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STANDARD INSURANCE COMPANY

A Stock Life Insurance Company 900 SW Fifth Avenue Portland, Oregon 97204-1282 (503) 321-7000 CERTIFICATE: GROUP ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE
Policyholder: Policy Number: Effective Date: TML Intergovernmental Employee Benefits Pool (IEBP) 645744-D September 1, 2007

A Group Policy has been issued to the Policyholder. We certify that you will be insured as provided by the terms of the Group Policy. If your coverage is changed by an amendment to the Group Policy, we will provide the Policyholder with a revised Certificate or other notice to be given to you. Possession of this Certificate does not necessarily mean you are insured. You are insured only if you meet the requirements set out in this Certificate. "We", "us" and "our" mean Standard Insurance Company. "You" and "your" mean the Member. All other defined terms appear with the initial letter capitalized. Section headings, and references to them, appear in boldface type.

GC190-ADD/S399

SI 14051-645744-D (4/08)

...... 3 WHEN AD&D INSURANCE BECOMES EFFECTIVE ......................... 9 TIME LIMITS ON LEGAL ACTIONS .. 7 BENEFIT PAYMENT AND BENEFICIARY PROVISIONS............................... 1 GENERAL POLICY INFORMATION .............................................................................................................................. 10 DEFINITIONS ........................................ 5 REINSTATEMENT OF INSURANCE ...................................................... 10 .................................................................................................................................................. 9 INCONTESTABILITY PROVISIONS ........ 5 WHEN AD&D INSURANCE ENDS ................. 2 SCHEDULE OF AD&D INSURANCE ..............Table of Contents COVERAGE FEATURES.......................................................................................... 2 REDUCTIONS IN INSURANCE ..................................... 2 ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE ...................................................................................................................................................................................................................... 1 PREMIUM CONTRIBUTIONS ................................................................................................................................................................................................................................................................................................... 5 CLAIMS ............................................................................................................................................................................................................................................................................. 1 BECOMING INSURED............... 2 OTHER PROVISIONS ........................ 7 ALLOCATION OF AUTHORITY ............ 6 ASSIGNMENT ...........................................................

18 Employer(s). 6 . 15 Seat Belt System. 1 Family Status Change. 18 Disabled. 14 Child. 10 Air Bag System. 7 Sickness. 19 Loss. 19 Group Policy Effective Date. 1 Pregnancy. 17 Automobile. 18 Eligibility Waiting Period. 19 Policyholder. 19 Prior Plan. 19 War. 12 Recipient. 19 Spouse. 7 Annual Earnings.Index of Defined Terms Active Work. 18 Group Policy. 18 Contributory. 7 Beneficiary. Actively At Work. 19 Proof Of Loss. 1 Group Policy Number. 1 Injury. 5 Member. 1 Physician.

3. 3. or 2. See When AD&D Insurance Becomes Effective. Class Definition: Eligibility Waiting Period: None You are eligible on the latest of the following: 1. but not less than 20 hours each week. The Table of Contents and the Index of Defined Terms help locate sections and definitions. provided the Employer has passed a resolution providing employee benefits to its elected officials. and 4. You are not a Member if you are: 1. appear in other sections. (b) Complete your Eligibility Waiting Period. Please refer to the text of each section for full details. and (d) Agree to pay premiums. Other provisions. (c) Apply in writing for insurance. The date your Employer elects to provide coverage under the Group Policy. including exclusions and limitations. 2. An active elected official of the Employer. An active employee of the Employer who is regularly working at least the minimum number of hours per week specified on your Employer’s participation agreement. Definition of Member: You are a Member if you are one of the following: 1. The date you become a Member. 2. 4. GENERAL POLICY INFORMATION Group Policy Number: Policyholder: Employer(s): 645744-D TML Intergovernmental Employee Benefits Pool (IEBP) Any employer participating in the TML Intergovernmental Employee Benefits Pool (IEBP) and which has been approved in writing by Standard. An independent contractor. 2007 Texas Group Policy Effective Date: State of Issue: BECOMING INSURED To become insured you must: (a) Be a Member. A leased employee. A full time member of the armed forces of any country. A temporary or seasonal employee.COVERAGE FEATURES This section contains many of the features of your group accidental death and dismemberment (AD&D) insurance. The Group Policy Effective Date. Printed 10/2007 -1645744-D . September 1. The date you complete the waiting period specified on your Employer’s participation agreement.

