kocot v. florida combined life insurance company, inc. complaint

8/12/2019 KOCOT v. FLORIDA COMBINED LIFE INSURANCE COMPANY, INC. complaint

1/43

CIIII'I

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I)I'I

ICLR

JEFF ATtVATER

snAI

Ii

oli

I I

OR) t&A

14-073149

RICHARD KOCOT,

P

LA

INTIFF(S),

VS,

CASE

JJ;

502014CA 007311

XXXX

MB

COURT:

CIRCUIT

COURT

COUNTY: PALM

BEACH

DFS-SOP{{1;

14-073149

FLORIDA

COMBINED LIFE

INSURANCE

COMPANY

DF

FENDANT(S),

CIVIL

ACTION SUMMONS,

COMPLAINT,

EXI-II

BITS

NOTICE

OF

SERVICE

OF

PROCESS

NOTICE IS HFREIBY GIVEN

of

acceptance

of

Service

of

Process

by

the Chief

Financial

Officer

of

the

State

of

Florida,

Said

process

was

received

in

my

office

by

PROCESS

SERVER

on

the 23rd

day

of June,

2014

and

a

copy

was forwarded

by

Electronic

Delivery

on

the 30th

day

of

June,

2014

to

the

designated

agent

for the

named

entity

as shown below.

FLORIDA

COIVIBINED

LIFE INSURANCE

COMPANY

LYNETTE COLEMAN

CORPORATION

SERVICE

COM

PANY

1201

HAYS

STREET

TALLAHASSEE,

FL

32301

*

Our

office cvill

only

serve the

initial

process (Summons

and

Complaint)

or

Subpoena

and

is not

responsible

for

transmittal of

any

subsctiuent

fiiings,

pleadings

or documents unless

othcmvisc

ortlcrcd

by

the

Court

pursuant

to

Florida

Rules of

Civil

procedure, Rulc gl.{)go.

Jeff

Atwater

Chief

Financial

Officer

ec

to,

Plaintiffs Representative

for

liling

in

appropriate

court,

MATTHEW

T,

RAMENDA

505

SOUTH

FLAGLER

DRIVE,

STE. 1100

WEST PALM

BEACH

FL

33401

TMB

EXHIBIT

1

Dividion of

Legal

Services

-

Service

ol'Process

Section

200

East Gsines Strcct

~

PQ Itov

6200

~

Tails))asses, Flotlda

323{4

6200

~

{810)

413%200

-

Fax

{850)

922

2544

Case 9:14-cv-80945-KAM Document 1-1 Entered on FLSD Docket 07/16/2014 Page 1 of 43


2/43

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CIVIL

ACTION

SUMMONS(

,'j

r

r(

I,',,'

&

I','-.,IN

THE

CIRCUIT

COURT

OF

THE

15TH

iC.

JiUDICIAL

CIRCUIT

IN

AND

FOR PALM

BEACH

COUNTY,

FLORIDA

CASE

NO.

502014CA007311XXXXlvIB

RICHARD KOCOT,

Plaintiff,

FLORIDA

COMBINED

L

IF

E

INSURANCE,

INC.

Deferrdant(s).

Tlm8'y:

THE STATE

OF

FLORIDA:

To All and

Singular

the

Sheriffs

of

the

State:

YOU ARE

COMMANDED

to

sei ve

this

Summons

aiid

a

copy

of

the

Complaint

in

this

action

orr

Defendant:

Name

of

corporation

13y

serving

its

Registered

Agent.

Address:

Florida

Combined

Life

Insur;incc

Company,~

Chief

Financial

Officer

200

E.

Gaines

Street

Tallahassee,

FL

32399-0000

Each Defendant

is

required

to

serve written

defenses to the

Complaint

on

Plaintiff's

attorney,

whose

name

and

address

is:

Matthew

T. Ranreiida,

Esquire

Jones,

Foster,

Jolinston

0,

Stubbs,

I'.h.

505

South

Flagler

Drive,

Suite

1100

West

Palm

Beach,

Florida33401-3475

(561)

659-3000

within

20

days

after senicc

of this

Summons

on

that

Defendant,

exclusive

of

the

day

ol'service,

and to

file the

original

of

the

defenses with

the

Clerk of

this

Court

either

before

service on

Plaintiffs attorney

or

immediately

thereafter. If

a

Defendant fails

to

do

so,

a

default

will

be

entered

against that

Defendant

fo 'h

relict

demanded

in the

Complaint,

DATED this

''~&RON

R

EIOC

lerk

rt

i

0,

QQX

8667

33~p

~~6

Roftdq

1Ar.

O)rr

e

I

V@~

OF

f'HARON

R,

BOCK

CI.ERK

8c

COMPTROLLER

PALM

BF

CHCO

Y

By:

~

arrl

L~~A~~

De

puty

Clerk

RObITI

Pigdp -



3/43

RICHARD

KOCOT,

Plaintiff,

IN THE

CIRCUIT

COURT

OF THE

FIFTEENTH

JUDICIAL

CIRCUIT IN AND

FOR

PALM

BEACH COUNTY,

FLORIDA

CASE

NO,

502014CA007311XXXXMB

Fl ORIDA COMBINED

LIFE

INSURANCE COMPANY, INC.,

a

Florida

corporation,

Defendant.

COMPLAINT

COMES NOW

Plaintiff

Richard

Kocot

to

sue Defendant

Florida

Combined

Life

Insurance

Company,

Inc.,

and alleges as

follows..

PARTIES

Richard

Kocot

(

Mr.

Kocot ),

a

natural

person,

is

the

beneficiary

of the

life

insurance

policy

issued

by

Defendant.

2.

Florida

Combined Life

Insurance

Company,

Inc.

(

Florida

Combined

Life

)

is

an active

Florida

corporation with

a

principal

place

of

business

located

at

the following

street

address,

4800

Deerwood

Campus

Parkway,

Building 200,

Suite

600,

Jacksonville,

FL

32246.

JURISDICTION

8 VENUE

3.

This

is

an

action for

damages

in

excess

of

$

15,000.00

exclusive

of

interest,

attorney's

fees

and costs

.

4.

This

Court has jurisdiction

of

this

action pursuant to

g

26.012,

Fla.

Stat.



4/43

Kocot

v. Florida

Combined

Life ins.

Co,

Case

No.

Complaint

Page

2of 5

5.

Venue

is

proper

in

Palm

Beach

County,

Florida

pursuant

to

H

47,011

8

47.051,

Fla, Stat.,

in

that:

(1)

the

contract

was breached

in

Palm

Beach

County,

Florida, and

(2)

the

Certificate

of Insurance

was issued in

Palm

Beach

County,

GENERAL

ALLEGATIONS

6. In

December

of

2010,

Dawn

Mi.

Kocot

( Ms,

Kocot )

applied

for

group

term

life

insurance

through

her

employer,

Comprehensive Pain

Management.

7.

Also

in

December

of

2010,

F'iorida

Combined

Life

delivered

to

Ms, Kocot

in

Palm

Beach County,

Florida,

a

19-page

document

executed

by

the

President

and

Secretary

of

Florida

Combined

Life

entitled

Certificate

for

Group

Life and

Short

Term

Disability

Insurance

(the

Certificate

of

Insurance,

attached

hereto

as

Exhibit

1).

8.

The

cover

page

of

the

Certificate of

Insurance

provides

the

following:

Policy:

We

haveissued

the

group policy

lo

the policyholder.

The

policy

is

a

contract

ofinsurance

1.

between

your

policyholder

and

us;

and

2.

fhrough

which vou

are

insured.

