Your group term life, dependent life, and accidental death & dismemberment plans : Flexible Benefits Program, state of Georgia

G- /\
IYl j OO
.'P I FSt
Iq'110
YOUR GROUP TERM LIFE, DEPENDENT LIFE, AND ACCIDENTAL DEATH & DISMEMBERMENT PLANS

FLEXIBLE BENEFITS PROGRAM
STATE OF GEORGIA

6 U NUM.
UNUM Life Insurance Company of America

CERTIFICATE OF COVERAGE
GROUP TERM LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE
UNUM LIFE INSURANCE COMPANY OF AMERICA (referred to as UNUM)
2211 Co ngress Street Portland, Maine 04 122
CER T IFIES that it has issued and deliv ered a Group Insuran ce Policy to the Policyholder shown belo w insur ing certain Emp loye es of the Emplo yer shown below.
EMPLOYER: STATE OF GEORGIA (STATEMERIT SYSTEM AND DEPARTMENTS)
POLI CYHOLDER: EMPLOYE E BENEFIT PLAN CO UNCIL
STAT E OF ISSUE: GEORGIA
GROUP POLIC Y NO.: 502147
EFFECTIVE DATE: July 1, 1993
Th is certificate is furn ished in accord ance w ith an d subje ct to the prov ision s of the group life, dep end ent life and/or accidental death and dismemberment insurance polic y referenced above and is issued to the EMPLOYEE BENEFIT PLAN COUNCIL on behalf of the $ TATE OF GEORGIA. The certificate is the certificate of cove rage to be delivered to Emp loyees who select life , dependent life and/or accidental death and dismemberment insurance under the Flexible Benefits Program. The contract rights of an Employee insured under this group po licy will be governed sole ly by the policy issued to the EMPLOYEE BENEFIT PLAN COUNCIL.
This booklet describes the benefits of the group policy. Fin al interpretation of any described benefit is governed by the po licy .
This booklet is your cert ificate of insurance only w hen you are entitled to the insu rance provided by the group policy as an eligible employee, you elect this coverage, and you retain coverage in accordance with the terms and conditions of the group pol icy. This book let is void if you are not entit led to, or have ceased to be entitled to, the coverage.
This booklet supersedes and replaces all certificates of coverage previously issued to you for life and accidental death and dismembe rment insurance under the State of Georgia, Flexible Benefits Program. This certificate describes the coverage in effect as of July 1, 1993. If the Group Policy is changed in a way which will affect the insurance, a rider or a new booklet will be issued to describe the change.
Page 1

Except when otherwise indicated by the context of this booklet, any masculine terminology herein will also include the feminine, and the definition of any terms in the singular may also indude the plural.
President UNUM LIFE INSURANCE COMPANY OF AMERICA Prepared On: March 22, 1996
NOTICE
If you have a disability and need assistance please notify the Flexible Benefits Program at (404) 651-6071, or for TOO Relay Service only: 1-800-255-0056 (Text-telephone) or 1-800-255-0135 (voice) .
Page2

TABLE OF CONTENTS Page Number
GENERAL PROVISIONS .. ...................................................... ... 5 Glossary of Terms ................................................................... 5 Employee Eligibility ..................................................................6 Coverage Effective Date ....................... .................................. 6 Premium Payments and Leave Without Pay ........................... 7 Coverage Termination ............................................................ 7
EMPLOYEE LIFE INSURANCE ................................................. 8 Benefits Available .................................................................... 8 ADEA (Age Discrimination in Employment Act/Age Reductions) ......................................... .................. 8 Benefit Salary Changes .............................. ... ..... ............ ........ 9 Enrollment If Agency Sponsored Plan Cancels .. .. .................. 9 Evidence Of Insurability ............. ........................................... 10 Beneficiary ............................................................................. 11
DEPENDENT LIFE INSURANCE ..................................... ........ 11 Benefits Available ........................ ...... .................................... 11 Evidence of Insurability ........................... .............................. 11 Coverage Effective Date ....................................................... 12 Eligible Dependents .. ............... ............... ............. .................. 12 Coverage Termination .......... ..... ................... ........................ 13 Beneficiary ............................................................................. 13
LIFE INSURANCE PAYMENTS AND CONTINUATIONS ........ 13 Disability ..... ........ ................................................................... 13 Total Disability- Annual Proof (Waiver of Premium) ......... 14 Total Disability- One Year Continuance ........................... 15 Continued Death Benefit and Conversion Privilege .......... 15 Suicide ............... .................... .............................................. . 15 Assignment ..................... ...................................................... 15
ACCELERATED BENEFITS ........... ....................................... .. 16
LIFE INSURANCE PORTABILITY PRIVILEGES ..................... 17
APPLYING FOR CONVERSION IF PORTABLE COVERAGE IS NOT AVAILABLE .. ..... ................. 20
CONVERSION PRIVILEGE ....................................... .. ............ 20 Limited Conversion If State Cancels Policy .......................... 20 Premiums ...... ................... ...................................................... 21 Death During The Thirty-One Day Conversion Period .......... 21 Applying For Conversion ......................................... ............. 21
Page3

EMPLOYEE ACCIDENTAL DEATH

AND DISMEMBERMENT INSURANCE

22

Benefits Available - Coverage Amount

22

Loss of Life, Limb. Sight, Speech or Hearing

22

Permanent Total Disability

23

Reserve - National Guard Coverage

24

Exposure and Disappearance

24

Repatriation Benefit

24

Seatbelt(s) and Air Bag Beneflt ..

