GL52-1-FP
The Lincoln National Life Insurance Company
A Stock Company Home Office Location: Fort Wayne, Indiana
Group Insurance Service Office: 8801 Indian Hills Drive, Omaha, NE 68114-4066 (402) 361-7300
CERTIFIES THAT Group Policy No. 00040500419300000 has been issued to
Ollie's Bargain Outlet, Inc.
(The Group Policyholder)
The Issue Date of the Policy is July 1, 2016.
Certificate of Insurance for Class 2
You are entitled to the benefits described in this Certificate only if you are eligible, become and remain
insured under the provisions of the Policy. If you have elected Dependent coverage on your enrollment form,
your Dependents are covered under this Certificate only if such Dependents are eligible for insurance under
the Policy and the required premium has been paid. This Certificate replaces any other certificates for the
benefits described inside. As a Certificate of Insurance, it is not a contract of insurance; it only summarizes
the provisions of the Policy and is subject to the Policy's terms. If the provisions of this Certificate and the
Policy do not agree, the provisions of the Policy will apply.
READ YOUR CERTIFICATE CAREFULLY
This is a limited benefit certificate. It provides Critical Illness insurance coverage. There is no
coverage for hospital, medical-surgical or major medical expenses.
THE POLICY IS NOT A MEDICARE SUPPLEMENT POLICY.
THIS CERTIFICATE CONTAINS A PRE-EXISTING CONDITION EXCLUSION.
CERTIFICATE OF GROUP CRITICAL ILLNESS INSURANCE
GL52-2-TC
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TABLE OF CONTENTS
SCHEDULE OF BENEFITS ....................................................................................................................................3
DEFINITIONS…………………………………………………………………………………………………………………..8
GENERAL PROVISIONS ........................................................................................................................................14
ELIGIBILITY AND EFFECTIVE DATES FOR PERSONAL CRITICAL ILLNESS INSURANCE.................15
TERMINATION OF PERSONAL CRITICAL ILLNESS INSURANCE ..............................................................17
ELIGIBILITY AND EFFECTIVE DATES FOR DEPENDENT CRITICAL ILLNESS INSURANCE .............19
TERMINATION OF DEPENDENT CRITICAL ILLNESS INSURANCE ..........................................................21
CRITICAL ILLNESS BENEFITS ............................................................................................................................22
EXCLUSIONS...........................................................................................................................................................24
BENEFICIARY .........................................................................................................................................................25
CLAIM PROCEDURES FOR CRITICAL ILLNESS INSURANCE .....................................................................26
GL52-3-SB
3
Ollie's Bargain Outlet, Inc.
00040500419300000
SCHEDULE OF BENEFITS
For Class 2
ELIGIBLE CLASS means: All Other Full-Time Employees with Weekly Payroll Deductions
MINIMUM HOURS PER WEEK: 20
ANNUAL/OPEN ENROLLMENT PERIOD: June 1 – June 30
ELIGIBILITY WAITING PERIOD (For Date Insurance Begins, Refer To "Effective Date" Section).
None
CONTRIBUTIONS: You are required to contribute to the cost for Personal Critical Illness Insurance and to
the cost for Dependent Critical Illness Insurance.
GL52-3-SB
4
SCHEDULE OF BENEFITS
(Continued)
PERSONAL CRITICAL ILLNESS INSURANCE
Class 2
Personal Critical Illness Principal Sum
(Option as elected by you)
Option 1
$5,000
Option 2
$10,000
Option 3
$15,000
Option 4
$20,000
Option 5
$25,000
Option 6
$30,000
DEPENDENT CRITICAL ILLNESS INSURANCE
(For Class 2)
Dependent Spouse Dependent Critical Illness Principal Sum
(Option as elected by you)
Option 1
$5,000
Option 2
$10,000
Option 3
$15,000
Dependent Child
(Option as elected by you)
Option 1
$5,000
HEART CATEGORY (Available for Insured Persons and Dependents)
Event/Illness Percentage of Principal Sum
Heart Attack 100%
Placement on United Network for Organ
Sharing (UNOS) List for Heart Transplant*
100%
Stroke 100%
Arteriosclerosis
10%, subject to a lifetime maximum of 2 payments
Aneurysm due to Arteriosclerosis 10%, subject to a lifetime maximum of 2 payments
GL52-3-SB
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SCHEDULE OF BENEFITS
(Continued)
CANCER CATEGORY (Available for Insured Persons and Dependents)
Event/Illness Percentage of Principal Sum
Cancer 100%
Cancer in Situ 25%
Benign Brain Tumor 25%
Placement on the Be the Match Registry
for Bone Marrow Transplant*
25%
ORGAN CATEGORY (Available for Insured Persons and Dependents)
Event/Illness Percentage of Principal Sum
End Stage Renal Failure 100%
Placement on United Network for Organ
Sharing (UNOS) List for Major Organ
Transplant (excluding Heart)*
100%
Acute Respiratory Distress Syndrome 25%
GL52-3-SB
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SCHEDULE OF BENEFITS
(Continued)
QUALITY OF LIFE CATEGORY (Available for Insured Persons and Dependents)
Benefits in this category are payable once per Event/Illness per Insured Person or Insured Dependent
during his or her lifetime.
Event/Illness
ALS/Lou Gehrig's Disease
Percentage of Principal Sum
100%
Advanced Alzheimer's Disease
100%
Advanced Multiple Sclerosis
25%
Advanced Parkinson's Disease
100%
Loss of Sight
25%
Loss of Hearing
25%
Loss of Speech
25%
WELLNESS CATEGORY (Available for Insured Persons and Dependents)
Critical Illness Assessment Benefit
Critical Illness Assessment Period: July 1st through June 30th
Critical Illness Assessment Benefit: $50 for each Critical Illness Assessment Test
performed, subject to a maximum of 1 Critical Illness
Assessment Test per person per Critical Illness
Assessment Period
Child Care Expense Benefit $25 per Child per day
For you or each of your Insured Dependents, the lifetime total benefits payable in any category shown in the
Schedule of Benefits (except the Wellness Category) are subject to an overall maximum of 150% of the
Principal Sum.
*A benefit for this Event may also be payable if you or your Insured Dependent:
(1) is determined to be too ill for a transplant, but otherwise meet the criteria for placement on
the network/registry; or
(2) receives a transplant prior to placement on the network/registry.
GL52-3-SB
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SCHEDULE OF BENEFITS
(Continued)
EVIDENCE OF INSURABILITY. Evidence of Insurability satisfactory to the Company must be
submitted when:
(1) Critical Illness Insurance amounts exceed the guarantee issue amount of $30,000 for Insured
Persons or $15,000 for Insured Dependent Spouses at initial enrollment;
(2) the amount of Critical Illness Insurance increases after the initial enrollment; or
(3) initial coverage is elected more than 31 days after first becoming eligible.
GL52-4-DF
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DEFINITIONS
ACTIVE WORK or ACTIVELY AT WORK means an Employee's performance of all customary duties of
his or her occupation at:
(1) the Group Policyholder's place of business; or
(2) any other business location designated by the Group Policyholder.
Unless disabled on the prior workday or on the day of absence, an Employee will be considered Actively at
Work on the following days:
(1) a Saturday, Sunday or holiday which is not a scheduled workday;
(2) a paid vacation day, or other scheduled or unscheduled non-workday; or
(3) a non-medical leave of absence of 12 weeks or less, whether taken with the Group
Policyholder's prior approval or on an emergency basis.
ACUTE RESPIRATORY DISTRESS SYNDROME means acute respiratory failure resulting in inadequate
oxygenation, due to aspiration or infection. Diagnosis is determined by a Physician and based on:
(1) demonstration of infiltrates in both lungs in the absence of clinical heart failure; and
(2) acute lung injury demonstrated by testing of blood gases.
ADVANCED ALZHEIMER'S DISEASE means dementia of the Alzheimer's Type that has progressed to
the point that the individual can be classified as Functional Assessment Staging (FAST) Scale Stage 6.
Diagnosis is made by a board-certified or board-eligible neurologist on the basis of neurological examination
and cognitive testing. Initial diagnosis of Alzheimer's Disease must occur while the Insured Person or
Insured Dependent is covered under the Policy.
ADVANCED MULTIPLE SCLEROSIS (MS) means Multiple Sclerosis with demonstrated neurological
deficits that have been present for six months or more. Diagnosis is made by a board-certified or board-
eligible neurologist on the basis of:
(1) neurological examination demonstrating functional impairments;
(2) imaging studies of the brain or spine demonstrating lesions consistent with MS; and
(3) analysis of cerebrospinal fluid consistent with the diagnosis.
Initial diagnosis of Multiple Sclerosis must occur while the Insured Person or Insured Dependent is covered
under the Policy.
ADVANCED PARKINSON'S DISEASE means Parkinson's Disease that has progressed to Stage 4, as
diagnosed by a board-certified or board-eligible neurologist based on abnormal findings from neurological
examination, cognitive testing, and results of imaging studies. Initial diagnosis of Parkinson's Disease must
occur while the Insured Person or Insured Dependent is covered under the Policy.
ALS/LOU GEHRIG'S DISEASE means amyotrophic lateral sclerosis (ALS or Lou Gehrig's Disease) of the
Middle Stage according to the Muscular Dystrophy Association. Definitive diagnosis must be made by a
board-certified or board-eligible neurologist according to diagnostic criteria for the specific illness. Other
motor neuron diseases are not considered to be ALS. Initial diagnosis of ALS/Lou Gehrig's Disease must
occur while the Insured Person or Insured Dependent is covered under the Policy.