See

Certificate

of

Insurance,

p.

1

(emphasis

supplied).

9.

Page'3

of

the

Certificate

of

Insurance provides

the

following

specific

and

unambiguous

information

relating

to

the

insurance coverage

Florida

Combined

Life

provided

to Ms.

Kocot:

POLICYHOLDER

COMPREHENSIVE

PAIN

MANAGEIIENT

GROUP

POLICY

NUMBER

85244003

CERTIFICATE

HOLDER

See

Certificate

of

Insurance,

p,

3.

DAWN

M.

KOCOT



5/43

Kocot v. Florida

Combined

Life ins.

Co.

Case

No,

Complaint

Page

3

of

5

10.

Page

3 of the

Certificate of

Insurance

further

provides

that

Effective

02/01/11

the

benefit

amount on the

Insured's

term

life

insurance

is

$

25,000.00.

11,

In

addition

to

the

information

contained on

Page

3 of the

Certificate of

Insurance

which

indicates that

coverage

commenced

effective

on

February

1,

2011,

the

DEFINITIONS

section contained

within the

Certificate

of

Insurance

provides

the

following

definition:

'Effective date'

the

date

the

policy

is

put

in

force,

it

is

shown

on

page

three

of the

certificate.

See

Certificate

of

Insurance,

p.

5.

12. The

Certificate

of

Insurance,

which

indicated that

coverage

was

effective

on February 1,

2011,

was

the

oniy

document

pertaining

to

the effective

date

of

insurance

coverage

received

by

Ms,

Kocot

from

Florida

Combined Life.

13.

Ms. Kocot received

no

written

communication

of

any

kind

from

Florida

Combined Life,

either

before

or

after

February

1,

2011,

indicating

that the

insured's

term

life

insurance

would

not or

did

not

become

effective

on

February

1,

2011,

14.

When

Ms.

Kocot

passed

away

on

January

14,

2013,

Ms.

Kocot

was

covered

by

the term

life insurance

provided

by

Florida

Combined

Life.

15. On

March

6,

2013,

the Employee

Death

Claim

Statement

(the

Claim

Statement,

attached

hereto

as

Exhibit

2)

was

properly

submitted to Florida

Combined

Life.

16.

Florida

Combined

Lif'e

has

refused

to

pay

Mr. Kocot

the

$

25,000

death

benefit

to

which

he

is entitled.



6/43

Kocot

v

Florida

Combined Life

Ins,

Co,

Case No.

Complaint

Page4of5

COUNT I

BREACH

OF

CONTRACT

17,

Mr.

Kocot

realleges

the

allegations

contained

in Paragraphs

1

through

16

and

fully

incorporates

each

and every

one of

those

paragraphs

into

Count

I.

18.

Mr.

Kocot is

the

beneficiary

of

a

life

insurance

contract

which

is'evidenced

by

the

Certificate

of

Service.

19.

Pursuant to

the

terms of

the

life

insurance

contract,

Mr.

Kocot is

entitled

to

receive

$

25,000

as

the beneficiary.

20,

Florida

Combined

Lif'e

has materially

breached

the life

insurance

contract

by

failing

to

pay

Mr.

Kocot

the

$

25,000

death

benefit to

which

he,

as

the beneficiary,

is

entitled.

21,

Mr.

Kocot

has

been

monetarily

damaged

as

a

direct

result of

Florida

Combined

Life's

material

breach.

WHEREFORE,

Mr.

Kocot respectfully

requests

this

Court

enter

judgment

in

favor

of

Mr.

Kocot

and against

Florida

Combined

Life:

(1)

providing

for

damages

in

the

amount

of

$

25,000,00,

(2)

awarding

attorney's fees

and

costs

in

favor

of

Mr.

Kocot and

to

be

paid

by

Florida

Combined

Life

pursuant

to

g

627.428,

Fla.

Stat.

and

g

57.041,

Fla.

Stat,,

and

(3)

providing

such

other

and

further

relief

in

favor

of

Mr. Kocot

as

the

Court

deems

just

and

proper.

I

r



7/43

Kocot

v.

Florida

Combined

Life

Ins.

Co,

gase

No.

Complaint

Page

5 of 5

DEMAND FOR

JURY

TRIAL

Plaintiff

demands

a

trial

by

jury

on

all

claims

and

issues

so

triable,

Dated

this

16th

day

of

June,

2014.

JONES,

FOSTER,

JOHNSTON

5

STUBBS,

P,A.

Counsel for l

lainfiff

505

South

Flagler Drive,

Suite 1100

West

Palm

Beach,

Florida

33401

Telephone:

(561)

659-3000

+Elec

Ionic

Mail:

mragmen

a~ja

eeioeier.corn

r

.,

jnW

Fla.

Bar

No,

863076



8/43

F(orlda

Cosnbined

Lite

Insurance

Company,

Inc,

ATTN;

Group

Claims

Dopa&trner&t

P.O.

EIox

45132

10

receive

claims

assistance,

please

Jacksonv(l(e,

Florida

32232-61'32 cz&(i

1-800-696-()552,

EMPLOYEE

DEATH

CLAIM

STATEMEh)T

If

you

are making

claim

for

a deceased

INSURED

DEPENDENT,

complete

Page 2

only.

BENEFiCIARY

REPORT OF

CLAIM

1.

Fait legalneme

O1deoeaeed emPIOyee;

'2.

DateOfblith t&E&fL/Oy/Yr):

)3.

D~te

OfdePth(&/&cp/Day/Yr);

)4

EmPIOyee

SCClal

~S'umber;

D

j&r

tern

VV//7

vyd/0.

~f/

I +-

(

Y-~op

5.

Causa of

employee's

death;

5,

VVneh

O&O ceoeaaed

emplOyee'S

hea(lh

grat

be00ma

(7,

VVffcrr

uru

.d

emplOyea

flret

///&7.

Irnpairad7

(/42&/Defy/Yr):

A &

/

o

consulf

a

physlclan7

(Mrf/027/Yr);

/&7&Cffshv

&C

C.X7du~

cA

I

(

Cme

I&-

2&i(

5

Benellclary 1ull legal

name:

9,

B~netictary

slgrature:

10,

Relationship

to

deceased

employee:

~Rf

c

fu&

c'.

&corT

.

'Id

~

c

&&~

T'aTppd

ri

'I

1

nr12

ii

lm

Cltv:

12,

Senegoia&y

phone

number.

13.

Beneficiary

Social

Security

number

)14:

Ben&&flc&ery

Date

of

btrth'tMrf/Ooy/Yr),

Nofe:

F'r

an

employee

/q

DfsD c/alm,

sf/ac/7 copies a(any

po/ico

invest/get/on

rapotLs

and,

//hvai/able,

fhe

autopsy

report.

AUTHORIZATION

TO.OBTAIN

/

RELEASE

INFORMATION

I authorize persons

or

entitles

thai

have any

records

or

knowledge

of

me

or

my

haallh

to

release

such

inforrnailon lo

Florida

combined

Ll(s

k&sucsnce

Co/nceny,

inc,

(FCL),

and

its

Insurance

affiliates, reinsure&s,

and

aulhorized

representatives,

Thaso persons or

enblies

include

any

licensed physician,

medical

prscillloner,

hospital,

clinic

or

other

medical

or

medically-related provider, employer,

Medical

insurance

Bureau

{I)/&IB),

consumer

repcrilj agency,

'or

insurance

company,

These

releases

include, but are nct

limited

to,

release

0(

eny

and

0'I

medical

records

and information about,

associated,v/Ilh,

oi

v&1th

rofcrence

lo

cert~in

condigons.

fhcse

conditions

Indude,

bul

alc

not

limiled

lo;

{a)

I

leman

)mmunodcficiency

Virus (HIV)

test

resultsp

(b)

AIDS.Rolated

Complex (ARC},

(c)

Acquirc:d

immune Defldcncy

Syndrome

(AIDS),

(d)

aicohol

ur

drug

abuse

or'0)

mun&al

illness,

7)&ls

Information

villi

be used

lo

evaluate

this request

for

cfaims

proceeds.