24

Pilot or Crew Member Benefit

25

Exclusions

25

Beneficiary

26

Assignment

26

ACCIDENTAL DEATH AND DISMEMBERMENT

CONVE RSION PRIVILEGE

27

Premiums

27

Death During The Thirty-One Day Conversion Period

28

Applying for Conversion

28

FILING A CLAIM

29

How To File A Claim

29

Notice and Proof of Claim

29

Payment of Claim

30

Legal Action

30

Page 4

GENERAL PROVISIONS
GLOSSARY OF TERMS
"Actively at work" means that you must:
1. be ab le to do the no rmal tasks of your job on a full time basis for a full work day on the day you r insu rance (or an increase in the amount) is to beg in; and
2. be able to do such tasks at one of your emp loyer's normal places of business or at a location to whic h yo u must travel to do you r job; and
3. not be absent from work because of sickness, disability or
te mporary lay-off.
"Benefit Calculation Date" is the date used to determ ine you r Be nefit Salary and age . For new employees, the Benefit Calculation Date is the date of emp loyment. For all subsequent years the Benefit Ca lculation Date is administratively set immediately prior to the open enro llment pe riod to allow for the preparation of materia ls for employees.
"Benefit Plan Year" is the twe lve (12) mo nth period beginning on Ju ly 1st of each year.
Your "Benefit Salary" is your sa lary on the Benefit Calculation Date. Benefit Sa lary is an annual amount which does not include sh ift differentials, overtime, incentives and other salary supplements .
"Covered Accident" means ac cidental bodily inju ry that occurs while insurance is in effect and wh ich results in a loss for which benefits are payable.
"Accidental Bodily tnlury" means bod ily ha rm caused so lely by external, violent and accidental means and not contributed to by any other cause.
Your "Effective Benefit Salary" is the Benefit Sa lary that took effect acco rd ing to the last scheduled effective date on wh ich yo u were actively at work.
"lnjury" means a loss described in "Employee Accidental Death and Dismemberment insurance" which occurs wh ile that coverage is in force. The loss must result di rectly and independently of all other causes from bodily injury caused by accident.
"Open Enrollment Perlcd" means an annual, thirty-one (31) day period during which you have an opportunity to enro ll or change coverage.
PageS

EMPLOYEE ELIGIBILI TY
Yo u are eligible for insurance coverage if you are:
a full-t ime employee of the State of Georgia, or of a State agency . "Full-time" means someone who works at least 30 hours a wee k, on a continuing basis, and whose employme nt is expected to last at least nine (9) months. Certain categories of employees are specifically excluded: student , seasonal, part-time, short-term, and shelt ered-workshop;
a public-school teacher who is emp loyed in a professionally certificated capacity , works half-t ime or more, and is not considered a "temporary" or "emergency" employee;
an emp loyee of a local school system who holds a non-certificated position ; who is eligible to participate in the Teachers Retirement System or its local equivalent; and who works at least 20 hours a week (or 60% of the time necessary to carry out the duties of the position, if that's more than 20 hours);
an employee who is eligible to participate in the Public School
Employee Retirement System , as defined by Paragraph 20 of
Section 47-4-2 of the Official Code of Georg ia, Annotated; and who works at least 20 hours a week (or 60% of the time necessary to carry out the duties of the posit ion).
COVERAGE EFFECTIVE DATE
Coverage under this group life and accidental death and dismemberme nt insurance plan will become effective on the scheduled effect ive date prov ided you are act ively at work on that date. If you are not acti vely at work on that date , the coverage will begin the day you return to work.
The schedu led effect ive date for newly eligible emp loyees who enroll is the first of the month follo wing employment for the full preceding calendar month.
An eligible employee may enroll for coverage or change multi ples of salary during an annual open enrollment period and in accor dance with the regulations governing the plan . New or changed coverage during an open enrollment per iod is scheduled to begin on the later of the succeeding Ju ly 1 or the first day of the month following approval by UNU M of the evidence of insurability.
Page 6

PREMIUM PAYMENTS AND LEAVE WITHOUT PAY Coverage is extended on a month by month basis. Prem iums for coverage must be paid in advance of coverage. Normally, premiums are paid through payroll reduct ion/deduction in the month prior to coverage. When an employee is not in pay status, the employee must pay the monthly prem ium amount to the Flexible Benefits Program prior to the first of each coverage month . If you cease to be Act ively at Work due to:
suspension without pay, or approved leave of absence without pay with respect to which you have a scheduled date of return, your insurance may be continued through the twe lfth (12th) calendar month through personal premium payments. If you are absent from work without pay for any reason, discuss continuing your insurance with you r personne l off icer. If you r coverage is termi nated for fai lure to pay premium, you r re-enrollment will be in accordance with the regulatio ns of the Employee Benefit Plan Counci l. COVERAGE TER MINATION Coverage under this plan terminates when any of the following conditions happen: 1. you are no longer eligible; 2. you areon suspension or an approved leave of absence without
pay for more than twelve (12) months; 3. you die; 4. you no longer pay premiums for the coverage; or 5. the policy is cancelled by UNUM or the policyholder. Any loss which occurs prior to the te rmination of coverage will not be affected.
Page?

EMPLOYEE LIFE INSURANCE
BENEfiTS AVA ILABLE
life insurance cov erage under this group plan is based on your annual Effective Benefit Salary and the multiple you choose. Eligibility for the salary multiple is as follows:
If you are under age sixty-five (65) upo n the Benefit Calculation Date:
(a) yo u may enro ll for coverage atone (1) times yo ur Bene fit Salary if you enro ll for or reta in an agency sponsored life insurance plan ; or
(b) you may enroll fo r coverage attwo (2) times your Benefit Salary if you do not enroll fo r, or you cancel, an agency sponsored life insurance plan (if two (2) times your Bene fit Salary is $50,000 or greater, you must submit evidence of your insurability satisfactory to UNUM); or
(c) you may enroll for cov erage at two (2) times you r Benefit Salary if you subm it satisfactory evidence of insurability to UNUM for approval, and you do not enro ll for or have not retained coverage at more than two (2) times your Benefit Salary in an agency sponsored life insurance plan; or
(d) you may enro ll for coverage at three (3) times your Benefit Salary if you submit satisfactory evidence of insurabi lity to UNUM for approval, and you do not enro ll for or have not reta ined coverage at more than one (1) times you r Benefit Salary in an agency sponsored life insurance plan ;
(e) but you m ay not enroll for multiples that exceed four (4) times your Benef it Salary in any combination of life insurance coverages under an agency sponsored plan and this group plan;
(1) and you may not enroll under this group plan for salary multiples which exceed an amo unt of $300,000.
ADE A (Age Discriminat ion In Employme nt Act1Age Reductions)
If you are age sixty -five (65) orolderon the Benefit Calculation Date, you are eligible for a percentage of the amount as shown in thetabJe on the next page:
Page 8

Age*

% of Eligible Coverage Amount

65 but less tha n 70 70 but less tha n 75 75 but less tha n 80 80 but less than 85 85 but less than 90 90 but less than 95 95 but less than 100

65% 43% 29% 19% 13%
9% 5%

*Age as of Benefit Calculat ion Date

All amoun ts of life insurance will be rou nded up to the next higher $1 ,000 after the benefrt is calculated in accordance with th is ta ble.

