Document DMjwMmzEpMk0zD6xj0XrjNeXB

- - - < .P M y cs METROi-OLITAN LIFE INSURANCE COMPANY Croup folic)- No__-------------------bearm; dale ^*TBi.ras-HjiKi7rii<, me. loliowi: J94L jtid imurinj the Employees o/ ------------------- is hereby amended I. Effective October 28, 19;5, by addin; to aaid Group Folley a, a part thereof Hoapltal 2xp--.e Insurance supples -.ctary Afraeuant Fora Z.Z.T.tiii. II. Effective oa tha data applicable to hia Unit or Qaa. aa tpeeifled In the '.TJir.z tebla as to eae.-s Saployt* wtio It actively at work os aueh applicable data and .a fCh Ibplo.'-aa aorlo/ad aubaapuant to aueh applicable data, effective as tba data :.ls return to actlva wore a a to aaen employee wiso la actively at verb on tba data 1 Icibla to bla Unit or date at tpaeifltd In the follow!*; t:ola, and affective oner IB, 1955 aa to BtpJoyoae set opacified In tba following tibia Unit or Bm Manhattan lubber Jlvlalon S/ft atlarlad Stployaaa cth*r than Baployeea as tba Main Office Payroll Obtobar IS, 1955 E=;io.-cj aui.'aet to tho iLr;air.ln; Afiraauant btw*r. .>nhettan (bibber aorcers Independent- L'nloa, Inc. and tne Uauottar. Runoar uivlelac Oetobar IS, 1955 Sarloyaaa who are aesbars of Manhattan Lodeo lc,7V, Inttmatlantl Aaieciation Of liaeiiniata Ibployeaa aa tha Mein Offlet Payroll Bavasbar 25, 1955 January 1, 1956 A. By addin; to Schedule 1 attached to aald Croup Folley aa a part tharoof, tba fell owln;a Onlt or Oats Aenllcetle Orta Employeea on tba Mala QTfloa Payroll JtnuTy 1, 1956* B. By aubatltutlnf far tha Sahatfula at Inaurase* and Esplayeea1 Marlaua Cantrlbutlona, ai aaasdad, lb daetioo 6 an Pa(a 2a at aald Group Policy, tho followlnfi Ufa Inauranca Aceldost aad Saalth lanrinaa (MaaklT Sanaflt)* Uployaac af a claaa or mit apaelflad la Scbodula A haraof, axeapt auah taployaaa at Kannah, Wlaccaala 61,000.00 S2S.OO Uployoaa at Saanth, ttlacanaia - 3,000.00 20.00 Zarlayoaa aapleyad at -------- , Pauaaylvanla with waakly asrnlac* (aa datarsinad by tha l^ilcyarlafi 250.00 ar nora 1mm than 410.00 tMfWIW>I4 ,2,000.00 2 000.00 Ba.-il-- 35.00 A.90 p-*-y Db CROUP HOSPITAL EXPENSE INSURANCE PERSONAL AND DEPENDENT BENEFITS SUPPLEMENTARY AGREEMENT ATTACHED TO AND MADE PART OF GROUP POUCY no.--I'I'tS..issued to.... ........................ ........................................................................................ ... (Ktu CALUD nu lUnOTU.) METROPOLITAN LIFE INSURANCE COMPANY (Hntn called tAt Iruuranct Company) IN CONSIDERATION of the application for the bunrtnec provided hr thu Supplementary Acrermeni, mi of tht payment by ih< Employer of the addinonal premium herder a< hamnaJvt provrdod. HEREBY AGREES. 10 make rha payment! herein provided. with reaped to the aevera! Employrei iniured hereunder, in accordance nth and lubiter to the provuieiu of thu Supplementary Atraameru. Sretlon l. v.fZLZIf.'I. Jr C.LT.l............ _r . ;._i. L'..L :: Dia tepj .sj-iloyee* na . fuil-tl-.: 'rrf.oyce -lr, ft:;' .. I, i r. er '`'trices Sy ti.e it nhsRtm Pub' er L1v1_Itp pi' the / vle/r. .Lr. I.T.-- ,u ; t.. :ar Hie tr-- '-..endeat* eut (l) m Ls.ilayie'' vlfe, (1) :ny -io-s ml-. chil. orer fnriiw Je j. a! jr. ns in .nr n,,n-v yerrr oi r 1 1 1' . v.iaym-, if c villa-rs I'.t. lc sA.,.icyrr or of S;.l '.-.yley.i hr.--- I.j tn: l.- ny. -c u- t cl lain, Is. i ay errr, (r) ;ny -.r.ia 'hr 1. <-ll.-'.:-ir f-r l.-. i -,;e n ; l-.> () my i-craon re. Ii in aiitii.c tr- Jai*. i . t. t-. iui.. i -n-. (c) .-ay rr a. cTlj--i.ee of res. :.e.ltr., fa*i.l.-hju ui eaoru.-net 'it* ti.-si. "a: ol .ctl.si T : :-c- of, is cat -t*J Pv the Ir'ii-i-iev ta ; ny n- jttl : tt. r . I:* vr. V.i.l::* -. - u;- le.?. liy tio/tvc ehli., .si.