Document 99dgb6MXEGgY9argZ7DM8y0g7

FILE NAME: Metropolitan Life (ML) DATE: 0000 DOC#: ML023 DOCUMENT DESCRIPTION: Met Life Group Insurance Certificate, Raybestos Manhattan - General Provisions & Schedule of Benefits P / f C ' & r / 1 ^ <X- (O /At - -1 M W3 % -, r 'V . '' f " ' v M F>M TM M M m S U K T W C H S C O iM P A N Y (HERFIN CAUED 1HE INSURANCE COMPANY) Group insurance Certificate Tik Insurance C ompany C ertifies that, under and subject to the terms and conditions o f G roup Policy N o.(si. 8 j / 7-G . which may be amended o r discontinued by the Insurance Company o r the Employer in accordance w ith the terms thereof, and the provisions o f which are summarized on this and the follow ing pages, the Employee nomed herein, an Employee of RATBE5TOS-MANHATTAN, INC. U PASSAIC DIVISION (HEREIN CAltEO 1HE EMPIOYER) Is insured on ihe e le c tiv e date o f this certificate, subject to the provisions o f the next follow ing paragraph, fe r insur ance determined in accordance w ith the Schedule o f Insurance herein. The insurance shown in such Schedule o f Insurance is subject to change in accordance with the provisions o f the G roup Policy Num bers] given above. If on the dele the Employee becomes insured under the G roup Policy fo r M edical Expense Insurance--Extended Coverage on account o f his Dependents, any Dependent o f the Employee is confined in o hospital o r other Institution fo r care o r treatment, o r is confined at home under the care o f a physician o r surgeon bocause o f a disabling physical or mental s'cxness or injury, the M edical Expense Insurance-- Extended C overage on account o f that Dependent shall not become effective until that Dependent is no longer confinod In a hospital o r other institution o r confined at home under the ca'c o f o physician o r surgeon. The insurance specified herein on account of Dependents is applicable only If the employee is eligible for, has requested, and is insured for such insurance. SERIAL NUHBER HAKE OF EMPLOYEE EFFECTIVE DATE y BCNENCIARY N o agent hes authority to accept o r w aive the required proof o f a claim , nor to extend the time w ithin which such pro of must be given. This certificate is non-cssignable and the insurance and benctfis ore non-ossignable prior to a loss. The insurance does not a t any time provide paid-up insurance, o r loan o r cosh values. METROPOLITAN LIFE INSURANCE CO M PANY, . r ; i . u ) I LIFE INSURANCE HOSPITAL EXPENSE INSURANCE . SUPPLEMENTAL HOSPITAL EXPENSE INSURANCE SUPPLEMENTARY HOSPITAL BENEFITS FOR PHYSICIANS' ATTENDANCE SURGICAL OPERATION INSURANCE SUPPLEMENTAL SURGICAL AND IN-HOSPITAL PHYSICIANS ATTENDANCE EXPENSE INSURA.NCE INSURANCE FOR DIAG NO SHC X-RAY EXAM INATIONS-- LIMITED MEDICAL EXPENSE INSURANCE-- EXTENDED COVERAGE SUPPLEMENTAL MEDICAL EXPENSE INSURANCE Fa* o liOO-l. IE. 5SA. 7. . VS. ISC. 2<D. 2<SA. X Aug. I<* F , lM < d h , U.SJL MATERNITY BENEFITS E x h ib it President. Num bor mu tP A * V N M O N C C 4 T IM C A 1 C O N < V n r i( A t C S U N *U C *<N T M l f T I K C TO T H C I M t M A N C f NCNCNNCO T O M C N C IN H A I C C M O C U V C rC O TO TM C C M N tO V C C N C *C *S O T O M CN C IK SUCH C K N T fS tC A Y C ON C C N Y trtC A T C * U N N C C T IS VO. SUMMARY OP PROVISIONS Gr THE GROUP POUCr PRINCIPALLY A FF E C T IN G THE EMPLOYEE LIFE INSURANCE Section A. LIFE INSURANCE BENEFIT l( Ihc Employee dies w h ilo in Ihe im p lo y o f ihe Employer ond w hile insured fo r life Insurance under Iho G roup Policy, tho amount o f Life Insurance in force on account o f the Employee ot the do te o f his death shall be p a id to the Beneficiary o f record. Section B. DEATH BENEFIT IN THE EVENT OF TO TAt DISABILITY 1. If the Employee, w h ile insured under the Group Policy ond p rio r to his sixtieth birth da y, becomes to ta lly disabled as a result o f b o d ily in jury o r disease so os to be w h o lly prevented thereby from engaging in an y ond every business o r occupa* lio n an d from perform ing any w o rk fo r com pensation o r p ro fit, an d continues to be so to ta lly disabled uninterruptedly beyond the term ination o f his employment and until the da le o f his d e ath, then upon receipt o f satisfactory p ro o f o f such death (and pro vid e d no Death Benefit is payable under the provi* sions o f subsection 2 o f Section C hereof), Ihe Insurance C om pany shall pay to tlie B eneficiary o f record the amount o f the Em ployee's life Insurance in force under the G roup P olicy o t the da te o f the term ination