To

fac&litate

rapid

submission of

such

Information,

I aut(&or)ze

all

said

sources

to

give

such

records

or

knowledge

to

any.

agency

employed

by

FCL

to

co lect

and

transmit

such

lnlcrmaticn,

(

also

authodze

FCL

to

release

any

information

described

above

to;

{1&

I'CL's

(a}

auditors,

(b)

insurance

rifi'isles

(c)

remsurere,

(d)

authorized

rapmseslalives

and

(e)

vendors;

and

(2)

with

the

exception

of In(orms(icn

a(&out, associated v(lh,

or

is(th

referenco

to

H )j

teel

results ARC

ced/cr

AIDS,

Iho

kfttg

cnd

other

irfsurance

came&s,

io

edmtrf

later

and

pay

claims under

any

insurance

coverage

l ssubd to

mo

by

FCL,

This

claims

{nfonnatlcn

incfudes

specific

medical Infcrrnailon

on

me,

A

photocopy

of

ibis auihorlzatlcn

shall

be

as

valid

as

the

original.

I

hcrebycerlifv

that

the

state&nants

cn

ihh

Corm,

Ii'chiding

sny

sgechmsnt

lc

it

are

huo

andiumplele

lo

lhe

best

of

my

knowledge

a&id

belief. I

unders(and

und

ag~ee

lhat

any

misslatemenls

may

result

In

bonefil

denial.

FRAUD

NOTiCE:

Any

person

whc

knowingly,

und

with lntvnt

to

in]ure,

or

deceive

nny

ir&surer, flips atatemont of

clsiin or an

applicatfon

containing

any

false,

incomplete, or

misleading

lnfovmaliun

is

guilty

of

a felony

of

the

third

dogrce.

NarnOOf

deCeaeed'S

neX

Of

kin

Cr

authcrlZed

rCPreSChiatiVe (Pleaee

Prihtc)

Signature (Signer

muSt be

oflegai

age)

Relationship

tc

deceased

(Please print

)

Date

EMPLOYER'S REPORT OF

CLAIM

I,

1.

Emcloyee's

full legal

name.

La-nm&o

nf

mrth

is&n/rf

~&;

)~n&w.d:r

cs&ritv

numbec

(4.

Insurancx&

class.

j)7 ~e

JC~O

~rodp

c

5.

Date Cf

hire

f&f&fr/Omy/Yr)

6,

past

aqtfvety

worked ob

fitlp:

P

insurance

Effective date (&d&c/os//fr); (0.

currenl

annual earnings:

0~A

Z-

Q~lz)

M//iC'6'a.L/ifs

'/'4/

O

-'C&

-

J

I

&I,

/7VD

s.

Date

of

iaaf

earnings

change

10,

Date

employsa

&a tac&lveiy

worked:

11.

Re~son

for

c'essincf

active

e n l c m a . ' M c / 0

ay/Yr)

'=u&i-time

(Mcf&DEY/Yr)',

~pa.

-lime

(Mrf/DEY/vr)i

Lt

yh(E/ q&fjxrp

gg-

(Cp-

&c/

(

~O~2.

go

tz

12 Employee

Coverage:

Amount

Claimed:

Mnnih&v Premiun&'aid

Thro&/ah

t&/&c[02y/Yr):1

Q

Term

Life

gee@

$

~

DOz, On

'&Uyv

tpv&fJlkI~&

(

~grh7

(zy/ZCQ

O

Supplemental

Term

Life

$

C3

Voluntary

Tenn

Life

$

LI

Group

Universal

Life

$

$

Q

Supplemental

AD&SD

$

13,'es

eppilcatlcn

subnutted peer

tc

crnpioyee's

death

fcr7

I

14.

VVas

deceeeod

employee

rcceiv&ng

disability

ber&slits

prior

to

Life

&nsuiance

congnuaiion

during disability

Q

Yes

Q

No

I

death7tg

Yas

g

No

Acceferated living

benefits C]

Yes

h(

No

15.

Use

for

comments or

exp&&nsion

oi'nswers

above, (At&ech additional

sheet of

paper,

If necessary.

Sign

and date ft

);

16,

Benetalary

full

legal

name

(a

listed:0

amo&oyer's records):

17,

Reif&&&unship

of beneficiary

tc Insurodi

111.

cmol

rel'

foll&

n om

fpolkrn

lde,If/ill

nli

19.

Eroopzoroo:

)25.5lolfl

~

rill:

C~O/fCEEO

2

fm

2'm,

2'nfd

d

dffnM

.~

Ci

V'ns

'R iu '1 . fd o m n

9

.

'2.5

I

9:

29.5 ll dd

c&fcr&monernrre

ld

I&EEET/,

omC

2d.

Emmmeondm

~.

1CitV'

5'&m&e;

Sip

Code

25. Emp&Epycf

eumOnZed

gr

up

benetlta

adrpiniStratcr:

mdrnfrerc~nnminf

ee

nmm

EXHiBIT

50035-040sn

&CTx

(Rev

1/10)

Page

1

I

2

I



9/43

FLORIDA

COIMEI(NEO

LIFE

tNSURANCE

COMPANY,

)NC,

P.O.

BOX

45132

JACKSONVILLE,

FLORIDA

32232-5132

Certiftcate:

This

is your

certificate,

which

1.

is

a

summary

of

your

insurance

under

the

group

policy;

2.

is

not

a

contract

of insurance;

3.

is

subject

to

the

terms of

tiie

group

policy,

and

4.

voids and

replaces

any

prior

certiticates

issued under

the

group policy

number

shown on

page

three.

Po~tic:

We have

issued

the

group

policy

to

the

policyholder,

The

policy

is

a contract

of

insurance

1.

between your

policyholder

and

us;

and

2.

through

v,hich

you

are insured,

To

present

inquiries

or

to

obtain

information

aboui

coverage,

please

call

us

at

1-800-

333-3256.

To

receive

claims

assistance,

please

call

us

at

1-B00-696-8562.