Changes in the amount of your insurance due to age reduct ions will occur on the July 1 following the Benefit Calculation Date on which your birthday for eac h age occurs as s how n above. Th is applies as long as you continue to be an eligibl e partic ipant in the plan .

BENE FIT SALARY CHANGES

C hanges in the amount of your insurance due to a change in your
Benefit Salary will tak e place on the July 1 following the Bene fit Calculation Date on whi ch a change in your Benefit Salary is calculated provided you are actively at work.

ENROLLMENT IF AGENCY SPON SORED PLAN CAN CELS

If your group term life insuranc e und er an agency sponsored policy is to be cancelled, you may enroll for tife insurance under this plan. If your agency sponsored plan is cancelled, you will be guaranteed an amount of life insurance under this plan equal to one (1) time s your Benefrt Salary. An amount of life insurance greater than one (1) times your Benefrt Salary under this ptan is subject to approval by UNUM of your eviden ce of insurability. Only one t1llimes your Benefit Salary is guaranteed during any Special Enrollment Period .

If you have previously elected life insur ance under this plan. you will be permitted to increase the amoun t up to the max imum allowed by the plan. Any increase in the amount wi ll be subject to the approval of YQur evidence Qf insurability by UNUM.

Coverage or any increase in cove rage will become effective on the scheduled effective date provided you are actively at wo rk on that date.H you are not actively at work on that date, the coverage or any increase in cove rage will begin the day you return to work.

Page 9

EVIDENCE OF INSURABILITY
Evidence of insurability is required for some coverage multiples as shown in the section for Benefrts Available. In addition, evidence of insurability is required:
1. if you do not enroll when first eligible (during the first open enrollment period or within 31 days of your eligibility);
2. if you enroll for any increase in coverage requested due to cancellation of an agency sponsored plan under which you have been covered;
3. if you increase coverage multiples during an annual enrollment period;
4 . if you enroll for the first time for one (1) times pay which is equal to or greater than $150,000; or
5. if you enroll for the first time for an amount equal to two (2) times pay ($50,000 or greater) or three (3) times pay.
If you applied for coverage when first eligible and evidence of insurability is required for some coverage multiples as shown in this booklet-certitlcete, you will be covered on the date UNUM approves your application and evidence of insurability. If UNUM does not approve your application and evidence of insurability for these coverage multiples, then you still may be issued guaranteed coverage as follows:
1. one (1) times pay if you have other coverage under an agency sponsored life insurance plan; or
2. two (2) times pay (coverage less than $50,000) if you have coverage under an agency sponsored life insurance plan.
If UNUM does not approve your application and evidence of insurability for an increase in earnings multiple during an annual enrollment period, your former Benefit Salary multiple will be retained and you will not be insured for the increase in earnings multiple.
Coverage or any increase in coverage will become effective on the scheduled effective date provided you are actively at work on that
date. If you are not actively at work on that date, the coverage or any
increase in coverage will begin the day you return to work.
In the event that a death claim or a request for total disability or accelerated benefits is filed within two (2) years of the approval through the medical underwriting process, UNUM has the right to contest the accuracy of any information furnished. If false or inaccurate statements on the evidence of insurability form result in approval of insurance, you will not be insured for the insurance benefit amount requested.
Page 10

BENEFICIARY
Beneficiary means the one you choose to receive th e amount of your life insurance coverage when you die. You may name a person, trust or your estate as your beneficiary and a person, trust or your estate as your contingent benefICiary. Your contingent beneficiary means the one you choose 10 receive the amount of your life insurance coverage when you die if all of the named beneficiaries are deceased.
You must name your beneficiary on the F lexible Benefit Program Beneficiary Election Form provided by your personnel office. The signed form w ill take effect when you file with your departm ent/ age ncy. Yo u may change your ben eficiary at any time w ithout the conse nt of your named beneficiary. The change will take effect w hen you file th e new signed form w ith your department/agency.
If you na me more than one be neficiary and you do not state the share that each beneficiary is to rec eive. each will be paid an equal share . If a beneficiary dies before you die, the share that be neficiary would have received will be divided amo ng you r other benetcianes
in the same proportion as you listed.
In any case in which you leave this group plan and convert to an individual policy and later return to coverage under this group plan. the latest beneficiary designation on file under this group plan with your department/agency will be given effect and gov ern ove r any other beneficiary designation.
The life insurance coverage amount will be paid to your estate if you do not name a beneficiary or your named beneficiary is not living when you die .

DEPENDENT LIFE INSURANCE

BENEFITS AVAILABLE

If you are covered by the group life insurance policy. you may cover your eligible dependents. If you and your spouse are eligible
employees and enroll for coverage under this group life insurance plan, you may cover each other as dependents. In addition. both of
you may enroll your eligible children for dependent coverage.

Depen dent life insurance cov erage is available in the following amo unts :

Spouse Each eligibl e dependent chil d

$6,000 3 ,000

EVIDENCE Of INSURAB ILITY

If you do not enroll your dependents during th e first open enrollment period , upo n employment or w ithin th irty-one (31) days followin g