C. not to exceed $30. multiplied by the appropriate percentage below.000. Seat Belt Benefit: The amount of the Seat Belt Benefit is the lesser of (1) $10.000 or (2) the amount of AD&D Insurance payable for loss of life. See Accidental Death and Dismemberment Insurance. Yes Yes Yes Yes Yes Printed 10/2007 -2- 645744-D .PREMIUM CONTRIBUTIONS Insurance is: Contributory SCHEDULE OF AD&D INSURANCE You may apply for AD&D Insurance in multiples of $5. as follows: Spouse only: Children only: Spouse and Children: 60% 20% for each Child. from $5. You may also elect to insure your Dependents.000 to $200.000. the amount of AD&D Insurance will be the amount determined from the Schedule of Insurance. The amount of AD&D Insurance for your Dependents is equal to a percentage of your AD&D Insurance. REDUCTIONS IN INSURANCE If you have reached an age shown below. Amount Payable.000 50% for your Spouse 10% for each Child The amount payable for certain Losses will differ. Age 70 through 74 75 through 79 80 or over Percentage 60% 40% 30% OTHER PROVISIONS Annual Earnings based on: Benefit for loss due to exposure: Benefit for disappearance: Benefit for loss of speech or hearing: Benefit for loss of thumb and index finger of same hand: Common Disaster Benefit: Earnings in effect on your last full day of Active Work.

B. whether civil or international. Amount Payable The amount payable is equal to a percentage of the AD&D Insurance in effect on the insured person on the date of the accident (see Coverage Features). The percentage is shown below. hand. foot or sight which: 1. C. Occurs independently of all other causes. and 3. Insuring Clause If a person has an accident while insured for AD&D Insurance. Printed 10/2007 -3- 645744-D . 3. Loss: Life One hand. one foot. Definition Of Loss Loss means loss of life. Committing or attempting to commit an assault or felony. chemical compound or drug. E. 2. 4. 5.ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE A. or sight of one eye. Actively participating does not include being at the scene of a violent disorder or riot while performing official duties. 2. and any substantial armed conflict between organized forces of a military nature. Loss means entire and irrecoverable loss of sight. Changes In AD&D Insurance An elective change in AD&D Insurance becomes effective on the date you complete and sign a new enrollment card. unless used or consumed according to the directions of a physician. D. while sane or insane. Loss means actual and permanent severance from the body at or above the wrist or ankle joint. A change in AD&D Insurance because of a change in age becomes effective on the first day of the calendar month coinciding with or next following the date of change in age. Occurs within 365 days after the accident. War or act of War. The voluntary use or consumption of any poison. Sickness or Pregnancy existing at the time of the accident. AD&D Insurance Exclusions No AD&D Insurance benefit is payable if the Loss is caused or contributed to by any of 1 through 8 below. War means declared or undeclared war. speech or hearing Two or more of the above Losses Percentage 100% 50% 100% No more than 100% of the amount of AD&D Insurance in effect on an insured person will be paid for all Losses incurred by that person as a result of one accident. With respect to a hand or foot. Suicide or other intentionally self-inflicted injury. 1. Is caused solely and directly by an accident. or actively participating in a violent disorder or riot. With respect to sight. we will pay benefits according to the terms of the Group Policy after we receive satisfactory Proof of Loss. and the accident results in a Loss.

