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CALIFORNIA LIFE AND HEALTH INSURANCE GUARANTEE ASSOCIATION ACTSUMMARY DOCUMENT AND DISCLAIMERResidents of California who purchase life and health insurance and annuities should know that theinsurance companies licensed in this state to write these types of insurance are members of theCalifornia Life and Health Insurance Guarantee Association ("CLHIGA").The purpose of thisAssociation is to assure that policyholders will be protected, within limits, in the unlikely event that amember insurer becomes financially unable to meet its obligations. If this should happen, theGuarantee Association will assess its other member insurance companies for the money to pay theclaims of the insured persons who live in this state and, in some cases, to keep coverage in force. Thevaluable extra protection provided by these insurers through the Guarantee Association is notunlimited, however, as noted below, and is not a substitute for consumers' care in selecting insurers.The California Life and Health Insurance Guarantee Association may not provide coverage for thispolicy. If coverage is provided, it may be subject to substantial limitations or exclusions, andrequire continued residency in California. You should not rely on coverage by the Association inselecting an insurance company or in selecting an insurance policy.Coverage is NOT provided for your policy or any portion of it that is not guaranteed by the insureror for which you have assumed the risk, such as a variable contract sold by prospectus.Insurance companies or their agents are required by law to give or send you this notice. However,insurance companies and their agents are prohibited by law from using the existence of theguarantee association to induce you to purchase any kind of insurance policy.Policyholders with additional questions should first contact their insurer or agent or may then contact:The California Life and Health Insurance Guarantee AssociationPO Box 17319Beverly Hills CA 90209-3319ORConsumer Services DivisionCalifornia Department of Insurance300 South Spring St, South TowerLos Angeles CA 90013The state law that provides for this safety-net coverage is called the California Life and HealthGuarantee Association Act. Below is a brief summary of this law's coverages, exclusions and limits.This summary does not cover all provisions of the law; nor does it in any way change anyone's rightsor obligations under the Act or the rights or obligations of the Association.COVERAGEGenerally, individuals will be protected by the California Life and Health Insurance GuaranteeAssociation if they live in this state and hold a life or health insurance contract, or an annuity, or ifthey are insured under a group insurance contract, issued by a member insurer. The beneficiaries,payees or assignees of insured persons are protected as well, even if they live in another state.
EXCLUSIONS FROM COVERAGEHowever, persons holding such policies are not protected by this Guarantee Association if:Their insurer was not authorized to do business in this state when it issued the policy or contract;Their policy was issued by a health care service plan (HMO, Blue Cross, Blue Shield), a charitableorganization, a fraternal benefit society, a mandatory state pooling plan, a mutual assessmentcompany, an insurance exchange, or a grants and annuities society;They are eligible for protection under the laws of another state. This may occur when the insolventinsurer was incorporated in another state whose guaranty association protects insureds who liveoutside that state.The Guarantee Association also does not provide coverage for:Unallocated annuity contracts; that is, contracts which are not issued to and owned by anindividual and which guarantee rights to group contract holders, not individuals;Employer or association plans, to the extent they are self-funded or uninsured;Any policy or portion of a policy which is not guaranteed by the insurer or for which the individualhas assumed the risk, such as a variable contract sold by prospectus;Any policy of reinsurance unless an assumption certificate was issued;Interest rate yields that exceed an average rate;Any portion of a contract that provides dividends or experience rating credits.LIMITS ON AMOUNT OF COVERAGEThe Act limits the Association to pay benefits as follows:LIFE AND ANNUITY BENEFITS80% of what the insurance company would owe under a policy or contract up to 100,000 in cashsurrender values, 100,000 in present value of annuities, or 250,000 in life insurance death benefits.A maximum of 250,000 for any one insured life no matter how many policies and contracts therewere with the same company, even if the policies provided different types of coverages.HEALTH BENEFITSA maximum of 200,000 of the contractual obligations that the health insurance company wouldowe were it not insolvent. The maximum may increase or decrease annually based upon changesin the health care cost component of the consumer price index.PREMIUM SURCHARGEMember insurers are required to recoup assessments paid to the Association by way of a surcharge onpremiums charged for health insurance policies to which the Act applies.
