CNA Group Life AssuranceCNA Group Life Assurance Company
INSURANCE IN TOUC~ W~TH YOUR WORLD
CNA Plaza
Chicago, Illinois 60685
A Stock Company
MASTER APPLICA TION PnOVEDASTOFOnUB
Application is hereby made to CNA Group Life Assurance Company for Accidental Death and
Dismemberment Insurance by:
1) Applicant City of Carmel
2) Address One Civic Square Carmel IN 46032
3)
4)
6)
6)
(Street and Number)
(City) (State) (Zip)
To be effective in the State of
Indiana
and governed by the laws thereof.
Coverage Applied for:
[] Accidental Death and Dismemberment Benefit
[] Dependent Accidental Death and Dismemberment Benefit
Eligibility
The classes of individuals eligible for coverage are identified in the Po[icy.
Effective Date
The Policy applied for will become effective at 12:01 a.m. Standard Time at the Applicant's address, given
herein, on September 1, 2003 provided this Application is accepted in writing by CNA Group Life
Assurance Company. It is agreed that the Policy cannot become effective until a deposit premium has
been paid. The Applicant agrees that the Policy cannot become effective until at least 20% of the eligible
individuals have enrolled in the contributory plan.
This Application is attached to and made a part of Policy Number SR-8308634'1.
City of Carmel
Applicant
By see attached signature page
Signature Title Date
Z3-140196-A
CNA Group Life Assurance Company
Master Application for Accidental Death and Dismemberment Insurance
CITY OF CARMEL, INDIANA
By and through its Board of Public Works and Safety
~mes Brainard, Presiding Officer Date
Mary ~nn Burke, Boar$l.4vlember
~~l~ard Member
7a~a C ordmy, IAMC, C~-~reasurer Date
Date
Date~/~ ~/
CNA Group Life Assurance Company
CNA Plaza
Chicago, Illinois 60685
A Stock Company
Holder:
Policy Number:
Policy Effective Date:
Anniversary Date:
City of Carmel
SR-83086341
September 1, 2003
September 1
The Policy is issued in consideration of the payment of premium and the statements made in the Master
Application.
We agree with the Holder to insure certain eligible persons under the Policy. We promise to pay benefits for loss
covered by the Policy in accordance with its provisions.
The Policy takes effect on the Policy Effective Date. All insurance periods will be computed from that date. The
Policy remains in force for the period for which premium has been paid. It may be renewed for further successive
periods by payment of premiums as stated in the Policy. We and the Holder have the right to non-renew the
Policy as of September 1, 2004 or any later premium due date. At least 31 days prior written notice of such non-
renewal must be provided.
All periods of insurance begin and end at 12:01 A.M., Standard Time, at the Holder's address.
ADDP-IAA
Signed for CNA Group Life Assurance Company
~oJf the
SBGADD-P
Group Accidental Death and Dismemberment Policy
It Does Not Pay Benefits for Loss from sickness
Renewable with the Consent of the Company
TABLE OF CONTENTS
PRO VISION PA GE
C/assification And Definition .............................................................................................................................. 3
Contributory ....................................................................................................................................................... 3
Premium Provisions .......................................................................................................................................... 3
Termination Of Policy ........................................................................................................................................ 4
Additional Provisions ................................................................................................................. : ............... ; ....... 4
Contract Provisions ........................................................................................................................................... 5
ATTACHMENTS:
· Master Application
· Certificate of Insurance
TOC-P
SBGADD-P 2
CLASSIFICATION AND DEFINITION
Eligible Classes
All individuals in the following classes are eligible for insurance:
Ali active, full-time Employees of the Holder working in the United States of America.
Full-time means Actively Working an average of at least 30 hours per week for the Holder. All pad-time,
temporary, seasonal or retired employees of the Holder are not eligible.
ADDP-2AA
CONTRIBUTORY
The coverage provided under the Policy will be on the Contributory plan for:
· Accidental Death and Dismemberment Benefit
· Dependent Accidental Death and Dismemberment Benefit
The Insured must apply for such insurance and agree to make the required premiums.
ADDP-4AA
PREMIUM PROVISIONS
Premiums
The premium rates shall be as proposed by Us and agreed to by the Holder. As of the Policy Effective Date, the
premium rates for the coverage provided are as follows:
Employee Only Insurance
Employee and Family Insurance
$0.960 per $10,000 of the Insured's Principal
Sum
$1.170 per $10,000 of the Insured's Principal
Sum
The Policy is issued in consideration of the payment of the monthly premium. Premium is due on the Policy
Effective Date, and thereafter on each premium due date. The premium due date is the first day of each month.