Signed

for

the

Florida Combined

Life

insurance

Company,

inc,,

at

Jacksonville,

Florida,

on

the

insured's

effective

date,

I

N&u4&

SECRETARY

PRESIDENT

Certificate

for

Group

Life

and

Short

Term

Disability

insurance

Florida

Combined

IIfe

Insurance

Company,

Inc.,

andils

parent,

Slue

CIOSS

end

Blue

Shield

of

Florida,

Inc.,

are

lndepr;ndent

licensees of

the

Blue

Cross and

Slue

Shield

Associaii'on,

50005-588

EXHIEIIT

ga

2



10/43

TABLE OF

CONTENTS

Page1-

Page

2-

Page

3-

Page

4-

Page

5-

Page

6-

Page

7-

Page8-

Pageg-

Page

10-

Page11-

FACE

PAGE

PROVISIONS

TABLE OF

CONTENTS

SCHEDULE

OF

BENEFITS

DEFiNITIONS

DEFINITIONS

(continued)

DEFINITIONS (continuecl)

DEFINITIONS

(conilriued)

BENEFIT

AND

BENEFICIARY

PROVISIONS

Benefit

Beneficiary

Change

of

Beneficiary

INSURING

PROVISIONS

Eligibility

Evidence

of

insurability

insured's

effective

date

Deferred

effective

date

Termination

af

employee's

Insurance

Incontestability

Misstatement

of

age

or class

Physical

exams

and

autopsy

Time

of

payment

of

claims

Other

insurance

Assignment

GENERAL

PROVtSIONS

ACCIDENT

AND

HEALTH

ONLY

Legal

Proceedings

Notice

of

claim

Claim

forms

Proof

of

loss

Page

12-

Page

14-

Page

15-

Page

16-

Pago

17-

Page

18-

Coverage

'I

-

Terra

L.ife

Insurance

(if

provided)

Term

life benefit

Term

life

proceeds

Facility

of

paymerit

Optional

inodes

of

settlement

Other

modes of

settlement

Extension of

employe'e

life

insurance

during

total

disability

Conversion

Coverage

2-Accidental

Death,

Dismemberment,

and

Loss

of

Sight

Insurance

(if provided)

Benefit

Exclusions

Coverage

3

Short Term Disability

Insurance

(if

provided)

Short

term

disability

benefit

Disability proceeds

tiuith

pregnancy

benefits

Coverage

4-

Dependent

Life

Insurance

(if

provided)

De pendent

life benefit

Dependent

life

proceeds

Beneficiary

Deferred

effective date

Termination

of

employee's

dependent

insurance

Conversion

50005-588



11/43

12/21/10

SCHEDULE OF BENEFITS

66RBM

TERM

LIFE

INSURANCE

(EFFECTIVE

02/01/11)

BENEFIT

AMOUNT:

$

25

(

000.

00

BENEFIT REDUCES

35%

AT

AGE

65(

TO 50%

AT

AGE

70

AND

TO

254

AT AGE 75.

ACCELERATED

LIVING

BENEFIT

AMOUNT

IS 50%

OF THE

TERM

LIFE

INSURANCE

IN

FORCE

TO A

MAXIMUM OF

$

50(000.

ADMINISTRATIVF.

FE

~

:

64

OF

THE

LIVING

BENEFIT

AMOUNT

IS

DEDUCTED PRIOR

TO

PAYMENT

OF THIS

BENEFIT.

ACCIDENTAL

DEATH AND

DISMEMBERMENT

(EFFECTIVE

02/01/11)

BENEFIT

AMOUNT:

)25(000.00

BENEFIT REDUCES 354

AT

AGE

65,

TO 50%

AT AGE

70

AND

TO

25&

AT

AGE

75.

24 HOUR

COVERAGE.

POLICYHOLDER

COMPREHENSIVE

PAI

N

MANAGEMENT

2051

45TH

ST

STE

108

WEST

PALM

BEACH FL

33407

GROUP

POLICY

NUMBER

CERTIFICATE

HOLDER

85244003

DAWN

M,

KOCOT

50005-588E



12/43

D

EF

l

NIT

t

D NS

Actively

at

work

or

active work

-

you

are

working

for

your

employer.

in the

usual

course

of

your

employer's

business;

2.

full

time

at

the

principal

place

of employment;

and

3.

for at

least

the greater of:

a.

the number

of

hours

per

week

your

employer

stated

in his

application

as

the normal

work

week;

or

b.

20

hours

per

week.

Aqe

-

the

age

at

your

last birthday,

Am

u

t -

the amount

of'nsurance.

n

5Ieneftciorv

-

the

person(s)

lo

whom

we

will

pay

the

proceeds.

Certificate

-

a

document

given

to

you

as proof

of

your

coverage

under

the

policy.

It

is

nct

part

of

the

entire

contract

of

insurance.

It

contains

all statements

required

by

law,

Children

his

term

Includes

your.

natural

child; or

2,

legally

adopted

child;

or

3.

siepchild

or foster

oh&id,

Each

child

must depend

on

you

fcr

support

and

either:

1,

live

with

you;

or

2. be

a

full-time

student.

Each

child must

also

be;

unmarried; and

2.

under

the

age(s)

shown

in

the

policy

schedule.

Class

-

a

grouping

ofinsureds:

1.

based on

their

job

positions;

and

2.

determined

by

thc

policyholder.

Contributorv

insurance

(if

required) you

must

pay

a

part

of

the premiums

Ali

such

paymunts

are;

made directly

to

the

policyholder;

and

2,

forwarded

tc

us.

Conversion

-

you may

exchange your

rights

under

the

policy

for

an individual

policy,

This

only

applies

to;

1)

term

fife insrance;

or

2)

dependent

life

insurance,

50005-588

Page

4



13/43

DEFfNIT JONS (contfnuecf)

Coverage

~

all

the

terms

and provisions

appearing

uitder

one of lhe

following captions of the

policy,

lf provided:

1)

Term Life

Insurance;

or

2)

Accidental

Death, Dismemberment,

and

Loss of

Sighi

Insurance;

or

3)

Dependent

Life Insurance;

or

4)

Shori

Term

Disabihty

Insurance; or

5)

other

benefit

riders.

Covered

-

you

are

insured

under the

policy.

Date

of

death

-

the date

of ihe

insured's

death.

Dependenl

-

your

spouse

and

children

who

are

not:

Insured

employees themselves

under the

policy;

or

2,

in

tull-time military

aeNice.

A

dependent

can

only

bs

insured:

under one

Insured employee;

and

2,

for contributory

insurance-

if the

eligible employee

has

made

a

wdNen

requesl

for

depeiident's Insurance

Earninqs

-

wage,

This

term

does

not

include.

'i.

overtime

pay;

or

2.

bonuses; or

8.

any

other

form of

extra compensation,

Except

for

cominissioned

salespersons,

the rate of

earnings

is

that in

e(feel

prior

to

when

the

disability

starts.

For

commissioned

salespersons:

1.

durinq

the

first

12

months

of coverage

-

earnings

exclude

commissions;

or

2.

afterthefirst

'l2rnonthscfcovei~ae

-

earnings

tnctudetheaverageweeklyormontlily

commissions

cerned

during

the iwelvo

montlis

)ust

prior

to

when the

disability began.

Effective

dale

-

the

date the

policy

is

put

in

force.

t is

shown on

page

three

of the certificate.

Eliqible e~mlo~ee

-

a person

who:

is a

inember of

the

eligible

classes

shown In

the

policy

schedule

of the

employer s masier

policy;

2.

has

sallsfied

any

waiting

period

shown

in

your employer s

application',

and

B.

is

actively

at

work

onlhe

insured's

effective

date. If

the

employee

is

not actively at

wort& on

the

date

he

would

otherwise be

eliglblo,

soe

Deferred effective

date,

found

under

insuring

Provisions,

Evidence of insurability

-

evidence

of

good

health

accoptable

to us,

50005-588

Page

5



14/43

DEFINITIONS

(continued)

He,

ehis,e

and

him -

refer

to,both

genders.

Illness

-

a

disease

process

that:

causes

the abnormal

function

of:

a)

an

organ;

b)

s

system

of the

body;

ore)

the whole

body;

and

2.

is

caused

by:

a)

a

pathogenlcchange;orb)

a

psychological

disturbance.