Page 11

acquisition of the dependent, you can not enroll these eligible dependents until the next open enr ollment period. In this case, evidence of insurability must be submitted and approved for depe ndent coverage . If you acqu ire a new dependent through birt h or marriage and you already have eligible dependents covered, you do not have to notify UNUM or your per sonnel off ice . Each new dependent will be automatically covered if you have dependent cov er age .
COVERAGE EFFE CTiVE DATE
If you enroll your elig ible dependents atthe same time yo u enroll for insu rance coverage, the dependent coverage will be effective at the time your life insurance coverage becomes effective. If you enro ll fo r dependent cove rage after your life insu rance coverage is in effect, the dependent coverage w ill be effective the fi rst of the month followin g payment of the ap propriate prem ium. Coverage fo r an eligible dependent, howeve r, can not begin w hile that dependent is co nfined to a hospital . In this case, coverage w ill begin on the day after the depe nden t is dis charged from the hospital and premium pay ment has been made.
ELIG IBLE DEPENDENTS
Your eligible de pendents are:
1. your spouse, if you are not legally separated or divorced; and
2. your unmarr ied:
(a) natu ral and adop ted ch ildren , regardless of w hether the y reside in the household with you ; and
(b) stepchildren who res ide in the household with you in a norm al parent-child relation sh ip; and
(c) other children for whom you have legal guardianship or custody who reside in the househo ld with you in a normal parent-child relationship.
your unmarried children, as defined above , must also be:
(d) age fourteen (14) days but less than nineteen (19) years; or
(e) age nineteen (19) but less than twenty-six (26) years and are :
(1) dependent on yo u fo r support; and
(2) fu ll-time students in a post-secondary institution of higher learning; or
(3) eligible to be full-time students in a post-secondary inst itution of higher learning but due to an injury or sickness are prevented from being a full-time student.
Your unmarried handicapped dependent children who are over age ninetee n (19) may con tinue coverage upon approval by UNU M if they are:
Page 12

1. physically hand icapped or mentally retarded;
2. livin g in your household in a pa rent-child relationship; and
3. who lly dependent upon you for support.
If coverage for a handicapped ch ild is to be continued, you must fil e a request with UNUM within sixty (60) days following th e child's nineteenth birthday . Contact UNUM at 1-8QO.421-Q344 .
You may not insure a depend ent child who is:
1. on active duty with the Armed Forces of any cou ntry; or
2. eligible to be insured under the group life insurance policy as an
employee.
COVER AG E TERMINATI ON
Coverage for eligible dependents ends on the da te yo ur group life insurance ends. Insurance for anyone dependent will end on the date he or she ceases to be an eligible dependent
BENE FICIARY
You are the beneficiary of all dependent life ins urance coverages.

LIFE INSURANCE PAYMENTS AND CONTINUATION S

Death Benefits w ill be paid by UN UM upon th e death of an indi vidual who is covered under the policy at the time of death. The benefit payment at the death of your spouse or dependent child will be the amount listed in Dependent Ute Benefits Ava ilable.

UNUM will pay the amo unt at yo ur death in one lump su m unless

UNU M rece ives a request from you or your beneficiary to pay the

amount in installments. UNUM will pay to yo u the scheduled amo unt

at the death of your spou se or dependent. If you are not living when payment is to be made, your estate will be paid .

,

DISABILITY
If you become tota lly disabled , death benefi ts may be continued under certain condition s after prem ium payments are stopped. The co nditio ns and requirements that you must meet to have the death ben efit co ntinu ed are described in the follo wing subsections.
You first ne ed to know the definition of the following terms as they apply to thi s sect ion.
1. "Totall y Disabted" means that you are not able to engage in any bus iness or job for which yo u are su ited by ed uca tion , training or experien ce . The disab ility must: (a) be caus ed by injury or sic kness; an d (b) begi n w hile you are co vered for the life insurance provided by the group policy. You will not be deemed
Page 13

to be totally disabled while you are engaged in a business or job for payor profit.
2. "Amount of Continued Death Benefit" means the amount of life insurance coverage that you had when you became totally disabled reduced by the amount of any Acce lerated Benefits which have been paid to you.
TOTAL DISABILITY ANN UAL PROOF (WAIVER OF PREMIUM)
If you become totally disabled, you are eligible for yo ur Continued Death Benefit without premium payment. In order to meet the requirements of this provision you must submit proof of your total disability and have it approved by UNUM. Your first proof must be filed between the 9th and 12th month of tota l disability. You must continue your premium payments until you file proof and UNUM approves your total disability. Th ese limits will not app ly during any time you or your authorized representat ive lack the legal capacity to give UNUM proof of claim.
UNUM will ask you to submit continuing proof of total disability at reaso nable intervals. After two (2) years, UNUM will not require proof more often than once a year.
UNUM may require you to be examined by a physician approved by them as part of the proof. UNUM will not require you to be examined more than once a year after the insurance has extended to two (2) full years.
The Amount of Continued Death Benefit will be paid when your death occurs at any time after premium payments are stopped if you meet the following requirements:
1. you become totally disabled while insured;
2. you become totally disabled before you reach age sixty (60);
3. you stay tota lly disabled until your death; and
4. due proof is furnishedto UNUM within one (1) year after the date of your death that: (i) you have been tota lly disab led for nine (9) months , (ii) you havemetthe requirements listed above , and (iii) you died within twe lve (12) months of the date of the last proof.
This Amount of Continued Death Benefit will not increase. This
amount will reduce or cease at any time it would reduce or cease
if you had not been tota lly disabled.
The Death Benefit based on tota l disability will automatically end if:
1. you recover and you are no longe r disabled;
2. you fail to give the proper proof that you are tota lly disabled;
3. you refuse to have an examinat ion by a doctor chosen by UNUM; or
4. you reach age sixty-five (65). Page 14

TOTAL DISAB IUTY ONE YEAR CONTINUANCE
If your death occurs within one (1) year after premiu m paymentsare stopped, the Amount of Continued Death Benefit will be paid if the following requirements are met:
1. you become totally disabled while insured;
2. you become totally disabled before you reach age sixty-five (65);
3. you stay totally disabled until your death ; and
4. due proof is furnished to UNUM within one (1) year after your death that you met the requirements listed above.
This Amount of Continued Death Benefit will not increase. This amount will reduce or cease at any time it would reduce or cease if you had not been totally disab led.
CONTINUED DEATH BENEFIT AND CONVERSION PRIVILEGE
You may use the life conversion privilege when you r life insurance terminates while you are satisfying the total disab ility requi rements or when the one (1) year continuance ceases. Please refer to the Conversion Privilege section for rules. You are not entitled to conversion if you return to work and you are again eligible for the life insurance under the Policy.
"an individual life insurance policy is issued to you , the Continued Death Benefit will be paid only if the individual policy is returned for surrender to UNUM. UNUM will refund all premium s paid for the individual policy, less any loans .
The Amount of Continued Death Benefit will be paid to your nam ed beneficiary for group life insurance. If, however, you named a new beneficiary for the individual policy and the policy is returned to UNUM for a refund, the latest benefICiary designation on file under this group plan with your department/agency win be given effect and govern over any other beneficiary desig nation.
SUICIDE
If you die as the result of suicide within one (1) year after the effective date of your initial enrollment in this life insurance, the benefit amount payable will be limited to the premiu ms paid for this life insurance. If you die as a result of suicide within one (1) year after the effective date of any increased insurance level selected during a subsequent open enrollment period, the benefit amount payable will be limited to the former Benefit Salary multiple, if any.
ASS IGNMENT
You may not assign your life insurance benefrts. This means you may not give or transfer the life insurance to anyone else.
Page 15

