Principal Sample Life Insurance Policy

DOROTHEA GLAUSE S655
RHODE ISLAND JOHN DOE 01/01/2014

711 HIGH STREET
GEORGE RI 02903
GROUP POLICY FOR:
RHODE ISLAND JOHN DOE

ALL MEMBERS
Group Member Life Insurance
Print Date: 07/16/2014

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POLICY RIDER
GROUP INSURANCE
POLICY NO: S655
COVERAGE: Life
EMPLOYER: RHODE ISLAND JOHN DOE
Effective on the later of the Date of Issue of this Group Policy or March 1, 2005, the following
will apply to your Policy:
From time to time The Principal may offer or provide certain employer groups who apply
for coverage with The Principal a Financial Services Hotline and Grief Support Services or
any other value added service for the employees of that employer group. In addition, The
Principal may arrange for third party service providers (i.e., optometrists, health clubs), to
provide discounted goods and services to those employer groups who apply for coverage
with The Principal or who become insureds/enrollees of The Principal. While The
Principal has arranged these goods, services and/or third party provider discounts, the third
party service providers are liable to the applicants/insureds/enrollees for the provision of
such goods and/or services. The Principal is not responsible for the provision of such
goods and/or services nor is it liable for the failure of the provision of the same. Further,
The Principal is not liable to the applicants/insureds/enrollees for the negligent provision of
such goods and/or services by the third party service providers.
EXCEPT AS SPECIFICALLY DESCRIBED IN THIS RIDER, ALL OTHER BENEFITS AND

PROVISIONS WILL BE AS DESCRIBED IN THE GROUP POLICY.
PRINCIPAL LIFE INSURANCE COMPANY

DES MOINES, IOWA 50392-0001
GC 806 VAL
PRINCIPAL LIFE INSURANCE COMPANY
(called The Principal in this Group Policy)
Des Moines, Iowa 50392-0002
This group insurance policy is issued to:
RHODE ISLAND JOHN DOE
(called the Policyholder in this Group Policy)
The Date of Issue is November 1, 2007.
In return for the Policyholder's application and payment of all premiums when due, The Principal
agrees to provide:
MEMBER LIFE INSURANCE
MEMBER ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE
DEPENDENT LIFE INSURANCE
subject to the terms and conditions described in this Group Policy.
GROUP POLICY NO. GL S655

RENEWABLE TERM - NON-PARTICIPATING
CONTRACT STATE OF ISSUE: RHODE ISLAND
This policy has been updated effective January 1, 2014
GC 6000 TITLE PAGE

TABLE OF CONTENTS
PART I - DEFINITIONS
PART II - POLICY ADMINISTRATION
Section A – Contract
Entire Contract Article 1

Policy Changes Article 2
Policyholder Eligibility Requirements Article 3
Policy Incontestability Article 4
Individual Incontestability Article 5
Information to be Furnished Article 6
Certificates Article 7
Assignments Article 8
Dependent Rights Article 9
Policy Interpretation Article 10
Electronic Transactions Article 11
Section B – Premium
Payment Responsibility; Due Dates; Grace Period Article 1

Premium Rates Article 2
Premium Rate Changes Article 3
Premium Amount Article 4
Contributions from Members Article 5
Section C - Policy Termination
Failure to Pay Premium Article 1

Termination Rights of the Policyholder Article 2
Termination Rights of The Principal Article 3
Policyholder Responsibility to Members Article 4
Section D - Policy Renewal
Renewal Article 1
PART III - INDIVIDUAL REQUIREMENTS AND RIGHTS
GC 6001 TABLE OF CONTENTS, PAGE 1

Section A – Eligibility
Member Life Insurance Article 1

Member Accidental Death and Dismemberment Insurance Article 2
Dependent Life Insurance Article 3
Section B - Effective Dates

Section C - Individual Terminations

Termination for Fraud Article 4
Coverage While Outside of the United States Article 5
Section D - Continuation

Dependent Insurance - Developmentally Disabled or
Physically Handicapped Children Article 2
Section E - Reinstatement
Reinstatement Article 1
Federal Required Family and Medical Leave Act (FMLA) Article 2
Reinstatement of Coverage for a Member or Dependent When
Coverage Ends due to Living Outside of the United States Article 3
Section F - Individual Purchase Rights

PART IV - BENEFITS

Section A - Member Life Insurance
Schedule of Insurance Article 1

Death Benefits Payable Article 2
Beneficiary Article 3
Facility of Payment Article 4
Settlement of Proceeds Article 5
Member Life Insurance - Coverage During Disability Article 6
Accelerated Benefits Article 7
Section B - Member Accidental Death and Dismemberment Insurance

Benefit Qualification Article 2
Benefits Payable Article 3
Seat Belt Benefit Article 4
Loss of Use or Paralysis Benefit Article 5
Loss of Speech and/or Hearing Benefit Article 6
Repatriation Benefit Article 7
Educational Benefit Article 8
Limitations Article 9
Section C - Dependent Life Insurance

Death Benefits Payable Article 2
Beneficiary Article 3
Section D - Claim Procedures
Notice of Claim Article 1

Claim Forms Article 2
Proof of Loss Article 3
Payment, Denial and Review Article 4
Medical Examinations Article 5
Autopsy Article 6
Legal Action Article 7
Time Limits Article 8

PART I - DEFINITIONS
When used in this Group Policy the terms listed below will mean:
Active Work; Actively at Work
A Member will be considered Actively at Work if he or she is able and available for active
performance of all of his or her regular duties. Short term absence because of a regularly
scheduled day off, holiday, vacation day, jury duty, funeral leave, or personal time off is
considered Active Work provided the Member is able and available for active performance of all
of his or her regular duties and was working the day immediately prior to the date of his or her
absence.
Activities of Daily Living (ADL)
a. Bathing - the ability to wash oneself in the tub or shower or by sponge with or without
equipment or adaptive devices.
b. Dressing - the ability to put on and take off garments and medically necessary braces or
artificial limbs usually worn and to fasten or unfasten them.
c. Eating/Feeding - the ability to get nourishment into the body by any means once it has been
prepared and made available.
d. Toileting - the ability to get to and from and on and off the toilet, to maintain a reasonable
level of personal hygiene and to care for clothing.
e. Transferring - the ability to move in and out of a chair or bed with or without equipment
such as canes, quad canes, walkers, crutches, grab bars or other support devices including
mechanical or motorized devices.
f. Continence - the ability to voluntarily control bowel and bladder function, or in the event of
incontinence, the ability to maintain a reasonable level of personal hygiene.
Activities of Daily Living (ADL) Disabled; Activities of Daily Living (ADL) Disability
A Member will be considered disabled under this provision if, as a result of sickness or injury,
the Member has lost the ability to safely and completely perform two or more Activities of Daily
Living without another person's assistance or verbal cueing or the Member has a deterioration or
loss in intellectual capacity and needs another person's assistance or verbal cueing for his or her
protection or for the protection of others and the Member is Totally Disabled.
Civil Union
GC 6002 PART I - DEFINITIONS, PAGE 1

The legally recognized union of two eligible individuals of the same sex established according to
law.
Civil Union Partner
For two persons to establish a Civil Union in Rhode Island, it shall be necessary that they satisfy
all of the following criteria:
a. not be a party to another Civil Union or marriage in Rhode Island;
b. be of the same sex and therefore be excluded from the marriage laws of Rhode Island or
any other state;
c. be at least 18 years of age;
d. not be related to the other proposed party to the Civil Union.
NOTE: For the purposes of this Group Policy, the term "spouse" will include Civil Union
Partner, except as otherwise provided in this Group Policy.
Date of Issue
The date this Group Policy is placed in force: November 1, 2007.
Dependent
a. A Member's spouse, if that spouse:
(1) is legally married to the Member; and

(2) is not in the Armed Forces of any country; and
(3) is not insured under this Group Policy as a Member.
A Member's spouse will also include a Civil Union Partner.
b. A Member's Dependent Child (or Children) as defined below.
Dependent Child; Dependent Children
a. A Member's natural child or stepchild, if that child is 0 days but less than 26 years of age.
b. A Member's foster child, if that child:
(1) meets the requirements above; and

(2) has been placed with the Member or spouse insured under this Group Policy by an
authorized state placement agency or by order of a court; and
(3) required documentation has been provided and the child is approved in Writing by
The Principal as a Dependent Child.
c. A Member's adopted child, if that child meets the requirements in a. above and the
Member:
(1) is a party in a law suit in which the Member is seeking the adoption of the child; or
(2) has custody of the child under a court order that grants custody of the child to the
Member.
An adopted child will be considered a Dependent Child on the earlier of: the date the
petition for adoption is filed; or the date of entry of an order granting the adoptive parent
custody of the child for the purpose of adoption.
d. A Civil Union Partner's child who otherwise qualifies above or if the Member or Civil
Union Partner has been appointed the child's guardian under a valid court order.
Developmental Disability
A Dependent Child's substantial handicap, as determined by The Principal, which:
a. results from mental retardation, cerebral palsy, epilepsy, or other neurological disorder; and
b. is diagnosed by a Physician as a permanent or long-term continuing condition.
Full-Time Student
A Member's Dependent Child attending a school that has a regular teaching staff, curriculum,
and student body and who:
a. attends school on a full-time basis, as determined by the school's criteria; and
b. is dependent on the Member for principal support.
Group Policy
The policy of group insurance issued to the Policyholder by The Principal, which describes
benefits and provisions for insured Members and Dependents.
Hospital