In

force

-

the

policy

is in

etfect, Premiums

are

paid

and

alt

insuring

conditions are met.

p~ln'u

-

bodllyinJurywhich:

results

directly

and

independently

of

all

other

causes from

an

accident;

2,

occurs

after

the

effective date

of

coverage for

such

iniury;

and

results

In:

a)

disability;

b)

death;

ore)

dismemberment,

Insured

-

person

who:

is an

eligible employee;

2.

has

fulfilled all

conditions

under

the

policy

to

become

insured;

and

3,

has

insurance

In

force

under

the

policy.

Insured's scnlicatlong

-

includes:

1, the

insured's

enroliment form

or card;

and

2, any

evidence

of

insurability,

elnSured'S

effeCtiVe

date

-

the date

yOu

beCOme

inSured

under

the

pOliCy,

It

iS

ShOWn On

yOur

schedule

of

benefits

on

page

three.

eNoncontributory

insurance

-

you

are not

required

tc

pay

any part

of the

premiums,

Notice

-

written

notice

in

a

form

satisfactory

to

us

for

that

purpose.

Perscne

-

is

used

in

the

singular,

There

may

be

more

than

one

person

-

natural or

legal,

~ph

sician

a

licensed physician practicing

rdthtn

the scape

cihis

license.

nPreqnancy

-

Includes;

a)

childbidh;

b)

normalmiscanlage;

c)

elective

abortion;

d)

Caesarean

section; and

o)

complications

from

these,

Proceeds

-

the

amount

of

insurance we will

pay.as

a

benefit.

This

amount

is;

1. shown

in

the

schedule

of

benefits;

and

2.

sub)ect

to

the

amount

thatyou

are eiigible For

asshownin the

einployer'sinasler

policy

schedule

for

your

class.

50005-588

Page

6



15/43

DEFINITIONS

(Coft

tinued)

Proof

-

a

properly

completed

claim

form,

plus:

1,

for

life

insurance

-

a)

a

certified

copy

of

the

death certificate; or

b)

death

decreed

by

a

court

order;

or

2.

for

disability

or

accidental

death

and

dismemberment

insurance

-

written proof

acceptable

to

us,

~Souse

-

your

legal

husband or

wife.

'Vfe,

us,

and

our

-

Florida

Combined Life

Insurance Company,

Inc.

You

and

your

-

Insured

employee.

50005-588

Page

7



16/43

BENEFIT AND

BENEFICIARY

P

RGVISIONS

Benefit:

We

will

pay

tho

proceeds

to the beneficiary:

when we

receive

proof

of

your:

a)

disability;

and/or

b)

death;

2.

if coverage Insuring

the

type

of'loss

has

boon

selocted:

a)

in

tho

policy;

and

b)

for

your

class;

3,

it the

premiums

have been

paid

for that coverage;

and

4,

subject

to

all

policy

provisions,

Bcneficlarar:

Your

onrollmcni

form

or

card lists your

choice

ofbeneficicry.

Proceeds

will

be

paid;

to

you

-

for proceeds

paid during your

lifetime;

or

2.

to

the

beneficiary

(as

defined);

or

S.

to your

estate

-

if

no

bonoficianes

sun/ive

you;

or

4.

according

to tho

Facility

of payment provision

for

term

life

insurance.

Number

4

applies

tc the life

coverage

only,

Change

of

beneficiary;

During your

lifetime,

you

may

change

tho

beneficiary,

Nalico oflhe

chango:

must

be sig wd

and

doled

by

you;

and

2.

should be given

to

the

policyholder.

He

will sendiiio us,

The change

takes

effect on

the date it

is signed

We

are not liable

for

any

action

we

take

before

we

receive

the

notice at

aur

home

office,

INSURING

PROVISIONS

Eligibility:

See

definition,

Eligible

employee.

Evidence

of

insurability:

Evidence

of

insurability:

1, may

be

required

by

us if the

amount of

insurance

exceeds

aur

underwriting

limitalion;

and

2.

must

be sent

to

us

if:

a.

your

enrollment

is

made more

than

31

days

after

you

ar your

dependent

was first

eligible;

Gr

b,

you

or

your

dependon(

has

converted

insurance

under

tho

policy:

1)

from

prior

employment;

and

2)

to

an

indivtdua

policy

which is

in

force. You must

submit

evidence

befare

you

and

your

dependent

are

eligible

after

Ihe ieomplayment,

Evidence

of

insurability,

if

required;

1.

will

bo

al

your

expanse;

and

2.

delays

the

effective

date until

wo

approve

the

evidence.

50005-588

Pago

8



17/43

lnSured'S

effeCtiVe

date;

Bubjeat

tO

tiie

wDeferred

effeCliVe

date,

yOu

beCOme inaured;

1.

for

noncontributory

insurance

-

when

you

become

an

eligible

employee;

or

2,

for

contributorv

Insurance;

a, ~ir

on

enrell

orl

orgriorlo

being an eligible

emnlovee

.

when

ye

become

an

eligibl

employee;

or

b,

~ri

avenroll

iihinar day

Il

rv

b

cornea~nay

ibleemolovee

-

whenyoo

enroll

or

c.

if you

enroll

more

than

31

days

aiter

you

become

an

eligible employee

-

when we

accept

evidence of

Insurability.

The

date

you

enroll

is

deemed

to

be

when:

1,

you

completed

the enrollment

form or card lo our

satisfaction

and signed

it;

and

2.

you

gave

the

form

ar card

ta the

Itolioyholder.

if

you

do

not give

evidence of insurabilily

as

required;

1,

your

eligibility

ends;

and

2.

you

will

be

subject

to

the same

requirements

If

you

become

eligible at

a

later date.

Deferred

effective

date;

Your

effective

dale or

an

increase

in

coverage will

be

deferred

1.

if

on

the

dale

you

would

otherwise

become

insured

ar

receive the

Increase

in

coverage,

a.

you

are

absent

from

active

work;

and

b,

your

absence

Is

caused

by

an

injury

or

Illness,

and

2.

until

the

date you

return

to

active

work.

Termination

of

e~mloyee's

insurance:

Your

i:overage

ends

when;

1. this policy

terminates;

or

2.

you

stop

paying

required

premiums

-

for

contrlbulory

insuranre;

ar

3.

the employer

does

not

remil

premiums

-

for

noncontributory

insurance;

or

4 you

cease

to be ln

an

eligible class;

or

5.

you

cease

ta

be

an

employee;

or

6.

you

enter

military

service

-

except

temporaiy

duty

ot

less

than

30

days.

Discontinuance

of

the

policy

during

disability

shall

have

no

e11ect

on

benefits

payable

for tiiat

disability,

Incontestability: Na

statement

made

by you

about

you

or

your

dependents'nsurability

wiil be used

to

contest

the vaiidity af your

insurance,

unless:

the

cove~age

has been in

force

prior

to

the contest

for

Jess than

two

years

during:

a.

far the

insured's

coverage

-

your

lifetime; or

b.

for

your

dependent's

coverage

-

your

dependent's lifetime,

2.

il

is

in

the

Jnsured's

application

signed

by

you;

and

3.

a

oopy

ofthe

insured's

application

is or

has

been given

to;

a,

you;

or

b. the

beneficiary.

50005-588

Page

9



18/43

Misstatement of age or

class:

We will

pay

based on the

amount

of insurance:

1.

~if

our

aae

or

class

is

misslated

-

that

you

are

entitled

ta

at

your

true

age

or class;

or

2,

if your

d~eendent's

aae is

iiiisstated

-

that

your

dependent is

entitled

tc

at

his

true

age,

Physical

exams

and

autopsy:

We

will

have

lhe

right

and

o

pporti nily

t'o

examine

you:

1, by

a

physician of

our

choice;

2,

at

our

own

expense;

3. while

a

claim

is

pending

ar

being paid;

and

4.

as often

as

we

may

reascnabty

require,

We

also have

the

right

to

make

an

autopsy:

1. in

case

af death;

2.

where

it

is

allowed

by

law;

and

3. at

our

expense.

