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Home My WebLink AboutAgr 2016-12-08 (Met Life) MetLife Town of Tiburon Heidi Bigall 1505 Tiburon Blvd. Tiburon, CA 94920 December 8, 2016 Group Number: KM 05573497-G Dear Heidi Bigall: Thank you for your continued business. At MetLife, we take pride in keeping up-to-date customer records. This helps to ensure that we have an accurate benefit plan on file in order to provide you and your employees with extraordinary service. Enclosed are two copies of the Policy Amendment for your group insurance. These pages need to be signed by the Executive Correspondent. Once signed, please retain one copy of the Policy Amendment page for your records and return the remaining signed copy of the Policy Amendment page to MetLife within seven (7)days to the address that appears in the bottom left hand corner of this letter. Please do not return to the New York address on the attached Amendment. You will be receiving a supply of riders to distribute to your employees. Thank you for your prompt attention to this request. If you have any questions regarding this information, please contact our Customer Service Center at 1-800-275-4638 or e-mail us at ASK4MET@metlifeservice.com. Sincerely, Small Market Customer Service Center Metropolitan Life Insurance Company 4150 North Mulberry Drive, Suite 300, Kansas City, MO 64116 MetLife Metropolitan Life Insurance Company 200 Park Avenue, New York, New York 10166-0188 POLICY AMENDMENT Group Policy No.: KM 05573497-G Policyholder: Town of Tiburon Effective Date: December 01,2016 Metropolitan Life Insurance Company("MetLife"), a stock company, issues this amendment to change the following: Add to Exhibit 2 of the policy the attached certificate form as: Certificate Form Applies To Effective Date Form G.8480 All Active Full-Time Service Employees December 01, 2016 International Union Represented Employees This amendment is to be attached to and made a part of the policy. This amendment is subject to the terms and provisions of the policy. To be completed by the Policyholder: Signed at: --fo all Date: I a, — I - f (City) (State) (Signature of Policyholders AutUlrized Representative) (Print Name and Title of&JhorizedRepresentative) Suzanrio Creekmorer �, , �Witn,, �� (Print Name of Witness) To be completed by Metropolitan Life Insurance Company: Signed at: Kansas City, Missouri Date:12/08/2016 (City) (State) / �(Dg (Signature of Authorized MetLife Representative) Steven A. Kandarian Chairman, President and Chief Executive Officer PA99 Long Term Disability Insurance RV 12/08/2016 MetLife Metropolitan Life Insurance Company 200 Park Avenue, New York, New York 1 01 66-01 88 CERTIFICATE RIDER Group Policy No.: KM 05573497-G Employer: Town of Tiburon Effective Date: December 01,2016 The certificate is changed as follows: The attached replaces the Plan Highlights in your certificate. This rider is to be attached to and made a part of the Certificate. Form G.8480 Long Term Disability Insurance All Active Full-Time Service Employees International Union Represented Employees RV 12/08/2016 PLAN HIGHLIGHTS This Plan Highlights section is a summary of your Long Term Disability Benefits and provisions. See the rest of your Certificate for more information. It is important to read the rest of your Certificate. It describes your benefits as well as any exclusions and limitations that apply to these benefits. Please read it carefully. You should talk with your Employer if you have any questions. You will notice that some of the terms used in your Certificate begin with capital letters.These terms have special meanings. They are explained in this Certificate. Employee Eligibility Eligible Employee: All Active Full-Time Service Employees International Union Represented Employees working at least 20 hours each week. However, if you do not have regular work hours you will be an Eligible Employee if you have worked at least an average of 20 hours a week during the preceding 12 calendar months(or during your period of employment if less than 12 months). Eligibility Waiting Period: Active Employees on and after December 01,2016: None Eligibility Date: December 01,2016 or the first day of the calendar month after you complete the Eligibility Waiting Period, whichever is later. Long Term Disability Benefits Monthly Benefit: 66 2/3%of the first$5,999 of your Predisability Earnings, but not more than the Maximum Monthly Benefit below, reduced by Other Income Benefits.Other Income Benefits are described in Section B. of Long Term Disability Benefits. Maximum Monthly Benefit: $4,000 Minimum Monthly Benefit: $100.The Minimum Monthly Benefit will not apply if you are in an Overpayment situation or are receiving income from employment. Elimination Period:30 days of continuous Disability Maximum Benefit Duration:The duration shown below: 1 Age on Date Maximum Benefit Disability Starts Duration Less than 60 To age 65 60 60 months 61 48 months 62 42 months 63 36 months 64 30 months 65 24 months 66 21 months 67 18 months 68 15 months 69 and over 12months Work Incentive: Work while Disabled: No offset for employment earnings during the first 24 months after you have satisfied your Elimination Period. However, your Monthly Benefit may be reduced if the total income you are receiving (including Rehabilitation Incentive and Family Care Expenses) exceeds 100%of your Predisability Earnings or Indexed Predisability Earnings. Rehabilitation Incentive: Your Monthly Benefit, before reduction for Other Income Benefits, is increased by 10%while participating in an approved Rehabilitation Program. Family Care Expenses:While participating in an approved Rehabilitation Program, up to $250 per month incurred for Eligible Family Care Expenses for each Eligible Family Member during the first 24 months after you have satisfied the Elimination Period. Survivors Benefit:A lump sum equal to 3 times the Monthly Benefit before reductions for Other Income Benefits. Conversion Privilege: If your coverage under This Plan terminates, you may be eligible to convert to a long term disability conversion plan. 2 Limitations Limitation for Pre-existing Conditions: Coverage for Pre-existing Conditions begins 12 months after your Effective Date of coverage. Limitation For Disabilities Due to Particular Conditions Limitation for Disability due to(i) Mental or Nervous Disorders or Diseases; or(ii) Neuromuscular, Musculoskeletal and Soft Tissue Disorder; or(iii) Chronic Fatigue Syndrome: 24 Monthly Benefits in your lifetime, or the Maximum Benefit Duration, whichever is less. Benefits may be paid beyond 24 months as described in the provision, subject to certain requirements. Limitation for Drug, Alcohol or Substance Abuse or Dependency: One period of Disability in your lifetime for up to: 24 Monthly Benefits; your successful completion of an approved rehabilitative program; your ceasing or refusing to participate in a rehabilitative program; or the Maximum Benefit Duration; whichever is less. Contributions Non-Contributory Insurance is coverage for which the Employer pays the entire premium. Contributory Insurance is coverage for which you have to pay all or any part of the premium. Please see your Employer regarding any contributions you may need to make for the coverage under This Plan. Benefits Checklist In order to receive benefits under This Plan, you must provide to us at your expense, and subject to our satisfaction, all of the following documents. These are explained in this Certificate. Initial submission of these documents should be made no later than the 12th week following your original date of disability. J Proof of Disability. J Evidence of continuing Disability. J Proof that you are under the Appropriate Care and Treatment of a Doctor throughout your Disability. J Information about Other Income Benefits. J Any other material information related to your Disability which may be requested by us. Form G.24303-A-NDC 3