during one or more periods of Hospital Confinement if: a) the Confinement is due to Injury; b) the first day of Confinement occurs
within 30 days after the accident; and c) the Confinement exceeds the Waiting Period of 7 days. For a period of less than one month,
1/30th of the Monthly Benefit will be paid for each day of Confinement for which benefits are payable, We will not
pay
for any day of
Confinement which: a) is applied to the Waiting Period at the beginning of Confinement; b) exceeds the Benefit Payment Period of 12
months; c) occurs after 2 years from the date of accident; or d) exceeds the Monthly Benefit, Payment will be made for the days
applied to the Waiting Period if the Confinement exceeds the Waiting Period. The Waiting Period is applied only once for any one
accident. Confined and Confinement mean: a) being admitted to a Hospital for receiving inpatient hospital services; and b) the
patient is charged for at least one day's room and board by the Hospital each time he or she is admitted. A period of Confinement
consists of consecutive days of Confinement following the date a Covered Person is admitted as an inpatient. The last calendar day of
a period of Confinement is not counted as a day of Confinement unless a charge is made for the last day. Hospital means an institution
which: a) operates pursuant to law; b) primarily and continuously provides medical care and treatment of sick and injured persons on
an inpatient basis; c) operates facilities for medical and surgical diagnosis and treatment by or under the supervision of a staff of
legally qualified physicians; and d) provides 24 hour a day nursing service by
or under the supervision of registered graduate nurses
(R.N,), Hospital does not mean any institution or part thereof which is used primarily as: a) a nursing home, convalescent home, or
skilled nursing facility; b) a place for drug addicts or alcoholics; or c) a place for rest, custodial care, or for the aged. An institution
which meets the preceding requirements, except that it lacks facilities for surgical diagnosis and treatment, will be regarded as a
hospital if: a) it is accredited by; 1) the Joint Commission of the Accreditation of Hospitals; 2) the American Osteopathic Association;
or 3) the Commission on the Accreditation of Rehabilitative Facilities; and b) it primarily provides rehabilitative treatment of physical
disabilities. Hospital shall also include any licensed hospital which provides needed care or treatment of a child and which: a) is
nonprofit; b) primarily provides diagnosis, treatment, or care for patients whose physical functions or movements are impaired by
accident, disease, or congenital deformity; and c) accepts patients for treatment without regard to race, color, national origin, sex,
religion, or affiliation; even though it does not have facilities for major surgery or because treatment and care are primarily of a
charitable nature, Your Principal Sum Amount under the Voluntary Plan, if elected, is stated in the Schedule, The Principal Sum
Amount for Your Covered Dependents, if any, is shown as a percentage of Your Principal Sum Amount in the Voluntary
Plan's
Accidental Death and Dismemberment Benefit.
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DAY CARE BFNEFIT (VOLUNTARY PI.AN): We will
pay a Day Care Benefit for each of Your Eligible Dependents who are
covered under the Policy if: a) a Principal Sum is payable under the Accidental Death and Dismemberment Benefit because of Your
death; and b) such dependent is under age 14 at the time of Your death; and c) proof of enrollment in a Day Care Program is provided
as described below. Payment will be made to the person who has legal physical custody of the Eligible Dependent and who has
primary responsibility for the Eligible Dependent's Expenses. Payment will be made in accordance with the Claims provision of the
Policy, Proof of enrollment for each child in a Day Care Program may be in the form of, but will not be limited to, the following: a) a
copy of the child's approved enrollment application in a Day Care Program; or b) cancelled check(s) evidencing payment to a Day
Care facility or Day Care Provider; or c) a letter from the Day Care facility or Day Care provider stating that the child: 1) is attending a
Day Care Program; or 2) has been enrolled in a Day Care Program and will be attending within 365 days of the date of Your death.
Proof of enrollment must be sent to Us prior to the last day of the
12'"
month on or next following the date of Your death. One Day
Care Benefit payment will be made each year, for a maximum of 2 Day Care benefit payments, for each Eligible Dependent Child.
The Day Care Benefit is the lesser amount of: a) the Maximum Amount of $2,000; or b) 2% of Your Principal Sum Amount. We will
pay
the Minimum Amount of $1,000 in accordance with the Claims Provision for payment of benefits for Loss of Life if: a) a Principal
Sum is payable because of Your death; and b) no person qualifies as an Eligible Child for a Day Care Benefit, Your Principal Sum
Amount under the Voluntary Plan, if elected, is stated in the Schedule, Day Care Program means a program of child care which: a) is
operated in a private home, school or other facility; and b) provides, and makes a charge for, the care of children; and c) is licensed as
a Day Care center or is operated by a licensed Day Care provider, if such licensing is required by
the state of jurisdiction in which it is
located; or d) if licensing is not required, provides child care on a daily basis for 12 months a year.