CALIFORNIA NOTICE OF COMPLAINT PROCEDUREShould any dispute arise about your premium or about a claim that you have filed, write to thecompany that issued the group policy at:Standard Insurance CompanyPO Box 2177Portland, OR 97208-2177(888) 937-4783If the problem is not resolved, you may also write to the State of California at:Department of InsuranceConsumer Services Division300 S. Spring Street, 11th FLLos Angeles, CA 900131-800-927-HELP (4357)This notice of complaint procedure is for information only and does not become a part orcondition of this group policy/certificate.
STANDARD INSURANCE COMPANYA Stock Life Insurance Company900 SW Fifth AvenuePortland, Oregon 97204-1282(503) 321-7000CERTIFICATE AND SUMMARY PLAN DESCRIPTIONGROUP LIFE INSURANCEPolicyholder:Policy Number:Effective Date:Pepperdine University145371-ASeptember 1, 2008A Group Policy has been issued to the Policyholder. We certify that you will be insured as provided bythe terms of the Group Policy. If your coverage is changed by an amendment to the Group Policy, wewill provide the Policyholder with a revised Certificate or other notice to be given to you.This policy includes an Accelerated Benefit. Death benefits will be reduced if an AcceleratedBenefit is paid. The receipt of this benefit may be taxable and may affect your eligibility forMedicaid or other government benefits or entitlements. However, if you meet the definition of"terminally ill individual" according to the Internal Revenue Code Section 101, yourAccelerated Benefit may be non-taxable. You should consult your personal tax and/or legaladvisor before you apply for an Accelerated Benefit.Possession of this Certificate does not necessarily mean you are insured. You are insured only if youmeet the requirements set out in this Certificate. If the terms of the Certificate differ from the GroupPolicy, the terms stated in the Group Policy will govern."We", "us" and "our" mean Standard Insurance Company. "You" and "your" mean the Member. Allother defined terms appear with the initial letter capitalized. Section headings, and references tothem, appear in boldface type.GC190-LIFE/S399
Table of ContentsCOVERAGE FEATURES. 1GENERAL POLICY INFORMATION. 1BECOMING INSURED. 1PREMIUM CONTRIBUTIONS. 3SCHEDULE OF INSURANCE . 3REDUCTIONS IN INSURANCE . 5OTHER BENEFITS . 5OTHER PROVISIONS . 5ERISA SUMMARY PLAN DESCRIPTION INFORMATION . 6LIFE INSURANCE . 8A. Insuring Clause . 8B. Amount Of Life Insurance . 8C. Changes In Life Insurance. 8D. Repatriation Benefit . 8E. Suicide Exclusion: Life Insurance . 8F. When Life Insurance Becomes Effective. 9G. When Life Insurance Ends . 9H. Reinstatement Of Life Insurance . 10DEPENDENTS LIFE INSURANCE . 10A. Insuring Clause . 10B. Amount Of Dependents Life Insurance. 10C. Changes In Dependents Life Insurance . 10D. Definitions For Dependents Life Insurance . 11E. Becoming Insured For Dependents Life Insurance . 11F. When Dependents Life Insurance Ends . 12ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE . 12A. Insuring Clause . 12B. Definition Of Loss For AD&D Insurance. 12C. Amount Payable . 13D. Changes In AD&D Insurance . 13E. AD&D Insurance Exclusions . 13F. Additional AD&D Benefits. 13G. Becoming Insured For AD&D Insurance . 15H. When AD&D Insurance Ends . 16ACTIVE WORK PROVISIONS . 16PORTABILITY OF INSURANCE . 16STRIKE CONTINUATION. 17WAIVER OF PREMIUM . 18ACCELERATED BENEFIT . 19RIGHT TO CONVERT . 21CLAIMS. 22ASSIGNMENT . 24BENEFIT PAYMENT AND BENEFICIARY PROVISIONS . 24ALLOCATION OF AUTHORITY . 26TIME LIMITS ON LEGAL ACTIONS . 27INCONTESTABILITY PROVISIONS. 27CLERICAL ERROR AND MISSTATEMENT . 28TERMINATION OR AMENDMENT OF THE GROUP POLICY . 28DEFINITIONS. 28ERISA INFORMATION AND NOTICE OF RIGHTS . 30