ALTERNATE CARE OR REHABILITATIVE FACILITY means a facility that is licensed according to
state and/or local laws to provide skilled care, intermediate care, intermingled care, custodial care, or
rehabilitative care as an alternative to care at a Hospital.
ANEURYSM DUE TO ARTERIOSCLEROSIS means an abnormal widening or ballooning of a portion of
an artery due to weakness of the arterial wall caused by Arteriosclerosis, of sufficient severity to require
angioplasty, stent placement, atherectomy, or bypass. Aneurysm is diagnosed by a Physician based on
arteriography or other appropriate imaging studies.
GL52-4-DF
9
DEFINITIONS
(Continued)
ANNUAL/OPEN ENROLLMENT PERIOD means the period in the calendar year, not to exceed 31 days,
during which the Group Policyholder allows eligible Employees to purchase or make changes to their
Personal or Dependent Critical Illness Insurance.
Participation in an Annual/Open Enrollment Period does not change Policy provisions related to the
Eligibility Waiting Period.
ARTERIOSCLEROSIS means blockage of a coronary artery of sufficient severity to require angioplasty,
stent placement, atherectomy, or bypass. Diagnosis is made by a board-certified or board-eligible
cardiologist and is accompanied by the demonstrated need for intervention.
BENIGN BRAIN TUMOR means a tumor within the brain cavity, known or presumed to be non-malignant,
that results in a fixed neurological deficit. Diagnosis of the tumor and neurological deficit must be confirmed
by imaging and examination findings conducted by a board-certified or board-eligible neurologist or other
Physician appropriately licensed to diagnose the deficit.
BONE MARROW TRANSPLANT means a transplant necessitated by a compromise of the bone marrow's
ability to appropriately produce blood cells. Diagnosis is made by a board-certified or board-eligible
hematologist or board-certified or board-eligible oncologist who determines that the bone marrow transplant
is necessary and places the Insured Person or Insured Dependent on the Be The Match registry. If the
Insured Person or Insured Dependent is determined to be too ill for a transplant, but otherwise meets the
criteria for placement on the registry; the registry requirement will be waived. The registry requirement will
also be waived if the Insured Person or Insured Dependent receives the transplant prior to placement on the
registry.
CANCER means malignant cells or tumors characterized by uncontrolled growth with spread beyond the
initial tissue. Diagnosis must be by a board-certified or board-eligible oncologist or board-certified or board-
eligible pathologist and based on microscopic tissue evaluation (biopsy). The following are not considered
Cancer for purposes of this definition:
(1) Cancer in Situ;
(2) basal cell carcinoma and squamous cell carcinoma of the skin; and
(3) melanoma that is diagnosed as Clark's level I or II, or Breslow less than 0.75 mm.
CANCER IN SITU means Cancer cells confined to the surface tissues (epithelium) without invasion of the
basement membrane and with no spread to regional lymph nodes or other tissues. Diagnosis is made by a
board-certified or board-eligible oncologist or board-certified or board-eligible pathologist and based on
microscopic examination of tissue (biopsy). Basal cell and squamous cell carcinomas of the skin are not
considered Cancer in Situ.
CHANGE IN FAMILY STATUS means a marriage, divorce, birth, adoption, death or change of
employment or eligibility status or other event which qualifies under the requirements of Section 125 of the
Internal Revenue Code of 1986, as amended. Change in Family Status also means the involuntary loss of
comparable coverage under a spouse's benefit plan.
COMPANY means The Lincoln National Life Insurance Company, an Indiana corporation. Its Group
Insurance Service Office address is 8801 Indian Hills Drive, Omaha, Nebraska 68114-4066.
GL52-4-DF
10
DEFINITIONS
(Continued)
DAY OR DATE means the period of time that begins at 12:01 a.m. and ends at 12:00 midnight, at the Group
Policyholder's place of business, when used with regard to eligibility dates and effective dates. When used
with regard to termination dates, it means 12:00 midnight, at the same place.
DEPENDENT CRITICAL ILLNESS INSURANCE means the coverage provided by the Policy for eligible
Dependents.
ELIGIBILITY WAITING PERIOD means the period of time a Person must be in an eligible class with the
Group Policyholder, before he or she becomes eligible to enroll for insurance under the Policy.
EMPLOYEE means a Full-Time Employee of the Group Policyholder.
END STAGE RENAL FAILURE means chronic and irreversible failure of the kidneys of such magnitude
that permanent dialysis or transplant is required to sustain life.
EVENT/ILLNESS means a Critical Illness event or illness:
(1) shown in the Schedule of Benefits; and
(2) for which the Insured Person or Insured Dependent is covered under the Policy.
FAMILY OR MEDICAL LEAVE means an approved leave of absence that:
(1) is subject to the federal FMLA law (the Family and Medical Leave Act of 1993 and any
amendments to it) or a similar state law;
(2) is taken in accord with the Group Policyholder's leave policy and the law which applies; and
(3) does not exceed the period approved by the Group Policyholder and required by that law.
The leave period may:
(1) consist of consecutive or intermittent work days; or
(2) be granted on a part-time equivalency basis.
If a Person is entitled to a leave under both the federal FMLA law and a similar state law, he or she may elect
the more favorable leave (but not both). If a Person is on an FMLA leave due to his or her own health
condition on the date insurance under the Policy takes effect, he or she is not considered Actively at Work.
GL52-4-DF
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DEFINITIONS
(Continued)
FULL-TIME EMPLOYEE means a person:
(1) whose employment with the Group Policyholder is the person's main occupation;
(2) whose employment is for regular wage or salary;
(3) who is regularly scheduled to work at such occupation at least the Minimum Hours shown in
the Schedule of Benefits per week;
(4) who is a member of an eligible class under the Policy;
(5) who is not a temporary or seasonal employee; and
(6) who is a citizen of the United States or legally works in the United States.
GROUP POLICYHOLDER means the person, partnership, corporation, trust, or other organization, as
shown on the Title Page of the Policy.
HEART ATTACK (MYOCARDIAL INFARCTION) means death of a portion of heart muscle due to
inadequate circulation in coronary arteries. If no death of heart muscle occurs, this is not considered a heart
attack. Diagnosis is made by a board-certified or board-eligible cardiologist and based on findings from an
electrocardiogram (EKG) and elevation of cardiac enzymes associated with heart attack.
HEART TRANSPLANT means the transplantation of a healthy heart from a suitable donor, necessitated by
the diagnosis of end-stage heart disease, as determined by a Physician appropriately specialized for the heart.
Acceptance to the UNOS (United Network for Organ Sharing) list is required for this determination. If the
Insured Person or Insured Dependent is determined to be too ill for a transplant, but otherwise meets the
criteria for placement on the UNOS list, the network requirement will be waived. The network requirement
will also be waived if the Insured Person or Insured Dependent receives the transplant prior to placement on
the network.
HOSPITAL means a general hospital which:
(1) is licensed, approved or certified by the state where it is located;
(2) is recognized by the Joint Commission;
(3) is operated to treat Inpatients;
(4) has a registered nurse always on duty; and
(5) has organized facilities and equipment for diagnosis and treatment of acute medical and
surgical conditions, either on its premises or in facilities available to it on a prearranged
basis.
It does not include a place that:
(1) is specialized solely in dentistry, mental illness or substance abuse;
(2) is a rest home, home for the aged, convalescent home or nursing home; or
(3) Alternate Care or Rehabilitative Facility, extended care or skilled nursing facility.
INPATIENT means an Insured Person or Insured Dependent who is an overnight resident patient.
GL52-4-DF
12
DEFINITIONS
(Continued)
INSURANCE MONTH means that period of time:
(1) beginning at 12:01 a.m. on the first day of any calendar month; and
(2) ending at 12:00 midnight on the last day of the same calendar month;
at the Group Policyholder's primary place of business.
INSURED DEPENDENT means a Dependent for whom Policy coverage is in effect.
INSURED DEPENDENT SPOUSE means the Insured Person's spouse for whom coverage is in effect.
INSURED PERSON means a Person for whom Policy coverage is in effect.
LOSS OF HEARING means permanent reduction in both ears to a point that the Insured Person or Insured
Dependent is unable to hear sounds at or below 70 decibels. Diagnosis is made by a board-certified or board-
eligible otolaryngologist as diagnosed by audiometric testing.
LOSS OF SIGHT means permanent loss of sight in both eyes such that corrected visual acuity is 20/200 or
less, or the field of vision is less than 20 degrees. Diagnosis is made by a board-certified or board-eligible
ophthalmologist or board-certified or board-eligible neuro-ophthalmologist based on the above criteria and
noted to be of permanent duration.
LOSS OF SPEECH means loss of the ability to speak to the extent that the individual is unintelligible to
another person with normal hearing, for at least 12 months. Diagnosis is made by a board-certified or board-
eligible otolaryngologist or board-certified or board-eligible neurologist.
MAJOR ORGA
N means the liver, lungs, pancreas, intestines, or combinations of these organs.
MAJOR ORGAN TRANSPLANT means the transplantation of a healthy Major Organ from a suitable
donor, necessitated by the diagnosis of end-stage organ disease (organ failure), as determined by a Physician
appropriately specialized for the involved organ. Acceptance to the UNOS (United Network for Organ
Sharing) list is required for this determination. If the Insured Person or Insured Dependent is determined to
be too ill for a transplant, but otherwise meets the criteria for placement on the UNOS list, the network
requirement will be waived. The network requirement will also be waived if the Insured Person or Insured
Dependent receives the transplant prior to placement on the network.