Benefit For Loss Of Speech Or Hearing If you or your Dependent suffers a Loss of speech or hearing. this exclusion will apply only to: a. You or your Dependent was wearing a Seat Belt at the time of the accident. and are not found within one year from the date of the accident. You or your Dependent dies as a result of an Automobile accident for which an AD&D Insurance benefit is payable. we will pay 25% of the AD&D Insurance in effect on the insured person on the date of the accident. Loss means entire and irrecoverable loss of speech or hearing. A pilot or crew member of the aircraft. This benefit will not be paid if benefits are payable under the Group Policy for Loss of that entire hand. we will pay 200% of your AD&D Insurance in effect on the date of the accident. as evidenced by a police accident report. as certified by a Diplomate of the American Board of Otolaryngology. H. the Common Disaster Benefit will not be paid. F. 8. this benefit will not be paid. 7. We will pay the amount of AD&D Insurance in effect on the insured person on the date of the accident. With respect to thumb and index finger of same hand. The Common Disaster Benefit will be paid in place of any other AD&D benefits payable under the Group Policy for the same accident. This benefit will be paid in place of any other AD&D benefits payable under the Group Policy for the same accident. Seat Belt Benefit The amount of the Seat Belt Benefit is the lesser of (1) $10.6. we will presume that you or your Dependent died. A passenger in an aircraft operated by or for the Employer. leaving. and both suffer Loss of life as a result of the same accident. Medical or surgical treatment for any of the above. With respect to speech or hearing. or being in or on any kind of aircraft. K. Common Disaster Benefit If you and your Spouse are both insured under the Group Policy. Benefit For Loss Of Thumb And Index Finger Of Same Hand If you or your Dependent suffers a Loss of thumb and index finger of same hand. J. Printed 10/2007 -4- 645744-D . This benefit will be paid in place of any other AD&D benefits payable under the Group Policy for the same accident. Benefit For Loss Due To Exposure If you or your Dependent suffers a Loss caused by exposure to the natural elements. I. we will pay 50% of the AD&D Insurance in effect on the insured person on the date of the accident. We will pay a Seat Belt Benefit if: 1. However. Benefit For Disappearance If you or your Dependent disappears as a result of an accident which could have caused Loss of life. Loss means actual and permanent severance from the body at or above the metacarpophalangeal joints.000 and (2) the amount of AD&D Insurance payable on the insured person for Loss of life. we will pay the amount of AD&D Insurance in effect for that Loss on the date of the accident. If you have no surviving Children. Heart attack or stroke. The amount payable will be paid in equal shares to each Child. If your spouse is also an insured Member under the Group Policy. G. or b. Boarding. and 2.

EF. each new Dependent becomes insured immediately. the date of your divorce. For any Dependent. unless it ends under 1 through 4 above.48 WHEN AD&D INSURANCE BECOMES EFFECTIVE A. and 2. 4. While AD&D Insurance for your Dependents is in effect. or other restraint approved by the National Highway Traffic Safety Administration. your insurance will be continued during a leave of absence if continuation of your insurance under the Group Policy is required by the state-mandated family or medical leave act or law. the following will apply.01X WHEN AD&D INSURANCE ENDS AD&D Insurance ends automatically on the earliest of: 1. 6. AD&D Insurance For Your Dependents AD&D Insurance for your Dependents becomes effective on the later of: 1. 2. The date the Group Policy terminates.19X REINSTATEMENT OF INSURANCE If your insurance ends. you may become insured again as a new Member. if you cease to be a Member because you are not working the required minimum number of hours. 8. VA. The date you cease to be a Member. 90 days after the date we mail a request for proof that the Disabled Child continues to qualify as a Disabled Child and proof is not given. the date the Dependent ceases to be a Dependent. and 5. lap and shoulder restraint. A Member may not be insured as both a Member and a Dependent. The last day of the calendar month in which your employment terminates. VA. A Child may not be insured by more than one Member.EN. if you apply after you become eligible.IC.Seat Belt means a properly installed seat belt. The date you apply for AD&D Insurance for your Dependents. The date your Employer ceases to participate under the Group Policy. if you apply on or before that date. For a Disabled Child. The date your AD&D Insurance becomes effective. Your AD&D Insurance Your AD&D Insurance becomes effective on: 1. 3. The date the last period ends for which you made a premium contribution. However. or 2. Printed 10/2007 -5- 645744-D . B. However. VA. For your Spouse. Automobile means a motor vehicle licensed for use on public highways. 7. The date you become eligible. The date you apply.