An institution that is licensed as a Hospital by the proper authority of the state in which it is
located, but not including any institution, or part thereof, that is used primarily as a clinic, Skilled
Nursing Facility, convalescent home, rest home, home for the aged, nursing home, custodial care
facility, or training center.
Insurance Month
Calendar Month.
Member
Any PERSON who is a full-time employee of the Policyholder and who regularly works at least
30 hours per week. The employee must be compensated by the Policyholder and either the
employer or employee must be able to show taxable income on federal or state tax forms. Work
must be at the Policyholder's usual place or places of business, at an alternative worksite at the
direction of the Policyholder, or at another place to which the employee must travel to perform
his or her regular duties. This excludes any person who is scheduled to work for the
Policyholder on a seasonal, temporary, contracted, or part-time basis.
An owner, proprietor, or partner of the Policyholder's business will be deemed to be an eligible

employee for purposes of this Group Policy, provided he or she is regularly scheduled to work
for the Policyholder at least 30 hours per week and otherwise meets the definition of a Member.
Period of Limited Activity
Any period of time during which a person is:
a. confined in a Hospital for any cause or confined in a Skilled Nursing Facility; or
b. Home Confined. "Home Confined" means that, due to sickness or injury, the person is
unable to carry on the regular and usual activities of a healthy person of the same age and
sex and unable to leave his or her home except to receive medical treatment.
Physical Handicap
A Dependent Child's substantial physical or mental impairment, as determined by The Principal,

which:
a. results from injury, accident, congenital defect, or sickness; and
b. is diagnosed by a Physician as a permanent or long-term dysfunction or malformation of

the body.
Physician

a. A licensed Doctor of Medicine (M.D.) or Osteopathy (D.O.); or
b. any other licensed health care practitioner that state law requires be recognized as a
Physician under this Group Policy.
The term Physician does not include the Member, an employee of the Member, a business or
professional partner or associate of the Member, any person who has a financial affiliation or
business interest with the Member, anyone related to the Member by blood or marriage, or
anyone living in the Member's household.
Policy Anniversary
November 1, 2014 and the same day of each following year.
Policyholder
The entity to whom this Group Policy is issued (see Title Page).
Prior Policy
The Group Term Life coverage of either:
a. the Policyholder; or
b. a business entity which has been obtained by the Policyholder through a merger or
acquisition;
for which this Group Policy is a replacement.
Proof of Good Health
Written evidence that a person is insurable under the underwriting standards of The Principal.
This proof must be provided in a form satisfactory to The Principal.
Qualifying Event
A Qualifying Event for Accelerated Benefits is a medical condition, which would, in the absence
of extensive or extraordinary medical treatment; result in a dramatically limited life span. Such
conditions may include, BUT ARE NOT LIMITED TO, one or more of the following:
a. coronary artery disease resulting in an acute infarction or requiring surgery;
b. permanent neurological deficit resulting from cerebral vascular accident;

c. end stage renal failure; or
d. acquired immune deficiency syndrome (AIDS).
Signed or Signature
Any symbol or method executed or adopted by a person with the present intention to authenticate
a record, and which is on or transmitted by paper or electronic media, and which is consistent
with applicable law and is agreed to by The Principal.
Skilled Nursing Facility
An institution (including one providing sub-acute care), or distinct part thereof, that is licensed
by the proper authority of the state in which it is located to provide skilled nursing care and that:
a. is supervised on a full-time basis by a Doctor of Medicine (M.D.) or Doctor of Osteopathy

(D.O.) or a licensed registered nurse (R.N.); and
b. has transfer arrangements with one or more Hospitals, a utilization review plan, and
operating policies developed and monitored by a professional group that includes at least
one M.D. or D.O.; and
c. has an existing contract for the services of an M.D. or D.O., maintains daily records on
each patient, and is equipped to dispense and administer drugs; and
d. provides 24-hour nursing care and other medical treatment.
Not included are rest homes, homes for the aged, nursing homes, or places for treatment of
mental disease, drug addiction, or alcoholism.
Terminally Ill
A Member will be considered Terminally Ill, for Accelerated Benefits, if he or she has
experienced a Qualifying Event and is expected to die within 12 months of the date he or she
requests payment of Accelerated Benefits.
Total Disability; Totally Disabled
A Member's inability, as determined by The Principal, due to sickness or injury, to perform the
majority of the material duties of any occupation for which he or she is or may reasonably
become qualified based on education, training or experience.
Written or Writing

A record which is on or transmitted by paper or electronic media, and which is consistent with
applicable law.

Section A - Contract
Article 1 - Entire Contract
This Group Policy, the current Certificate, the attached Policyholder application, and any
Member applications make up the entire contract. The Principal is obligated only as provided in
this Group Policy and is not bound by any trust or plan to which it is not a signatory party.
Article 2 - Policy Changes
Insurance under this Group Policy runs annually to the Policy Anniversary, unless sooner
terminated. No agent, employee, or person other than an officer of The Principal has authority to
change this Group Policy, and, to be effective, all such changes must be in Writing and Signed
by an officer of The Principal.
The Principal reserves the right to change this Group Policy as follows:
a. Any or all provisions of this Group Policy may be amended or changed at any time,
including retroactive changes, to the extent necessary to meet the requirements of any law
or any regulation issued by any governmental agency to which this Group Policy is subject.
b. Any or all provisions of this Group Policy may be amended or changed at any time when
The Principal determines that such amendment is required for consistent application of
policy provisions.
c. By Written agreement between The Principal and the Policyholder, this Group Policy may
be amended or changed at any time as to any of its provisions.
Any change to this Group Policy, including, but not limited to, those in regard to coverage,
benefits, and participation privileges, may be made without the consent of any Member or
Dependent.
Payment of premium beyond the effective date of the change constitutes the Policyholder's
consent to the change.
Article 3 - Policyholder Eligibility Requirements
To be an eligible group and to remain an eligible group, the Policyholder must:

GC 6003 Section A - Contract, Page 1
a. be actively engaged in business for profit within the meaning of the Internal Revenue
Code, or be established as a legitimate nonprofit corporation within the meaning of the
Internal Revenue Code; and
b. make at least the level of premium contributions required for insurance on its eligible
Members. The Policyholder must:
(1) contribute at least 50% of the required premium for all Members (including disabled
Members, if any); and
c. if the Member is to contribute part of the premium, maintain the following participation
percentages with respect to eligible employees and Dependents, excluding those for whom
Proof of Good Health is not satisfactory to The Principal:
(1) Employees:
- at least 75% of all eligible employees must enroll;
(2) Dependents:
- maintain a Dependent participation of at least 75% of eligible Dependents; and
d. if the Member is to contribute no part of the premium, 100% of eligible employees and
Dependents must enroll.
Article 4 - Policy Incontestability
In the absence of fraud, after this Group Policy has been in force two years, The Principal may
not contest its validity except for nonpayment of premium.
Article 5 - Individual Incontestability
All statements made by any individual insured under this Group Policy will be representations
and not warranties. In the absence of fraud, these statements may not be used to contest an
insured person's insurance unless:
a. the insured person's insurance has been in force for less than two years during the insured's
lifetime; and
b. the statement is in Written form Signed by the insured person; and

c. a copy of the form which contains the statement is given to the insured or the insured's
beneficiary at the time insurance is contested.
However, these provisions will not preclude the assertion at any time of defenses based upon the
person's ineligibility for insurance under this Group Policy or upon the provisions of this Group
Policy.
In addition, if an individual's age is misstated, The Principal may at any time adjust premium and
benefits to reflect the correct age.
Article 6 - Information to be Furnished
The Policyholder must, upon request, give The Principal all information needed to administer
this Group Policy. If a clerical error is found in this information, The Principal may at any time
adjust premium to reflect the facts. An error will not invalidate insurance that would otherwise
be in force. Neither will an error continue insurance that would otherwise be terminated.
The Principal may inspect, at any reasonable time, all Policyholder records, which relate to this
Group Policy.
Article 7 - Certificates
The Principal will give the Policyholder Certificates for delivery to insured Members. The
delivery of such Certificates will be in either paper or electronic format. The Certificates will be
evidence of insurance and will describe the basic features of the coverage. They will not be
considered a part of this Group Policy.
Article 8 - Assignments
No assignments of Member Life Insurance will be allowed under this Group Policy.
Article 9 - Dependent Rights
A Dependent will have no rights under this Group Policy except as set forth in PART III, Section
F, Article 2.
Article 10 - Policy Interpretation

The Principal has complete discretion to construe or interpret the provisions of this group
insurance policy, to determine eligibility for benefits, and to determine the type and extent of
benefits, if any, to be provided. The decisions of The Principal in such matters shall be
controlling, binding and final as between The Principal and persons covered by this Group
Policy, subject to the Claims Procedures in PART IV, Section D.
Article 11 - Electronic Transactions
Any transaction relating to this Group Policy may be conducted by electronic means if
performance of the transaction is consistent with applicable state and federal law.
Any notice required by the provisions of this Group Policy given by electronic means will have
the same force and effect as notice given in writing.