MILITARY LEAVE means a leave of absence that:
(1) is subject to the federal USERRA law (the Uniformed Services Employment and
Reemployment Rights Act of 1994 and any amendments to it);
(2) is taken in accord with the Group Policyholder's leave policy and the federal USERRA law;
and
(3) does not exceed the period required by that law.
PAYROLL PERIOD means that period of time established by the Group Policyholder for payment of
employee wages.
PERSON means a Full-Time Employee of the Group Policyholder:
(1) who is a member of a class that is eligible for insurance under the Policy; and
(2) who has completed an enrollment form.
PERSONAL CRITICAL ILLNESS INSURANCE means the insurance provided by the Policy for Insured
Persons.
GL52-4-DF
13
DEFINITIONS
(Continued)
PHYSICIAN means:
(1) a legally qualified medical doctor who is licensed to practice medicine, to prescribe and
administer drugs, or to perform surgery; or
(2) any other duly licensed medical practitioner who is deemed by state law to be the same as a
legally qualified medical doctor.
The medical doctor or other medical practitioner must be acting within the scope of his or her license.
Physician does not include the Insured Person or a relative of the Insured Person receiving treatment.
Relatives include:
(1) the Insured Person's spouse, siblings, parents, children and grandparents; and
(2) his or her spouse's relatives of like degree.
POLICY means this Group Critical Illness Insurance policy issued by the Company to the Group
Policyholder.
PREMIUM means the amount charged for insurance coverage.
STROKE means permanent neurological damage to the brain due to inadequate blood flow in any of the
cranial vessels, due to either blockage or rupture of the vessel and categorized as Score 3 on the Modified
Rankin Scale. Diagnosis of permanent neurological damage should be made by a neurologist and
demonstrated by imaging (CT or MRI) and examination demonstrating lasting neurological deficits (motor,
cognitive, or sensory). Transient Ischemic Attacks (TIA) are not considered Strokes.
YOU and YO
UR means an eligible Employee for whom the coverage provided by the Policy is in effect.
GL52-5-GP
14
GENERAL PROVISIONS
ENTIRE CONTRACT. The entire contract between the parties consists of:
(1) the Policy and any amendments to it; and
(2) the Group Policyholder's application.
In the absence of fraud, all statements made by the Group Policyholder and by Insured Persons or Insured
Dependents are representations and not warranties. No statement made by an Insured Person or Insured
Dependent will be used to contest the insurance provided by the Policy, unless:
(1) it is contained in a written statement signed by that Insured Person or Insured Dependent;
and
(2) a copy of the statement has been furnished to that Insured Person or Insured Dependent.
INCONTESTABILITY. Except for the non-payment of premiums or fraud, the Company may not contest
the validity of the Policy after it has been in force for two years from its date of issue; and as to any Insured
Person or Insured Dependent, after his or her insurance has been in force for two years during his or her
lifetime. This clause does not preclude, at any time, the assertion of defenses based upon:
(1) the Policy's eligibility requirements, exclusions and limitations; and
(2) other Policy provisions unrelated to the validity of insurance.
RESCISSION. The Company has the right to rescind any insurance for which Evidence of Insurability was
required, if:
(1) an Insured Person or Insured Dependent incurs a claim during the first two years of
coverage; and
(2) the Company discovers that the Insured Person or Insured Dependent made a Material
Misrepresentation on his or her application.
A "Material Misrepresentation" is an incomplete or untrue statement that caused the Company to issue
coverage that it would have disapproved, had it known the truth. "To rescind" means to cancel insurance
back to its effective date. In that event, the Company will refund all premium paid for the rescinded
insurance, less any benefits paid for Insured Person's or Insured Dependent's claims. The Company reserves
the right to recover any claims paid in excess of such premiums.
MISSTATEMENT OF FACTS. If relevant facts about any Insured Person or Insured Dependent were
misstated:
(1) a fair adjustment of the premium will be made; and
(2) the true facts will decide if and in what amount insurance is valid under the Policy.
If any Insured Person's or Insured Dependent's age has been misstated and the amount of benefit depends
upon age; then the benefit will be that which would have been payable, based upon his or her correct age.
GROUP POLICYHOLDER'S AGENCY. For all purposes of the Policy, the Group Policyholder acts on
its own behalf or as an agent of the Insured Person. Under no circumstances will the Group Policyholder be
deemed the agent of the Company.
CURRENCY. In administering the Policy all premium and benefit amounts must be paid in U.S. dollars.
WORKERS' COMPENSATION OR STATE DISABILITY INSURANCE. The Policy does not replace
or provide benefits required by:
(1) Workers' Compensation laws; or
(2) any state temporary disability insurance plan laws.
GL52-6-ELE
15
ELIGIBILITY AND EFFECTIVE DATES FOR
PERSONAL CRITICAL ILLNESS INSURANCE
ELIGIBILITY. A Person becomes eligible for insurance provided by the Policy on the later of:
(1) the Policy's date of issue; or
(2) the date the Waiting Period is completed (For Waiting Period, see Schedule of Benefits).
Prior Service Credit Towards Waiting Period. The Waiting Period is shown in the Schedule of Benefits.
Prior service in an Eligible Class will apply toward the Waiting Period, when:
(1) a former employee is rehired within six months after his or her employment ends; or
(2) an employee returns from an approved Family or Medical Leave within:
(a) the leave period required by federal law; or
(b) any longer period required by a similar state law; or
(3) an employee returns from a Military Leave within the period required by federal USERRA
law.
ENROLLMENT. A Person may enroll for Personal Critical Illness Insurance only:
(1) when first eligible;
(2) during any Annual/Open Enrollment Period; or
(3) within 31 days following a qualifying Change In Family Status.
EFFECTIVE DATE. Personal Critical Illness Insurance becomes effective on the latest of:
(1) the first day of the Insurance Month following the date you become eligible for the insurance;
(2) the date you resume Active Work, if not Actively at Work on the day you become eligible
(You will be deemed Actively at Work on any regular non-working day, if you:
(a) are not totally disabled or Hospital confined on that day; and
(b) were Actively at Work on the regular working day before that day);
(3) if you contribute to the cost of the Personal Critical Illness Insurance, the first day of the
Insurance Month following the date you make written application for insurance and pay the
required premium to the Company; or
(4) the first day of the Insurance Month following the date the Company approves your Evidence
of Insurability, if required (See Schedule of Benefits).
Any increase in insurance or benefits becomes effective at 12:01 a.m. on the latest of:
(1) the first day of the Insurance Month following the date you become eligible for the increase,
if Actively at Work on that day;
(2) the day you resume Active Work, if not Actively at Work on the day the increase would
otherwise take effect; or
(3) the first day of the Insurance Month following the date any required Evidence of Insurability
is approved by the Company (See Schedule of Benefits).
Any reduction in insurance or benefits will take effect on the day of the change, whether or not you are
Actively at Work.
ANNUAL/OPEN ENROLLMENT PERIOD. You again become eligible to enroll, re-enroll, or change
benefit options for Personal Critical Illness Insurance under the Policy during the Group Policyholder's
Annual/Open Enrollment Period (See Schedule of Benefits).
GL52-6-ELE
16
ELIGIBILITY AND EFFECTIVE DATES FOR
PERSONAL CRITICAL ILLNESS INSURANCE
(Continued)
REINSTATEMENT RIGHTS. If your insurance terminates due to one of the following breaks in service,
you will be entitled to reinstate the insurance upon resuming Active Work with the Group Policyholder within
the required timeframe. "Reinstatement" or "to reinstate" means to re-enroll for the Policy's insurance
coverage, without satisfying a new Eligibility Waiting Period. Reinstatement is available upon:
(1) return from an approved Family or Medical Leave within:
(a) the period required by federal law; or
(b) any longer period required by a similar state law;
(2) return from a Military Leave within the period required by federal USERRA law;
(3) return from any other approved leave of absence within 6 months after the leave begins;
(4) return within 12 months following a lay off; or
(5) return within 12 months following termination of employment for any other reason.
To reinstate insurance coverage, you must apply for coverage or be re-enrolled within 31 days after resuming
Active Work in an eligible class unless the Group Policyholder contributes the entire cost of the premium.
The required premium payments must be received from the Group Policyholder for coverage to be reinstated.
Reinstatement will take effect on the date you return to Active Work.
GL52-7-TE
17
TERMINATION OF PERSONAL CRITICAL ILLNESS INSURANCE
TERMINATION. Your insurance will terminate at 12:00 midnight on the earliest of:
(1) the date the Policy terminates (but without prejudice to any claim incurred prior to
termination);
(2) the date your Class is no longer eligible for insurance;
(3) the date you cease to be a member of the Eligible Class;
(4) the last day of the Insurance Month in which you request termination;
(5) the last day of the last Insurance Month for which premium payment is made on your behalf;
(6) the end of the period for which the last required premium has been paid;
(7) with respect to any particular insurance benefit, the date the portion of the Policy providing
that type of benefit terminates;
(8) with respect to any category shown in the Schedule of Benefits, the date benefits payable
reach the overall maximum for that category;
(9) the date you cease to be covered under at least one category other than the Wellness
Category;
(10) the date your employment with the Group Policyholder terminates; or
(11) the date you enter armed services of any state or country on active duty, except for duty of
30 days or less for training in the Reserves or National Guard. (If you send proof of military
service, the Company will refund any unearned premium.);
unless insurance is continued as provided below.