COMMON CARRIER BENEFIT (VOI.UNTARY PLAN): If a Loss is sustained by a Covered Person while riding as a passenger
on any Common Carrier, the amount of Principal Sum payable under the Voluntary Accidental Death and Dismemberment Benefit will
be doubled. Your Principal Sum Amount under the Voluntary Plan, if elected, is stated in the Schedule. The Principal Sum Amount
applicable to Your Covered Dependents, if any, is shown as a percentage of Your Principal Sum Amount in the Voluntary Plan's
Accidental Death and Dismemberment Benefit,
EDUCATION BENEFIT (VOLUNTARY PLAN): If: a) Your Eligible Dependent Child(ren) are covered under the Policy; and b) a
Principal Sum is payable under the Accidental Death and Dismemberment Benefit because of Your death; We will
pay
an Education
Benefit to each Student as provided below. A Student is a person for whom We receive proof that he or she: a) is covered as Your
Eligible Dependent on the date of Your death; and b) is a full-time post-high school student in a school for higher learning on the date
of Your death; or c) became a full-time post-high school student in a school for higher learning within 365 days after Your death and
was a student in the 12th grade on the date of Your death. He or she is not considered to be a Student after the first to occur of: a) Our
payment of the fourth Education Benefit to or on behalf of that person; or b) the end of the 12th consecutive month during which We
have not received proof that he or she is a Student. The Education Benefit is equal to the amount determined by applying 2% to the
amount of Your Principal Sum under the Voluntary Plan, We will not pay
more than one Education Benefit to any one Student during
any one school year. The Education Benefit is payable to each person: a) on the date; and b) for whom; We have received proof that
he or she is a Student, If he or she is a minor, We will
pay
the benefit to the Student's legal representative. If: a) a Principal Sum is
payable because of Your death; and b) no person qualifies as a Student; We will
pay
2% of Your Principal Sum under the Voluntary
Plan in accordance with the claims provision for payment of benefits for Loss of Life.
CLAIMS: Notice of Claim; The person who has the right to claim benefits (the claimant or beneficiary) must give Us written notice
of a claim within 30 days after a covered Loss begins, If notice cannot be given within that time, it must be given as soon as
reasonably possible. The notice should include Your name and the Policy number. Send it to Our Plan Administrator, P.O. Box
40606, Nashville, TN 37204. Claim Forms, When We receive the notice of claim, We will send forms to the claimant for giving Us
proof of Loss. The forms will be sent within 15 days after We receive the notice of claim, If the forms are not received, the claimant
will satisfy the proof of Loss requirement if a written notice of the occurrence, character and nature of the Loss is sent to Us, Proof of
Loss; Proof of Loss must be sent to Us in writing within 90 days after: a) the end of a period of Our liability for periodic payment
claims; or b) the date of the Loss for all other claims. If the claimant is not able to send it within that time, it may be sent as soon as
reasonably possible without affecting the claim. The additional time allowed cannot exceed one year unless the claimant is legally
incapacitated. Time of Claim Payment: We will
pay any monthly benefit due: a) on a monthly basis, after We receive the proof of
Loss, while the Loss and Our liability continue; or b) as soon as possible after We receive the required proof of Loss following the end
of Our liability. We will
pay any other benefit due as soon as possible after We receive proof of Loss and other forms that may be
necessary to adjudicate the claim. Payment of Claims: We will
pay any benefit due for Loss of Your Life: a) according to the
beneficiary designation in effect under the Policy at the time of Your death; otherwise b) to the survivors, in equal shares, in the first of
the following classes to have a survivor at Your death; 1) spouse, 2) children, 3) parents, 4) brothers and sisters, If there is no survivor
in these classes, payment will be made to Your estate, All other benefits due and not assigned will be paid to You, if living.
Otherwise, the benefits will be paid according to the above, If a benefit due is payable to: a) Your estate; or b) You or any person who
is either a minor or not competent to give a valid release for the payment; We may pay up to $1,000 of the amount to some other
person, The other person will be someone related to the minor or the incompetent person by blood or marriage who We believe is
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Case 9:14-cv-80945-KAM Document 1-1 Entered on FLSD Docket 07/16/2014 Page 42 of 43
entitled to the payment. We will be relieved of further responsibility to the extent of any payment made in good faith. Physical
Examinations and Autopsy: While a claim is pending We have the right at Our expense: a) to have the person who has a Loss
examined
by a physician when and as often as We feel is necessary; and b) to make an autopsy in case of death where it is not
forbidden
by
law, Legal Actions: You cannot take legal action against Us; a) before 60 days following the date proof of Loss is sent
to Us; b) after 3 years following the date proof of Loss is due. Naming a Beneficiary: You may name a beneficiary or change a
revocably named beneficiary by giving Your Written Request to the Policyholder, Your request takes effect on the date You execute it,
regardless of whether You are living when the Policyholder receives it. We will be relieved of further responsibility to the extent of
any payment We made in good faith before the Policyholder received Your request. Assignment: We will recognize any assignment
You make under the Policy, provided: a) it is duly executed; and b) a copy
is on file with Us. We and the Policyholder assume no
responsibility for the validity or effect of an assignment.
Third Partv Administrator Notice: The Hartford Life and Accident Insurance Company has contracted with an independent Third
Party Administrator to provide administrative services under a Policy issued to the Policyholder named in this Certificate,
The Insurance Carrier for the Policy is;
Hartford Life and Accident Insurance Company
200 Hopmeadow Street
Simsbury, CT 06089
Plan Administrator
P.O, Box 40606
Nashville, TN 37204
Please submit all claim forms to Administrator
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