Section B - Premiums
Article 1 - Payment Responsibility; Due Dates; Grace Period
The Policyholder is responsible for collection and payment of all premiums due while this Group
Policy is in force. Payments must be sent to the home office of The Principal in Des Moines,
Iowa.
The first premium is due on the Date of Issue of this Group Policy. Each premium thereafter
will be due on the first of each Insurance Month. Except for the first premium, a Grace Period of
31 days will be allowed for payment of premium. "Grace Period" means the first 31-day period
following a premium due date. The Group Policy will remain in force until the end of the Grace
Period, unless the Group Policy has been terminated by notice as described in PART II, Section
C. The Policyholder will be liable for payment of the premium for the time this Group Policy
remains in force during the Grace Period.
Article 2 - Premium Rates
The premium rate(s) for each Member insured for Life Insurance will be:
a. Member Life Insurance

$0.210 for each $1,000 of insurance in force.
b. Member Accidental Death and Dismemberment Insurance

$0.025 for each $1,000 of Member Life Insurance in force.
c. Dependent Life Insurance

$1.46 for each Member insured for Dependent Life Insurance.
If the Policyholder has at least two other eligible group insurance policies underwritten by The
Principal, as determined by The Principal, the Policyholder may be eligible for a multiple policy
discount.
Article 3 - Premium Rate Changes
The Principal may change a premium rate:
a. on any premium due date, if the initial premium rate has then been in force 24 months or
more and if Written notice is given to the Policyholder at least 31 days before the date of
change; or

GC 6004 Section B - Premiums, Page 1
b. on any date the definition of Member or Dependent is changed; and
c. on any date the Policyholder's business, as specified on the Policyholder application, is

changed; and
d. on any date that a schedule of insurance or class of insured Members is changed; and
e. on any premium due date, if the Policyholder has been receiving a multiple policy discount
rate and the Policyholder drops below the minimum number of coverages to receive such
discount rate; and
f. on any date the premium contribution required of Members is changed; and
g. with respect to Member Life Insurance, on any Policy Anniversary, if the average age,
average Scheduled Benefit amount, or the male/female distribution for then insured
Members has changed since the last Policy Anniversary; and
h. on any Policy Anniversary, if the volume of insurance for then insured Members has
increased or decreased by more than 25% since the last Policy Anniversary.
If the Policyholder has other group insurance with The Principal, and if life coverage is initially
added on a date other than the Policy Anniversary and it is more than six months before the next
Policy Anniversary, The Principal reserves the right to change the premium rate on the next
Policy Anniversary. Written notice will be given to the Policyholder at least 31 days before the
date of change.
If the Policyholder agrees to participate in the electronic services program of The Principal and,
at a later date elects to withdraw from participation, such withdrawal may result in certain
administrative fees being charged to the Policyholder.
Article 4 - Premium Amount
The amount of premium to be paid on each due date will be determined in these ways:
a. Member Life Insurance

The total volume of insurance in force will be divided by 1,000. The result will then be
multiplied by the premium rate then in effect.
b. Member Accidental Death and Dismemberment Insurance

The total volume of insurance in force will be divided by 1,000. The result will then be
multiplied by the premium rate then in effect.
c. Dependent Life Insurance

The number of Members insured for Dependent Life Insurance will be multiplied by the
premium rate then in effect.
To ensure accurate premium calculations, the Policyholder is responsible for reporting to The
Principal, the following information during the stated time periods:
a. Members who are eligible to become insured are to be reported during the month prior to
or during the month that coverage becomes effective.
b. Members whose coverage has terminated are to be reported within a month of the date
coverage terminated.
c. Changes in Member insurance class are to be reported within a month of the date that the
change in insurance class took place.
If a Member is added or a present Member's insurance is increased or terminated on other than

the first of an Insurance Month, premium for that Member will be adjusted and applied as if the
change were to take place on the first of the next following Insurance Month.
Article 5 - Contributions from Members
Members are not required to contribute a part of the premium for their Member insurance under
this Group Policy.
Members are required to contribute a part of the premium for their Dependent's insurance under
this Group Policy.

Section C - Policy Termination
Article 1 - Failure to Pay Premium
This Group Policy will terminate at the end of the Grace Period if total premium due has not
been received by The Principal before the end of the Grace Period. Failure by the Policyholder
to pay the premium within the Grace Period will be deemed notice by the Policyholder to The
Principal to discontinue this Group Policy at the end of the Grace Period.
Article 2 - Termination Rights of the Policyholder
The Policyholder may terminate this Group Policy effective on the day before any premium due
date by giving Written notice to The Principal prior to that premium due date. The
Policyholder's issuance of a stop-payment order for any amounts used to pay premiums for the
Policyholder's coverage will be considered Written notice from the Policyholder.
Article 3 - Termination Rights of The Principal
The Principal may nonrenew or terminate this Group Policy by giving the Policyholder 31 days
advance notice in Writing, if the Policyholder:
a. ceases to be actively engaged in business for profit within the meaning of the Internal
Revenue Code, or be established as a legitimate nonprofit corporation within the meaning
of the Internal Revenue Code; or
b. fails to maintain the participation percentages requirements of PART II, Section A with
respect to eligible employees, excluding those for whom Proof of Good Health is not
satisfactory to The Principal; or
c. fails to maintain three or more insured employees under this Group Policy; or
d. fails to pay premium in accordance with the requirements of PART II, Section B; or
e. has performed an act or practice that constitutes fraud or has made an intentional
misrepresentation of material fact under the terms of this Group Policy; or
f. does not promptly provide The Principal with information that is reasonably required; or
g. fails to perform any of its obligations that relate to this Group Policy.

GC 6005 Section C - Policy Termination, Page 1
The Principal may terminate the Policyholder's coverage on any premium due date if the
Policyholder relocates to a state where this Group Policy is not marketed, by giving the
Policyholder 31 days advanced notice in Writing.
Article 4 - Policyholder Responsibility to Members
If this Group Policy terminates for any reason, the Policyholder must:
a. notify each Member of the effective date of the termination; and
b. refund or otherwise account to each Member all contributions received or withheld from
Members for premiums not actually paid to The Principal.

Section D - Policy Renewal
Article 1 - Renewal
Insurance under this Group Policy runs annually to the Policy Anniversary, unless sooner
terminated.
While this Group Policy is in force, and subject to the provisions in PART II, Section C, the
Policyholder may renew at the applicable premium rates in effect on the Policy Anniversary.

GC 6005 A Section D - Policy Renewal, Page 1
Section A - Eligibility
Article 1 - Member Life Insurance
A person will be eligible for Member Life Insurance on the date the person completes 30
consecutive days of continuous Active Work with the Policyholder as a Member.
In no circumstance will a person be eligible for Member Life Insurance under this Group Policy
if the person is eligible under any other Group Term Life Insurance policy underwritten by The
Principal.
Article 2 - Member Accidental Death and Dismemberment Insurance
A person will be eligible for Member Accidental Death and Dismemberment Insurance on the
latest of:
a. the date the person is eligible for Member Life Insurance; or
b. the date the person enters a class for which Member Accidental Death and Dismemberment
Insurance is provided under this Group Policy; or
c. the date Member Accidental Death and Dismemberment Insurance is added to this Group
Policy.
Article 3 - Dependent Life Insurance
A person will be eligible for Dependent Life Insurance on the latest of:
a. the date the person is eligible for Member Life Insurance; or
b. the date the person first acquires a Dependent; or
c. the date the person enters a class for which Dependent Life Insurance is provided under
this Group Policy; or
d. the date Dependent Life Insurance is added to this Group Policy.

GC 6006 Section A - Eligibility, Page 1
If a Member's Dependent is employed and is covered under group term life coverage or
coverages provided by the Dependent's employer, the date such coverage terminates because the
Dependent is no longer eligible under his/her employer's coverage will be considered the date the
Member first acquires that Dependent (and any other Dependent who was also covered under
such group coverage or coverages).

Section B - Effective Dates
a. Actively at Work
A Member's effective date for Member Life Insurance will be as explained in this article, if
the Member is Actively at Work on that date. If the Member is not Actively at Work on
the date insurance would otherwise be effective, such insurance will not be in force until
the day of return to Active Work.
However, this Actively at Work requirement will be waived for Members who:
(1) are absent from Active Work because of a regularly scheduled day off, holiday, or
vacation day; and
(2) were Actively at Work on their last scheduled work day before the date of their
absence; and
(3) were capable of Active Work on the day before the scheduled effective date of their
insurance or change in their insurance, whichever is applicable.
This Actively at Work requirement may also be waived as described below.
When insurance under this Group Policy replaces coverage under a Prior Policy, the Active
Work requirement may be waived for those Members who:
(1) are eligible and enrolled under this Group Policy on its Date of Issue; and
(2) were covered under the Prior Policy on the date of its termination.
In no event will the Active Work requirement be waived for those Members who, on the
date of termination of the Prior Policy, either:
(1) had the option, under the terms of the Prior Policy, to convert their coverage under
the Prior Policy to an individual policy; or
(2) were eligible under the terms of the Prior Policy, to have their premiums waived due
to ADL Disability or Total Disability.
NOTE: When insurance under this Group Policy replaces coverage under a Prior Policy
and the Active Work requirement is waived, any benefits payable will be the lesser of the
Scheduled Benefit of this Group Policy or the amount that would have been paid by the
Prior Policy had it remained in force.
b. Effective Date for Initial Insurance When Proof of Good Health is Required

GC 6007 Section B - Effective Dates, Page 1
Insurance for which Proof of Good Health is required (see e. below) will be in force on the
later of:
(1) the date insurance would have been effective if Proof of Good Health had not been
required; or
(2) the date Proof of Good Health is approved by The Principal.
c. Effective Date for Initial Noncontributory Insurance When Proof of Good Health is
not Required
Unless Proof of Good Health is required (see b. above and e. below), insurance for which
the Member contributes no part of premium will be in force on the date the Member is
eligible.
d. Effective Date for Initial Contributory Insurance When Proof of Good Health is not
Required
If a Member is to contribute a part of premium, insurance must be requested in a form

provided by The Principal. Unless Proof of Good Health is required (see b. above and e.
below), the requested insurance will be in force on:
(1) the date the Member is eligible, if the request is made on or before that date; or
(2) the date of the Member's request, if the request is made within 31 days after the date
the Member is eligible.
If the request is made more than 31 days after the date the Member is eligible, Proof of
Good Health will be required before insurance can be in force (see b. above and e. below).
e. Proof of Good Health Requirements
The type and form of required Proof of Good Health will be determined by The Principal.
A Member must submit Proof of Good Health:
(1) If insurance for which a Member contributes a part of premium is requested more
than 31 days after the date the Member is eligible including any insurance the
Member refuses and later requests.
(2) If insurance is requested under this Group Policy by a Member that was eligible under
the Prior Policy, but elected to waive coverage under the Prior Policy.
(3) If a Member has failed to provide required Proof of Good Health or has been refused
insurance under this Group Policy at any prior time.
(4) If a Member elects to terminate insurance and, more than 31 days later, requests to be
insured again.
(5) If, on the date a Member becomes eligible, fewer than five Members are insured.