CONTINUATION RIGHTS. Ceasing Active Work results in termination of your eligibility for insurance,
but insurance may be continued as follows.
Disability. If you are disabled due to an event or illness shown in the Schedule of Benefits, then insurance
may be continued until the earlier of:
(1) 12 Insurance Months after the disability begins; or
(2) the date you are no longer disabled.
The required premium payments must be received from the Group Policyholder, throughout the period of
continued insurance.
Family or Medical Leave. If you go on an approved Family or Medical Leave and are not entitled to any
more favorable continuation available during disability, insurance may be continued until the earliest of:
(1) the end of the leave period approved by the Group Policyholder;
(2) the end of the leave period required by federal law, or any more favorable period required by
a similar state law;
(3) the date you notify the Group Policyholder that you will not return; or
(4) the date you begin employment with another employer.
The required premium payments must be received from the Group Policyholder throughout the period of
continued insurance.
Military Leave. If you go on a Military Leave, insurance may be continued for the same period allowed for
an approved Family or Medical Leave or any more favorable leave in which employees with similar
seniority, status, and pay who are on furlough or leave of absence are granted by the Group Policyholder.
The required premium payments must be received from the Group Policyholder throughout the period of
continued insurance.
GL52-7-TE
18
TERMINATION OF PERSONAL CRITICAL ILLNESS INSURANCE
(Continued)
Conditions. In administering the above continuations, the Group Policyholder must not act so as to
discriminate unfairly among Insured Persons in similar situations. Insurance may not be continued when an
Insured Person ceases Active Work due to a labor dispute, strike, work slowdown or lockout.
PORTABILITY. If insurance under the Policy would end for any reason other than nonpayment of
premiums, you have the option to continue Personal Critical Illness Insurance and Dependent Critical Illness
Insurance. To continue insurance under this section, you must:
(1) notify the Company within 31 days of the date the insurance would otherwise end; and
(2) pay the applicable premium to the Company.
Portability is not available when insurance terminates solely because your spouse or child ceases to be an
eligible Dependent.
Insurance continued under this section ends on the earliest of:
(1) the last day of the period for which you paid premiums; or
(2) the date the Company receives a written request from you to terminate the insurance; or
(3) the date you attain age 90, or die.
INDIVIDUAL TERMINATION. Termination will have no effect on benefits payable for claims incurred
by you while you were insured under the Policy.
GL52-8-ELD PA
19
DEPENDENT means your:
ELIGIBILITY AND EFFECTIVE DATES FOR
DEPENDENT CRITICAL ILLNESS INSURANCE
(1) legal spouse, who is not legally separated from you;
(2) child less than 26 years of age; or
(3) child age 26 years or older, who is:
(a) continuously unable to earn a living because of a physical or mental disability; and
(b) chiefly dependent upon you for support and maintenance.
The child must be covered by the Group Policyholder's Critical Illness plan on the day
before insurance would otherwise end due to his or her age. Proof of the total disability
must be sent to the Company:
(a) within 31 days of the day coverage would otherwise end due to age; and
(b) thereafter, when the Company requests (but not more than once every two
years).
Dependent will also include a child that you are required to provide insurance for under the terms of a
Qualified Medical Child Support Order (QMCSO). A QMCSO will also include a judgment, decree or order
issued by a court of competent jurisdiction or through an administrative process established under, and having
the force and effect of, state law and which satisfies the QMCSO requirements of ERISA (section 609a).
''Child'' includes:
(1) your natural child, legally adopted child, or stepchild;
(2) a child placed with you for the purpose of adoption, from the date of placement;
(3) a child for whom you are required by court order to provide Critical Illness insurance;
(4) a grandchild who resides in your household; and who is chiefly dependent on you for
support;
(5) a child of a civil union partner or domestic partner; and
(6) a foster child for whom you have assumed full parental responsibility and control.
ELIGIBILITY. You become eligible to enroll for Dependent Critical Illness Insurance on the latest of:
(1) the date you become eligible for Personal Critical Illness Insurance;
(2) the issue date of the Policy; or
(3) the date you first acquire a Dependent.
You again become eligible to enroll for Dependent Critical Illness Insurance under the Policy:
(1) within 31 days following a qualifying Change In Family Status; or
(2) during any Annual/Open Enrollment Period.
You must be insured for Personal Critical Illness Insurance to insure your Dependents. Dependents to be
insured by the Policy must be enrolled in and approved for the same plan of benefits as you.
GL52-8-ELD PA
20
ELIGIBILITY AND EFFECTIVE DATES FOR
DEPENDENT CRITICAL ILLNESS INSURANCE
(Continued)
ANNUAL/OPEN ENROLLMENT PERIOD. You again become eligible to enroll, re-enroll, or change
benefit options for Dependent Critical Illness Insurance under the Policy during the Group Policyholder's
Annual/Open Enrollment Period.
EFFECTIVE DATES. Except as provided in the NEW DEPENDENTS section, Dependent Critical Illness
Insurance will become effective on the latest of:
(1) the first day of the Insurance Month following the date you become eligible for Dependent
Critical Illness Insurance;
(2) the first day of the Insurance Month following the date you make written application for
Dependent Critical Illness Insurance and pay the required Dependent Premium to the
Company; or
(3) the first day of the Insurance Month following the date the Company approves any Evidence
of Insurability, if required. (See Schedule of Benefits).
COURT ORDERED COVERAGE. If insurance is provided to a child based on a court order which
requires you to provide Critical Illness benefits for the child, the insurance will become effective on the date
stated in the court order; subject to:
(1) any eligibility and Evidence of Insurability requirements set forth in the Policy; and
(2) payment of any additional premium.
NEW DEPENDENTS. If additional premium is required to add a new Dependent, coverage for the new
Dependent will become effective on the date the Dependent is acquired; provided:
(1) you complete a written application; and
(2) the additional premium is paid to the Company;
within 31 days of the date the Dependent is acquired.
If additional premium is not required, coverage for a new Dependent will become effective on the date the
Dependent is acquired.
EXCEPTION FOR NEWBORN. If you acquire a newborn Dependent child, the child will be automatically
insured for the first 31 days following birth. If you elect not to enroll the newborn child and pay any
additional premium within 31 days following birth, the newborn child's insurance will terminate.
GL52-9-TD
21
TERMINATION OF
DEPENDENT CRITICAL ILLNESS INSURANCE
TERMINATION. Critical Illness Insurance on a Dependent will cease on the earliest of:
(1) the date he or she ceases to be an eligible Dependent, as defined in the Policy;
(2) with respect to any category shown in the Schedule of Benefits, the date benefits payable
reach the overall maximum for that category; or
(3) the date he or she ceases to be covered under at least one category other than the Wellness
Category.
Dependent Critical Illness Insurance will cease for all of your Dependents on the earliest of:
(1) the date your Critical Illness Insurance terminates;
(2) the date Dependent Critical Illness Insurance is discontinued under the Policy;
(3) the date you cease to be in a class eligible for Dependent Critical Illness Insurance;
(4) the date you request that the Dependent Critical Illness Insurance be terminated;
(5) with respect to a benefit or a specific type of benefit, the date the portion of the Policy
providing that type of benefit terminates; or
(6) the date through which premium has been paid on behalf of the Insured Dependents.
SURVIVING DEPENDENTS. If Personal Critical Illness Insurance terminates due to your death,
Dependent Critical Illness Insurance may be continued:
(1) for three Insurance Months; or any longer period, if required by state or federal law;
(2) provided the Group Policyholder submits the premium on behalf of the surviving
Dependents; and the Policy remains in force.
REINSTATEMENT OF DEPENDENT INSURANCE If you reinstate your Personal Critical Illness
Insurance, you may also reinstate Dependent Critical Illness Insurance at the same time. To do so, you must
follow the same requirements that apply in the reinstatement of your Personal Critical Illness Insurance.
DEPENDENT TERMINATION. Termination will have no effect on benefits payable for claims incurred
by the Insured Dependent while he or she was insured under the Policy.
GL52-12-CIB
22
CRITICAL ILLNESS BENEFITS
GENERAL CRITICAL ILLNESS BENEFITS. The Company will pay a Critical Illness Benefit if you or
an Insured Dependent sustains an Event/Illness shown in the Schedule of Benefits while covered under the
Policy.
Benefit amounts payable are shown in the Schedule of Benefits.
For each Insured Person or Insured Dependent, the lifetime total benefits payable in any category shown in
the Schedule of Benefits (except the Wellness Category) are subject to an overall maximum, as shown in the
Schedule of Benefits. Certain Events/Illnesses are also subject to separate lifetime maximums, as shown in
the Schedule of Benefits. If benefits paid to you or an Insured Dependent reach the overall maximum for a
category, your or your Insured Dependent's coverage for that category will terminate.
Except for the Wellness Category, benefits are not payable if an Event/Illness shown in the Schedule of
Benefits occurs within:
(1) 180 days of another Event/Illness in the same category; or
(2) 90 days of an Event/Illness in a different category.
If you or your Insured Dependent sustains two or more Events/Illnesses simultaneously, the highest
applicable benefit is payable. Certain Events/Illnesses are only payable once per your or your Insured
Dependent's lifetime, as shown in the Schedule of Benefits.