ACCELERATED BENEFITS
If you become terminally ill while you are Insured by the Group Policy. UNUM agrees to pay you a portion of your Death Benefit This does not apply to any amount of life insurance on your
dependentsorto anyterrninal illness resulting from an intent ionally
self-inflicted injuryorsuicideattempt. Themaximum portion ot your Death Benefit payable will be 50% . However, in no event will the benefit paid be:
1. greater than $ 100,000; or
2. less than the lesser of:
(aj $10,000; or
(b) 50% of the amount of your Death Benefit.
Benefits paid ma y be taxable. If so, y ou or y ou r benef ic iary may incur a tax ob ligation. As w ith all tax matte rs , you should
consult your person al tax advisor to asses s t he impact of this
benefit. Rece ipt of these be nefits may also adversely affect elig ib ility for Med icaid or other gov ern ment be nefits or entttreme nts.
Before any benefit can be paid. you must furnish med ical ir rtormation. The medical information must be in the form of a certification of your med ical condition from a doctor. The certification must state tha t in the doctor's opinion your life expectancy has been reduced to tess than six (6) months.
When you submit certificatio n of your life expectancy, UNUM may requir e you to be ex amined at its expense and by a doctor chosen by UNUM.
Your right to exercise op tions and rec eive payments are subje ct to the followi ng:
1. your life insurance must be in force under the Group Pol icy;
2. your request must be made in writing; and
3. you must be terminally HI at the time of payment of the Accelerated Benefit
Accelerated death be nefits are available to you on a voluntary basis. You are not requ ired to acc ess proc eed s. Therefore, you are not eligible for benefits if:
1. yo u are required by law to use this benefit to meet the claims of creditors, whether in bankruptcy or oth erwi se; or
2. yo u are required by a government age ncy to use this ben efit in order to app ly for, obtai n, or otherwise kee p a government be nefit or entitl ement.
Page 16

The conditions for payment of the benefit are as follows :
1. the benef it will be paid to you in a lump sum; and
2. the Accelerated Benefit is payab le one (1) time only.
Election to receive an Acce lerated Benefrt will have the following effect on other benefits:
1. the Death Benefit payab le will be reduced by any amount of Accelerated Benefit that has been paid; and
2. any amo unt of insurance that would be continued under a total disability cont inuation prov ision or that may be availab le under the Conversion Privilege will be reduced by the amount of the Acce lerated Benefit paid .

LIFE INSURANCE PORTABILITY PRIVI LEGES

If your emp loyment ends, you retire from your employer, you begin working less than the minimum number of hours as described under "Employee Eligibility~ in this group plan, or if your approved Leave of Absence without pay for twelve (12) months ends and you have paid the costs of coverage during the twelve (12) month leave period, you may elect portable coverage for life and dependent life. However, you may not elect portable cove rage if leaving work due to an injury or sicknes s.

The maximum portable coverage wilt be the current cove rage amount for which you and your dependents are insured under your employer's group plan. However, the amount of your portable coverage will not be more than $300,000.

The amou nt of portab le coverage for your dependents will be $6,000 for the spouse and $3,000 per dependent child.

The minimum amou nt of portab le coverage that you may elect for

yourself is the lesser of:

v

1. 1 times Benefit Salary; or

2. $10 ,000.

You must apply for portable coverage for life and dependent life insurance and pay the first premium within 31 days after the date:

1. your coverage ends due to the cessation of employment (l.e. termination, res ignation or retirement);

2. you beg in working less than the minimu m number of hours as described under "Employee Eligi b il ity~ in this gro up plan; or

3. your approved Leave of Absence wit hout pay for twe lve (12) months ends .
Page 17

If you oryour covered dependents die within the 3 1 da y portable life protection enrollment application period . UNUM will pay you or your beneficiary(ies) the amount of insurance that could have been po rt ed.

In the event of you r death du ring the 31 day application period. the
el igible dependent who wants to continu e coverage thr ough the portability privilege must apply for the coverage and rem it the first premium pay me nt within 3 1 da ys of your death. All oth er conditions of the portability priv ilege mu st also be met.

You are not elig ible to apply fo r portable coverage if:

1. you are insured under any other UNUM group life insurance plan ;

2. you are leaving work due to an injury or sickness; 3 . the group policy is cancelled ; or

4 . you failed to pay th e requ ired premium under th e terms of th is group plan .

You are not elig ible to apply for portable coverage for a dependent if :

1. your dependent is insured under any other UNUM group tife insurance plan ;

2. you are leaving work due to an injury or sickness;

3. your dependent has an injury or sick ness;

4. the group policy is cancelled;

5 . you fa iled to pay the required premium under the terms of this group plan; or

6. you choose not to enroll in portable life prot ection.

In case of your death, a dependent is not elig ible to apply for portable coverage if:

1. your su rviving spouse is not ins ured und er thi s group plan;

2. your dependent has an injury or sic kne ss; 3. the group po licy is can ce lled; or

4. you failed to pay the req uired premium under the term s of this group plan for your dependents.

You may increase or decrease the amount of life insu rance cover-

age subject to the minimums and maximums described previously.