This

provision

also

applies

lo dependents

-

if

dependent

life

insurance

is

included,

Time

of

payment

of

claims;

We

will

pay

the proceeds

for

insured

losses

as soon

as we

receive proof,

Other

insurance: This

insurance is not in

lieu

of

workers'ompensation; it

does

nat

affect

any

requirement

for

workers'ompensation

coverage.

Ass qnrnent:

Yau

may

asslgil

any

of

yaui'rights.

We

are not

liable

for

the assignmenl's;

1)

validity;

or

2)

sufficiency.

We

are

nct

bound

bythe

assignment

uritil

we receive it.

GENERAL

PROVISIONS

ACCIDENT

AND

HEALTH

ONLY

~eceaal

proceedings:

A

claimant

may

not file suit

unless:

1.

proofs

af

loss

are

filed

within three years of

the

time

required

by

this

policy;

and

2,

at

least

60

days

have

passed

since

the

required

praofs of(oss

are

filed.

Notice of

claim:

Written

notice

of

claim must ba

given

to

us:

1,

within

60

days

after

the date of

loss

co'vered

by

this

policy;

or

2,

as

soon

thereafter

as

reasonably possible,

Claims

forms:

We will

furnish

the

claimant with

forms

for

fiillng

proof

of

loss

within

15

days after

we

receive

notice of the claim. if

we

do

not do

so,

the claimant can

comply

with

the

requirements

far filing

proof of

loss

by

giving

us

this

proof:

1, within

the

tenn

fixed in

the

Proof

of

loss

provision;

and

2, covering

the

loss's

a)

occurrence;

b)

character,

and

c)

extent,

50005-586

Page

10



19/43

Proof

of

loss;

Written

proof

of

loss:

must

be

furnished

to

us at

our

home office;

and

2.

should

be

furnished within

90

days

aRer

the period

for

which we

are

liable.

In

case

of

a claim

for

any

other

loss,

the

proof

must

be

provided within

90

days

aRer

the date

cf

loss.

Failure to

furnish

the

proof

within

these

times wi(l not

invalidate

nor

reduce the claim If

proof

is

furnished

as

soon

as

is

reasonable

possible,

Coveraqe 1

-

Term

Life Jnsttrance

(only

available to

employees)

Term

life benefit:

We will

pay

the

proceeds to

the

beneficiary:

1,

If this

coverage

has been selected;

a.

in

the

policy;

b.

for

your

class,

and

c. as

shown

in

the

policy

schedule;

2, if

the

premiums

have

been

paid for this coverage;

3,

subject

to all

policy

provisions;

and

4,

when

we

receive

proof

of

your

death,

Term

life

proceeds: The proceeds

we

will

pay

is

tho

amount

that your'life

is

iiisiiied

for

at

the date of

death.

Facility

of

pa~ment:

We

have

the

option

to

pay

the proceeds

to

any

one

or more of

your

surviving

relatives:

1.

Instead

of

paying

your

estate;

and

2.

these

relatives

includo your.

a)

spouse;

or

b)

parent;

or

c)

brother; or

d)

sister,

WB have the

option

to

pay

up

to $

2,000

of

the

proceeds:

1, If

allowed

by

law;

and

2,

io

any

person

who

appears

to us as

having

incurred costs from

your.

a)

test

illness; or

b)

death,

ore)

funeral,

If

the

beneficiary

Is a

minor

or

nol

competent,

we have

the

optioii;

1.

to

pay

up

to

$

2,000

to

the

person or

institution

whc

appears

to us to

havo

assumed

tho

beneficiary's.

a)

custody;

and

b)

principal supporl;

and

2,

unless

or until a

formal

claim

is

made

by

a

legal

representative

of

ihe beneficiary,

Our

liability

for

the payment

ends if

we

make

It ln good

faith,

Optional

modes

of

settlement'The

proceeds

inay

be

paid

on a

monthly

basis

for

a

fixed

term

of

years:

1.

if

you

send

us your

written

request;

2.

Ifwe

agree;

and

3. if each

payment

will

be

at

toast

$

25,00.

50005-588

Page 11



20/43

The

amount

of the payments

Is

figured

from

this

table,

TABLE OF

MONTHLY

PAYMENTS

PER

$

1,000

OF PROCEEDS

Years Payable

Monthly

Payments Years

Payabie

Monthly

Payments

1

2

3

$

84,28

42,66

28.79

2'l.86

5

10

15

20

$

17.70

9,39

6.84

5.27

Thoso

payments

are

based

on an

Interest rate;

1,

of

2

1)2%

per year,

and

2.

compounded yearly.

We

will

also

pay

any

excess

interest

that

we

may

declare from

year

to

year,

The

first

payment

will

be

paid;

1, on

the

date

the proceeds

would

have

been

paid

in one

sum,'r

2, on

tho

date

you

request.

If all

beneficiaries

under

this

mode die,

we

will',

1,

pay

the

unpaid

proceeds

pius

lho earned

interest

In

one

sum;

and

2,

pay

this

one sum

to:

a. the

beneficiary's

estate; or

(at

our

option)

b.

to

one or

more of the

boneficiary's

surviving

relatives.

Other

modes of

setttement:

Other

modes

of

settlement

may

be

arranged

if

you

and

wc

agree,

We

will

furnish data

on

these

modes

upon

reques .

Extension of

employee

life

insurance

during

total

disability

(accidental

death

and

dismemberment,

sl;oit

term

disability,

and dependent

lite benefits aro

not

Included)

Definition

(for

this

provision

only)

'yolalfydtnabted

ar

~total

dlnabtltt

-

you

are unable

to

work

el youremploymanl

orna

ap

tl

~

n

due

to dlsabiiiiy

causod

by

injury

or

illness. However,

atter the first

24 months of

disability,

you

must

also

bo

unable

to

engage

ln

any

employment

or

occupation

for which

you

aro or

become

qualified

by

roason

of

education, training,

or

experience.

50005-588

Pago 12



21/43

Your

life

insurance will

exlend

beyond

when

il

would

otherwise

end:

1.

if

you

become

totally

disabled

prior

to

age

60,

while

you

are

insured

under

this

policy;

2.

ifthe

required

life

premiums

have

been

paid

For the first six months

of

total

disability;

3,

while your total disability

fs

continuous;

4. if

you

give

us written

notice

of

your

total

disability

wllhin

one

year

from the

date

it

started;

and

5.

if

you

give

us

proof

of your

continuous total disability:

a,

first

proof

-

between the sixth

and twelfth

month

after

the date the total disability

began;

and

b.

subsequent proof

-

during

the

last

three

months

of each

subsequent

12-month

term

atter

the

first.

lf

nolice

of proof

of'your

continuous total

disability

cannot

be

given

witfiin

these times;

it musl

be

given

as soon

as

ls

reasonably

possible;

and

2, it

rnusl be

given

within

three months

after

the

time

it

is

otherwise

required.

When

we

are satisfied

with

the

proof,

life

insurance

will

be

extended,

without

fujther preiniums

after the

first

six

months

is

paid;

and

2. while

your

total

disability

continues.

We

will

still

pay

the

life proceeds

even thouqh

ycu

become

disabled after

age

80

or

do

not

give

us

the first

proof

if;

1.

you

die

prior

to

age

71 and

within

one

yearofthe

date

that the premium

payments stop;

and

2. we

are

given

proof

of:

a,

your

continuous

total

disabiliiy

irom

the

day

it

began;

and

b. your

death.