o f his employment, p ro vid e d (A) tho t in itia l satisfactory p ro o f that such to to l d isa b ility exists an d has continued uninterruptedly fo r ot least nine months is subm itted eilhor be fore the term ination o f the Employee's em ploym ent (as defined in subsection 1 o f Section F hereof) . o r w i*hin one year thereafter, and (B) th a t acknow ledgm ent o f the receipt o f such in itia l satis fa c to ry p ro o f is endorsed on the Employee's certifica te by ` t he Insurance C om pony, ond (C) tha t each yea r, w ith in the three months preceding the anniversary o f such endorsem ent, during the entire re m ainder o f the Employee's lifetim e, further satisfactory p ro o f is subm itted that such to ta f d isa b ility continues, and (D) th a t upon the death o f the Employee, satisfactory .p ro o f Is subm itted thot such to ta l d isa b ility continued to the d a te o f his death. If, how ever, the Em ployee's death occurs w ith in one year a fte r the term ination o f his employment and before any such p ro o fs have been subm itted, then satisfactory p ro o f that the Em ployee w as to ta lly disabled uninterruptedly from the dote . o f the term ination o f his employment to the date' o f his death - must be subm itted w ith in one year a fte r the date o f his death. 2 . A ll such p ro ofs o f to ta l d isa b ility and o f death must be sub m itted In w ritin g to the Insurance Com pany o t its Home O ffice o r a t one o f its H ead O ffices on the in itia tive o f the disabled Employee o r b y someone on his beha lf, w ithout any o b lig a tio n on the p a rt o f the Insurance Com pany to request any such p ro o f. 3. W henever p ro o f o f the Employee's to ta l d isa b ility is sub m itted, the Insurance Com pony shall have the rig h t and o p p o rtu n ity to have him exam ined b y physicians designated b y it. 4. II the Employee ceases to be so to ta lly disabled o r fa ils to submif any required p ro o f w ithin tho time prescribed therefor, his rights under this Section shall autom atically and imme d iately cease. 5. If an individual p o licy o f life Insurance has been issued in accordance w ith the provisions o f tho follow ing Section, pay ment may bo made under the provisions o f this Section only if such individual po licy is surrendered to the Insurance Com pany w ithout claim thereunder. In such case, any premiums paid on such individual p o licy shall bo refunded by the insurance Com pany to the Beneficiary o f record o f tlycy Employee. Section C. PRIVILEGE OF OBTAINING A N IN D IVID U AL POLICY OF LIFE INSURANCE 1. Upon w ritten applicatio n made to the insurance Com pany w ithin thirty-one days after either (1 the date o f the term ination o f tho Employee's employment, or (ii) the date o f the discontinuance o f the G roup Policy, p ro vided such date is five years o r m ore a fte r the effective date o f the Employee's Insuronce under such Policy, o r (iii) the date o f the cessation pursuant to subsection 4 o f the preceding Section, o f the Employee's rights under that S e ctio n , the Employee shall be entitled to have issued to him b y the Insurance Com pany, w ithout evidence o f insurability, on in dividual p o lic y o f life Insuronce on ly, w ithout D isability o r A ccidental M oons Death Benefits, subject to the follow ing conditions and provisions: (A) such individual p o licy shall be upon one o f the forms then custom arily issued b y Ihe Insurance Com pany, except Term Insurance, ond (B) the premium fo r such individual p o licy shall be the pre mium applicab le to the class o f risk to w hich the Employee belongs and to the form ond am ount o f th e 'In d iv id u a l p o lic y o t the Employee's attained ag e (nearest birthday) a t the d a te o f issue o f such in dividu al p o licy, and (C) the am ount o f such individual p o lic y shall bo equal to (or a t the op tion o f the Employee less than) the amount o f the Employee's life Insurance o r Death Benefit under the G roup P olicy, os the case m ay be , on whichever o f Ihe dates specified in paragraphs (i), (ii) and (iii) above is applicable, except that if the Employee's life Insurance under the G roup Policy ceases because o f the discontinu ance o f the G roup P olicy five years o f more a fte r the effec tive da te o f his insurance thereunder, the amount o f such individual p o licy siK ill not exceed the lesser o f (a) the am ount o f the Employee's life Insuronce thereunder o t the da te o f the cessation o f such