Payment of the required premium 5y the due date will pay the Policy to the next premium due date. All premiums
are to be paid by the Holder to Us or to Our duly authorized agent.
If a Covered Person's insurance:
1 ) becomes effective; or
2) changes in amount;
on other than a premium due date, premium will be charged for that person as of the next premium due date.
If a Covered Person's insurance ceases on other than a premium due date, premium must be paid for that person
up to the next due date.
We have the right to change the premium rates on any premium due date in accordance with the Premium Rate
Guarantee provision. We also reserve the right to inspect the Holder's books and records as they relate to the
insurance under the Policy. This right to inspect the Holder's books and records will be exercised at reasonable
times.
ADDP-SAA
SBGADD-P 3
Premium Rate Guarantee
We agree not to change the premium rates. Such agreement shall be valid until September 1,2004 if:
1) there are no changes made to the Policy;
. 2) there is a minimum of 10 Insureds, and there is less than a 25% change to the number of Insureds since
the effective date of the Policy; and
3) there are no new classes of employees, subsidiaries, affiliated employers or new acquisitions of the Holder
added after the effective date of the Policy.
We have the right to change premium rates on any premium due date after September 1, 2004. We will give 31
days written notice of the change to the Holder before any change in rate will become effective.
Grace Period
A grace period of 31 days from the premium due date is allowed for the payment of any unpaid premium. The
Policy will remain in force during the grace period. If the premium is not paid by the end of the grace period, the
Policy will terminate on that date. The Holder will continue to be liable to Us for any unpaid premium.
AODP-7AA
TERMINATION OF POLICY
The Holder can terminate the Policy or a plan under the Policy by giving written notice to Us at least 31 days prior
to the termination date.
We may terminate the Policy only if:
1) there is less than 20% participation of those Eligible Persons for a Contributory plan;
2) the Holder fails to perform any of its obligations that relate to the Policy;
3) there are fewer than 10 Insureds under the Policy; or
4) the Holder fails to pay any premium within the grace period.
If We terminate the Policy for reasons other than the Holder's failure to pay premium, a written notice will be
delivered to the Holder at least 31 days prior to the termination date.
ADDITIONAL PROVISIONS
Registry of Individuals
Upon Our request, the Holder must furnish Us with:
1 ) the names of all persons who are insured on the Policy Effective Date;
2) the names of all persons who become eligible for insurance after the Policy Effective Date;
3) names of all persons whose eligibility for insurance ceases before the Policy terminates; and
4) all data necessary to determine the premium for the Policy.
ADDP-9,~A
Individual Certificates
We will deliver certificates of insurance to the Holder for issuance to each Insured. The certificate will state or
describe the coverage provided, and to whom benefits are payable. It will also state the rights to which an Insured
is entitled under the Conversion PriviJege.
ADDP-10AA
Agency
For all purposes of the Policy, the Holder acts on its own behalf or as the Insured's agent.
circumstances will the Holder be deemed Our agent.
ADDP-I 1AA
Under no
SBGADD-P 4
CONTRA CT PROVISIONS
Entire Contract
The Policy and the following documents form the entire contract between the par[les:
1) the attached Master Application;
2) the attached Certificate of insurance for each eligible class under the Policy;
3) the individual applications of the Insureds, if any; and
4) any attached papers.
ADDP-12AA
Policy Changes
No change to the PolicY is valid unless it is approved in writing on the Policy by one of Our executive officers. No
agent has the right to change the Policy or waive any of its provisions.
ADDP-13AA
Incontestability
All statements made by the Holder will be deemed representations and not warranties. Except for non-payment of
premium, the Policy cannot be contested after 2 years from the Policy Effective Date.
SBGADD-P 5
Companies (herein CNA)
Continental Assurance Company
Continental Casualty Company
CNA Group Life Assurance Company
Insurance Products
Group Disability Income Group Hospital indemnity
Group Life Group Dental
Group Accident Group Long Term Care
Group Medical
STATEMENT OF PRIVACY POLICY
The nature of insurance requires that insurers periodically gather individuals' personal information in order to
properly underwrite, administer, or service insurance products. However, CNA recognizes that the protection of
individuals' personal information under your group insurance policies is a matter of great importance. This notice
explains our overall commitment to privacy with respect to nonpublic personal financial or health information
(herein called "personal information").
Information We May Collect
We collect personal information about individuals where necessary to review, process or service requests for
products, benefits or other services. For example, we may collect personal information to determine eligibility for
coverage or benefits under one or more of our products.