Index of Defined TermsAccelerated Benefit, 19Active Work, Actively At Work, 16AD&D Insurance, 28Air Bag System, 14Annual Earnings, 28Automobile, 14L.L.C. Owner-Employee, 30Life Insurance, 30Loss, 12Member, 1Noncontributory, 30Beneficiary, 25Child, 29Class Definition, 2Contributory, 29Conversion Period, 21P.C. Partner, 30Physician, 30Policyholder, 1Pregnancy, 30Prior Plan, 30Proof Of Loss, 22Dependent, 11Dependents Life Insurance, 29Disabled, 29Domestic Partner, 30Qualifying Event, 21Qualifying Medical Condition, 19Eligibility Waiting Period, 29Employer(s), 1Evidence Of Insurability, 30Group Policy, 30Group Policy Effective Date, 1Group Policy Number, 1Guarantee Issue Amount (forDependents Life Insurance), 2Guarantee Issue Amount (for Plan 2), 2Injury, 30Insurance (for Accelerated Benefit), 20Insurance (for Right to Convert), 21Insurance (for Waiver Of Premium), 18Recipient, 26Right To Convert, 21Seat Belt System, 14Sickness, 30Spouse, 30Supplemental Life Insurance, 30Totally Disabled, 18, 21Waiting Period (for Waiver Of Premium),18Waiver Of Premium, 18War, 13You, Your (for Right To Convert), 21
COVERAGE FEATURESThis section contains many of the features of your group life insurance. Other provisions, includingexclusions and limitations, appear in other sections. Please refer to the text of each section for fulldetails. The Table of Contents and the Index of Defined Terms help locate sections and definitions.GENERAL POLICY INFORMATIONGroup Policy Number:145371-AType of Insurance Provided:Life Insurance:YesSupplemental Life Insurance:Not applicableDependents Life Insurance:YesAccidental Death And Dismemberment(AD&D) Insurance:YesPolicyholder:Pepperdine UniversityEmployer(s):Pepperdine UniversityGroup Policy Effective Date:September 1, 2008Policy Issued in:CaliforniaBECOMING INSUREDTo become insured for Life Insurance you must: (a) Be a Member; (b) Complete your Eligibility WaitingPeriod; and (c) Meet the requirements in Life Insurance and Active Work Provisions. Therequirements for becoming insured for coverages other than Life Insurance are set out in the text.Definition of Member:You are a Member if you are one of the following:1. An active regularly assigned, full-time staff employee ofthe Employer who is regularly working at least 30hours each week (except where applicable law requiresa lesser number of hours);2. An active regularly assigned, staff employee of theEmployer approved for a 9 to 12 month position who isregularly working at least 30 hours each week; or3. An active regularly assigned, full-time faculty memberunder a regular (non-adjunct) faculty contract, servingat least a half-time appointment (.5 FTE) per academicyear.You are not a Member if you are:1. A temporary or seasonal employee.2. A leased employee.3. An independent contractor.4. A full time member of the armed forces of any country.Printed 09/11/2009-1-145371-A
Class Definition:NoneEligibility Waiting Period:You are eligible on one of the following dates:If you are a Member on the Group Policy Effective Date,you are eligible on that date.If you become a Member after the Group Policy EffectiveDate, you are eligible on the first day of the calendarmonth following the date you become a Member.Evidence of Insurability:Required:a. For late application for Contributory insurance.b. For reinstatements if required.c. For Members and Dependents eligible but not insuredunder the Prior Plan.d. For any Plan 2 Life Insurance Benefit in excess of theGuarantee Issue Amount of 150,000. However, thisrequirement will be waived on the Group PolicyEffective Date for an amount equal to the amount oflife insurance under the Prior Plan on the day beforethe Group Policy Effective Date, if you apply on orbefore the Group Policy Effective Date.e. For any Dependents Life Insurance Benefit in excess ofthe Guarantee Issue Amount of 50,000.f.For any increase resulting from a plan or optionchange you elect.Certain Evidence Of Insurability Requirements Will Be Waived. Your insurance is subject toall other terms of the Group Policy.Open Enrollment Period September 1 through September 30, 2008If you were eligible for or insured for additional life insurance under the Prior Plan on the daybefore the Open Enrollment Period, certain Evidence Of Insurability requirements will be waivedwith respect to Life Insurance and Dependents Life Insurance. However, we will not waive theEvidence Of Insurability requirements if you, your Spouse or Child previously submitted evidenceof good health that was not approved by the insurer(s) of the Prior Plan or any preceding plans.1. If you were eligible but not insured for additional life insurance