CRITICAL ILLNESS ASSESSMENT BENEFIT. The Company will pay a Critical Illness Assessment
Benefit to an Insured Person or Insured Dependent who has one of the following Critical Illness Assessment
Tests:
(1) abdominal aortic aneurysm ultrasound;
(2) blood test for triglycerides;
(3) bone marrow testing;
(4) bone density screening;
(5) breast ultrasound;
(6) CA 15-3 (blood test for breast cancer);
(7) CA125 (blood test for ovarian cancer);
(8) carotid ultrasound;
(9) CEA (blood test for colon cancer);
(10) chest x-ray;
(11) colonoscopy;
(12) CT Angiography;
(13) EKG;
(14) double contrast barium enema;
(15) fasting blood glucose test;
(16) flexible sigmoidoscopy;
(17) hemoccult stool analysis;
(18) mammography;
(19) pap smear;
(20) PSA (blood test for prostate cancer);
(21) serum cholesterol HDL/LDL;
(22) serum protein electrophoresis (blood test for myeloma);
(23) stress test; or
(24) thermography.
The Critical Illness Assessment Test must be performed during the Critical Illness Assessment Period as
shown in the Schedule of Benefits, while your or your Insured Dependent's coverage under the Policy is in
effect. The Critical Illness Assessment Benefit is subject to the maximums shown in the Schedule of Benefits.
GL52-12-CIB
23
CRITICAL ILLNESS BENEFITS
(Continued)
CHILD CARE EXPENSE BENEFIT. The Company will pay a Child Care Expense Benefit if you or your
Insured Dependent Spouse incurs Child Care Expenses while confined as an Inpatient in a Hospital or
Alternate Care or Rehabilitative Facility for an Event/Illness shown in the Schedule of Benefits.
"Child Care Expense" means an expense for the care of a Child, charged by a licensed care provider who:
(1) is not a member of your immediate family; and
(2) is not living in your home.
"Child," as used in the Child Care Expense Benefit, means your naturally born child, legally adopted child,
stepchild, foster child, or child for whom you are the legal guardian, if the child is:
(1) less than age 16 and living with you; or
(2) age 16 years or older, who is:
(a) unmarried;
(b) living with you; and
(c) incapable of independent living due to a mental or physical condition.
Amount. The amount of the Child Care Expense Benefit is shown in the Schedule of Benefits.
Proof. You must submit to the Company satisfactory proof that a Child Care Expense has been incurred for
a Child (as defined in this provision) and paid by you or your Insured Dependent Spouse. Satisfactory proof
is a signed receipt from the Child care provider showing:
(1) Child name;
(2) Child age;
(3) dates of care;
(4) total charges for care;
(5) total payments for care; and
(6) provider name, address, telephone number, and Federal Employer Identification
Number/Taxpayer Identification Number.
Duration. The Child Care Expense Benefit will be payable for up to a maximum of 30 days from the date
you or your Insured Dependent Spouse were confined as an Inpatient in a Hospital. This Benefit will cease
on the earliest of:
(1) the date you or your Insured Dependent Spouse is released from Inpatient treatment;
(2) the date your or your Insured Dependent Spouse's Child(ren) no longer meet(s) the definition
of Child in this provision; or
(3) the date the maximum duration ends.
GL52-13-EX PA
24
EXCLUSIONS
GENERAL EXCLUSIONS. Benefits are not payable for any Event/Illness or loss resulting, directly or
indirectly, from or in any degree caused by:
(1) intentional self-inflicted injury, self-destruction, or suicide, or any attempt thereof; whether
sane or insane;
(2) participation in, commission of or attempt to commit a felony;
(3) war or any act of war, declared or undeclared; or participation in a riot, insurrection or
rebellion of any kind;
(4) duty as a member of any military, including Reserves or National Guard; or
(5) an Event/Illness sustained while residing outside the United States, U.S. Territories, Canada,
or Mexico for more than 12 months.
Benefits are also not payable while you or your Insured Dependent is incarcerated in any type of penal or
detention facility.
PRE-EXISTING CONDITION EXCLUSION. Benefits are not payable for any Event/Illness or loss:
(1) resulting, directly or indirectly, from or in any degree caused by a Pre-Existing Condition;
and
(2) diagnosed in the first 12 months following your or your Insured Dependent's Effective Date.
''Pre-Existing Condition'' means an illness or event for which you or your Insured Dependent received
Treatment within the 3 months prior to your or your Insured Dependent's Effective Date.
''Treatment'' means a Physician's consultation, care or services; diagnostic measures; and the prescription,
refill or taking of prescribed drugs or medicines.
The above Pre-Existing Condition Exclusion will also apply to:
(1) any increase in the Critical Illness Principal Sum;
(2) the addition by amendment of a benefit or category of benefits under the Policy;
(3) an Insured Person's election after initial enrollment of any category of benefits under the
Policy; and
(4) the election after initial enrollment of any benefit provided by an amendment to the Policy.
GL52-14-B PA
25
BENEFICIARY
PAYMENTS TO BENEFICIARY. At your death, any amount payable under the Policy will be paid to the
named Beneficiary who survives you. If you have not named a Beneficiary, or if no named Beneficiary
survives you; then payment will be made to your:
(1) surviving spouse; or, if none
(2) surviving child or children in equal shares; or, if none
(3) surviving parent or parents in equal shares; or, if none
(4) surviving sibling or siblings in equal shares; or, if none
(5) estate.
In determining who is to receive payment, the Company may rely upon an affidavit by a member of the class
to receive payment. Unless the Company receives written notice at its Group Insurance Service Office of a
valid claim by some other person before paying the proceeds, the Company will make payment based upon
the affidavit it has received. Such payment will release the Company from any further obligation for the
death benefit.
The amount payable to anyone shown above will be reduced by any amount paid in accord with the Facility
of Payment section.
If the person who would otherwise receive payment dies:
(1) within 15 days of your death; and
(2) before the Company receives satisfactory proof of your death;
payment will be made as if you had survived that person; unless other provisions have been made.
NAMING THE BENEFICIARY. Your Beneficiary will be as shown on your enrollment form, unless
changed. If the Policy replaces a group policy providing similar coverages; then your beneficiary named
under the prior policy will be the Beneficiary under the Policy, until changed.
CHANGING THE BENEFICIARY. Only you or your assignee may change the Beneficiary. A new
Beneficiary may be named by filing a written notice of the change with the Company at its Group Insurance
Service Office prior to your death. The change will be effective as of the date it was signed; subject to any
action taken by the Company before it received notice of the change.
FACILITY OF PAYMENT. If any benefit under the Policy becomes payable to your estate, a minor, or
any person who (in the Company's opinion) is not competent to give a valid release; then the Company, at its
option, may make payment to any one or more of the following:
(1) a person who has assumed the care and support of you or a Beneficiary;
(2) a person who has incurred expense as a result of your last illness or death;
(3) the personal representative of your estate; or
(4) any person related by blood or marriage to you.
No payment made to anyone named above may exceed $1,000. Any payment made in good faith under this
section will fully discharge the Company to the extent of the payment.
GL52-15-CP PA
26
CLAIM PROCEDURES FOR CRITICAL ILLNESS INSURANCE
NOTICE AND PROOF OF CLAIM
Notice of Claim. Written notice of claim must be given within 20 days after a claim is incurred; or as soon
as reasonably possible after that.* The notice must be sent to the Company's Group Insurance Service
Office. It should include:
(1) the Group Policyholder's name and Policy number;
(2) your name, address and certificate number, if available; and
(3) the patient's name and relationship to you.
Claim Forms. When notice of claim is received, the Company will send claim forms for filing the required
proof. If the Company does not send the forms within 15 days; then you may send the Company written
proof of claim in a letter. It should state the nature, date and cause of the claim.
Proof of Claim. The Company must be given written proof of claim within 90 days after a claim is incurred;
or as soon as reasonably possible after that.* Proof of claim must be provided at the claimant's own expense.
It must include:
(1) the nature, date and cause of the claim;
(2) a description of the services provided; and
(3) a signed authorization for the Company to obtain more information.
Within 15 days after receiving the first proof of claim, the Company may send a written acknowledgment. It
will request any missing information or additional items needed to support the claim. This may include:
(1) any study models, treatment records or charts;
(2) copies of any x-rays or other diagnostic materials; and
(3) any other items the Company may reasonably require.
* Exception: Failure to give notice or furnish proof of claim within the required time period will not
invalidate or reduce the claim; if it is shown that it was done:
(1) as soon as reasonably possible; and
(2) in no event more than one year after it was required.
These time limits will not apply while the claimant lacks legal capacity.
PHYSICAL EXAMS. While a Critical Illness claim is pending, the Company may have the claimant
examined:
(1) by a Physician of its choice;
(2) as often as is reasonably required.
In case of death, the Company may also have an autopsy done, where it is not forbidden by law. Any such
exam or autopsy will be at the Company's expense.
TIME OF PAYMENT OF CLAIMS. Any Critical Illness benefits payable under the Policy will be paid
immediately after the Company receives complete proof of claim and confirms liability.
TO WHOM PAYABLE. All benefits payable under the Policy, including any benefits for Insured
Dependents, will be paid to you, while living, unless:
(1) an overpayment has been made and the Company is entitled to reduce future benefits; or
(2) state or federal law requires that benefits be paid to a Insured Dependent child's custodial
parent or custodian.
If any benefits remain to be paid after your death, such benefits will be paid in accord with the Beneficiary
provision.
GL52-15-CP PA
27
CLAIM PROCEDURES FOR CRITICAL ILLNESS INSURANCE
(Continued)
NOTICE OF CLAIM DECISION. The Company will send the claimant a written notice of its claim
decision. If the Company denies any part of the claim; then the written notice will explain:
(1) the reason for the denial, under the terms of the Policy and any internal guidelines;
(2) how the claimant may request a review of the Company's decision; and
(3) whether more information is needed to support the claim.