insurance, reduced b y an y am ount o f life Insuronce fo r w hich he may be o r m ay becom e e lig ib le under any G roup Policy issued o r reinstated b y the Insurance Com pany o r by any other insurer w ith in thirty-one days a fte r such cessation, and (b j $2,000. to rn G.SM5--1 tSJI-C. lions) (3) LIFE INSURANCE-- Continued 2. Any individual policy o f lile Insurance so issued shall become . effective not earlier thon the expiration o f the thirty-ono-doy period during which application lo r such individual policy may be made. If, however, the Employee dies during such thirty-one-day period, the Insurance Company shall poy to his Beneficiary o f record whether or not the Employee shod hove mode application fo r such individual policy, the maximum amount o f Life Insurance for which on individual policy could hove been issued under this Section. If the Employee sholl have been entitled to make such application pursuant to paragraph (iii) o f subsection 1 o f this Section and shall die w ithin one year a fte r the term ination o f his employment but before his certificate shall have been endorsed in accordance w ith the provisions o f Section B hereof, then satisfactory pro of o f the Employee's death w ithin such thirty-one-doy period and that he was totally disabled uninterruptedly from the dote o f the term ination o f his employment to w ithin thirty-one days o f the date o f his death must be submitted to the Insurance Company w ithin one year after the date o f his death. Section 0 . BENEFICIARIES The Employee may change his Beneficiary at any time upon w ritten request accom panied by this certificate fo r endorsement. Consent o f the Beneficiary shall not be requisite to any change o f b e n e fic ia ry . If, at the death o f the Employeo, there shall be more than one designated Beneficiary, then, unless the Employee shall have specified the respective interests o f such Beneficiaries, the inter ests o f such Beneficiaries shall be several and equal. If any designated Beneciary shall die before the Employee, the rights ond interest o f such Beneficiary shall thereupon auto m atically terminate. If, of the death o f the Employee, there be no designated Beneficiary as to a ll or any part o f the insurance, then the amount o f insurance payable fo r which there is no designated Beneficiary shall be payable to the estate o f the Em ployee, provided, however, that the Insurance Company moy, in such cose, at its option, pay such amount to ony one o f the follow ing surviving -elatlves: w ife, husband, mother, father, child or children, and payment to any one o r more o f such surviving relatives sholl com pletely discharge the Insurance Company's lia b ility with respect to the amount o f insurance so paid. The designation by the Employee o f a Beneficiary under an individual po licy o f life Insurance issued in accordance w ilh the provisions o f Section C hereof, other than the Beneficiary o f record of the Employee under the G roup Policy, shall effect a change o f Beneficiary under the G roup Policy to the Beneficiary o f record under such individual policy, regardless o f whether o r not such change is endorsed on this certificate. Section E. OPTIONAL MODES OF SETTLEMENT Arrangements may be made w ith the Insurance Company, subject to the provisions o f the G roup Policy, whereby the amount o f life Insurance poyablo at the decth o f the Employee w ill be retained by the Insurance Compony ond pa id to the Beneficiary in instalments instead o f in one sum. Inform ation con cerning such O ptional Modes o f Settlement may be obtained from the Employer upon request. Section F. CESSATION OF INSURANCE 1. The life Insurance shall autom atically cease on the dole o f termination o f the Employee's employment. For the purposes o f the life Insurance, term ination o f employment means cessation o f active work os an Employee as defined in the G roup Policy, except that in circumstances specified in the G roup Policy the Employer may deem the Employee's employment To continue after such cessation, subject to the terms o f the G roup Policy. 