under the Prior Plan on the daybefore the Group Policy Effective Date, requirement(s) c. above will be waived if you apply forPlan 2 Life Insurance up to the Guarantee Issue Amount during the Open Enrollment Period.2. If you were insured under the Prior Plan on the day before the Group Policy Effective Date foran amount less than the Guarantee Issue Amount, requirement(s) f. above will be waived if youapply for an increase in your Plan 2 Life Insurance up to the Guarantee Issue Amount duringthe Open Enrollment Period.3. If your Spouse and Child were eligible but not insured for dependents life insurance under thePrior Plan on the day before the Group Policy Effective Date, requirement(s) c. above will bewaived if you apply for Dependents Life Insurance for your Spouse and Child during the OpenEnrollment Period.4. If your Spouse was insured for an amount less than the Guarantee Issue Amount under thePrior Plan on the day before the Group Policy Effective Date, requirement(s) f. above will bewaived if you apply for an increase in Dependents Life Insurance for your Spouse up to theGuarantee Issue Amount during the Open Enrollment Period.Printed 09/11/2009-2-145371-A
LI.EV.07PREMIUM CONTRIBUTIONSLife Insurance:Plan 1:NoncontributoryPlan 2:ContributoryAD&D Insurance:NoncontributoryDependents Life Insurance:ContributorySCHEDULE OF INSURANCESCHEDULE OF LIFE INSURANCEFor you:Life Insurance Benefit:You will become insured under Plan 1 if you meet the requirements to become insured underthe Group Policy.If you are insured under Plan 1, you may also become insured under Plan 2 if you meet therequirements to become insured under Plan 2 Life Insurance under the Group Policy. Plan 2 isa Contributory plan requiring premium contributions from Members.Plan 1 (basic):2 times your Annual Earnings, rounded to the next highermultiple of 1,000, if not already a multiple of 1,000.The maximum amount is 750,000.Plan 2 (additional):You may apply for Life Insurance in multiples of 10,000,from 10,000 to the lesser of (1) 500,000; or (2) 5 timesyour Annual Earnings.The Repatriation Benefit:The expenses incurred to transport your body to amortuary near your primary place of residence, but not toexceed 5,000 or 10% of the Life Insurance Benefit,whichever is less.For your Spouse:Dependents Life Insurance Benefit:You may apply for Dependents Life Insurance in multiplesof 5,000, from 5,000 to 250,000.The amount of Dependents Life Insurance for your Spouse may not exceed 100% of the amount ofyour Life Insurance.For your Child:Dependents Life Insurance Benefit:You may elect one of the following amounts:Option 1: 2,500Option 2: 5,000The amount of Dependents Life Insurance for your Child may not exceed 100% of the amount ofyour Life Insurance.Printed 09/11/2009-3-145371-A
SCHEDULE OF AD&D INSURANCEFor you:AD&D Insurance Benefit:The amount of your AD&D Insurance Benefit is equal tothe amount of your Plan 1 Life Insurance Benefit. Theamount payable for certain Losses is less than 100% ofthe AD&D Insurance Benefit. See AD&D Table Of Losses.Seat Belt Benefit:The amount of the Seat Belt Benefit is 10% of the amountof AD&D Insurance Benefit payable for Loss of your life.The maximum amount is 75,000.Air Bag Benefit:The amount of the Air Bag Benefit is the lesser of (1) 5,000; or (2) the amount of AD&D Insurance Benefitpayable for Loss of your life.Career Adjustment Benefit:The tuition expenses for training incurred by your Spousewithin 36 months after the date of your death, exclusive ofboard and room, books, fees, supplies and other expenses,but not to exceed 5,000 per year, or the cumulative totalof 10,000 or 25% of the AD&D Insurance Benefit,whichever is less.Child Care Benefit:The total child care expense incurred by your Spousewithin 36 months after the date of your death for allChildren under age 13, but not to exceed 5,000 per year,or the cumulative total of 10,000 or 25% of the AD&DInsurance Benefit, whichever is less.Higher Education Benefit:The tuition expenses incurred per Child within 4 yearsafter the date of your death at an accredited institution ofhigher education, exclusive of board and room, books,fees, supplies and other expenses, but not to