Proof Of Loss must be in writing and must be provided at the expense of the claimant. F. If we request additional information. Notice Of Decision On Claim We will evaluate a claim for benefits promptly after we receive it. 2. we will notify the claimant of the following: (a) the reasons for the extension. Proof Of Loss Proof Of Loss means written proof that a Loss occurred: 1. it must be provided as soon as reasonably possible. the claimant will have 45 days to provide the information. and (c) any additional information we need to decide the claim. E. and 3.01 CLAIMS A. If your insurance ends because you are on a federal or state-mandated family or medical leave of absence. Time Of Payment We will pay benefits within 60 days after Proof Of Loss is satisfied. Investigation Of Claim We may have you or your Dependents examined at our expense at reasonable intervals. No benefits will be paid until we receive Proof Of Loss. (b) when we expect to decide the claim. Printed 10/2007 -6- 645744-D .1. If Proof Of Loss is filed outside these time limits. the claim may be submitted in a letter to us. the Eligibility Waiting Period will be waived. VA. If that is not possible. except where prohibited by law.RE. If your insurance ends because you cease to be a Member. If the claimant does not provide the requested information within 45 days. We may have an autopsy performed at our expense. 2. your insurance will be reinstated pursuant to the federal or state-mandated family or medical leave act or law. D. the claim will be denied. B. If we extend the period to decide the claim. or (b) a notice that we are extending the period to decide the claim for an additional 90 days. Which is not subject to any exclusions. Time Limits On Filing Proof Of Loss Proof Of Loss must be provided within 90 days after the date of the Loss. but not later than one year after that 90 day period. Meets all other conditions for benefits. we may decide the claim based on the information we have received. If we do not provide our forms within 15 days after they are requested. These limits will not apply while the Member or Beneficiary lacks legal capacity. and if you become a Member again within 90 days. Within 90 days after we receive the claim we will send the claimant: (a) a written decision on the claim. Filing A Claim Claims should be filed on our forms. Proof Of Loss includes any other information we may reasonably require in support of a claim. and you become a Member again immediately following the period allowed. Any such examination will be conducted by specialists of our choice. For which the Group Policy provides benefits. C.

the claimant may request a review. the extended time period for review of the claim will not begin until the claimant provides the information or otherwise responds. b. See B through E of this section. The claimant must request a review in writing within 60 days after receiving notice of the denial. The reasons for our decision.If we deny any part of the claim. Information concerning the claimant's right to receive. free of charge. c. If we extend the review period. If we request additional information. The Group Policy does not provide voluntary alternative dispute resolution options.12 ASSIGNMENT The rights and benefits under the Group Policy cannot be assigned. A description of any additional information needed to support the claim. Reference to the parts of the Group Policy on which our decision is based. VA. Review Procedure If all or part of a claim is denied. and (c) any additional information we need to decide the claim. c. Printed 10/2007 -7- 645744-D . If the extension is due to the claimant's failure to provide information necessary to decide the claim on review. we may conclude our review of the claim based on the information we have received. or (b) a notice that we are extending the review period for 60 days. Within 60 days after we receive the request for review we will send the claimant: (a) a written decision on review. the claimant will receive a written notice of denial containing: a. The claimant may review and receive copies of any non-privileged information that is relevant to the request for review. Information concerning the claimant's right to a review of our decision. G. If you are not living. If we deny any part of the claim on review. benefits will be paid in equal shares to the first surviving class of the classes below. b. Our review will include any written comments or other items the claimant submits to support the claim.CL. we will notify the claimant of the following: (a) the reasons for the extension. The claimant may send us written comments or other items to support the claim. (b) when we expect to decide the claim on review. the claimant will have 45 days to provide the information. we will send the claimant a written notice of denial containing: a. Benefits payable because of the death of a Dependent will be paid to you.01 BENEFIT PAYMENT AND BENEFICIARY PROVISIONS A.AS. Payment of Benefits Benefits payable because of your death will be paid to the Beneficiary you name. The reasons for our decision. We will review the claim promptly after we receive the request. There will be no charge for such copies. d. Reference to the parts of the Group Policy on which our decision is based. copies of non-privileged documents and records relevant to the claim. VA. If the claimant does not provide the requested information within 45 days.