(6) If, on the date a Member becomes eligible for any increased or additional Scheduled
Benefit amount, fewer than five Members are insured.
(7) To make effective any Scheduled Benefit amounts for the Member that are, initially
or through later increases, in excess of:
- $10,000 for Members who are under age 65; and

- $10,000 for Members who are age 65 or over but under age 70; and
- *$10,000 for Members who are age 70 or over.
*If a Member is insured under this Group Policy on its Date of Issue and this
insurance replaces insurance in force on the day immediately before the Date of
Issue: the lesser of the amount shown above or the amount for which the Member
was insured under the replaced insurance.
f. Effective Date for Benefit Changes Due to Change in Insurance Class
(1) A change in the Member's Scheduled Benefit amount because of a change in the
Member's insurance class for which Proof of Good Health is not required (see e.
above) will normally be effective on the date of change. However, if the Member is
not Actively at Work on the date a Scheduled Benefit change would otherwise be
effective, the Scheduled Benefit change will not be in force until the date the Member
returns to Active Work. Any decrease in Scheduled Benefit amounts due to a change
in a Member's insurance class will be effective on the date of the change, whether or
not the Member is Actively at Work.
Any termination of Scheduled Benefit amounts due to a change in the Member's

insurance class will be effective on the date of the change, whether or not the Member
is Actively at Work.
(2) A change in a Member's Scheduled Benefit amount because of a change in the

Member's insurance class for which Proof of Good Health is required (see e. above)
will be effective on the later of:
- the date the change would have been effective if Proof of Good Health had not
been required; or
- the date Proof of Good Health is approved by The Principal.
g. Effective Date for Benefit Changes Due to Change by Policy Amendment
Schedule of Insurance (as described in PART IV, Section A) by amendment to this
Group Policy for which Proof of Good Health is not required (see e. above) will be
effective on the date of change. However, if the Member is not Actively at Work on
the date an increase in the Scheduled Benefit would otherwise be effective, the

Scheduled Benefit in force for the Member before the change will continue to apply
to the Member until the day of return to Active Work. When the Member returns to
Active Work, the Scheduled Benefit increase will then be in force for the Member.
Any decrease in Scheduled Benefit amounts due to a change by amendment to this
Group Policy will be effective on the date of change, whether or not the Member is
Actively at Work.
Schedule of Insurance (as described in PART IV, Section A) by amendment to this
Group Policy for which Proof of Good Health is required (see e. above) will be
effective on the later of:
been required; or
h. Effective Date for Benefit Changes Due to Changes Requested by the Member
(1) A change in a Member's Scheduled Benefit amount because of a request by the

Member for which Proof of Good Health is not required (see e. above) will normally
be effective on the date of the request. However, if the Member is not Actively at
Work on the date a Scheduled Benefit change would otherwise be effective, the
Scheduled Benefit change will not be in force until the date the Member returns to
Active Work. Any decrease in Scheduled Benefit amounts due to a request by the
Member will be effective on the date of the change, whether or not the Member is
Actively at Work.
(2) A change in the Member's Scheduled Benefit amount because of a request by the
Member for which Proof of Good Health is required (see e. above) will be effective
on the later of:
been required; or
i. Effective Date for Benefit Changes Due to Change in the Member's Family Status
A Member may request an increase in Scheduled Benefit amount, a decrease in Scheduled

Benefits, or the addition of Scheduled Benefits for which he or she was not previously
insured if a change in the Member's family status as described below has occurred,
provided a request for such increase, decrease, or addition is made in Writing within 31
days after the date of the change in family status:

(1) marriage or establishment of a Civil Union partnership or divorce or termination of a
Civil Union partnership;
(2) death of a spouse or child;
(3) birth or adoption of a child;
(4) termination of employment by the Member's spouse or a change in the spouse's
employment that causes loss of group coverage;
(5) the Member's employment or the Member's spouse's employment changes from part-
time to full-time or from full-time to part-time;
(6) the Member or the Member's spouse takes an unpaid leave of absence.
A change in the Scheduled Benefits because of a request by the Member when a change in
family status has occurred for which Proof of Good Health is not required (see e. above)
will normally be effective on the date of the request. However, if the Member is not
Actively at Work on the date a Scheduled Benefit change would otherwise be effective, the
Scheduled Benefit change will not be in force until the date the Member returns to Active
Work. Any decrease in Scheduled Benefit amounts due to a request by the Member will be
effective on the date of the change, whether or not the Member is Actively at Work.
A change in the Scheduled Benefits because of a request by the Member when a change in
family status has occurred for which Proof of Good Health is required (see e. above) will
be effective on the later of:
(1) the date the change would have been effective if Proof of Good Health had not been
required; or
(2) the date Proof of Good Health is approved by The Principal.
Member Accidental Death and Dismemberment Insurance will be effective under the same terms
as set forth for Member Life Insurance in this Section B, Article 1. However, in no event will
Member Accidental Death and Dismemberment Insurance be in force for a Member who is not
insured for Member Life Insurance.
Any change in a Member's Scheduled Benefit will be as stated in this Section B, Article 1.
Dependent Life Insurance is available only with respect to Dependents of Members currently
insured for Member Life Insurance. If a Member is eligible for Dependent Life Insurance, such
insurance will be effective under the same terms as set forth for Member Life Insurance in this
Section B, Article 1, except as described below.

a. In no event will Dependent Life Insurance be in force for a Member who is not insured for
Member Life Insurance.
b. If a Dependent spouse is in a Period of Limited Activity on the date Dependent Life

Insurance or an increase in Dependent Life Insurance Scheduled Benefit due to a change in
the Member's Annual Compensation or insurance class would otherwise be effective, such
insurance or increase will not be in force for that Dependent spouse until the Period of
Limited Activity ends.
However, this Period of Limited Activity requirement may be waived as described below.
When insurance under this Group Policy replaces coverage under a Prior Policy, the Period
of Limited Activity requirement may be waived for those Dependent spouses' who:
(1) are eligible and enrolled under this Group Policy on its Date of Issue; and
(2) were covered under the Prior Policy on the date of its termination.
In no event will the Period of Limited Activity requirement be waived for those Dependent
spouses' who, on the date of termination of the Prior Policy had the option, under the terms
of the Prior Policy, to convert their coverage, under the Prior Policy, to an individual
policy.
NOTE: When insurance under this Group Policy replaces coverage under a Prior Policy
and the Period of Limited Activity requirement is waived, any benefits payable will be the
lesser of the Scheduled Benefit of this Group Policy or the amount that would have been
paid by the Prior Policy had it remained in force.
c. If insurance is requested under this Group Policy for a Dependent spouse that was eligible
under the Prior Policy, but elected to waive coverage under the Prior Policy.
d. If a Dependent is confined in a Hospital or Skilled Nursing Facility on the date an increase

in the Dependent Life Insurance Scheduled Benefit would otherwise be effective, the
Scheduled Benefit in force for the Dependent will continue to apply to the Dependent until
such confinement ends. When the Hospital or Skilled Nursing Facility confinement ends,
the Scheduled Benefit increase will then be in force for the Dependent.
e. Any required Proof of Good Health will be with respect to the health of the Member's
Dependents.
f. If Dependent Life Insurance is in force for a Dependent of the Member, a Member will be
insured with respect to a new Dependent (other than a newborn child) on the date the new
Dependent is acquired, provided the new Dependent is not then confined in a Hospital or
Skilled Nursing Facility. Requests for insurance and Proof of Good Health are not required

provided The Principal has been notified of the new Dependent within 31 days after the
date the Dependent is acquired.
g. If Dependent Life Insurance is in force for a Dependent of the Member, a newly born child
will be covered under this Group Policy on the date the child is 0 days old, provided the
child meets the definition of a Dependent Child as defined in PART I.

Section C - Individual Terminations
A Member's insurance under this Group Policy will terminate on the earliest of:
a. the date this Group Policy is terminated; or
b. the date the last premium is paid for the Member's insurance; or
c. any date desired, if requested by the Member before that date; or
d. the date the Member ceases to be a Member as defined in PART I; or
e. the date the Member ceases to be in a class for which Member Life Insurance is provided;
or
f. the date the Member retires; or
g. the date the Member ceases Active Work.
A Member's Accidental Death and Dismemberment Insurance under this Group Policy will
terminate on the earliest of:
a. the date his or her Member Life Insurance ceases; or
b. the date Member Accidental Death and Dismemberment Insurance is removed from this
Group Policy; or
c. the date the last premium is paid for the Member's Accidental Death and Dismemberment
Insurance; or
d. any date desired, if requested by the Member before that date; or
e. the date the Member ceases to be in a class for which Member Accidental Death and
Dismemberment Insurance is provided.