2. The lile Insurance shall autom atically cease upon the discon tinuance o f the G roup Policy. N otice to the Employee-- If you leave w ork because o f total disability commencing before age 0, you should be sure to submit w ritten proof to the Home O ffice o r one o f the Head O ffices o f the Insurance Company, as required, as soon as possible after you have been to ta lly disabled for nine months, and in no event more thon one year, after the term ination o f your employment. GROUP POLICY No-- & * M ( <: . ^j IN CONSIDERATION of die application of the Employer for due Policy, t copy ofwhich application it attached hereto and madea perthereof, andoftheindividual writtep application--if toy-- 0/those Employeesof __________________________ U TS&S& Z m h T tM t . m . i __________:_____________ whoarc eligible for the insurance provided hereunderin accordancewith the Formula andSchcd- ule o fBenefits hereinafter contained, and in conaideratioo o f die peymeot by die Employer of <Tl the preraranidue00 thedsreo/issveofthisTolley d o f the paymentof the premiumsdue thaw* g after, during the continuanceo f thia Poliey, on the---------- 3gfl............................day of each o i*b" th________________ ,,(herein called the doe-datea), aa hereinafter provided, yi i DOTH HEREBY AGREE * to pay die benefit* act forth in aaid Schedule o f Benefits, with respect to the several Em ployees insured hereunder, ite accordance with and subject to the Terms of thia Policy. The Formula, Schedule o f Benefits, General Provisions and Administrative Provisions hereinafter contained are pan of thia Group Policy aa hilly as if rested over the signatures hereto affixed. 3 u Q U n rttl the Metropolitan Life Insurance Company haa canted thia Policy to be executed thia--------- %MA------------------------- day of------- ---------------------------- - to ttVc effect aa of ! ^ last date ia the date o f issue hereof. ^y of .-- .iftllJEs--i.?.? ? . whi^ Stenur j. JtrgfsOer. Creep Prtcy Ufa Inasrsnro- Temporary OUabiUty Taaomase Aaasal Ofattibettsa of DMsibJe Surpioa ra n , Q X X . IM S W ta. C FrtsidtnL  * SCHEDULE OF INSURANCE AND EMPLOYEES' CONTRIBUTIONS MAXIMUMAMOUNTWHICHAMIMFLOUZ MOSftTAL tXHMM SUaOtCAiORMimt 1 DBUMMCS taxiAsa (oaht mSOTAJC* (MtfMUU mSONAL tNSUKAHCt AKO cum team )* com) vn> OCfWOIKT UWIAWCC UnOTQ AND JOKAL was an ts 04 IMWU win CKttS AHCE ii OULDO WTOAN CXQOftlN CXOOO' nan* fio m OKU amjDU ; 111 iaployoee A *10.00 *10j 3 10.00 *215.00 *175.00 *175.00 *0.11 .3 7 *0.37 .3 7 Including Supplnantej7 Hospital B n e flti for Ptqrsleian*' I t Undone - {.00 I t is understood and screed th a t fo r tho purpose o f d e te re ln ln s e ffe c tiv e data* . o f insurance undr tho P o lle r h *r ia a p p lie d fo r , the v r itU n requesU o f Eaplor* insured under Oroup P o lle r So 9677M on Ja n u u y 21, 1951 fo r Personal Insurance o r fo r Personal . Insurance and Sepondent Insurance s h a ll be deeeed' to be W ritte n request* fo r Personal In surance o r fo r Personal Insurance and Dependent Insurance, as th e case a * r he, under the . . P o lle r h e re in applied, fo r . 0 ii. Fo r m u la F IN IT IO N O F T H E T E R M "E M P L O Y A S " ifi (T. Th* m -Employer," u m l hircin. ahall idadt-ttnll^lW 7l9T 3W l..an.-th.J9M T al^,,aO A a.JJa.lt d S tato in b g atafl-H iylglea_cnil .th o ..g an o ral,,iah aatfl _ m il Jlu h b o rd T l l< in o f th a > p lo ? r ' > 1G IQ 1U TT O F M H jOYES AU prtent E i ptoyw^.m.m w npioycr* ih*U be etigtbk for .!______ xsrsU . " fo - ^ m T a s E ir a n ^ ^ p c ^ O *< rn . z1 tifMo far in u f tm k n w d tfac (fa n e f inuc o f dm P ote*. A il ocher p la n t Employ end o r onths c i c o n tin u a it i Emplcyee t ce w n t (70L er aryr tkall noc be digiblc h t Tem pera DUabifity t ntraner kctarndcr. SE AMENUMENTd* S * 9 / 9 1-T E C riV DATES OK INSU RA N CE Aa Employt a u ; keceate inawed kcraiiiuler d y ky m akiaf fktc a appOeaen m Cornu fiim ithed by ehc Company. The J U tn M i aay Employe wke ia eugMe en tbe date a f m ue c l tkia PeScy and wke maket teck application w e t befon auck data tkall b attait effectue t tke date f iatut c l th it P o S e y J -P tg M fllA i L i i J i 8 ^ a a L 8 l 3 g f t L f ilS j.f e S f c ___ Th tiatonn ce on aay Em pteyteehe .cetnct tlig ib k a fttr dm date e f m at a i tkia Peficy and wke maket teck application en or bcfarc tke date e f h it ebgiW ity, duU beceme effeettre i tk e ................ - . ----- ...j- .....---- ........... ......................................... ....................--. ................. date ad k it cGeibiEty, etonded kc ia tm ly a t mark a aack dfeetiee data. The teaennee te aay Employt hn aaakat aaek apoGcaden dut tke data o fk it egiW ity end ea er fera tke d d tty d n t day ftOem iaf tke date d k it d ip b ility , a r m e r bedon tke tk in y 4 n t day faBoeinf tke date edU aittum to aetm varie keeraa a o ta e tm ly a t nathan tke data c l k it cfigibity,duU kaeaaK fa r ine aa h ............