All increases are subject to ev idence of insur abil ity and w ill occur on

the ann iversary ofthe portable life protection coverage . Evidence of

insurability will be at your own expen se . Portable coverage will

reduce at the ages and amou nts sho wn in the table on pag e 9 of th is

booklet

Page 18

Your portable cov erage will end for the following reaso ns:
1. the dat e you beco me insured under any other UNUM group life insurance plan; or
2. the date you fail to pay any required premium.
Portable coverage for a dependent will end for the following reasons:
1. the date your dependent beco mes insured under any other UNUM group life insurance plan;
2. the date you or your dependent fail to pay any required pre-
mium ;
3. the datethe depend ent child no longer qualifies as a depend ent; or
4. the date the surviving spouse dies.
If porta ble co verage ends due to failure to pay required premium. portable coverage cannot be reinstated.
If you leave the group plan and elect portable coverag e, the n you return to work , and , again become insured under the group policy, you must terminate your ported coverage no later than 12:00 midn ight on the day before you become insured under the group plan.
UNUM may change premiu m rates for portable cove rage at any time for reason s whic h affect the risk ass umed, includ ing those reasons shown below:
1. changes occur in the coverage levels;
2. changes occu r in the overall use of benefits by all insureds;
3. changes occur in other risk factors; or
4. a new law or a change in any existing law is enacted which applies to portable coverage.
The change in premium rates will be made on a class basis
according to UNUM'sunderwriting risk studies and will be based on the above age bands for the first fiveyearsof coverage. UNUM will notify the insured in writing at least 3 1 days before a premium rate is changed.
Automatic increases of 4% will be made to the premium rate every year on the coverage anniversary after the fifth year. We will bill for the increased premium.
Page 19

APPLYING FOR CONVERSION, IF PORTABLE COVERAGE IS NOT AVAILABLE
tf you or your covered dependent are not eligible to apply for portable coverage, then you or your covered depe ndent may qualify for conversion coverage. (Refer to Conti nue d Death Benefit and Conversion Privileges under this group plan.)
The Insurance Company will provide conversion applications to you or your dependents upon request. The conversion application form will include cost information.
You must complete the con version appl icatio n and send it within 3 1 days of the loss of coverage with the first premium amount to:
UNUM - Individual Life Adm inistration 2211 Congress Street
Portland, Maine 041221350 ' eOO-343-5406
CONVERSION PRIVILEGE
Upon termination of coverage und er this group life insu rance plan, you and your spouse can con vert your coverages under th is group life insurance plan to individual policies, without evidence of insurability . Th e maximum con version amounts are the amounts you and your spo use are insured for under th is group life insu rance plan . You may convert a low er amount of life insurance. The first
prem ium and the written application must be fil ed withUNUM within
th irty-one (31) days ofthe date yo ur coverage ends under this group life insu rance plan when:
1. you r emp loyme nt ends ; or
2. you are no longer eligible to participat e in the coverage of the grou p policy.
If you con ve rt to an individual po licy and then return to work and again become insured under this group life insurance plan, you will not be entitled to duplicate the conversion policy.
Converted insurance may be of any type of life insurance writt en by UNUM excep t for term life insurance. tt cannot co nta in disability or other extra benefits.
LIMITED CONVERSION IE STATE CANCELS PO LICY
You and yo ur spouse may convert a lim ited amount of life insura nce if you have been enrolled in thi s UNUM Insurance Program for at lea st five (5) years and th e State of Georgia :
1. cancels the group pol icy with UNUM; or
2. changes the pol icy so that yo u are no long er el igible. Pag e 20

The individual policy maximum for each of you w ill be the lesser of: 1. $2,000 ; or 2. your or your spouse's coverage amounts under this group life
insurance plan less any amounts that become available under any other group plan offered by the State of Georgia with in thirty-one (31) days after UNUM's cancellation.
PREMIUMS
Prem iums for the converted insurance will be based on: 1. the age at the person's nearest birthday on the effective date of
that policy; 2. the type and amount of insurance to be converted; 3. UNUM's customary rates in use at that time; and 4. the class of risk to which the person belongs. If the premium payment has been made, the individual policy will be effective at the end of the thirty-one (31) day app licat ion period. DEATH DURING THETHIRTY-ONE DAY CONVERSION PER IOD If you or your spouse die within the thirty-one (31) day conversion period, UNUM will pay the beneficiary the amount of insurance that could have been converted. This coverage is avai lable whether or not you have applied for an individual conversion po licy. APPLYING FOR CONVERSION You or your spouse are responsible for contacting UNUM to obtain an application for conversion. [f interested, you should call UNUM at 1-800-343-5406. Information about the cost will be furnished by UNUM - Individual Ufe Administration . When you complete the application, send it with the first premium amount to:
UNUM - Individual Life Administration 2211 Congress Street
Portland, Maine 04122-1350
Page 21

EMPLOYEE ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE

BENEFITS AVAIlABLE - COVERAGE AMOUNT

Benefits under the polic y are available for the employee only. No coverages are included for your spouse or dependents. The insurance coverage amount under the policy is based on your annual Benefit Salary and th e multipl e you choose. Yo u are eligible to enroll for coverage at one (1) times, two (2) times, or th ree (3)
times your Benefit Salary, subject to a maximum of $300,000.

Your Coverage Amount is subject to the percentages shown in the follo wing table :

~

% of Eligible Coverage Amount

Accidental Death and Permanent Total

Dismemberment

Disability

Less than 75 75 or more but less than BO 80 or more

100% 50% 25%

100% 20% 10 %

*Age as of Benefit Calculation Date

All amounts of accidental death and dismemberment lnsur encewln be rounded up to the next higher $1,000 after the benefit is calculated in ac cordance with this table.

Changes in the amount of your insurance dueto age reductions w ill occur on the July 1 follow ing the Benefit Calculation Date on which
your birthday for each age occ urs as shown above. Th is applies as long as you continue to be an eligible participant in the plan .
LOSS OF LIFE, LIMB, SIGHT. SPEECH OR HEARING
If injury results in anyone ofthe following sp ecific losses w ithin one (1) year from the date of the covered accident, UNU M w ill pay the benefit specified. However , only one (1) benefit (the large r) w ill be pai d for more than one (1) loss resu lting from anyone (1) covered acc ident.

Loss of Life

Coverage Amount

Loss of Two or More Members

Coverage Amount

Loss of Speech and Hearing

Coverage Amount

Loss of One Member

One-Half The Coverage Amount

Loss of Speech or Hearing One-Half The Coverage Amount

Loss of Thumb and Index Finger

of the Same Hand

One-Fourth The Coverage Amount

"Member" means hand, foot , or eye.