exceed 5,000 per year, or the cumulative total of 20,000 or25% of the AD&D Insurance Benefit, whichever is less.Occupational Assault Benefit:The lesser of (1) 25,000; or (2) 50% of the amount of theAD&D Insurance Benefit otherwise payable for the Loss.Public Transportation Benefit:The lesser of (1) 200,000; or (2) 100% of the amount ofthe AD&D Insurance Benefit otherwise payable for theLoss of your life.AD&D TABLE OF LOSSESThe amount payable is a percentage of the AD&D Insurance Benefit in effect on the date of theaccident and is determined by the Loss suffered as shown in the following table:Loss:Percentage Payable:a.Lifeb.One hand or one foot50%c.Sight in one eye, speech, orhearing in both ears50%d.Two or more of the Losses listedin b. and c. above100%e.Thumb and index finger of the25% *Printed 09/11/2009100%-4-145371-A
same 0%No more than 100% of your AD&D Insurance will be paid for all Losses resulting from oneaccident.* No AD&D Insurance Benefit will be paid for Loss of thumb and index finger of the samehand if an AD&D Insurance Benefit is payable for the Loss of that entire hand.REDUCTIONS IN INSURANCEIf you or your Spouse reaches an age shown below, the amount of insurance will be the amountdetermined from the Schedule Of Insurance, multiplied by the appropriate percentage below:Plan 1 Life and AD&D Insurance:Age of MemberPercentageSeptember 1 following age 70:65%September 1 following age 80:50%Plan 2 Life Insurance and Dependents Life Insurance:Age of MemberPercentageSeptember 1 following age 65:65%September 1 following age 70:Your insurance will terminateOTHER BENEFITSWaiver Of Premium:YesAccelerated Benefit:YesOTHER PROVISIONSSuicide Exclusion:Applies to:a. Plan 2 Life Insuranceb. AD&D InsuranceThe maximum Leave Of Absence Periods are as follows:1. If you are on a Leave Of Absence due to a sabbatical or other leave and receive at least one-quarterof the Annual Earnings paid to you immediately before the start of such leave, your Life Insurancemay be continued to the end of 12 months, or, if earlier, the end of such leave.2. If you are on any other Leave Of Absence, your Life Insurance may be continued to the end of 60days, or if earlier, the period approved by your Employer.Printed 09/11/2009-5-145371-A
Leave Of Absence means a period when you are absent from Active Work during which your LifeInsurance under the Group Policy will continue and employment will be deemed to continue, solely forthe purposes of determining when your Life Insurance ends, provided the required premiums for youare remitted and such a leave of absence for you is approved by your Employer and set forth in awritten document that is dated on or before the leave is to start and shows that you are scheduled toreturn to Active Work.During a Leave Of Absence your Life Insurance will be based on the amount that was in effect on yourlast day of Active Work immediately before the start of your Leave Of Absence.Strike Continuation:Yes. The Strike Continuation premium percentage is 120%of the Premium Rate.Insurance Eligible For Portability:For you:Life Insurance:YesMinimum combined amount: 10,000Maximum combined amount: 750,000For your Spouse:Dependents Life Insurance:YesMinimum combined amount: 5,000Maximum combined amount: 250,000For your Child:Dependents Life Insurance:YesMinimum combined amount: 1,000Maximum combined amount: 5,000For you:AD&D Insurance:YesMinimum combined amount: 10,000Maximum combined amount: 750,000Annual Earnings based on:Staff:Annual Earnings means your gross annual income fromyour Employer as established during the month ofSeptember (but not later than September 30) immediatelystpreceding each December 1 .Faculty and Faculty Members on Approved Sabbatical Leave:Annual Earnings means your base annual contract salaryin effect at the beginning of the academic year immediatelystpreceding December 1 .ERISA SUMMARY PLAN DESCRIPTION INFORMATIONName of Plan:Life, AD&D and Dependents Life InsuranceName, Address of Plan Sponsor:Pepperdine UniversityPrinted 09/11/2009-6-145371-A