The Company will send this notice within 15 days after resolving the claim. If reasonably possible, the
Company will send it within 90 days after receiving the first proof of a Critical Illness claim.
Delay Notice. If the Company needs more than 15 days to process a claim, in a special case; then an
extension will be permitted. If needed, the Company will send the claimant a written delay notice:
(1) by the 15
th
day after receiving the first proof of claim; and
(2) every 30 days after that, until the claim is resolved.
The notice will explain the special circumstances which require the delay, and when a decision can be
expected.
In any event, the Company must send written notice of its decision within 180 days after receiving the first
proof of a Critical Illness claim. If the Company fails to do so; then there is a right to an immediate review,
as if the claim was denied.
Exception: If the Company needs more information from the claimant to process a claim; then it must be
supplied within 45 days after the Company requests it. The resulting delay will not count towards the above
time limits for claim processing.
REVIEW PROCEDURE. The claimant may request a claim review, within 60 days after receiving a denial
notice of a Critical Illness claim. To request a review, the claimant must send the Company a written
request, and any written comments or other items to support the claim. The claimant may review certain
non-privileged information relating to the request for review.
Notice of Decision. The Company will review the claim and send the claimant a written notice of its
decision. The notice will explain the reasons for the Company's decision, under the terms of the Policy and
any internal guidelines. If the Company upholds the denial of all or part of the claim; then the notice will
also describe:
(1) any further appeal procedures available under the Policy;
(2) the right to access relevant claim information; and
(3) the right to request a state insurance department review, or to bring legal action.
For a Critical Illness claim, the notice will be sent within 60 days after the Company receives the request for
review; or within 120 days, if a special case requires more time.
Delay Notice. If the Company needs more time to process an appeal, in a special case; then it will send the
claimant a written delay notice, by the 30
th
day after receiving the request for review. The notice will
explain:
(1) the special circumstances which require the delay;
(2) whether more information is needed to review the claim; and
(3) when a decision can be expected.
Exception: If the Company needs more information from the claimant to process an appeal; then it must be
supplied within 45 days after the Company requests it. The resulting delay will not count towards the above
time limits for appeal processing.
GL52-15-CP PA
28
CLAIM PROCEDURES FOR CRITICAL ILLNESS INSURANCE
(Continued)
Claims Subject to ERISA (Employee Retirement Income Security Act of 1974). Before bringing a civil
legal action under the federal labor law known as ERISA, an employee benefit plan participant or beneficiary
must exhaust available administrative remedies. Under the Policy, the claimant must first seek two
administrative reviews of the adverse claim decision, in accord with this section. If an ERISA claimant
brings legal action under Section 502(a) of ERISA after the required reviews; then the Company will waive
any right to assert that he or she failed to exhaust administrative remedies.
RIGHT OF RECOVERY. If benefits have been overpaid on any claim, then the Company has the right to
recover the excess from one or more of the following:
(1) the claimant or claimant's estate;
(2) the claimant's Beneficiary, or Beneficiary's estate; or
(3) an insurance company or other organization which has been overpaid.
LEGAL ACTIONS. No legal action to recover any benefits may be brought until 60 days after the required
written proof of claim has been given. No such legal action may be brought more than three years after the
date written proof of claim is required.
COMPANY'S DISCRETIONARY AUTHORITY. Except for the functions that the Policy clearly reserves
to the Group Policyholder, the Company has the authority to:
(1) manage the Policy and administer claims under it; and
(2) interpret the provisions and to resolve questions arising under the Policy.
The Company's authority includes (but is not limited to) the right to:
(1) establish and enforce procedures for administering the Policy and claims under it;
(2) determine eligibility for insurance and entitlement to benefits;
(3) determine what information the Company reasonably requires to make such decisions; and
(4) resolve all matters when a claim review is requested.
Any decision the Company makes, in the exercise of its authority, shall be conclusive and binding; subject to
the claimant's rights to:
(1) request a state insurance department review; or
(2) bring legal action.
GL52-AMEND.ACC PA
CERTIFICATE AMENDMENT
TO BE ATTACHED TO THE CERTIFICATE FOR POLICY NO. 00040500419300000
ISSUED TO: Ollie's Bargain Outlet, Inc.
FOR: Class 2
The Certificate is amended by the addition of the following Accident Benefit provision.
ACCIDENT BENEFIT
The Company will pay an Accident Benefit if you or your Insured Dependent sustains one of the following
incidents as a result of an Accident:
(1) Coma;
(2) Severe Burn; or
(3) Paralysis.
The Accident must occur while this Certificate Amendment is in force for you or your Insured Dependent.
The benefit is payable once per Accident.
The benefit does not affect any other benefits payable under the Policy.
AMOUNT. The amount of the Accident Benefit equals your or your Insured Dependent's Critical Illness
Principal Sum shown in the Policy's Schedule of Benefits.
DEFINITIONS. The following additional definitions apply to this Accident Benefit.
"Accident or Accidental" means an event or occurrence that was not reasonably foreseeable, or that could
not have been reasonably expected or anticipated.
"Coma" means a state of complete mental unresponsiveness, due to Accidental Injury, during which you or
your Insured Dependent:
(1) cannot be awakened;
(2) does not respond to pain, light or sound; and
(3) does not take voluntary actions.
It does not include a medically-induced coma. For the purpose of this definition, these traits must be met for a
continuous period of time lasting at least 7 days. Diagnosis is made by a board-certified or board-eligible
neurologist and based on findings from clinical diagnosis.
"Injury or Injuries" means bodily injury solely due to an Accident. It includes all complications of and all
injuries received from the same Accident.
"Paralysis" means complete and permanent loss of the use of two or more limbs. Diagnosis must be
confirmed by findings from physical examination conducted by a board-certified or board-eligible neurologist,
physiatrist, or other Physician.
"Severe Burn" means:
(1) a third-degree (full thickness) burn covering at least 18% of the body; or
(2) a second-degree (partial thickness) burn covering at least 36% of the body.
Diagnosis is made based on clinical examination findings conducted by a board-certified or board-eligible
plastic surgeon or other Physician.
GL52-AMEND.ACC PA
CERTIFICATE AMENDMENT
(Continued)
EXCLUSIONS. The Exclusions contained in the Policy apply to this Certificate Amendment. In addition,
no Benefits will be paid for any loss resulting, directly or indirectly, from or in any degree caused by:
(1) disease, physical or mental infirmity, illness, infection (except when the infection is due to
an Accidental cut or wound), or medical or surgical treatment of these;
(2) deliberate use of drugs, poison, gas or fumes, whether by ingestion, injection, inhalation or
absorption, except when administered within the therapeutic levels and dosage prescribed by
a licensed Physician or while conducting duties in the course of employment;
(3) an Injury arising out of, or in the course of any employment for wage or profit;
(4) you or an Insured Dependent having a blood alcohol level of .08 grams of alcohol or more
per 100 milliliters of blood;
(5) high risk sports or extreme sports such as, but not limited to, bungee jumping, parachuting,
base jumping, or mountaineering;
(6) cosmetic or elective surgery;
(7) being incarcerated in any type of penal or detention facility;
(8) participating in or practicing for, or officiating any semi-professional or professional sport;
(9) riding in or driving in any motor driven vehicle for race, stunt show or speed test; or
(10) an Injury sustained while residing outside the United States, U.S. Territories, Canada, or
Mexico for more than 12 months.
OTHER PROVISIONS. Unless stated otherwise, this benefit is subject to all other provisions of the Policy.
This amendment takes effect on July 1, 2016, or on your effective date of coverage under the Policy,
whichever is later. In all other respects, the Certificate remains the same.
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY
Officer of the Company
Information We May Collect And Use
depends on the products or services you request and may include the following:
• Information from you:
• Information about your transactions:
• Information from outside our family of companies: If you are purchasing insurance products, we may
• Information from your employer: If your employer purchases group products from us, we may obtain information
How We Use Your Personal Information
however, we require our service providers to protect your personal information and to use or disclose it only for the work they are
We do not sell or share your information with outside marketers who may want to offer you their own
products and services; nor do we share information we receive about you from a consumer reporting agency. You do
not need to take any action for this benefit.
Page 1 of 2
GB06714 10/15
Lincoln Financial Group
®
Privacy Practices Notice
Security of Information
Your Rights Regarding Your Personal Information
Access:
Accuracy of Information: If you feel the personal information we have about you is inaccurate or incomplete, you may ask us
we will send the updated information, at your request, to any person who may have received the information within the prior two
Accounting of Disclosures: If applicable, you may request an accounting of disclosures made of your medical information,
except for disclosures:
•
•
•
•
•
•
•
Questions about your personal information should be directed to:
Lincoln Financial Group
Please include all policy/contract/account numbers with your correspondence.
*This information applies to the following Lincoln Financial Group companies:
Lincoln Financial Investment Services Corporation Lincoln Variable Insurance Products Trust
Page 2 of 2
GB06714 10/15
Page 1 of 4
GB06735 6/11
Lincoln Financial Group is the marketing name for Lincoln National Corporation and its af
fi liates.