- .i-,K.Il i.-.i re-l.e. - ts. .j: 1 ve 'a l--a. :..ti , -s.' ny ehll. /niulj- l-..- M' . -..iayii. i_rt . tr. .n..-.tl;- r- ,1.1a- In tl In i.'.alt o" vt.lcl. -*J'.. .-i-iploy-- 1 t.r Lc . Ice itrs *Prrsou l hojpitti Lx;en_e L. snatr' -a: t loser-ne . ;.-avl In Lim- fltt ;v;.tU1c ti uI .yljyr-' Lu Vi.- event a' hi.' o-.-. IV '. s:u.'ln -uuit. Tie tun .s.rnneat La.,..t. 1 flta /-ole t? uii TMiployer la tv. "T^it in u.*..nce* r.v lr. iiruc- ra-I Vs; ".r.'tl_ -j ,'lul r..::lr. -r.ot r- my f ... ISe trrap *r.r--la*, t;r.fpr, ral '. *cr-.rr*, - -j--a Is t. 1 t;- ,-lejesrurj ;.tTrsaaat refer eaciu. Iv-l7 to ,tl<l- -us^.-hjiw ?y - .--a*at > os n:t to :'-l- Cm? folic/. ectloa 3. >.IIi si 1 ... w. i. J1 .La. is.-l .....I 'l JC.-aJ-LLH1t.ct Lt.lci'oe -.o L>. cssyli tnu tin-, aatli of cactinoour- ia.r*it.. . risr to the cute of lr** of Vi1. .a.:,-l*=jlti-y .e-l 1. 'li/lhir for lonaa'l i-ei.lt 1 . ss.-oarv Isrirsut t' -runrr an Im cst. of l ..ao of Uil: -s'-1-J4-Ata.r7 ;.;-r.- vat. . el. Eaaloyoo vio l.r-r- oat eo.t letod thrve eatiir of eoatlisivj* . -rrlse .-lor to V. -ttr -.f Iona of thla S^.Tl-a-eitcr/ ,iTacat ins erefe -~>la..-e mOoyoo -U tens to ta- ts tr of Isaac ol tUa Lcypl--root .sy >rrassMt `t-11 be r-iL,it'.e fsr . is. -ail l.v. It* 1 x r.ir- Xoeanaeo borassor on tn- oaf LoaraUtU/ folio--liv tie cot- of eo-.;^rtlcei of U..-.-. aantho of cantloeouf err ice. leak laala/oo !'.! oo ellyLBlo 1- -t'.-a^ot Pa'/lt 1 -o - lo-arrner i-r-- aouor U-'* of his rll - IM'.ltr 'er.cn 1 Lorylt 1 is-.rc-e In ar oc> l er .n r jr^o Setr Ur* flr*t yorma biinn IppweeA os roeL U-.,io r, i14er.-rrr :-.tc 1* Form ORE. OOl Math 1912 Scmo 3. EFFECTIVE DATES OF INSURANCE. --An EmrWuwe m*y become insured hereunder for Fcnoful Hoariral Expense Insurance only by makmc wrracn rajunr to th Employer for such insurance on formi furnished by the Insurants Company. The Ftrioiu) Hospital Expense Insurance on any Employe* who make* ruth rcqucyc on or before the date of hu clioheltiy for iuh miurance shall become elective on the date of hu eligibility for such insurance, provided _______ *__________________ X________________ JE________ X____ ____________ X .______ _______ X he is actively at work on the date of hu aiipbihty. The rmona! Hospital Expense insurance on any Employe* who makes such request after the dare of his ehpbtltry for such insurance and on or before the chtrry-dra day following the date of hu ciiobtltty for such insurante, m on or before the thmy*6rsr day fallowing the date of hia mum to active work tf he a not actively at work on the dare of hu eligibility for such insurance, shall become elective. prowled he u chert senveiy at wmk.on the----------T--^ F ^ ------- ... _______ --------- XX&____________________________________ ___ ____X________ _________ X_________ __ ______________ date of such request. Any Employee making such request for Fersonal Hospital Expense Insurance after such rhirrv'Artf day and any Employee roguesang teuutat-- of his Personal Hospital Expense Insur* oce after hu Personal Hospital Expense Insurance hereunder has been dssconanued in accordance with subdivision (e) of Section j hereof, must Airmah at ho own expense evidence of hu insurabilxry saasfsctory to the Insurance Company before he may be insured hereamder. Any such tnauranee shall become tfecav*. provided such Employee u then senveiy at work. on the___ <* ___________ XX_______ __ ___ 2t 1 date the Insurance Company mips as aaselactory aurh evidence of insurability. TW fenonol Keepmi Expense Insurance