Page 22

"Loss" means, with regard to:
a. hand or foot, actual severance through or above the wrist or ankle joint;
b. eye, entire and irrecoverable loss of sight;
c. speech, entire and irrecoverable loss of function;
d. hearing, entire and irrecoverable loss of function;
e. thumb and index finger, actual severance through or above
the metacarpophalangeal joint.
PERMANENT TOTAL DISABILITY
You first need to know the definition of the following terms as they apply to this section:
"Total Disability" means you are not able, due to injury, to perform all of the material duties of your occupation for a period of twelve (12) continuous months. After twelve (12) months, Total Disability means the same as Permanent Total Disability.
"PermanentTotal Disability~means you are not able to perform the duties of any occupation for which you are suited by education, training or experience.
If you become Permanently and Totally Disabled as herein defined
while covered under the policy, you will be paid each month 1% of your Coverage Amount. This provision applies if all of the following occur:
(1) you become totally disabled within 180 days following the date of the covered accident;
(2) the total disability continues for a period of twelve (12) consecutive months after onset; and
(3) it is shown by proper medical authority at the end of these twelve (12) months that disability is continuous and permanent.
The amount to be paid under this provision will be less any other Accidental Death & Dismemberment benefit paid or payable as the result of the same covered accident.
The total of all benefits paid or payable cannot exceed your Coverage Amount. If death occurs while such payments are being made, your beneficiary will be paid an amount equal to the balance of your Coverage Amount. The amount will be the difference between your Coverage Amount and the total of all monthly payments made already.
UNUM has the right to have a doctor of its choice examine you as often as necessary to determine continued disability. This section applies while a claim is pending or benefits are being paid .
Page 23

RESE RVE NATIONAL GUARD COVE RAGE
Coverage will apply while you are a member of an organ ized Reserve Corps or National Guard Unit and are: (1) attendi ng any active duty training of less than sixty (60) days
or enroute to or fro m that training; or (2) attending a service school no matter how long it is, or enroute
to or from that school; or (3) taking part in any author ized inactive duty training ; or (4) taking part as a unit member in a parade or exh ibition autho -
rized by officia l orde rs.
EXPOSURE AND DISAP PEARANCE
If you are exposed to the elements due to a covered accident and sustain a loss for which benef its wou ld otherwise be payab le, UNUM will pay for that loss.
UNUM will presume you have suffered loss of life due to a covered accident if:
(1) you are riding in a conveyance that is involved in a covered accident; and
(2) as a result of the covered accident, the conveyance is wrecked, sinks or disappears; and
(3) your body is not found within one (1) year of the accident.
REPATRIATION BENE FIT
UNUM will pay up to $5,000 for the preparation and transportation of your body to a mortuary, if, as the result of a covered acc ident, you suffer loss of life at least 75 miles away from your principle place of residence.
SEATBELT(S) AND AIR BAG BENEFIT
UNUM will pay an additional accidental death benefit if you sustain an injury which causes a loss of life while you are driving or riding in a Private Passe nger Car, provided:
For seatbe lt(s) - $10,000:
1. the Private Passenger Car is equipped with seatbelt(s); and
2. the seatbe lt(s) were in actual use and properly fastened at the time of the covered accident; and
3. the position of the seatbelt(s) are cert ified in the offic ial report of the covered accident, or by the investigating offic er. A copy of the police accident report must be submitted with the claim.
Page 24

If such certification is not avai lable , and it is unclear whether you were properly wea ring seatbelt(s), then UNUM will pay a fixed benefit of $1 ,000.
For Air Bag - $5,000:
1. the Private Passenger Car is equipped with a single air bag and you are the driver; or
2. the Private Passenger Car is equipped with an air bag for both the driver and an air bag forthe front passenger seat and you are the driver or front seat passenger; or
3 . the Private Passenger Car is equipped with an air bag for the driver seat, air bag for frant passenger seat and air bags for rear passenger seats and you are the driver, front seat passenger or rear seat passenger; and
4 . the seatbelt(s) must be in actual use and proper ly fastened at the time of the covered accident.
No benefit will be paid if you are the driver of the Private Passenger Car and do not hold a current and valid driver's license.
The covered accident causing your loss of life must occu r while you are insured under the policy.
PILOT OR CREW MEMBER BENEF IT
UNUM will cover you if you are employed as a pilot or crew member for the Employer, for loss while riding as a pilot or crew member of
(including getting into and out of) an aircraft that is:
1. a tested and approved civilian aircraft; and
2. owned, or operated by or on behalf of the Emp loyer; and
3. being used at the time for travel that is author ized by or at the direction of the Employer for the purpose of further ing the Employe r's business; and
4. operated by the then current rules of the authority having jurisdiction ove r the operation of the aircraft.
EXCLUS IONS
The policy does not cover any loss:
(a) caused by or res ulting from war. declared, undec lared, or any act of war; or
(b) from an accident that occurs while you are in the armed forces of any country . except as shown under Reserve - National Guard Coverage; or
(c) caused by or resulting from you riding in, getting into or out of any aircraft EXC EPT if:
Page 25

(1) the aircraft is any tested and approved civil ian aircraft;
(2) the aircraft is being used at the time for transportation of passengers;
(3) the aircraft is operated by the then current rules of the authority having jurisdiction over the operation of the aircraft ;
(4) youare a passenger, oryouare employed as ,and acting as,
a pilot or crew member for the STATE OF GEORGIA; or
(d) to wh ich sickness or disease is a contributing factor; or
(e) caused by Intentionally self-inflicted injuries ; or
(1) caused by suicide; or
(g) voluntary use of any controlled substance. (This is defined in Title II of the Comprehensive Drug Abu se Prevention and Control Act of 1970 and all amendments.) Thi s exclu sion will not apply if the controlled substance is prescribed for you by a
physician; or
(h) committing or attempting to commit an assault or a felony.
BE NEFI CI AR Y
Beneficiary means the one you choose to receive the amount of your accide ntal death insurance coverage when you die. You may name a perso n, trust, or your estate as your beneficiary and a person , trust, or your estate as your contingent beneficiary. Your contingent beneficiary means the one you choose to receive the amount of your accidental death insurance cov erage when you die
an if of the named beneficiaries are deceased.
Yo u must name your beneficiary on the Flexible Benefit Program BenefICiary Election Form provided by your personnel office. The signed form will take effect when you file it with your departmenV agency . You may change your beneficiary at any time without the con sent of your named beneficiary. The change will take effect when you file the new signed form with your department/agency.
If you name more th an one beneficiary and you do not state the share that each benefciary is to receive , each will be paid an equal share." a beneficiary dies before you die , the share that bene ficiary would have rece ived will be divided among your other beneficiaries in the same proportion as you listed.
You are the benefic iary of any payments und er the dismemberment and disability provisions.
ASSIGNMENT
You may not assig n your benefits under the policy. This means you
may not give or transfer the insurance to anyone else.
Page 26