* _ .................... ____ _______ K ..-- -- _____ - . d tie efaaek appeatiaa,praei j ed keia a n h e ly a tm tk ta m c k riTcttree det t . Any Employ makbtf iek applic ttiaa after taek tfctydktt day aad aay Eaipkiyt a tcuplyitg fa r b it ieaerance hateandar bat been diteeatbiacd ia attewanee nith iieg rtp k (F) uadt r D ttcatm atiao ct e t luauaaaca kttow, aaat fara'nh t t k it a w eapenee eatdcate o f Inaarahilhy aatitfactaty ta tke Caatptay afibethm en tke ....... -.... - _ date o f tke dttan aian io a k y dm Campany f the i -endcd aack km qdoyteitactrtdy e t mark aa aack tic e tie e date. Tbe in e w iiK i aa any t kick ko ia aethcly a t matk. , (M a _dW ,, a t eratk an tke data tdwa km M O U N T O F IN SU RA N CE T k e ament e f intat aatt kq eanda ta a a a y Employe tkaS k a la ctetrftact n ith tke Stkedalc a f E earfta k ct a tfttr ta t fcrak and aay ........ ___ ia tke t ramait efiach iatrance,iaactedaacewik teid Stkt daleafB encdtt, tkall hccamecdtctnrc.. ........ ........ _________ m .k h e .d n t* J h w iiJ & J M S ia i S S ___________________________________________ __prtoidid ke ta acrirtiy a t nark oa teck e fa r iee data; if eot thea actnrdy t t Work, toek c h u ft ia tke maunt e f U ta rante akall fa tn v ea tke aaat fcjbm tg. . . . . . . ..... .. ............ ... ........ ......... -- ,en kick ke ia actm ly JISCONTJNUANCE OF INSURANCE (a ) T h e L iftla to rae ce aa any Im playea iatatad kttteadtrtkallceaae eetqotadcaBy tktttyen e P U d a y ta fa r*e d a tte !tk e te n a U a . ion e f candepmcet e f taek Emplayea, oe r p t aa roaided k l tke attend parafrtpk keioar. Tke Tca^araty Dabity Inau-tace en any taek atpIeyee akaBaM et tntam trin lly eaithe date e f ke tartaan iia a f tmpleyamat a f teck Employe, eaeept atpiaeided ia tke thitd ptragraph r iaiat in i f i r i r r -- *r * 7 ~ *~ r*~ r~ r -*-'*- *------ 1----------- --------------------------------'*'----- ---------------------p- -- )-- paragraphe acat M te iap. ------_ \ i1t ia ika 1 ih l aeat ta fi bi m i mV r la raaa r f it a ik t ann tfa n g T r ' T~i r~i ------- --------^ --------- ------- ---------------- " r T , ------------------- a fka e a af eeadm eaotfl tuefc acrm m atai ky dwEmjpteycr, en a cc e n t e f tke lif c l aaar ta w keicandcr en taek Emplty ta. Aa aa tk cT etn m a ty n w U G ty lemnmee bctteaihr.k taaaf tke abacacc o f an Employe fmm aedea e w k an tceaunt of ndtaem ar in lw y , die eauduymca t o f auck Employe tkall, fie tke p at|at* a f ht T im m u w D iu liilU y lnw w ee hcraander, be dcand ta intinue fi rn t rntee dut dm m inieeei eembcfe f ancka Carluek eetkl Tcaqaaary DoaUBty Bcacfits ara payaU* h m andn ; and. idranet notice ia m a M and apjm m d ky the Campeny,th m o fu Employe fram aetira w atk anaoe iuat a ftemporary U y -T fc r not U * Aan hiftjrexie (31) d n a d u 8 not bc detaud te caneatutt termiaanoa a f m plarineet eekae and an til tke Employer tk all aoefy tke Ctmpany c l tke tcnmnaooa af eeiploymcn t i f mek Jbnidaycc a r tkall etaaa ta aube pm aiam payawnta aa aeeauat n f tbc Ttmpormry DuabiEty Imoraaec hetcm de an mek E mploye. (A Tke U la Inaaranee m any Kmidnyte kwnttd fceteandet, ekn tk all knae nmifirr the Employer A a t hn motreiKe wwl tk r.dey U ta h t ifiacm tlum d, hall eeatc tU rty ^ n t (S I) daya afttr.tba date ntek notice a f dmenatMtmacc t e e n m l by tke Kmpbiyef. T lie T o n p i*iy DlaakSIty la ta rince en any tn tk Em pbiyn tkafl ke ilii t m t it im l aaa fthe.................. .............. -- ------------------------------------------------------------------ .......... .- auck aedet a f dkaantinntnraarai taedead. _ Paik a f any Em playccts makc em tributian erhe* due.at rrquiitd I,y [bt r n i| l ftr. W ttil m r tf*~Lr t-- -- -- k n itn ilrr ahnt! S '------J -- PT* * ^ -- >-- 'i-- -- < M Tke Teataorary DitabHty Inaaranee an any daaablcd Emplayee, k a hea tccmecd neddy hcnaltt for the m tnnttm namber o f t k t tpadficdln tkia PaBcy, akattba diacentinecd aa d t -- *' ' ` 1 '' 1 id tn d tln n w rt ta n ntd> Empleyte thag bafaiwtated enly if and %....... .........................i i i i i mink fnij Tll T` "l -- I -, L . the araeinoat a f the acat paragmph. AoU fat acootooc4 cm t<K rencwal dote \ V ,| ^ X * H G X Q H S rV 33S 0 I 1L SC H ED U LE O F B E N E FIT S elnae 1 Htbonto a nuotar Piviale - t a r j Baplojroo e u tlT o , Furoaon, S uparrlaei? i Offla toplo?aa 1 r.tu te a Aabeeto P lv U lc n <tV .ik ad H I * M-| loya tanta and H x tcv X lrtt^ i. yaaa I c a lta f Ju ljr S i I N I ttMUnt 9t l i fa Inorane___ 00.00 1000.00 900.00 1000.00 1000.09 jrk l? Tooporar? Blaablllty Ean'flt $ 9. SO 10.00 9 . S0 10.00 X X I s a A K E u o a a f l ^ f lfr n Mi * = rltftt M i artlva!? a l vork a aeeattat af allkaaaa ar lajr? (oxapl a r.plo? la ra tlra d Uh a r libavi paoalaa) e tha ffaatlva la ta a f ikia palla? ha u laowl e palietaa 3431 0 ani 1441.CH baarlas dato af JMa 3 1339 polla? 