LINCOLN FINANCIAL GROUP
®
PRIVACY NOTICE FOR PROTECTED HEALTH INFORMATION
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED
AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
You have received this Notice because you have applied for, or currently have, insurance coverage or an annuity (“Coverage”),
that contains benefi t provisions subject to the federal privacy regulations that were issued as a result of the Health Insurance
Portability and Accountability Act, as amended (“HIPAA”). This is Coverage that has been, or will be issued with one of
the Lincoln Financial Group insurance companies* (“Company”). This Notice refers to the Company by using the terms
“us,” “we,” or “our.” We value our relationship with you and are committed to protecting the confi dentiality and security of
information we collect about you, especially health information.
We collect, use and disclose information about you to evaluate and process any requests for coverage and claims for benefi ts
you may make regarding your Coverage. This notice describes how we protect the protected health information we have about
you which relates to your Coverage (“Protected Health Information”), and how we may use and disclose this information.
Protected Health Information includes individually identifi able information that relates to your past, present or future health,
treatment or payment for health care services. This Notice also describes your rights with respect to the Protected Health
Information and how you can exercise those rights.
We are required to provide you with this Notice in accordance with federal health privacy regulations that were issued as a
result of HIPAA. We are required by law to maintain the privacy of your Protected Health Information; to provide you this
Notice of our legal duties and privacy practices with respect to your Protected Health Information; and to follow the terms
of this Notice.
We reserve the right to change the terms of this Notice. Any such changes will apply to all Protected Health Information
we already have about you as well as any Protected Health Information we may receive in the future. If we make a material
change to the terms of the Notice, we will promptly send the revised Notice to you should you still maintain coverage with
us when the revised Notice becomes effective.
USES AND DISCLOSURES OF YOUR PROTECTED HEALTH INFORMATION
The following describes when we may use and disclose your Protected Health Information with your written authorization
and without your authorization:
Authorization: Except as described below, we will not use or disclose your Protected Health Information for any reason unless
we have a signed authorization from you or your legal representative to use or disclose your Protected Health Information.
You or your legal representative has the right to revoke an authorization in writing, except to the extent that we have taken
action relying on the authorization or if the authorization was obtained as a condition of obtaining your Coverage.
Treatment: We may use and disclose your Protected Health Information as necessary for your treatment. For instance, a
doctor or health facility involved in your care may request Protected Health Information that we hold about you in order to
make decisions about your care.
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P
ayment of Claims: We may use and disclose your Protected Health Information to pay for benefi ts under your Coverage. For
example, when you present a claim for benefi ts, we may obtain medical records from the doctor or health facility involved in
your care to determine if you are eligible for benefi ts under the insurance policy and to reimburse you for services provided.
Other payment-related uses and disclosures that are permitted and we may engage in include: making claim decisions,
coordinating benefi ts with other insurers or payers, billing, claims management, collection activities, obtaining payment
under a contract for reinsurance, and related health care data processing.
Health Care Operations: We may use and disclose your Protected Health Information for our insurance operations. Our
insurance operations may include underwriting, premium rating, and other activities related to the issuance, renewal or
replacement of Coverage, or for reinsurance purposes. For example, when you apply for insurance we may collect medical
information from your doctor (health care provider) or a medical facility that provided you health care services to determine
if you qualify for insurance. We may also use and disclose Protected Health Information to conduct or arrange for medical
review, legal services, contract for reinsurance, business planning and development regarding the management and operation
of our Coverage processes, or auditing, including fraud and abuse detection and compliance programs. Protected Health
Information may also be disclosed for customer service, servicing our current and future customer relationships permitted
by law, resolution of internal grievances and as part of a potential sale, transfer, merger, or consolidation in order to make an
informed business decision regarding any such prospective transaction. For group plans Protected Health Information may
be disclosed to your Plan Sponsor for purposes of administering your Plan or other health plan maintained by your employer
to facilitate claims payments under the plan.
Business Associates: We may also disclose Protected Health Information to non-affi liated business associates, but only if
the receipt of Protected Health Information is necessary to provide a service to us and the business associate agrees to protect
the Protected Health Information according to HIPAA rules. Examples of business associates are: billing companies, data
processing companies, auditors, claims processing companies and companies that provide general administrative services.
Where Required by Law, for Public Health or Similar Activities: We may also disclose Protected Health Information
where required by law, for public health or similar activities. Examples include:
• Releasing Protected Health Information to state or local health authorities, as required by law, of particular
communicable diseases, injury, birth, death, and for other required public health investigations;
• Releasing Protected Health Information to a governmental agency or regulator with health care oversight
responsibilities;
• Releasing Protected Health Information to a coroner, medical examiner or funeral director to assist in identifying a
deceased individual or to determine the cause of death;
• Releasing Protected Health Information to public health or other appropriate authorities, as required by law, when
there is reason to suspect abuse, neglect, or domestic violence;
• Releasing Protected Health Information to the Food and Drug Administration (FDA) for purposes related to quality,
safety or effectiveness of FDA-regulated products or activities;
• Releasing Protected Health Information if required by law to do so by a court or administrative ordered subpoena or
discovery request, or for law enforcement purposes as permitted by law. We will make efforts to notify you of such
requests or to obtain an order protecting the Protected Health Information requested. We may disclose Protected
Health Information to any governmental agency or regulator with whom you have fi led a complaint or as part of a
regulatory agency examination;
• Releasing Protected Health Information for certain research purposes when such research is approved by an institutional
review board with established rules to ensure privacy;
• Releasing Protected Health Information if you are a member of the military as required by armed forces services;
• Releasing Protected Health Information to federal offi cials for intelligence, counterintelligence, and other national
security activities authorized by law.
• Releasing Protected Health Information to worker’s compensation agencies if necessary for your worker’s
compensation benefi t determination;
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•
Releasing Protected Health Information to avert a serious threat to someone’s health or safety, including the disclosure
of Protected Health Information to government or privacy disaster relief or assistance agencies to allow such entities
to carry out their responsibilities to specifi c disaster situations.
• Uses and Disclosures to Family, Friends or Others Involved in Your Care: With your written approval, we may disclose
your Protected Health Information to designated family, friend, personal representative, or other individual that you
may identify as involved in your care or involved in the payment for your care. Should you become incapacitated
or be in the face of an emergency medical situation and not able to provide us with your written approval, we may
disclose Protected Health Information about you that is directly relevant to such person’s involvement in your care
or payment for such care.
YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION
You have the following rights as a consumer under HIPAA concerning the Protected Health Information we have about you in
our records. Any request to exercise your rights as described below should be made in writing and sent to Lincoln Financial
Group, Attn: Enterprise Compliance – Corporate Privacy Offi ce - 7C-01, 1300 S Clinton Street, Fort Wayne IN 46802.
Also, should you wish to terminate a request that has been accommodated, such termination request must also be in writing
and sent to the same address listed above. Your request should include the following information: your full name, address,
and policy number. Generally, we will respond to these requests within 30 days of receipt.
Right to Request Restrictions: You have the right to request that we restrict or limit our use or disclosure of your Protected
Health Information that would otherwise be permitted for purposes related to treatment, payment or our health care operations,
including disclosure to someone who may be involved in your care or payment for your care, like a family member, friend
or personal representative. While we will consider your request, we are not required to agree to your restriction. If we do
agree to the restriction, we will not use or disclose your Protected Health Information as requested but reserve the right to
terminate the agreed to restriction if we deem appropriate. In your request to restrict use and disclosure, you must tell us (1)
what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want
the limits to apply (for example, disclosures to your spouse or parent). We will not agree to restrictions on Protected Health
Information uses or disclosures that are legally required, or which are necessary to administer our business.
Right to Request Confi dential Communications: You have the right to request that we communicate with you about
Protected Health Information in a certain way or using a certain address or email address, if you make such a request in
writing and send it to the address provided above. Your request must specify how or where you wish to be contacted. We will
accommodate all reasonable requests.
Right to Inspect and Copy Your Protected Health Information: In most instances, you have the right to inspect and obtain
a copy of the Protected Health Information that we maintain about you. Your request must be in writing and sent to the address
provided above. We will deny inspection and copying of certain Protected Health Information, for example psychotherapy
notes and Protected Health Information collected by us in connection with, or in reasonable anticipation of, any claim or
legal proceeding. We reserve the right to charge a fee for the costs of copying, mailing or other supplies associated with
your request. In those limited circumstances that we deny your request to inspect and obtain a copy of your Protected Health
Information, you have the right to request a review of our denial. Your request to review our denial should be submitted in
writing and sent to the address provided above.
Right to Amend Your Protected Health Information: You have the right to request that we amend your Protected Health
Information in our records if you believe it is inaccurate or incomplete. Your request must be in writing and sent to the address
provided above. Your request must provide your reason(s) for seeking the amendment or correction. If an amendment or
correction request is accepted, we will amend or correct all appropriate records as well as notify others with whom we have
disclosed the erroneous Protected Health Information. We may deny your request if you ask us to amend Protected Health
Information that is accurate and complete; was not created by us, unless the creator of Protected Health Information is no
longer available to make the amendment; is not part of the Protected Health Information kept by or for us; or is not part of the
Protected Health Information which you would be permitted to inspect and copy. If we deny your request, we will provide
you with an explanation for our denial and any further rights you may have regarding your request to amend.
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Right
to Receive an Accounting of Disclosures of Your Protected Health Information: You have the right to request an
accounting or list of disclosures we have made of your Protected Health Information. This list will not include disclosures
• For treatment;
• For payment or health care operations;
• To law enforcement, for purposes of national security
• To department of corrections personnel;
• Pursuant to your authorization;
• or directly to you.