Any such benefits remaining unpaid at that person's death will be paid according to the provisions for payment of a death benefit. C. Your estate. 5. benefits will be paid in equal shares to the first surviving class of the classes below. Lump Sum If the amount payable to a Recipient is less than $25. Must be delivered to the Policyholder or Employer during your lifetime. D. Methods of Payment Recipient means a person who is entitled to benefits under this Benefit Payment and Beneficiary Provisions section. unless you specify otherwise. You must name or change Beneficiaries in writing. Printed 10/2007 -8- 645744-D .000 or more. and 4. B. Standard Secure Access Checking Account If the amount payable to a Recipient is $25. No Surviving Beneficiary If you do not name a Beneficiary. Is owned by the Recipient. Two or more surviving Beneficiaries will share equally. 3. 4.1. we will deposit it into a Standard Secure Access checking account which: a. Dismemberment benefits will be paid to the person who incurred the Loss for which the benefits are payable. 3. b. 2. The children of the Dependent. Simultaneous Death Provision If a Beneficiary dies on the same day you die. Your estate. 2. You may name or change Beneficiaries at any time without the consent of a Beneficiary. You may name one or more Beneficiaries. The parents of the Dependent. or if you are not survived by one. 1. 1. benefits will be paid as if that Beneficiary had died before you.000. Your designation: 1. Naming A Beneficiary Beneficiary means a person you name to receive death benefits. Must be dated and signed by you. unless Proof of Loss with respect to your death is delivered to us before the date of the Beneficiary's death. Will take effect on the date it is delivered to the Policyholder or Employer. 2. we will pay it in a lump sum. Your parents. Bears interest. or within 15 days thereafter. Your children. Must relate to the insurance provided under the Group Policy. 3. 2. E. Your brothers and sisters. Your spouse.

The date we receive Proof of Loss. Our authority includes. To the extent permitted by law. 3. The amount payable is $25. Is subject to the terms and conditions of a confirmation certificate which will be given to the Recipient. b. c. d. The right to determine: a. and 2.BB. and to interpret the Group Policy and resolve all questions arising in the administration. Your entitlement to benefits. We agree. The time within which Proof of Loss is required to be given.01 ALLOCATION OF AUTHORITY Except for those functions which the Group Policy specifically reserves to the Policyholder. any decision we make in the exercise of our authority is conclusive and binding. or c. the amount payable to a Recipient will not be subject to any legal process or to the claims of any creditor or creditor's representative. to administer claims. Installments Payment to a Recipient may be made in installments if: a.. VA. and d. Subject to the review procedures of the Group Policy. but is not limited to: 1. The right to resolve all matters when a review has been requested. and application of the Group Policy. b. Is fully guaranteed by us.. 2. The right to establish and enforce rules and procedures for the administration of the Group Policy and any claim under it.. The sufficiency and the amount of information we may reasonably require to determine a.01 Printed 10/2007 -9- 645744-D .01 TIME LIMITS ON LEGAL ACTIONS No action at law or in equity may be brought until 60 days after we have been given Proof of Loss. interpretation.000 or more. we have full and exclusive authority to control and manage the Group Policy.AL. 3. The Recipient chooses. VA. VA.c. and c. No such action may be brought more than three years after the earlier of: 1.TL. above. b. The amount of benefits payable. Your eligibility for insurance.