304S>0 baarine lata af alar 31 1933 r pollar 10S3G& ta tr ie ; tela af ttcvat 11 1933 a tho 4? lanadlotel? ' aa41as Iha dffoatlva 4ta a f Ih io palla? ahall ka al le bla fa r faavraaaa haravadar la ai ni aqual l a Iha jpeunt fa r tolak ha vaa laturad vaiar avah paltalaa 9 avch 4a? and aeh n a t a ahall ha dlaaballaaad vpaa hla ratura la ark ar apaa prlor vali la Iha iaavraaaa aa? h? Iha aplapar Ihat avah aapla?aa*a a q l a p m t haa ha lam laatad. &## % w. .. -- . ,,,*_ . _ . . ,* . _ -j---- ' ........................' " " ' ' . * < ' r u . U v / V l M ' U |i 0 0 IV. g e n e iP l p r o v is io n s Section A I nsuring Clauses--<*i ) L ire [hu*anci--Upon receipt by the Company o f due notice and proof--in writing---of the death if any Employee, while insured hereunder, and upon the surrender o f the Certificate and all Certificate Riders--if any--issued hereunder to such imployee, the Company shall pay, subject to the Terms hereof, to the Beneficiary of record, the amount of life Insurance, if any, In force on leeount of such Employee at the date o f his death, according to the Schedule o f Benefits. (>) T emporary Disability Insurance--Upon receipt by the Company of due notice and proof--in writing--that any Employee, while mured hereunder, has become wholly and continuously disabled, as a result of bodily injury Of disease, so M to be prevented thereoy from per forming a n r ttm! every duty of his occupation, the Company shall pay, subject to die Terms hereof, to such disabled Employee, the Temporary IMsnhility IWitrfit* to which lie in entitled according to else Schedule of Benefits, during the continuance of such temporary disability and up to the time such Employee able to eit|fl|*c in nny gntnful (iceupntton o r employment for wage or profit; but in no case shall such T cim w a/y Disability Bcnc/it* lie payable for the first, thereafter, for any one disability,. ........ of disablement, nor for more than.. _______ .week. (U*kof III#Uctol'ty(it period) Section 2. Extended D eath Benefit--Upon receipt by the Company o f due notice and proof--in writing--that the death o f any Em ployee formerly insured hereunder has occurred prior to jiu sixty-fifth birthday and (a) within twelve 0 2 ) months from the date o f termination of hiu employment, u defined by the Formula, or 0 ) within a period, beginning with die date of termination of employment, ecus! to the time during which the Life Insurance hereunder on such Employee had been In force; whichever Is less, and upon receipt o f further proof--in writing-- that such Employee was, from the date o f termination of Ms employment to the date of his death, continuously and totatiy disabled, as a result of bodily injury or disease, to as to have been thereby prevented from engaging in any and every business or occupation and from performing any and ill work for compensation or profit, and upon the surrender of all Certificates and Certificate Riders, if any, issued hereunder to such Em ployee, the Company shall pay, subject to the Terms hereof, to'the Beneficiary of record, the amount of Life Insurance, if any, in force on account of itc h Employee a t the date o f the termination o f hif employment, according to the Schedule of Besefits; provided, however, that no payment shall be made under the provisions of this Section unless such notice and proof of such death and of such disability Is submitted to the Company within ninety (90) days after the date of such death; nor shall anyauch payment be made unless this Policy is in full force and effect a t the date o f tie death o f such Employee. I I f an individual policy shall have been issued and become effective pursuant to application made hi accordance with the Conversion Privilege grunted by Section 12 hereof, no payment ahull 1< marie under the provisions of the preceding paragraph unless such individual policy ahnl'i he xurrciuleml to the Company without claim thereunder, in which case the Company will refund to the beneficiary under such individual policy the premiums jwutl thereon, with Interest a t the rate o f aix (6) per centum per annua. Section 3. I.imitations on the PAr*o:trr o r T emporary Disariutv Benefits--(a) I f any Temporary Disability Benefits are payable bem tndcr on account of disability due to, or accompanied by, mental disablement, such benefits may, a t the option of the CompAny, be paid to *the Beneficiary of rccurtl o f the Employee so disabled. ( i ) _____ E ac..