ACCIDENTAL DEATH AND DISMEMBERMENT CONVERSION PRIVILEGE

You may convert Accidental Death and Dismemberment coverage. You may do so if eligibility ends for any reason , except age or termination of the group policy. You must apply for conv ersion within31daysfromthedateyourcoverageends.You must alsopay
the first premium at that time.

The converted coverage will:

1. take effect at the end of the 31 day period during which your application may be made; and

2. be issued without evidence of insurabil ity.

The conv erted policy's Acci dental Death and Dismemberment
Coverage Amount will be the lowe r at

1. the amou nt of the Accidental Death and Dismemberment Benefit applicable to you; or

2. $150,000 .

The converted coverage may provide that it will be renewable on any anniversary withour consent, subject to the percentage shown in the following table:

~

% of Elig ible Coyerage Amount

Accidental Death and Perm anent Total

Dism emb erm ent

Disabil ity

Less than 75 75 or mor e but less than 80 80 or more

100% 50% 25%

100 % 20% 10%

*Age as of Benefit Calculation Date

,

The converted coverage may exdude any condition or hazard which applied to you at the time the group policy terminated. No
benefit will be payabte under the converted cove rage for a clai m
originati ng under the group po licy.

You may convert to any individual Accidental Death and Dismem-
berment co verage that we offer in the state where you live. You may do so if w e canno t issue to you the conversion cerfftcate ava ilable in the State of Georgia.

PREMIUMS:

Premiu ms for the converted insurance will be based on :

1. the type and amount of insuranc e to be converted;

Page 27

2. our customary rates in use at that time ; and 3. the class of risk 10 which you belong. DEATH DURING THE TH IRTYONE pAY CON VERSION PERIOD: If yo u die during the 31 day conv ersio n period, we will pay the be nefi ciary the amount of insurance tha t co uld have been converted. The coverage is ava ilable wheth er or not you have applied for a con ve rsion certificate . APPLY ING FOR CON VERSION : You are res ponsible for con tacting UNUM to obtain an applicat ion for con version . If interest ed. you should ca ll UNUM at 1-800 -343-
5406.
When you complete the application, send it with the first premium amoun :to:
UNUM - Individual Ufe Administration 22 11 Congress Street
Portland , Maine 041221350
Pag e 28

FILING A CLAIM
HOW TO FILE A CLAIM
Get a claim form from the State of Georgia's Ae xible Benefit Program orbycalling UNUM at 1-800-445-0402. The different claim forms to be used are:
Group Tenn Employee ute, Dependent Life and Employee Accide ntal Death Form is to be used in cases of an employee 's death, a dependent's death or an emp loyee's accidental death.
Gro up T erm Employee Accidental Dismemberment Form is to be used in cases of an employee's loss of limb, sight, speech, hearing, and or in cas es of Perman ent Total Disabili ty resulting from an accident.
Group T erm Employee Life Accelerated Benefit Fo rm is to be used in cases of an employee's request for Acce lerated Benefits under Life Insurance.
Group Term Employee life Disability Benefit Form (waiver of premium) is to be used in case of an employee's requ est for term life insurance. waiver of premium due to total disabil ity .
The forms have instru ctions on how to complete and where to send the claim.
Please read the instructions carefully. Answer all questions and send all required information.
NOTIC E AND PROOF OF CLAIM
Notice of Claim
Written notice of a claim must be given to us within thirty (30) days after the date of death or dismemberment on which claim is based . If that is not possible, we must be notified as soon as it is reasonably possible to do so.
The Claim Form
When we have written notice of claim, we will send our claim forms unless the employer has already provided them. tf the claim forms are not rece ived by you with in fffteen (15) wo rking days afte r that notice is sent , written proof of cla im can be sent to us without waiting for the forms.
Proo f of Claim
f. Proof of claim must be given to us no later tha n ninety (90) days after the date of loss. A certified copy of a death certifi cate must be given to us for proof of death.
2. If it is not possible to give proof within this time limit, it must
be given as soon as reasonably possible. Butproof of claim
Page 29

may not be given later than one (1) yearafter the time proof
is otherwise requ ired, except if the adm inistrator or ex ecuto r of the estate are legally unable to notify us . 3 . Th e proof must cover.
a what the loss is;
b. the date of the loss ; and c. the cause of the loss .
4. We may req uire as part of the proof auth orizations to obtain
medical and nonmedica l information. PAY MENT OF CLAIM
11 you die, death benefits and any other accrued benefits wi ll be paid
to the be neficiary on file with your de partmem/aqency. If no benenciary is named, payment will be made to your estate. Payment will be made after written proof of loss is rece ived by UNUM . Benefits tha t provide for per iod ic payments will be made monthly. UNUM also has the right to request an auto psy in case of death , unl ess the law forbids it. Ally cost associated with the examination
or the autopsy will be paid by UNUM.
LEGAL ACTION No lawsuit or action in eq uity ca n be broug ht to recover on the
policy:
(a) before sixty (60) days fo llowing the date proof of loss was furnished to UNUM; or
(b) after three (3) years fol lowing the date proof of loss is required.
Pag e 30

6 UNUM.
Underwritten By UNUM Life Insurance Company of America Portland, Maine

A dminist ered By Georgia St ate Merit System
Personne l Ad mi nistration A t lanta, Georgia

9196

State Merit System