GC 6008 Section C - Individual Terminations, Page 1
A Member's insurance under this Group Policy for a Dependent will terminate on the earliest of:
a. the date his or her Member Life Insurance ceases; or
b. the date Dependent Life Insurance is removed from this Group Policy; or
c. the date the last premium is paid for the Member's Dependent Life Insurance; or
d. any date desired, if requested by the Member before that date; or
e. the date the Member ceases to be in a class for which Dependent Life Insurance is
provided; or
f. for a Dependent spouse on the date that Dependent spouse ceases to be a Dependent as
defined in PART I; or
g. for each Dependent Child, on the date that Dependent Child ceases to be a Dependent as
defined in PART I.
Article 4 - Termination for Fraud
The Principal may at any time terminate a Member's or Dependent's eligibility under the Group
Policy:
a. in Writing and with 31-day notice, if the individual submits any claim that contains false or
fraudulent elements under state or federal law; or
b. in Writing and with 31-day notice, upon finding in a civil or criminal case that a Member
or Dependent has submitted claims that contain false or fraudulent elements under state or
federal law; or
c. in Writing and with 31-day notice, when a Member or Dependent has submitted a claim
which, in good faith judgement and investigation, a Member or Dependent knew or should
have known, contains false or fraudulent elements under state or federal law.
Article 5 - Coverage While Outside of the United States
If a Member or Dependent is temporarily outside the United States, the Member or Dependent
may choose to continue his or her insurance, subject to premium payment for a period of six
months or less for one of the following reasons:
a. travel; or

b. a business assignment; or
c. full-time student status, provided the Member or Dependent is either:
(1) enrolled and attending an accredited school in a foreign country; or

(2) is participating in an academic program in a foreign country, for which the institution
of higher learning at which the student is enrolled in the U.S. grants academic credit.
The six-month period will not be reduced for any time covered under a Prior Policy.
If a Member or Dependent is outside the United States for any other reason than those listed
above, coverage for the person concerned will automatically terminate.

Section D - Continuation
a. Sickness or Injury (Other Than ADL Disability or Total Disability)
If Active Work ends because a Member is sick or injured but not ADL Disabled or Totally
Disabled, insurance for that Member may be continued until the earlier of:
(1) the date insurance would otherwise cease as provided in PART III, Section C; or
(2) the date the Member recovers.
b. Layoff or Approved Leave of Absence
If Active Work ends because a Member is on layoff or approved leave of absence,

insurance for that Member may be continued until the earliest of:
(1) the date insurance would otherwise cease as provided in PART III, Section C, Article
1 a. through g.; or
(2) the date the layoff or approved leave of absence ends; or
(3) the date the Member becomes eligible for any other group life coverage; or
(4) the date one month after the date Active Work ends.
c. Family and Medical Leave Act (FMLA)
If a Member ceases Active Work due to an approved leave of absence under FMLA, the
Policyholder may choose to continue the Member's insurance, subject to premium
payment.
A Member may qualify to have his or her insurance continued under one or more of the
continuation provisions described in a., b., and c. above. If a Member qualifies for continuation
under more than one provision, the longest period of continuation will be applied, and all periods
of continuation will run concurrently.
Article 2 - Dependent Insurance - Developmentally Disabled or Physically Handicapped

Children
a. Qualification
Dependent Life Insurance for a child may be continued after the child reaches the
maximum age for Dependent Children as defined in PART I of this Group Policy, provided
that:

GC 6009 Section D - Continuation, Page 1
(1) the child is incapable of self-support as the result of a Developmental Disability or
Physical Handicap and became so before reaching the maximum age and is
dependent on the Member for primary support; and
(2) except for age, the child continues to be a Dependent Child as defined in PART I; and
(3) proof of the child's incapacity is sent to The Principal within 31 days after the date the
child reaches the maximum age; and
(4) further proof that the child remains incapable of self-support is provided when The
Principal requests; and
(5) the child undergoes examination by a Physician when The Principal requests. The
Principal will pay for these examinations and will choose the Physician to perform
them.
b. Period of Continuation
Insurance for a Dependent Child who qualifies as set forth above may be continued until
the earlier of:
(1) the date insurance would cease for any reason other than the child's attainment of the
maximum age; or
(2) the date the child becomes capable of self-support or otherwise fails to qualify as set
forth in a. above.

Section E - Reinstatement
Article 1 - Reinstatement
A Member's terminated insurance will be reinstated if:
a. insurance ceased because of layoff or approved leave of absence; and
b. the Member returns to Active Work for the Policyholder within six months of the date
insurance ceased.
The Member's reinstated insurance will be in force on the date of return to work. However, the
Actively at Work and Period of Limited Activity provisions discussed in PART III, Section B,
will apply. Also, Proof of Good Health will be required to place in force any Scheduled Benefit
that would have been subject to Proof of Good Health had the Member remained continuously
insured.
Only the period of time during which a Member is actually insured will be included in
determining the length of his or her continuous coverage under this Group Policy. For this
purpose the period of time during which a reinstated Member's insurance was not in force:
a. will not be considered an interruption of continuous coverage; and
b. will not be used to satisfy any provision of this Group Policy which pertains to a period of
continuous coverage.
In addition, a longer reinstatement period may be allowed for an approved leave of absence taken
in accordance with the provisions of the federal law regarding the Uniformed Services
Employment and Reemployment Rights Act of 1994 (USERRA).
Article 2 - Federal Required Family and Medical Leave Act (FMLA)
A Member's terminated insurance may be reinstated in accordance with the provisions of the
Federal Family and Medical Leave Act (FMLA), subject to the Actively at Work and Period of
Limited Activity provision discussed in PART III, Section B.
Article 3 - Reinstatement of Coverage for a Member or Dependent When Coverage Ends

due to Living Outside of the United States

GC 6010 Section E - Reinstatement, Page 1
If coverage for a Member or Dependent terminates because the person is outside of the United
States as discussed in PART III, Section C, Article 5, the Member or Dependent may become
eligible again for coverage under this Group Policy, but only if:
a. the Member or Dependent return to the United States within six months of the date on
which coverage terminated because the person is outside of the United States; and
b. in the case of a Member, the Member returns to Active Work in the United States for the
Policyholder for a period of at least 30 consecutive days. The Member will be eligible for
coverage on the day immediately following completion of the 30 consecutive days of
Active Work; and
c. in the case of the Dependent, he or she remains in the United States for 30 consecutive
days. If the Dependent does so, he or she will be eligible for reinstatement of coverage on
the day after completion of the 30 consecutive days of residence.
The reinstated coverage will be on the same basis as that being provided on the date coverage is
reinstated. However, any restrictions on this coverage that were in effect before reinstatement
will continue to apply. If the Member or Dependent does not complete the 30 consecutive days
of residence, the coverage for such person will not be reinstated.

Section F - Individual Purchase Rights
a. Individual Policy
If a Member qualifies and makes timely application, he or she may convert the group
coverage by purchasing an individual policy of life insurance under these terms:
(1) The Member will not be required to submit Proof of Good Health.
(2) The policy will be for life insurance only. No disability or other benefits will be
included.
(3) The policy will be on one of the forms, other than term insurance, then issued by The
Principal to persons in the risk class to which the Member belongs on the individual
policy's effective date.
(4) Premium will be based on the Member's age and the standard rate of The Principal for
the policy form to be issued.
b. Purchase Qualification
A Member will qualify for individual purchase if insurance under this Group Policy
terminates and:
(1) the Member's total Life Insurance, or any portion of it, terminates because he or she
ends Active Work or ceases to be in a class eligible for insurance; or
(2) after the Member has been continuously insured under this Group Policy for at least
five years, his or her total Member Life Insurance terminates because this Group
Policy terminates or is amended to exclude the Member's insurance class; or
(3) the Member's Coverage During Disability as described in PART IV, Section A,
ceases because Total Disability ends and he or she does not return to Active Work
within 31 days; or
(4) the Member's Accelerated Benefits Premium Waiver Period as described in PART
IV, Section A, ceases and he or she does not qualify for Coverage During Disability .
c. Application/Effective Date
Notice of the individual purchase right must be given to the Member by the Policyholder
before insurance under this Group Policy terminates, or as soon as reasonably possible
thereafter.
A Member must apply for individual purchase and the first premium for the individual
policy must be paid to The Principal within 31 days after the date Member Life Insurance
or Coverage During Disability terminates under this Group Policy.

GC 6011 Section F - Individual Purchase Rights, Page 1
Any individual policy issued will then be in force on the 32nd day following such
termination date.
d. Individual Policy Amount
The amount of insurance that may be purchased may vary:
(1) If termination is as described in b. (1) above, the maximum amount will be the
Member Life Insurance benefit in force on the date of termination or the portion of
Member Life Insurance that has terminated, less any individual policy amount
purchased earlier under this Article 1, and less any Accelerated Benefit payment as
described in PART IV, Section A, Article 7.
(2) If termination is as described in b. (2) above, the maximum amount will be the lesser
of:
- $10,000; or
- the Member Life Insurance benefit in force on the date of termination, less any
Accelerated Benefit payment as described in PART IV, Section A, Article 7 and
less the amount for which the Member becomes eligible under any group policy
within 31 days.
Coverage During Disability benefit in force on the date Total Disability ceases, less
any individual policy amount purchased earlier under this Article 1, and less any
Accelerated Benefit payment as described in PART IV, Section A, Article 7.
Member Life Insurance benefit in force on the date the Member ceases Active Work,
less any individual policy amount purchased earlier under this Article 1, and less any
Accelerated Benefit payment as described in PART IV, Section A, Article 7.
a. Individual Policy
If a Dependent qualifies and makes timely application, he or she may purchase an

individual policy of life insurance under these terms:
(1) The Dependent will not be required to submit Proof of Good Health.
(2) The policy will be for life insurance only. No disability or other benefits will be
included.
(3) The policy will be on one of the forms, other than term insurance, then issued by The
Principal to persons in the risk class to which the Dependent belongs on the
individual policy's effective date.
(4) Premium will be based on the Dependent's age and the standard rate of The Principal
for the policy form to be issued.
b. Purchase Qualification
A Dependent will qualify for individual purchase if:
(1) Dependent Life Insurance, or any portion of it, terminates because he or she ceases to
be a Dependent as defined in PART I; or because the Member dies, ends Active
Work, or ceases to be in a class eligible for such insurance; or
(2) the Dependent spouse's Dependent Life Insurance terminates as described in PART
III, Section C; or
(3) the Dependent spouse's or Civil Union Partner's Dependent Life Insurance terminates
because of divorce or separation or termination of a Civil Union partnership from the
Member; or
(4) after the Dependent has been continuously insured for Dependent Life Insurance for
at least five years, such insurance terminates because the Group Policy terminates, or
is amended to eliminate Dependent Life Insurance, or the Member's insurance class;
or
(5) the Dependent's Life Insurance terminates because the Member's Coverage During
Disability as described in PART IV, Section A, ceases because Total Disability ends
and the Member does not return to Active Work within 31 days ; or
(6) the Dependent's Life Insurance terminates because the Member's Accelerated
Benefits Premium Waiver Period as described in PART IV, Section A, ceases and the
Member does not qualify for Coverage During Disability.
c. Application/Effective Date
Notice of the individual purchase right must be given to the Member by the Policyholder
before insurance under this Group Policy terminates, or as soon as reasonably possible
thereafter.
A Dependent must apply for individual purchase and the first premium for the individual
policy must be paid to The Principal within 31 days after the date Dependent Life
Insurance for the Dependent terminates under this Group Policy.
Any individual policy issued will then be in force on the 32nd day after such termination
date.
d. Individual Policy Amount
The amount of insurance that a Dependent may purchase may vary:

Dependent Life Insurance benefit in force for the Dependent on the date of
termination or the portion of Dependent Life Insurance that has terminated, less any
individual policy amount purchased earlier under this Article 2.
(2) If termination is as described in b. (2), b. (3) or b. (5) or b. (6) above, the maximum
amount will be the Dependent Life Insurance benefit in force for the Dependent on
the date of termination, less any individual policy amount purchased earlier under this
Article 2.
(3) If termination is as described in b. (4) above, the maximum amount will be the lesser
of:
- $10,000; or
- the Dependent Life Insurance benefit in force for the Dependent on the date of
termination, less the amount for which the Dependent becomes eligible under
any group policy within 31 days.
PART IV - BENEFITS
Section A - Member Life Insurance
Article 1 - Schedule of Insurance
Subject to the Effective Date provisions of PART III, Section B, and the qualifying provisions of
this Section A, the Scheduled Benefit for an insured Member will be based on his or her class:
Class *Scheduled Benefit
ALL MEMBERS $10,000
However, if a Member has received any payments under the Accelerated Benefits provision as
described in Section A, Article 7, the Scheduled Benefit will be reduced by the amount of such
payment.
*The Scheduled Benefit is subject to the Proof of Good Health requirements as shown in PART
III, Section B, Article 1. Because of the Proof of Good Health requirements, the amount of
insurance approved by The Principal may be different than the Scheduled Benefit. If the
approved amount of insurance is different than the Scheduled Benefit, the approved amount will
apply.
For the age(s) shown below, the amount of a Member's insurance will be the percentage of the
Scheduled Benefit (or approved amount, if applicable) as shown below.
Age % of Scheduled Benefit (or approved

amount, whichever applies)
Age 70 but less than age 75 65%
Age 75 and over 45%
Article 2 - Death Benefits Payable
If a Member dies while insured for Member Life Insurance under this Group Policy, The
Principal will pay his or her beneficiary the Scheduled Benefit (or approved amount, if
applicable) in force on the date of death, less any Accelerated Benefit payment as described in
PART IV, Section A, Article 7. However, if a beneficiary is suspected or charged with the
PART IV - BENEFITS
GC 6013 Section A - Member Life Insurance, Page 1
Member's death, the Death Benefits Payable may be withheld until additional information has
been received or the trial has been held.
If a Member who was insured dies within the 31-day individual purchase period described in
PART III, Section F, The Principal will pay his or her beneficiary the individual policy amount,
if any, the Member had the right to purchase.
No payment will be made before The Principal receives Written proof of the Member's death.
Article 3 - Beneficiary
A beneficiary should be named at the time a Member applies or enrolls under this Group Policy.
A Member may name or later change a named beneficiary by sending a Written request to The
Principal. A change will not be effective until recorded by The Principal. Once recorded, the
change will apply as of the date the request was Signed. If The Principal properly pays any
benefit before a change request is received, that payment may not be contested. Further:
a. The naming of a new beneficiary in an application for individual purchase under PART III,
Section F, Article 1, will be treated as a beneficiary change request under this Group
Policy.
b. If a Member's terminated insurance is reinstated, his or her beneficiary will be as recorded

on the date of termination.
If a Member is insured under this Group Policy on its Date of Issue and this insurance replaces
insurance in force on the day immediately before the Date of Issue, the beneficiary named in
such replaced insurance and recorded by the Policyholder or The Principal will be the
beneficiary under this Group Policy until a new beneficiary is named.
Article 4 - Facility of Payment
If any of the below occur, benefits will be paid as stated. All such payments will discharge The
Principal to the full extent of those payments.
a. If a beneficiary is found guilty of the Member's death, such beneficiary may be disqualified
from receiving any benefit due. Payment may then be made to any contingent beneficiary
or to the executor or administrator of the Member's estate.
b. Any benefit due a beneficiary who dies before the Member's death will be paid in equal
shares to the Member's surviving beneficiaries.

c. If a beneficiary dies at the same time or within 15 days after the Member dies, but before
The Principal receives Written proof of the Member's death, payment will be made as if the
Member survived the beneficiary.
d. If no beneficiary survives the Member or if the Member has not named a beneficiary,
payment will be made in the following order of precedence as numbered:
(1) to the Member's spouse;

(2) to the Member's children born to or legally adopted by the Member;
(3) to the Member's parents;
(4) to the Member's brothers and sisters; or
(5) if none of the above, to the executor or administrator of the Member's estate.
e. If The Principal believes a person is not legally able to give a valid receipt, as determined
by The Principal, for a payment, and no guardian has been appointed, The Principal may
pay whoever has assumed the care and support of the person.
Article 5 - Settlement of Proceeds
When The Principal receives Written proof of the Member's death, the Scheduled Benefit (or
approved amount, if applicable) in force for the Member, less any Accelerated Benefit payment
as described in PART IV, Section A, Article 7 will be placed in an interest-bearing draft account
at an interest rate determined by The Principal, unless a lump sum or other settlement option has
been elected. With the interest-bearing draft account, the balance will be available to the
beneficiary at any time, in total or in part, subject to the following terms:
a. withdrawals must be made by draft furnished by The Principal; and
b. the draft amount must be at least $500 or more and may not exceed the account balance;
and
c. if the account balance falls below $500, the balance will be paid to the beneficiary in a
lump sum and the account closed; and
d. the account cannot be assigned or used as collateral.
The Interest Draft Account will not be available if the Scheduled Benefit amount payable is
$5,000 or less; or if the beneficiary is anything other than a natural person. In these instances, a
lump sum payment will be made.
In the event the Interest Draft Account is not available or otherwise does not apply, The Principal
reserves the right to make payment of proceeds according to other settlement options if agreed
to, in Writing, by The Principal.

Payment of benefits will be subject to the Beneficiary and Facility of Payment provisions of this
PART IV, Section A.
Article 6 - Member Life Insurance - Coverage During Disability
A Member may be eligible to continue his or her Member Life and Member Accidental Death
and Dismemberment Insurance and Dependent Life Insurance coverage during the Member's
ADL Disability or Total Disability.
a. Coverage Qualification
To be qualified for Coverage During Disability, a Member must:
(1) become ADL Disabled or Totally Disabled while insured for Member Life Insurance;
and
(2) become ADL Disabled or Totally Disabled prior to the attainment of age 60; and
(3) remain ADL Disabled or Totally Disabled continuously; and
(4) be under the regular care and attendance of a Physician; and
(5) send proof of ADL Disability or Total Disability to The Principal when required; and
(6) submit to Medical Examinations or Evaluations when required; and
(7) return to The Principal, without claim, any individual policy issued under his or her
Individual Purchase Rights as described in PART III, Section F, Article 1. Upon
return of such policy, The Principal will refund premiums paid, less dividends and
less any outstanding policy loan balance.
b. Proof of ADL Disability or Total Disability
Written proof of ADL Disability or Total Disability must be sent to The Principal within
one year of the date ADL Disability or Total Disability begins. Further proof that ADL
Disability or Total Disability has not ended must be sent when The Principal requires.
After ADL Disability or Total Disability has continued for two years from the date the first
proof is received, The Principal may not ask for further proof more than once each year.
If the Member dies while ADL Disabled or Totally Disabled, final proof that ADL
Disability or Total Disability continued to the date of death must be sent to The Principal.
If death occurs within one year of the start of ADL Disability or Total Disability, but
before The Principal has received first proof, then final proof must be sent within one year
of the date ADL Disability or Total Disability began.
c. Medical Examinations and Evaluations

The Principal may require that a ADL Disabled or Totally Disabled Member be examined
by a Physician or undergo an evaluation, at reasonable intervals, during the course of a
claim. After ADL Disability or Total Disability has continued two years from the date first
proof of ADL Disability or Total Disability is received, examinations or evaluations may
not be required more than once each year.
The Principal will pay for these examinations and evaluations and will choose the
Physician or evaluator to perform them. Failure to attend a medical examination or
cooperate with the Physician may be cause for denial of the Member's benefits. Failure to
attend an evaluation or to cooperate with the evaluator may also be cause for denial of the
Member's benefits. If the Member fails to attend an examination or an evaluation, any
charges incurred for not attending an appointment as scheduled may be his or her
responsibility.
d. Effective Dates and Premium Waiver
Coverage During Disability will be effective for a qualified Member on the earliest of:
(1) the date nine months after the date the Member becomes Totally Disabled; or
(2) the date one month after the date the Member becomes ADL Disabled; or
(3) the date the Member dies.
Premium will not be charged for Member Life and Member Accidental Death and
Dismemberment Insurance and Dependent Life Insurance while the Member's Coverage
During Disability is in force.
e. Benefits Payable
If death occurs while Coverage During Disability is in force, The Principal will pay the
Member's beneficiary the Member Life Insurance benefit amount that would have been
paid had the Member remained insured under the Schedule of Insurance in force on the
date Total Disability began.
Such benefit shall be subject to any reduction provided under the Schedule of Insurance.
However, NO BENEFIT WILL BE PAID if Written proof of ADL Disability or Total