24255 Pacific Coast HwyMalibu CA 90263Plan Sponsor Tax ID Number:95-1644037Plan Number:501Type of Plan:Group Insurance PlanType of Administration:Contract AdministrationName, Address, PhoneNumber of Plan Administrator:Name, Address of Registered Agentfor Service of Legal Process:If Legal Process Involves ClaimsFor Benefits Under The GroupPolicy, Additional Notification ofLegal Process Must Be Sent To:Plan Sponsor(310) 506-4194Plan AdministratorStandard Insurance Company1100 SW 6th AvePortland OR 97204-1093Sources of Contributions:Employer/MemberFunding Medium:Standard Insurance Company - Fully InsuredPlan Fiscal Year End:August 31Printed 09/11/2009-7-145371-A
LIFE INSURANCEA. Insuring ClauseIf you die while insured for Life Insurance, we will pay benefits according to the terms of the GroupPolicy after we receive Proof Of Loss satisfactory to us.B. Amount Of Life InsuranceSee the Coverage Features for the Life Insurance schedule.C. Changes In Life Insurance1. IncreasesYou must apply in writing for any elective increase in your Life Insurance.Subject to the Active Work Provisions, an increase in your Life Insurance becomes effective asfollows:a. Increases Subject To Evidence Of InsurabilityAn increase in your Life Insurance subject to Evidence Of Insurability becomes effective onthe date we approve your Evidence Of Insurability.b. Increases Not Subject To Evidence Of InsurabilityAn increase in your Life Insurance not subject to Evidence Of Insurability becomes effectiveon the first day of the calendar month coinciding with or next following the date you applyfor an elective increase or the date of change in your classification, age or Annual Earnings.2. DecreasesA decrease in your Life Insurance because of a change in your classification, age or AnnualEarnings becomes effective on the first day of the calendar month coinciding with or nextfollowing the date of the change.Any other decrease in your Life Insurance becomes effective on the first day of the calendarmonth coinciding with or next following the date the Policyholder or your Employer receivesyour written request for the decrease.D. Repatriation BenefitThe amount of the Repatriation Benefit is shown in the Coverage Features.We will pay a Repatriation Benefit if all of the following requirements are met.1. A Life Insurance Benefit is payable because of your death.2. You die more than 200 miles from your primary place of residence.3. Expenses are incurred to transport your body to a mortuary near your primary place ofresidence.E. Suicide Exclusion: Life InsuranceThe Coverage Features states which Life Insurance plan is subject to this suicide exclusion.If your death results from suicide or other intentionally self-inflicted Injury, while sane or insane, 1and 2 below apply.1. The amount payable will exclude the amount of your Life Insurance which is subject to thissuicide exclusion and which has not been continuously in effect for at least 2 years on the dateof your death. In computing the 2-year period, we will include time you were insured under thePrinted 09/11/2009-8-145371-A
Prior Plan.2. We will refund all premiums paid for that portion of your Life Insurance which is excluded frompayment under this suicide exclusion.F. When Life Insurance Becomes EffectiveThe Coverage Features states whether your Life Insurance is Contributory or Noncontributory.Subject to the Active Work Provisions, your Life Insurance becomes effective as follows:1. Life Insurance subject to Evidence Of InsurabilityLife Insurance subject to Evidence Of Insurability becomes effective on the date we approveyour Evidence Of Insurability.2. Life Insurance not subject to Evidence Of Insurabilitya. Noncontributory Life InsuranceNoncontributory Life Insurance not subject to Evidence Of Insurability becomes effective onthe date you become eligible.b. Contributory Life InsuranceYou must apply in writing for Contributory Life Insurance and agree to pay premiums.Contributory Life Insurance not subject to Evidence Of Insurability becomes effective on:(i) The date you become eligible if you apply on or before that date.(ii) Th
The California Life and Health Insurance Guarantee Association PO Box 17319 Beverly Hills CA 90209-3319 OR . in the health care cost component of the consumer price index. . You should consult your personal tax and/or legal