To request this list, you must submit your request in writing to the address provided above. Your request must state the time
period from which you want to receive a list of disclosures. The time period may not be longer than six years and may not
include dates before April 14, 2003. The fi rst list you request within a 12-month period will be free. We reserve the right to
charge you for responding to any additional requests. We will notify you of the cost involved and you may choose to withdraw
or modify your request at that time before any costs are incurred.
Right to a Paper Copy of this Notice: You have the right to obtain a paper copy of this Notice upon request, even if you
received this Notice electronically.
Right to File a Complaint: If you believe your privacy rights have been violated, you may fi le a complaint with us or with
the Secretary of the U.S. Department of Health and Human Services. To fi le a complaint with us, you must submit a written
complaint to the address provided above. You can be assured that the Company will not retaliate against you for fi ling a
complaint.
For Further Information: For further information regarding this Notice or the Company’s privacy practices, please contact
Lincoln Financial Group, Attn: Enterprise Compliance – Corporate Privacy Offi ce - 7C-01, 1300 S Clinton Street,
Fort Wayne IN 46802, or call 1-877-275-5462.
Effective Date: This Notice is effective June 1, 2011.
*This information applies to the following Lincoln Financial Group companies:
First Penn-Pacifi c Life Insurance Company
Lincoln Life & Annuity Company of New York
The Lincoln National Life Insurance Company
Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affi liates.
GL-SPD-1 2010 CI
SUMMARY PLAN DESCRIPTION
The f
ollowing information together with your group insurance certificate issued to you by The Lincoln National Life Insurance
Company of Fort Wayne, Indiana, is the Summary Plan Description required by the Employee Retirement Income Security Act of
1974 to be distributed to participants in the Plan. This Summary Plan Description is only intended to provide an outline of the Plan's
benefits. The Plan Document will govern if there is any discrepancy between the information contained in this Description and the
Plan.
The na
me of the Plan is: Group Critical Illness Insurance for Employees of Ollie’s Bargain Outlet, Inc.
The name, address and ZIP code of the Sponsor of the Plan is:
Ollie’
s Bargain Outlet, Inc.
6295 Allentown Boulevard
Harrisburg PA 17112
Emp
loyer Identification Number (EIN): 25-1589489 IRS Plan Number: 520
The n
ame, business address, ZIP code and business telephone number of the Plan Administrator is:
Ollie’
s Bargain Outlet, Inc.
6295 Allentown Boulevard
Harrisburg PA 17112
(717) 657-2300
The Plan Administrator is responsible for the administration of the Plan and is the designated agent for the service of legal process for
the Plan. Functions performed by the Plan Administrator include: the receipt and deposit of contributions, maintenance of records of
Plan participants, authorization and payment of Plan administrative expenses, selection of the insurance consultant, selection of the
insurance carrier and assisting The Lincoln National Life Insurance Company. The Lincoln National Life Insurance Company has the
sole discretionary authority to determine eligibility and to administer claims in accord with its interpretation of policy provisions, on
the Plan Administrator's behalf.
Typ
e of Administration. The Plan is administered directly by the Plan Administrator with benefits provided in accordance with
provisions of the group insurance policy issued by The Lincoln National Life Insurance Company whose Group Insurance Service
Office address is 8801 Indian Hills Drive, Omaha, Nebraska.
Typ
e of Plan. The benefits provided under the Plan are: Group Critical Illness Insurance
Typ
e of Funding Arrangement: The Lincoln National Life Insurance Company
All
employees are given a Certificate of Group Insurance which contains a detailed description of the Benefits, any Benefit Waiting
Period, and Exclusions, including any Pre-Existing Condition Exclusion. The Certificate also contains the Schedule of Benefits which
includes the Categories of Benefits, Critical Illness Principal Sum, Benefit Amounts, Eligibility Waiting Period, and any age reduction
information. If your Booklet, Certificate or Schedule of Benefits has been misplaced, you may obtain a copy from the Plan
Administrator at no charge.
Eligib
ility. Full-time employees working at least 20 hours per week.
Employees become eligible on the first day of the Insurance Month following the date of active full-time e
mployment.
Cont
ributions. You are required to make contributions for Personal Critical Illness Insurance. You are required to make
contributions for Dependent Critical Illness Insurance.
The P
lan's fiscal year ends on: June 30
th
of each year
The n
ame and section of relevant Collective Bargaining Agreements: None
The
name, title and address of each Plan Trustee: None
GL-SPD-2 2010 CI
Loss of Benefits. The Plan Administrator may terminate the policy, or subject to The Lincoln National Life Insurance Company's
approval, may modify, amend or change the provisions, terms and conditions of the policy. Coverage will also terminate if the
premiums are not paid when due. No consent of any Insured Person or any other person referred to in the policy will be required to
terminate, modify, amend or change the policy. See your Plan Administrator to determine what, if any, arrangements may be made to
continue your coverage beyond the date you cease active work.
Claims Procedures. You may obtain claim forms and instructions for filing claims from the Plan Administrator or from the Group
Insurance Service Office of The Lincoln National Life Insurance Company. To expedite the processing of your claim, instructions on
the claim form should be followed carefully; be sure all questions are answered fully. In accordance with ERISA, The Lincoln
National Life Insurance Company will send you or your beneficiary a written notice of its claim decision within:
• 90 days after receiving the first proof of a Critical Illness claim (180 days under special circumstances); or 45
days after receiving the first proof of a disability claim, if applicable (105
th
day under special circumstances).
If a claim is partially or wholly denied, this written notice will explain the reason(s) for denial, how a review of the decision may be
requested, and whether more information is needed to support the claim. You, or another person on your behalf, may request a review
of the claim by making a written request to The Lincoln National Life Insurance Company within:
• 60 days after receiving a denial notice of a Critical Illness claim; or 180 days after receiving a denial notice of a
claim for disability benefits, if applicable.
This written request for review should state the reasons why you feel the claim should not have been denied and should include any
additional documentation to support your claim. You may also submit for consideration additional questions or comments you feel
are appropriate, and you may review certain non-privileged information relating to the request for review. The Lincoln National Life
Insurance Company will make a full and fair review of the claim and provide a final written decision to you or your beneficiary
within:
• 60 days after receiving the request for a review of a death or other Critical Illness claim (120 days under special
circumstances); or 45 days after receiving the request for review of a claim for disability benefits, if applicable (90
days under special circumstances).
If more information is needed to resolve a claim, the information must be supplied within 45 days after requested. Any resulting delay
will not count toward the above time limits for claims or appeals processing. Please refer to your certificate of insurance for more
information about how to file a claim, how to appeal a denied claim, and for details regarding the claims procedures.
Statement of ERISA Rights
The following statement of ERISA rights is required by federal law and regulation. As a participant in this plan, you are entitled to
certain rights and protections under the Employee Retirement Income Security Act of 1974 (ERISA). ERISA provides that all Plan
participants shall be entitled to:
Receive Information About Your Plan and Benefits. Examine, without charge, at the Plan Administrator's office and at other
specified locations, such as worksites and union halls, all documents governing the plan, including insurance contracts and collective
bargaining agreements, and a copy of the latest annual report (Form 5500 Series), if any, filed by the plan with the U.S. Department of
Labor and available at the Public Disclosure Room of the Pension and Welfare Benefit Administration.
Obtain, upon written request to the Plan Administrator, copies of documents governing the operation of the plan, including insurance
contracts and collective bargaining agreements, and copies of the latest annual report (Form 5500 Series), if any, and updated
summary plan description. The administrator may make a reasonable charge for copies.
Receive a summary of the plan's annual financial report if the plan covers 100 or more participants. The Plan Administrator is
required by law to furnish each participant with a copy of this summary annual report.
Prudent Actions by Plan Fiduciaries. In addition to creating rights for plan participants, ERISA imposes duties upon the people
who are responsible for the operation of the employee benefit plan. The people who operate your plan, called "fiduciaries" of the plan,
have a duty to do so prudently and in the interest of you and other plan participants and beneficiaries. No one, including your
employer, your union, or any other person, may fire you or otherwise discriminate against you in any way to prevent you from
obtaining a welfare benefit or exercising your rights under ERISA.
Enforce Your Rights. If your claim for a welfare benefit is denied or ignored, in whole or in part, you have a right to know why this
was done, to obtain copies of documents relating to the decision without charge, and to appeal any denial, all within certain time
schedules.
Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request a copy of plan documents or the
latest annual report from the plan and do not receive them within 30 days, you may file suit in a Federal court. In such a case, the
court may require the Plan Administrator to provide the materials and pay you up to $110 a day until you receive the materials, unless
the materials were not sent because of reasons beyond the control of the Administrator. If you have a claim for benefits which is
denied or ignored, in whole or in part, you may file suit in a state or Federal court. If it should happen that plan fiduciaries misuse the
plan's money, or if you are discriminated against for asserting your rights, you may seek assistance from the U.S. Department of
Labor, or you may file suit in a Federal court. The court will decide who should pay court costs and legal fees. If you are successful
the court may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and
fees, for example, if it finds your claim is frivolous.
Assistance with Your Questions. If you have any questions about your plan, you should contact the Plan Administrator. If you have
any questions about this statement or about your rights under ERISA, or if you need assistance in obtaining documents from the plan
administrator, you should contact the nearest office of the Employee Benefits Security Administration, U.S. Department of Labor
(listed in your telephone directory) or contact the Division of Technical Assistance and Inquiries, Employee Benefits Security
Administration, U.S. Department of Labor, 200 Constitution Avenue, N.W., Washington, D.C. 20210. You may also obtain certain
publications about your rights and responsibilities under ERISA by calling the publications hotline of the Employee Benefits Security
Administration.