Disability is not sent to The Principal within one year of the date ADL Disability or Total
Disability began. Failure to give Written proof within the time specified will not invalidate
or reduce any claim if Written proof is given as soon as reasonably possible. Further, if a
death benefit is paid under this section of the Group Policy, it will be in place of all other
Member Life Insurance benefits provided under this Group Policy.
f. Termination (Premium Waiver)

Coverage During Disability will cease on the earliest of:
(1) the date the Member's Total Disability ends; or

(2) the date the Member fails to send The Principal any required proof of ADL Disability
or Total Disability; or
(3) the date the Member ceases to be under the regular care and attendance of a
Physician; or
(4) the date the Member fails to submit to a required Medical Examination or Evaluation;
or
(5) the date the Member attains age 70.
g. Limitations
No benefits will be paid for any disability that:
(1) results from willful self-injury or self-destruction, while sane or insane; or

(2) results from war or act of war; or
(3) results from voluntary participation in an assault, felony, criminal activity,
insurrection, or riot.
Article 7 - Accelerated Benefits
a. Accelerated Benefits Qualification
To be qualified for an Accelerated Benefit payment, a Member must:
(1) be Terminally Ill and insured for a Member Life Insurance benefit of at least $10,000;
and
(2) send a request for Accelerated Benefit payment to The Principal; and
(3) provide proof satisfactory to The Principal that he or she is Terminally Ill.
b. Proof of Terminal Illness
Proof that a Member is Terminally Ill will consist of:
(1) a statement from the Member's Physician; and

(2) any other medical information that The Principal believes necessary to confirm the
Member's status.
c. Benefit Payable
The Principal will pay a Member who is qualified for Accelerated Benefits whatever
amount he or she requests; except that:

(1) only one Accelerated Benefit payment will be made during the Member's lifetime;
and
(2) the amount requested must be at least $5,000; and
(3) in no event will payment exceed the lesser of:
- 75% of the Member Life Insurance benefit in force on the date of the request; or
- $250,000.
The Accelerated Benefit payment will be made in a lump sum.
d. Effect on Member Life Insurance Benefits
If an Accelerated Benefit is paid, the Member Life Insurance Benefit otherwise payable
upon the Member's death will be reduced by any Accelerated Benefit payment.
e. Premium Waiver Period
A premium waiver period will be established on the date The Principal pays an Accelerated
Benefit to a Member. This period will end on the earlier of the Member's death or the date
two years after the date of the Accelerated Benefit.
During a premium waiver period:
(1) there will be no Member Life and Member Accidental Death and Dismemberment
Insurance and Dependent Life Insurance premium charge for the Member; and
(2) Member Life Insurance will not be terminated if the Member ceases Active Work
because of his or her Terminal Illness.

Section B - Member Accidental Death and Dismemberment Insurance
Subject to the Effective Date provisions of PART III, Section B, and the qualifying provisions of
this Section B, the Scheduled Benefit for an insured Member will be based on his or her class:
Class *Scheduled Benefit
ALL MEMBERS $10,000
apply.
For the age(s) shown below, the amount of a Member's insurance will be the percentage of the
Scheduled Benefit (or approved amount, if applicable) as shown below.
Age % of Scheduled Benefit (or approved

amount, whichever applies)
Age 70 but less than age 75 65%
Age 75 and over 45%
Article 2 - Benefit Qualification
To qualify for benefit payment, all of the following must occur:
a. the Member must be injured while insured for Member Accidental Death and
Dismemberment Insurance under this Group Policy; and
b. the injury must be through external, violent, and accidental means; and
c. the injury must be the direct and sole cause of a loss listed in this Section B, Article 3; and
d. the loss must occur within 365 days of the injury; and
e. the limitations listed in this Section B, Article 9, must not apply; and
PART IV - BENEFITS
GC 6015 Section B - Member Accidental Death and
Dismemberment Insurance, Page 1
f. claim requirements listed in PART IV, Section D, must be satisfied; and
g. all medical evidence must be satisfactory to The Principal.
Article 3 - Benefits Payable
If all of the benefit qualifications are met, The Principal will pay:
a. 100% of the Scheduled Benefit (or approved amount, if applicable) in force for loss of life;
or
b. 50% of the Scheduled Benefit (or approved amount, if applicable) in force if one hand is
severed at or above the wrist; or
c. 25% of the Scheduled Benefit (or approved amount, if applicable) in force for loss of
thumb and index finger on the same hand; or
d. 50% of the Scheduled Benefit (or approved amount, if applicable) in force if one foot is
severed at or above the ankle; or
e. 50% of the Scheduled Benefit (or approved amount, if applicable) in force if the sight of
one eye is permanently lost (For this purpose, vision not correctable to better than 20/200
will be considered loss of sight.); or
f. 100% of the Scheduled Benefit (or approved amount, if applicable) in force for more than
one of the losses listed in b., d., or e. above.
Total payment for all losses under this Article 3 that result from the same accident will not
exceed the Scheduled Benefit (or approved amount, if applicable). Payment for loss of life will
be to the beneficiary named for Member Life Insurance. Payment will be subject to the
Beneficiary, Facility of Payment and Settlement of Proceeds provisions of PART IV, Section A.
Payment for all other losses will be to the Member.
Disappearance
It will be presumed that a Member has lost his or her life if:
a. the Member's body has not been found within 365 days after the disappearance of a
conveyance in which the Member was an occupant at the time of disappearance; and
b. the disappearance of the conveyance was due to its accidental wrecking or sinking; and
c. this Group Policy would have covered the injury resulting from the accident.
Exposure
Exposure to the elements will be presumed to be an injury if:
a. such exposure is due to an accidental bodily injury; and
b. within 365 days after the injury, the Member incurs a loss that is the result of the exposure;
and
c. this Group Policy would have covered the injury resulting from the accident.
Article 4 - Seat Belt/Airbag Benefit
If the Member loses his or her life as a result of an accidental injury sustained while driving or
riding in an Automobile, an additional benefit of $10,000 will be paid to the beneficiary named
for Member Life Insurance, provided all Benefit Qualifications as described in Article 2 are met
and:
a. the Automobile is equipped with factory-installed Seat Belts; and
b. the Seat Belt was in actual use by the Member and properly fastened at the time of the
accident; and
c. the position of the Seat Belt is certified in the official report of the accident or by the
investigating officer.
This additional benefit payment will also apply if the Member was driving an Automobile
equipped with a properly functioning driver-side air bag or riding as a passenger in an
Automobile equipped with a properly functioning passenger-side air bag, although the Member's
Seat Belt may not have been fastened at the time of the accident. The properly functioning
and/or deployment of the air bag must be certified in the official report of the accident or by the
investigating officer.
For the purpose of this benefit, "Automobile" means a four-wheel passenger vehicle, station
wagon, pick-up truck, or van-type vehicle, but excludes recreational-type vehicles such as a
"dune-buggy" or an "all-terrain" vehicle.
The term "Seat Belt" means a factory-installed device that forms an occupant restraint and injury
avoidance system.
Article 5 - Loss of Use or Paralysis Benefit

If a Member sustains an injury, and as a result of such injury, one or more of the covered losses
listed below are incurred, The Principal will pay the following percentages of the Member's
Scheduled Benefit (or approved amount, if applicable) in force, provided all Benefit
Qualifications as described in Article 2 are met.
% of Scheduled
Covered Loss Benefit
Loss of Use or Paralysis

Quadriplegia 100%
Paraplegia 50%
Hemiplegia 50%
Both Hands or Both Feet 50%
One Hand and One Foot 50%
One Arm or One Leg 25%
One Hand or One Foot 25%
The Principal does not pay an Accidental Death and Dismemberment benefit for any paralysis
caused by a stroke.
Paralysis must be determined by a Physician to be permanent, complete, and irreversible.
Total payment for all losses that result from the same accident will not exceed the Scheduled
Benefit (or approved amount, if applicable). Payment for Loss will be to the Member.
For this benefit, the term "Loss of Use" means a total and irrevocable loss of voluntary
movement, which has continued for 12 consecutive months. The term "Quadriplegia" means
total paralysis of all four limbs. The term "Paraplegia" means total paralysis of both lower limbs.
The term "Hemiplegia" means paralysis of one arm and one leg on the same side of the body.
Article 6 - Loss of Speech and/or Hearing Benefit
If a Member sustains an injury, and as a result of such injury, one or more of the covered losses
listed below are incurred, The Principal will pay the following percentages of the Member's
Scheduled Benefit (or approved amount, if applicable) in force, provided all Benefit
Qualifications as described in Article 2 are met.
% of Scheduled
Covered Loss Benefit
Loss of Speech and/or Hearing