The

amount

of life

insurance

extended wi8

be lhe

lesser of;

the

amount

shown

in

the schediile;

or

2, ihe

amount

in

force

on

the last

dayof

active

work,

These

provisions

apply

if

they

are n

effect

on

the last

day

of

active

work:

1.

reductions

provisions;

2.

termination

provisions;

and

3.

retirement

provisions,

Extended life

insurance

will

end at the sooner

of

the

date

you:

1,

are

no

longer

totally

disabled; or

2,

fail

to

give

us

the

roquired proof

of

continuous

total

disability;

or

3.

refuse to

be

examined

as

required;

or

4.

retire

at the normal

age

according

to each

company's

requirements

-

unless

retiree

coverage

is provided.

60006-588

Page

13



22/43

If

extended

)ife

insurance

ends

because

you

retire,

you

become entitled to the

rights

under

Conversion,

u n ic ' .

you

return

to

work;

and

2.

you

are

insured

again

under

the

policy,

We

are

not

liable

for

a

death

claim

under this

coverage,

unless

we

receive

proof;

of

your

death, and

2. within 12

months after

tho

date

of death.

Conversion

You

may

convert

aH

or

part

of the insurance

under this

coverage

without evidence

of

insurability

to

an

individual life

policy:

1.

if

insurance ends

because;

a.

of

termination

of

your.

1)

employment;

or

2)

membership

In an eligible class; or

b.

of your retirement;

ar

c,

you

reach

a

specified

age,

or

d,

of

a

policy

change

affecting

your

class; or

e.

the

poHcy

or

the

employer's participation

ends

oi

Is

amended;

and

2. if

within

3'I

days

after

termination you:

a.

give

us

a

written

request

to

converl; and

b,

pay

the first.

premium

un

the

new

policy,

The new

policy

may

be

on

any

plan

of

life insurance, except term,

issued

by

us;

1,

at the age

and

for

the

amount

applied

for;

and

2. without

dfsabiiity

or

other

supplemental

benefits,

The

new

policy:

1.

face

amount

may

not

exceed:

a,

ihe amount

of

insuiance

in

force on

the

convcisii&n

date;

or

b.

Ior

1.e.

above

-

the lesser

of:

1)

the amount which

terminated

-

less

the

amoiint

of

any

life

insurance for which

you

are

or

become

eligible

under

any

group

policy.issued

or reinstated;

a)

by

us

or

by

any company;

and

b)

within

31

days

after

the

terminagon

of your

coverage;

or

2)

$

10,00D.OO;

2.

premium

rate will

be

based on:

a,

your

age

on

its

effective dato;

b,

the

rates

then

in

use

by

us;

and

3,

effective

date will

begin

at

the

end

of the 31-day

term

to

convert

after

termination,

If you

die during

the 31-day

term

to

convert,

the

proceeds

we

will

pay:

1,

will

be

paid

under

the

group

policy;

and

2, will

be

the

maximum

amount

which

could

have

been

converted,

whether

or

not:

a,

the

application

to

convert

was

made;

or

b.

the

first

prerniurn

was

paid

Any

life

conversion

policy

must

be

surrendered

without claim. We

will

refund

any

premium

paid

for

it,

50005-568

Page

14



23/43

Coverage

2

-

Accidental

Death,

Dismemberment,

and

Loss

of

Sight

Insurance

(only

available to

employees)

Definition

(for

this

coverage

only)

Loss

-

means

with

regard

to:

1.

life

-

death;or

2.

hands

and

feet

-

complete

severance through

or

above the

wrist

or

ankle

joint;

or

3.

~si

ht

-

loss

ofsight

which

is'.

a)

entire;

and

0)

irrecoverable.

Benefit:

We

will

pay

the proceeds

to

the

beneficiary:

1, if

this coverage

has

been

selected;

in

the

policy;

b, for

yo

ur

class;

and

c.

as

shown in the

policy

schedule;

2.

if the

premiums

have

been

paid

for

this coverage;

3.

subject

to

all

policy

provisions;

when we receive proof

of

your

loss

stiown

betovr,

a. that

wes

caused

by

injury

while

you

were

Insured

under this

coverage,

and

b.

that

occurs

vjithin

365

days

from the

rlate of the,

injury;

and

5.

if

the loss is

not

excluded below.

The principal

sum

that

applies

to the

insured

is shown in

the

policy

schedule

for

loss

of',

Life.

Both

hands

or

both

feet

or sight

of

both

eyes,

One

hand and

one

foot

One

hand and sight

of

one

eye

One

foci

and

sight

of

one

eyo

Sight

ofone

eye..One hand or

one

foot..

,.Principal

Sum

Principal

Sum

,.Principal Sum

..

Principal

Sum

..Principal

Sum

One

half

of tho

Principal

Sum

One half

of the

Principal

Sum

50005-588

Page

15



24/43

Exclusions:

We will not

pay

the

proceeds

for

any

loss

resulting

from:

1,

intentional

self-inflicted

injury

-

or

any

attempt

to

injure

oneself while

sane; or

2. travel,

flight

in,

or

descent from

any

kind

of

aircratt

-

unless

solely

as

a

fare-paying

passenger:

a,

of

a cammercia

airline;

end

b.

without

any

duties

with

the

airline;

or

5. taking part

in

a

riot;

or

4.

any

war

or

act of

war

-

deciared

or undeclared; or

5. military

service;

or

6.

taking part

in an

assault

or

a

felony;

or

7.

voluntary

use

of

any

controlled

substance.*

This

exclusion

will

i,ot

apply

it the

controlled

substance

is

prescribed

for

yau

by

a

physician;

or

6.

bodily

Infirmity

or

disease from bacterial infectians

{except

accidentai

ingestion

of

contaminated

foods)

-

other

than

Infection

caused from

an

injury

covered

under this

Gavel'age,

Controlled

substance

is

defined

in

Title

II

of

the Comprehensive

Drug

Abuse

Prevention arid

Control

Act

af 1970 and

all

amendments.

Coveraqe

3

-

Short

Term

Disability

Insurance

(only

available

to

employees)

Definition

{/or

this

coverage

only)

Disabled

or

disability

-

you

are

unable

ta do the

m%r

duties

of

your

occupation due

to

an:

1)

injury;ar2)

illness.

Short term

disability

benefit;

We

will

pay

the shart

term proceeds to

you;

1, if

this

coverage has

been

selecled:

a, in

the

policy;

b,

for

your

class,

and

c.

as

shown in

the

policy

schedule;

2. if the premiums

have

been

paid

for

this

coverage;

5.

subject

to

all

policy

provisions;

4,

while

you

remain

disabled;

and

5.

When

we

receive

proof

that

you:

a.

became

disabled

while

insured; and

b,

have

been seeii

and

treated

by

a physician

for liie

disability.

Disability

proceeds,

The

policy

schedule shows

these

data

for

your

class;

the

amount of gie

short

term

proceeds;

2,

the

day

we

begin

paying

short lerm proceeds

after

your

disability starts;

8.

the maximum term

that we will

pay

the

short term

proceeds;

a.

for

any

one

continuous term of

disability

-

whether due to

one

or more

causes;

or

b. for

all

successive

terms of

disability;

1)

due to

the same or related

causes(s);

and

2)

which are separated

by

less

than

two

weeks

of continuous active

work.