Fraudulent misrepresentations. or b. Shift differential pay. We have given the Policyholder a copy of a written instrument signed by the Policyholder which contains the misrepresentation. and 2.IN. except for: 1. Incontestability Of Group Policy Any statement made by the Policyholder to obtain the Group Policy is a representation and not a warranty. The Group Policy would not have been issued if we had known the truth. Incontestability Of Insurance Any statement made to obtain insurance is a representation and not a warranty. The validity of the Group Policy will not be contested after it has been in force for two years. No misrepresentation will be used to reduce or deny a claim unless: 1.INCONTESTABILITY PROVISIONS A. Annual Earnings includes: 1.01 DEFINITIONS AD&D Insurance means your accidental death and dismemberment insurance under the Group Policy. 403(b). Your Annual Earnings will be based on your earnings in effect on your last full day of Active Work unless a different date applies (see Coverage Features). Annual Earnings does not include: Printed 10/2007 . An executive nonqualified deferred compensation arrangement. and 2. An IRC Section 401(k). we will not use a misrepresentation to reduce or deny a claim. B. 3. Nonpayment of premiums. 408(k) or 457 deferred compensation arrangement. We have given you or any other person claiming benefits a copy of the signed written instrument which contains the misrepresentation. VA.10 - 645744-D . After the insured's insurance has been in effect for two years. 2. unless it was a fraudulent misrepresentation. or 2. The insurance would not have been approved if we had known the truth. Annual Earnings means your annual rate of earnings from your Employer. Amounts contributed to your fringe benefits according to a salary reduction agreement under an IRC Section 125 plan. No misrepresentation by the Policyholder will be used to deny a claim or to deny the validity of the Group Policy unless: 1. Contributions you make through a salary reduction agreement with your Employer to: a.

we may require further proof. On and after the effective date of your Employer's coverage under the Group Policy continuously meets the requirements of 1 and 2 above. 4. or institutionalized because of mental retardation or physical handicap. and b. Spouse means a person to whom you are legally married. or related medical conditions. on and after the date on which AD&D Insurance would end because of the child's age. Overtime pay. illness. a grandchild and an adopted child. or disease. Sickness means your sickness. but not more than once a year. Any other extra compensation. 3. At reasonable intervals thereafter. On the day before the effective date of your Employer's coverage under the Group Policy was insured under the Prior Plan. You must give us proof of Disabled Child status on our forms and within 31 days after a) the date on which insurance would otherwise end because of the Child's age or b) the effective date of your Employer's coverage under the Group Policy if your child is a Disabled Child on that date. Disabled Child includes your unmarried child over age 20 (or over age 24 and a registered student in full-time attendance at an accredited educational institution) who: a. and 2. A child is considered your grandchild if the child is your dependent for federal income tax purposes at the time the application for coverage for your grandchild is made. 5. Eligibility Waiting Period means the period you must be a Member before you become eligible for insurance. Dependent does not include a full-time member of the armed forces of any country.1. Chiefly dependent upon you for support and maintenance. A child is considered your adopted child if you are a party in a suit in which you are seeking adoption. and have your Disabled Child examined at our expense. See Coverage Features. Disabled Child means your unmarried child who. is continuously: 1.11 - 645744-D . Dependent means your Spouse or Child. Pregnancy means your pregnancy. Your Employer's contributions on your behalf to any deferred compensation arrangement or pension plan. Incapable of self-sustaining employment because of mental retardation or physical handicap. Printed 10/2007 . childbirth. Child includes a stepchild living in your home. Child means your unmarried child from live birth through age 24. Bonuses. including complications of pregnancy. Group Policy means the group voluntary accidental death and dismemberment insurance policy issued by us to the Policyholder and identified by the Group Policy Number. Commissions. 2.