Most information we collect is obtained from the policyholder or directly from the individuals in your group
insurance program. Generally, we request identification information such as name, address, phone number, and
social security number. Additional information maY be collected from third parties, depending on the product or
service. Third parties may include employers, insurance agencies or brokers, other CNA companies, information
service companies, other insurers, consumer reporting agencies and health care providers. Information collected
may relate to the individuals' finances, employment, health, avocations, or other personal characteristics.
How We May Disclose Collected Information
We use the collected information to carry out our normal business activities such as making coverage, service,
benefit and other insurance-related decisions. As a result, we sometimes share information with CNA affiliates
and nonaffiliated third parties to carry out our normal business activities, service your business, or in connection
with offering additional products. Examples of nonaffiliated third parties include health care providers, employers,
health information clearinghouses, other insurers and consumer reporting agencies. Affiliates are those
companies within the CNA family of companies. They may include life insurers, property and casualty insurers,
insurance agencies and brokers, third party administrators, information service companies, securities firms,
broker/dealers and financial advisors. We may also share information with business partners with whom we
jointly offer products.
Other than as described above, or otherwise permitted by law, we will not share personal information with
nonaffiliated third parties without first giving an individual the opportunity to tell us that he or she does not want us
to share his or her personal information. As a result, individuals need not do anything further at this time to enjoy
the protections of this Privacy Policy.
We understand the sensitive nature of medical record information. As a result, we do not disclose an individual's
medical record information (or information received from consumer reports) unless it is required to carry out our
normal business activities, where such disclosure is required by law, or authorized by the individual whose
information is being disclosed. Information that may be obtained from a report prepared by an insurance-support
organization (such as a consumer report) may be retained by that organization and disclosed to other persons to
the extent allowed by law.
How We Protect Information
CNA restricts access to personal information to those employees or service providers who need to know the
information in order to provide products or services. We regularly review our security measures and employee
education programs to help ensure the protection of personal information held in our records. When we share
personal information with nonaffiliated third parties, we require that they have standards to keep the information
private.
An individual has the right to request a review or correction of personal recorded information collected in
connection with a request for insurance under your group insurance policy. Individuals may write to us for more
information on how to exercise such rights. Our address is CNA Plaza, Attn: Group Benefits Compliance,
Chicago, IL 60685.
General Terms of This Notice
This privacy policy is not in lieu of any other privacy notice issued by any other affiliate, business unit, department
or division of CNA Financial Corporation. We reserve the right to change this privacy policy at any time. If our
information sharing practices change, we will notify affected individuals and explain if any action may be required
on their part. Please note that our overall commitment to privacy does not change even if our relationship with
you has ended.
If you have any questions concerning this Statement of Privacy Policy, please contact us toll-free at
1-800-491-3817.
STATE SUPPLEMENT
The following policies apply only to those individuals in your group insurance program who reside in the
referenced states.
Arizona and Maine
Except as otherwise permitted by law, we will not disclose collected personal information about an individual to a
nonaffiliated third party with whom we jointly offer products without giving the individual an opportunity to tell us
that he or she does not want us to share his or her personal information.
Minnesota and Montana
Except as otherwise permitted by law, we will not disclose collected personal information about an individual to a
nonaffiliated third party with whom we jointly offer products without obtaining the individual's written authorization.
Montana
Upon written request, an individual who has authorized the collection of health information is entitled to receive a
record of CNA's disclosures of any of his medical record information made within the preceding 3 years.
Oregon
An individual has the right to authorize disclosure of his or her personal information to an insurance company. An
Oregon resident can exercise this right by requesting an authorization form in writing. Our address is CNA Plaza,
Attn: Group Benefits Compliance, Chicago, IL 60685.
September 1,2003
CNA Group Life Assurance Company
CNA Plaza
Chicago, illinois 60685
A Stock Company
AMENDMENT
This Amendment is attached to and forms a part of Group Insurance Policy SR-83086341 effective September 1,
2003 (herein the Policy). The Policy is issued to City of Carmel as Holder.
Effective September 1,2003, the Policy replaces and supersedes Group Insurance Policy SR-830863~tl effective
September 1, 1992 (herein the Prior Policy). Letters of intent issued under the Prior Policy are hereby attached
to, and form part of, the Policy.
All rights and obligations accruing on and after September 1,2003 will be governed by the terms and conditions of
the Policy. All rights and obligations accruing prior to September 1, 2003 will be governed by the terms and
conditions of the Prior Policy.
This Amendment takes effect and ends at the same time as the Policy. Nothing herein contained will be held to
alter, vary or affect any of the terms, provisions, or conditions of the Policy other than as above stated.
Signed for CNA Group Life Assurance Company
~Chair~man of the Board~¢/
BG-140197-A