50005-588

Page

'I6



25/43

For

disability

lasting

less than

one

futt

week,

the

proceeds

we

will

pay

wili

be ihe

ratio

of

the

number

of

days

of

disability

divided

by

the

number

ofdays in

the

week.

Any

subsequent

disability will

be

deemed

to

be

a new

disability:

for

the

same

causes of

disability

~

If

you

retuni

to

active

work

for

a

continuous

terin

of

at

least two

weeks;

or

2,

for diFferent

snd unrelated

causes

ofdisab~itit

-

if

the

disability

is separated

by

at least

one

day

of

active

work,

Your

disabihty cannot

be

caused

by.

1.

any

injury:

a. which

results

from

work;

and

b. for

which

you

are

entitled

to

benefits

under

any

workers'ompensation

law;

or

7,

any

illness

for

which

you

are entitled to

benefits

under

any:

a.

workers'ompensation

law;

or

b.

occupational

disease

law;

or

3. intentionally

self-inflicted

injury,

With

preqnancy

benefits:

Disability

caused

by

your

pregnancy

is covered:

for

any

one

pregnancy;

2,

if

you

become.disabled

while insured;

and

3,

up

to

the

maximum

term

shown

in the

policy

schedule,

Coverage

4

-

Dependent

Life Insurance

Definition

(for

this coverage

only)

Dependent's

effective

dato

-

the

date

the dependent

becomes

insured under the

policy,

Dependent

life benefit;

We

will

pay the

proceeds

to

tho

boneticiary:

1. if this coverage

lies

been selected:

a. in the

policy;

b, for

yourclass;

and

c, es

shown in the

policy

schedule;

2.

if

the

premiums

have

been

paid forthis coverage;

3.

subject

to

all

policy

prOvisions;

and

4.

when

we

receive

proof

of

the

dependent's

death,

Dependent

life

proceeds:

The

procoods

we

will

pay

is tho

amount:

that

your

dependents

ill'e

Is

Insured

for

ai tho date

of

his

death;

and

2.

shown in

the

policy

schedule

for

dependents in your

class on

ihe

date

of

his

death.

Beneficiary:

We

will

pay

the proceeds

to

1.

you

-

if

you

are

living;

otherwise

2.

your

estate,

or

(at

cur

option)

3, your

spouse

-

if

living.

50005-588

Page

17



26/43


27/43

If

he

dies

during

the

31-day

term Ic

convert,

the

proceeds

we

will

pay:

1,

will

be

paid

under the

group

policy,

and

2.

will be the

maximum amount

which

could

have

been

converted,

whether

or not:

a.

the application to

ronvert

was

made;

or

b.

the

first

preinium

was

paid,

Any

life

conversion

policy

must

be

surrendered

without

claim,

We will

refund

any

premium

paid

for it.

50005-588

Page

19



28/43

HARTFORD

LIFF.

AND

ACCIDENT

INSURANCE

COMPANY

Hartford

Plaza

Hartford,

Connecticut

(A

stock

insurance

company)

Will

pay

benefits

according

to the

conditions

of this

Policy.

Signed

for

the

Company

Richard

G.

Costello, Secretary

Thomas

M. Marra,

President

Policyholder

Name:

Policvholder Address:

CFE

FEDERAL

CREDIT UNION

1200WEBER

STREET

ORLANDO,

FL

32803

Policv

Number:

Place

of

Deliverv:

Policv

Effective

Date:

ADD-12205

ORLANDO,

FL

March

1,

2006

TABLE OF

CONTENTS

Schedule

Contract

Provisions

Incorporation

Provision

Certificate

of Insurance

Riders

(if

any)

Accepted

by:

Policyholder

Form

7582

A2

Printed

in U,S,A,

8507443

1

EXHIBIT

2o



29/43

SCHEDULE

ELIGIBLE PERSONS;

C

1iiss

Descrintion

All

members

of

the

Policyholder;

a)

who are

age

18 or

over;

and

b)

who were

covered

under the

Prior

Policy's

Basic

Plan of

Accidental

Death and

Dismemberment

Coverage

prior

to

the

Policy

Effective Date

of this Policy.

All

members

of the

Policyholder;

a)

who

are

age

18

or

over;

and

b)

who

were

covered

under

the

Prior

Policy's

Voluntary

Plan

of

Accidental

Death

and

Dismemberment Coverage

prior

to

the

Policy

Effective Date of

this Policy,

All members of the

Policyholder;

a)

who are

age

18 or

over;

and

b)

for

whom We

have

received a completed

Enrollment

Form for

the

Basic Plan of

Coverage

under

this

Policy.

All

members

of the

Policyholder:

a)

who are

age

18 or

over;

and

b)

for whom

We

have

received a

completed

Enrollment

Form

for

the

Voluntary

Plan

of

Coverage

under

this

Policy.

Prior Policy

means the

Accidental

Death

and

Dismemberment Policy

issued

by

the

prior

carrier

to

the

Policyholder,

This Policv

means the

Accidental

Death and

Dismemberment

Policy

issued

by

Hartford

Life and

Accident

Insurance

Company

to

the

Policyholder.

Each

Prior

Covered

Person

will be

covered for the

same

Benefit

Amounts for

which he or

she

was covered

under

the

Prior

Policy

on

the

day

before the Policy

Effective Date

of

This

Policy.

The

Beneficiary

Designation

under

the Prior

Policy

in

effect

prior

to

the

Policy

Effective Date

of This

Policy

will

be

considered

to

be

the Beneficiary

Designation

under

This

Policy,

subject

to the Naming

a

Beneficiarv provision.

This

Policy

will not

pay

any

benefits

for

a

claim

in

effect

before

the effective

date of

This Policy.

ELIGIBLE

DEPENDENTS;

Eligible

Person's

Spouse

and

Child(ren)

under

the Voluntary

Plan

Only.

When a

husband and

wife

are both Eligible

Persons:

a)

coverage

may

not be duplicated

by

applying

as dependents

of each

other;

and

b)

coverage

for

an Eligible

Dependent

Child

may

be

requested

by

either

the wife

or

the

husband,

but

not

both.

No Eligible

Child

will

be

covered

unless

either the Eligible

Person or

the Eligible

Spouse

is

covered,

ELIGIBILITY

RESTRICTIONS:

If an Eligible

Person

has

more

than

one

Certificate

under

this

Policy,

the

total

amount of Voluntary

coverage

under

all

Certificates

may

not

exceed

300,000.

If

coverage

does

exceed

300,000,

premiums

paid

for

coverage

over

300,000

will

be

refunded.

Form

7582

B6

8507443

i

SCHEDULE

(Elieibilitv)



30/43

SCHEDULE

POLICY

AGE

LIMIT:

None

EVIDENCE OF

INSURABILITY:

None

Form

7582

B7

8507443 1

SCHEDULE

(Ave,

Insurabilitv

and

Class)



31/43

SCHEDULE

BENEFITS

AND

AMOUNTS;

Basic

Plan

of Coverage

-

Classes

I

and 3:

Accidental Death

and

Dismemberment

Benefit:

Principal

Sum for each

Insured Person:

Princinal Sum

Amount:

$

2,000

Voluntary

Plan of

Coverage

-

Class

2:

Accidental

Death and

Dismemberment

Benefit;

Princioal Sum

The Principal

Sum applicable

to

an

Insured Person is the

amount

for which he or

she

was covered

under the

Prior

Policy,

provided

the

required

premium

is

paid,

subject

to

the

Minimum

and Maximum

Amounts

stated

below.

Princinal

Sum

kocot v. florida combined life insurance company, inc. complaint

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