Group Hospital Insurance Certificate

Life Status Changes that qualify an Employee to apply or increase coverage for Himself include: 6. marriage; 7. loss of a spouse; whether by death, divorce, annulment or legal separation; 8. birth or adoption of a child, or acquiring a child through marriage; 9. a change in the group benefit plan available to the Employee’s Spouse; 10. a change in the Employee’s employment status that affects eligibility for group benefits for either the Employee or His Spouse; 11. termination of a Spouse’s employment; and 12. as specified in the Employer’s Plan which this Policy insures. Life Status Changes that qualify an Employee to apply or increase coverage for His eligible Spouse and Dependent Child include: 3. marriage; 4. loss of a spouse; whether by death, divorce, annulment or legal separation; 5. birth or adoption of a child, or acquiring a child through marriage; 6. a change in the group benefit plan available to the Spouse; 7. a change in the Spouse’s employment status that affects eligibility for group benefits for either the Employee or His Spouse; 8. termination of a Spouse’s employment; and 9. as specified in the Employer’s Plan which this Policy insures. Annual Re-Enrollment An Employee who is eligible to apply, but did not previously enroll, may apply or is insured may apply for an increase for coverage. Changes to coverage for an Employee who applies during the enrollment period and agrees to make required contributions 31 days after enrollment period ends are as follows:

The Employee may apply for an increase in coverage on an insured Spouse or for coverage on a Spouse who is eligible to be insured but was not previously enrolled by the Employee.

The Dependent Child who is eligible to apply, but was not previously enrolled by the Employee, the Employee may apply or is insured the Employee may apply for an increase for coverage.

For all Employee, Spouse and Dependent Child coverage, Evidence of Insurability is not required.

Coverage for which an Employee, Spouse and Dependent Child is eligible will be effective on the effective date of this Policy’s anniversary following the enrollment period.

Group Enrollment Effective Dates Annual Group Enrollment Period Coverage up to the Guaranteed Issue amount for which an Employee, Spouse and Dependent Child is eligible, will be effective on the effective date of this Policy's anniversary following the enrollment period.

For all Employee and Spouse coverage up to the Guaranteed Issue amount, Evidence of Insurability is not required.

The Employee may apply for an increase in coverage on an insured Spouse or for coverage on a Spouse who is eligible to be insured but was not previously enrolled by the Employee.

For all Dependent Child coverage Evidence of Insurability is not required.

The Dependent Child who is eligible to apply, but was not previously enrolled by the Employee, the Employee may apply or is insured the Employee may apply for an increase for coverage.

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