Speech and Hearing 100%
Speech or Hearing 50%
Hearing in One Ear 25%
Loss must be determined by a Physician to be permanent, complete, and irreversible.
Total payment for all losses that result from the same accident will not exceed the Scheduled
Benefit (or approved amount, if applicable). Payment for Loss will be to the Member.
For this benefit, the term "Loss" means a total and irrevocable Loss of speech or hearing, which
has continued for 12 consecutive months.
Article 7 - Repatriation Benefit
If a benefit is paid under this Section B for loss of the Member's life and death occurred at least
100 miles away from the Member's permanent place of residence, all customary and reasonable
expenses incurred for preparation of the body and its transportation to the place of burial or
cremation will be paid up to a maximum benefit payment of $2,000.
Article 8 - Educational Benefit
If a benefit is paid under this Section B for loss of the Member's life, an extra benefit of $3,000
will be paid annually for a maximum of four years to each Qualified Student. This annual
benefit will be paid consecutively, while the Qualified Student continues his or her education as
a Full-Time Student at an accredited post-secondary school.
For the purpose of this benefit, "Qualified Student" means a Dependent Child who is, at the time
of the Member's death, a Full-Time Student at an accredited post-secondary school. A 12th
grade student will become a Qualified Student if he or she enrolls in an accredited post-
secondary school within 12 months of the Member's death.
Article 9 - Limitations
Payment will not be made for any loss to which a contributing cause is:
a. willful self-injury or self-destruction, while sane or insane; or
b. disease, medical or surgical treatment of disease, or complications following the surgical

treatment of disease; or
c. voluntary participation in an assault, felony, criminal activity, insurrection, or riot; or
d. participation in flying, ballooning, parachuting, parasailing, bungee jumping or other

aeronautic activities, except as a passenger on a commercial aircraft or as a passenger in a
Policyholder-owned or leased aircraft on company business; or
e. duty as a member of a military organization; or
f. war or act of war; or
g. the use of alcohol if, at the time of the injury, the Member's alcohol concentration exceeds
the legal limit allowed by the jurisdiction where the injury occurs; or
h. the operation by the Member of a motor vehicle or motor boat if, at the time of the injury,
the Member's alcohol concentration exceeds the legal limit allowed by the jurisdiction
where the injury occurs; or
i. the use of any drug, narcotic, or hallucinogen not prescribed for the Member by a licensed
Physician; or
j. injury arising from or during employment for wage or profit.

Section C - Dependent Life Insurance
Subject to the Effective Date provisions of PART III, Section B, the Scheduled Benefit for an
insured Dependent will be based on the status of the Dependent:
Class
ALL MEMBERS
Dependent *Scheduled Benefit
Spouse $5,000
Children (age at death)

0 days old but less than 6 months $1,000
6 months and older $2,000
apply.
In no event will a Dependent's Scheduled Benefit be more than 50% of the Member's Scheduled
Benefit amount. If a Member elects a Dependent Life benefit in excess of 50% of the Member's
Scheduled Benefit amount, the Dependent will be given the highest amount available, not to
exceed 50%.
Article 2 - Death Benefits Payable
If a Dependent dies while insured for Dependent Life Insurance under this Group Policy, The
Principal will pay the Scheduled Benefit (or approved amount, if applicable) in force for that
Dependent on the date of death.
PART IV - BENEFITS
GC 6016 Section C - Dependent Life Insurance, Page 1
If a Dependent who was insured dies during the 31-day individual purchase period described in
PART III, Section F, Article 2, The Principal will pay the individual policy amount, if any, the
Dependent had the right to purchase.
Unless a Beneficiary has been designated, payment will be to the Member if he or she survives
the Dependent. If the Member does not survive the Dependent and a beneficiary for Dependent
Life has not been named, payment will be to the person named as beneficiary for Member Life
Insurance. However, if the Member is suspected or charged with the Dependent's death, the
Death Benefits Payable may be withheld until additional information has been received or the
trial has been held. If the Member is found guilty of the Dependent's death, he or she may be
disqualified from receiving any benefit due. Payment may then be made to the executor or
administrator of the Dependent's estate. Payment will be subject to the Beneficiary provisions in
Article 3 and the Facility of Payment and Settlement of Proceeds provisions of PART IV,
Section A.
No payment will be made before The Principal receives Written proof of the Dependent's death.
Article 3 - Beneficiary
A Member may name or later change a named beneficiary by sending a Written request to The
Principal. A change will not be effective until recorded by The Principal. Once recorded, the
change will apply as of the date the request was Signed. If The Principal properly pays any
benefit before a change request is received, that payment may not be contested.

Section D - Claim Procedures
Article 1 - Notice of Claim
Written notice must be sent to The Principal by or for a Member or Dependent who wishes to file
claim for benefits under this Group Policy. This notice must be sent within 20 days after the date
of the loss for which claim is being made. Failure to give notice within the time specified will
not invalidate or reduce any claim if notice is given as soon as reasonably possible.
Article 2 - Claim Forms
The Principal, when it receives notice of claim, will provide appropriate claim forms for filing
proof of loss. If the forms are not provided within 15 days after The Principal receives notice,
the person will be considered to have complied with the requirements of this Group Policy upon
submitting, within the time specified below for filing proof of loss, Written proof covering the
occurrence, character, and extent of the loss.
Article 3 - Proof of Loss
Written proof of loss must be sent to The Principal within 90 days after the date of the loss.
Proof required includes the date, nature, and extent of the loss. The Principal may request
additional information to substantiate loss or require a Signed unaltered authorization to obtain
that information from the provider. Failure to comply with the request of The Principal could
result in declination of the claim. For purposes of satisfying the claims processing timing
requirements of the Employee Retirement Income Security Act (ERISA), receipt of claim will be
considered to be met when the appropriate claim form is received by The Principal.
Article 4 - Payment, Denial, and Review
ERISA permits up to 45 days from receipt of claim for processing the claim. If a claim cannot
be processed due to incomplete information, The Principal will send a Written explanation prior
to the expiration of the 45 days. The claimant is then allowed up to 45 days to provide all
additional information requested. The Principal is permitted two 30-day extensions for
processing an incomplete claim. Written notification will be sent to the claimant regarding the
extension.
In actual practice, benefits under this Group Policy will be payable sooner, provided The
Principal receives complete and proper proof of loss. Further, if a claim is not payable or cannot
be processed, The Principal will submit a detailed explanation of the basis for its denial.
PART IV - BENEFITS
GC 6018 Section D - Claim Procedures, Page 1
A claimant may request an appeal of a claim denial by Written request to The Principal within
180 days of receipt of notice of the denial. The Principal will make a full and fair review of the
claim. The Principal may require additional information to make the review. The Principal will
notify the claimant in Writing of the appeal decision within 45 days after receipt of the appeal
request. If the appeal cannot be processed within the 45-day period because The Principal did
not receive the requested additional information, The Principal is permitted a 45-day extension
for the review. Written notification will be sent to the claimant regarding the extension. After
exhaustion of the formal appeal process, the claimant may request an additional appeal.
However, this appeal is voluntary and does not need to be filed before asserting rights to legal
action.
For purposes of this section, "claimant" means Member, Dependent, or Beneficiary.
Article 5 - Medical Examinations
The Principal may have the Member or Dependent whose loss is the basis for claim, be
examined by a Physician during the course of a claim. The Principal will pay for these
examinations and will choose the Physician to perform them.
Article 6 - Autopsy
If payment for loss of life is claimed, The Principal may require an autopsy. The Principal will
pay for any such autopsy.
Article 7 - Legal Action
Legal action to recover benefits under this Group Policy may not be started earlier than 90 days
after required proof of loss has been filed and before the appeal procedures have been exhausted.
Further, no legal action may be started later than three years after that proof is required to be
filed.
Article 8 - Time Limits
Any time limits in this section will be adjusted as required by law.

Principal Life Insurance Company
Des Moines, Iowa 50392-0002

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DOROTHEA GLAUSE S655

RHODE ISLAND JOHN DOE 01/01/2014

GROUP POLICY FOR:

RHODE ISLAND JOHN DOE

Print Date: 07/16/2014

POLICY NO: S655

EMPLOYER: RHODE ISLAND JOHN DOE

EXCEPT AS SPECIFICALLY DESCRIBED IN THIS RIDER, ALL OTHER BENEFITS AND

PRINCIPAL LIFE INSURANCE COMPANY

This group insurance policy is issued to:

RHODE ISLAND JOHN DOE

(called the Policyholder in this Group Policy)

The Date of Issue is November 1, 2007.

MEMBER LIFE INSURANCE

MEMBER ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE

DEPENDENT LIFE INSURANCE

subject to the terms and conditions described in this Group Policy.

GROUP POLICY NO. GL S655

This policy has been updated effective January 1, 2014

GC 6000 TITLE PAGE

PART II - POLICY ADMINISTRATION

Entire Contract Article 1

Payment Responsibility; Due Dates; Grace Period Article 1

Section C - Policy Termination

Failure to Pay Premium Article 1

Section D - Policy Renewal

PART III - INDIVIDUAL REQUIREMENTS AND RIGHTS

This policy has been updated effective January 1, 2014

GC 6001 TABLE OF CONTENTS, PAGE 1

Member Life Insurance Article 1

Section B - Effective Dates

Member Life Insurance Article 1

Section C - Individual Terminations

Member Life Insurance Article 1

Member Life Insurance Article 1

Section F - Individual Purchase Rights

Member Life Insurance Article 1

This policy has been updated effective January 1, 2014

Schedule of Insurance Article 1

Section B - Member Accidental Death and Dismemberment Insurance

Schedule of Insurance Article 1

Section C - Dependent Life Insurance

Schedule of Insurance Article 1

Section D - Claim Procedures

Notice of Claim Article 1

This policy has been updated effective January 1, 2014

Active Work; Actively at Work

Activities of Daily Living (ADL)

This policy has been updated effective January 1, 2014

GC 6002 PART I - DEFINITIONS, PAGE 1

Civil Union Partner

a. not be a party to another Civil Union or marriage in Rhode Island;

c. be at least 18 years of age;

d. not be related to the other proposed party to the Civil Union.

The date this Group Policy is placed in force: November 1, 2007.

a. A Member's spouse, if that spouse:

(1) is legally married to the Member; and

A Member's spouse will also include a Civil Union Partner.

b. A Member's Dependent Child (or Children) as defined below.