<M |ilQ yQ fla..aQ caiod..IrLi'anhB lo_riu,..thjrp!ffiorarx,,D U ablU .V _ I n w r m i e s ^ h a U ___ r , nny cmplovmnnt f o r wnt;a o r pr o f i t . `7 f T __________ ,, (r) The Temporary Disability Benefits shall not be payable for any period of disablement for which the Employee is not under treat ment by a physician legally licensed to practice medicine; nor shall such benefits cover sdf-deitruction or self-inflicted injury, while sane or insane. (<Q In event of disablement caused by, or resulting from, a pregnancy, including resulting childbirth or miscarriage, not more than six (6) weeks' benefits shall be paid for disablement during and due to such pregnancy. . (e) I f the Employee Ik over age slaty (60) at the time o f any richness disablement, he shall not be entitled to receive more than ,, . AhACiHS!i..i _______ weeks' benefits for sickness disability suffered during any twelve (12) consecutive months. (/) Other l i mitritium......................................................................h ........... ................................ ..............- ...........-- ........... .................. ...... -- _______ * _________________ .__________ K t ..:\~ ,, ; . . 'Ur-- S icttm 4. PavnrKT o r P n m iu m --The premiums due on and after the date of issue of this Policy lor benefits provided hereunder shall be determined and shall be payable in accordance with Sections 5 and IS hereof. All premiums falling due under thia Policy, including adjustments thereof--if any--are payable by the Employer, on or W ore their respective due-dates, direct to the Company, b u t may be paid to an Agent or other authorised representative of the Company, in which case the Company's official premium receipt signed by the President, Yice-Prestdent, Actuary, Treasurer or Secretary o f the Company and countersigned by the Agent or other authorised representative of the Company receiving the premium, shall be exchanged for such payment. The payment of any premium shall not maintain the insurance under this Policy in force beyond the date when the next premium becomes payable, except a t pro. vided in the next paragraph. ........... .. ..... I f the Employer has not previously given written notice to the Company that this Policy is to be discontinued, a grace period o f thirty- one (31) days, without interest charge, shall be granted to the Employer for the payment of every premium after the first, during which period this Policy shall coorimie in force. lo |!>OtlCC iw|.i y 'v - | j --- re* 1 ' ^ y v . I v. - ** to the Company fur thr payment o f a p ro rata premium for the prnnri cnnimctKing with the date on which the last premium became due and ending with the dote of receipt of such written notice iiy the Company. Ju ly 3 1934 S u lim S . Rr.XEWAL P atviutan--The Employer may renew this Policy on----------- -------------------------- --------- and a t each succeeding anniversary o f such date for the term o f one year, provided the number of Employees then Insured hereunder is, in the case o f a Contributory Policy, not less than seventy-five (75) per cent, of the number o f eligible Employees and, in the case of s Non-Contributory Policy, not less than Rtheenteowtaall insucmolnicdritoiofneeldigiubpleonEmdipelopyaeyems,eanntdofprtohveidperedminiuemitshtehreenasdeuteheasncuommbpeurtoedf Einmtphloeymeeasntnheernseint sfuorretdh hinerSeuecntdioenr iIsSnhoetrleeouf atnhdanbafsifetdy u(SpOon). \ such Schedule of life insure-- u -- jum s and such Temporary Disability m e n ? --- tejs m a y then be determined by the Company. s i . ffffl ~ p --. Imploycr, angnnved by the Company, pr^r " 1 `lu u jo payable, be changed a t any ,-ncwal of t r T S a t* * ." . * 'h e --saMe I ?rrr< *' ' / - - /'I T-- ^ ` '" * L IC ^ IO N is hereby made to the M tr r w ^ ^ilTAN LIFE INSURANCE COMPANYj |a Croup Policy providing tKc'ineurancc ified Jn the schedule of insurance below for t' "iigible Employees (as defined below) of / J . ' ______ ____________________^ YTff:sTos- t: fflAr r AH. xwc.- ...... \C_ * (HEREIN CALUO THE ZMrLOYER) ............ ................... n address of Employer................... .................................................................................................................... .............. ................................ (where y o u is to a t delivered and from which address premiums 'are'to d e"?au>)""* ire of business.____ ,, ______________ ^oehnni.Cfsl_.nuJbtrajr_K.miu_tWjctupo3rn________________ _____ . (is more than one business, state all) "" ' _ ........ , ~.TM The word "Employee", as used herein, means&_?MJk,,*.i!?S_SSElfiY99_Sl!a -C" Pm^5il,,P.E-8e.C^Ca,,bj.Th9jlfaoh^tt.^M bl?9.r.Jjfg.. DiylBlon of Raybestoa-tia n h attan, I n c .,______ ..o.r...by-'?h9..1kmh&t.tfln..Bub!;ec..l.lter...Ca,.^..a,..?i,a.<;.<?^i&.fors.oratlpn..yhfllly..ormad by th e ,employer,________ ,,0.JL.?...?.,ill_S tei..?B B layna_on..ihQ ..llain..O J'i'ic...and..fiB iral,,T arritQ cy..E iyraIla_nhQ ,,ta..dir.ec.tly.________ ^ffiR3iJ.d_flnd,,cnp.9nasJifi!L.CE..a&rKtc.9.s..Jby..JRay.hofl.tDfl.TKjjbairm4..Inc^..but.ti.jL a.je ajei.jJialL nn y_ ____ " aUeh-emPloyea-aaimlnff-laaB. than..$] .OQ.par wawlr h s ________________________________ ______ ELIGIBILITY--tAll present Em ployees...._______t._t..r___________ ___ _____________________________________________ l be eligible for insurance on tbe date of issue o f the Policy. All other present and new Employees shall be eligible for insurance on the immediately'following the date of completion of------ tyree____________months of continuous service. The insurance on any ale Employee shall become cifcctive in accordance with the provisions of the Group Policy, In no event, however, shall the insurance me effective as to any such Employee on a date on which he Is not actively at world f,l< y SCHEDULE OF INSURANCE AND EMPLOYEES' CONTRIBUTIONS CLASS tin IN SU R A N C E A C C ID E N T AND HEALTH IN S U R A N C E ^ hcwmal) WEEKLY BENEFITS A C C ID E N T A L DEATH AND D ISM EM SERMENT IN SU R A N C E H O S P IT A L ! Z A T IO N EXPENSE IN S U R A N C E (daily benefits) SUROICAL O P E R A T IO N IN SU RA N CE (m a x im u m b e n e fit s) EMPLOYEES* CONTRXBU TTONS G eneral P la n t H ourly P aid Em ployees.... earninK .4l5r.Q O .w eekly.or. more.. ... JlU.i5ftlarittd.S!mBlQ3Cflfla______ !__________ 4 1 .0 0 0 .. -1,000. 410.00 4 .26 w eekly . ..60.J5.9B.tbly , * vf5* .6p_ a mont h ^ ^ f i . ^ O O ^ _____ of such in, urance. it is understood and agreed that, if Accident and Health Insurance is applied for, Weekly Benefits shall not be payable for the first f?5,__ days of d i s a b l e m e n t _________ . . . nor in any case for more th a n .^ h lrta o n _ weeks. understood and agreed that, if Hospitalization Expense Insurance is applied for, Daily Benefits shall n o t be payable for more than &___ .days, insurance herein applied for is nor to replace, nor ia it in addition to, any Group or Wholesale Insurance now or previously in his or nny other Company on any persons eligible for this insurance, nor has any application been submitted to any other Comot similar insurance on persons eligible for this Insurance, cxccpe of Insurance Company___-l.'cmQ___ _____________ _____ ____ ____ .....___________________ ____ ______ _______ j j e . ........K ona__________________ _____ ___________ __________ Date of discontinuance.____ Jf.QDD________________ a igrccd that the Policy will nor become effective unless this application Is approved and accepted by the Insurance Company at its bl&ce, not shall the Policy, if Issued, become effective prlot to the payment of an approximate initial premium, and, if the Employees '/Distribute toward the initial cost, unless at lease 75 percent of all eligible Employees have made written request for insurance there in turns willbe p a i d . . . _________ ______ u ____ _________(annually, semi-annually, quarterly, monthly). ' tn n ee payment, herewith, to be applied to payment of premiums under the Policy herein applied for, when and If issued, $JtiQQfi. . J x agreed that necessary particulars concerning Employees to be Insured on or subsequent to the date of Issue of the Policy, and ioyccs whose insurance is to be changed o t discontinued, shall be furnished monthly to the Insurance Company by the Employer on s provided for the purpose. , t a c A .g a ? . ^ i ^ .Y ..fe is a y ..w g n ^th is__________ M r i _____________M i of ____________RAYBESTOS^MNHATTAN. I NC.___________( i J (W im eu)' i \ (Emptier) / _____ __________________ iw i S L , , 4911-3--Jan. 1910--frinted in u.s.a. By-------- _____________________________ (Title)