on ftny Employee ooc Moh at worl on the date erhen hia Pimonal Hneprtl Expense Insurance hereunder aeald other-- bocosoe rfsm<i aheO become eiacnve on do mb hisatd-- ---------------------------- dey------------------------------------- - An Employee may became meurad h--ds hr Cbpendem Hospital Expense Insurance only by --kind tranoi asnnt as the Empioiet for built N--J Hospital Eapenac Insurance and D--wdrar Haapiraf Eipratat hoyranee hereunder on farms fraolahad by dw ance hereunder, whichever dare ti lam. The Dbqend* ent Hospital Expense insurance on any Employee who makes such request after the date of hu chphtitrv for such insurance and on or before the chmy.fim day following the date of hu ehgibtinr for rueh insurance or on or before the thirry.hrsc day following the date of his return to arm** work if he u not actively at work on the date of his eligibility for such insurance, shall become e/TecriiT nth respect to those persons who arc then Ocpeniena of such Employee, on cbe ------------ 1Xi dace of such request or on the rfonn date of the Employee s Personal HocptiaJ Expense Insurance here* under, whichever date is later. Any Employ** nuking such request after such thirrydru day and any Em ployee requesting remssatemcoi of btis Dependent Hospital Expense Insurance hereunder after his De pendent Hospital Expense Insurance hereunder has bom discontinued m accordance with subdivision (e) of Sniiaan 5 hereof, must furnish at his own expense evidence satisfactory to the Insurance Company of the pood health of each person who o a Oq--dcra of tueh Employee on the date of such raqumt before the Dependent Hospital Expense Insurance with respea to any such Dependent shall bteo-- eiccavt. Such Dependant Hoapitai Expense Insurance shall became rfaema wuh raspvcr to each such Dependent whose evtdenei of good health la arrepiarl by dm Insurance Company as acoafaceorr, on x X XX -- ........... * , .............. ,*d*r of such acceptance by the Insurance Company er eci the tinov* dm of the Eaplevee's Personal Hospital Expense Insurance hereunder, wtuchorar date a lata. In tha event that the evtdeset ef good health of any such person b nor ace--ed by the Ineursnca Company as --nee hereunder, be deemed a Dependent and no Depend-- Heepoal Expense Ira lirenra shall be prm vidad h--under *nch trapes m nach penoo. The Cbpendem HoapttaJ Expenae Insurance with re--a m any pemon who ha-- a D--ad-- of in Employee while such Employee la Iwwal for Depend os Ho--al Expense 1m--i b--unds ahofl I rfrahte on the data such prawn braenm a T ft mA SaeneM 4. SMUorny CCWnUSUTONS.- N tmjUrm Hm AiwiOaHaNI dDMMMiu* Ul>Sa*atl I Haflal Emm Iww* onorhsd--dtodateofhtsetiiMtayfar shall busa-- tfcon with --p-- m As are that Orpendinn of --h 1 hfc cfctfbOff fee such fatawrat--or -- ] 5. CXSATUN CP WSUHANC1.-U) 7W rwiMt HmpmI Eim fawnaa mU OipoU- FaMcar.cn Mart 1*C f-H-A mured hereunder thal) automatically cxete nr <h dart ol the temunauen of ha emptorment. Trrminjijar ot employment, foe rhe piirryuca of the Hoapntl Exrente Inaunnce hereunder. meant cemanen of aenve wort at an Employee u defined in Section ] hereof, except diet (i) in cate of (he efcaence of an Empiore* from active wvrt hrci it of atcfincat or injur,, hit employ* mem mar, for the purpueea of hit Hospital f*p*" Inturance hereunder, be deemed to continue until terminated by the Employer, or (ii) in eaae of the absence of an Employee from acme work beexuae of temporary UytXf, hie employ* mom may, foe the putpoact of ho Hoepnal Expense Inturance hereunder, be dexmed to eon* trauc until temuneicd by the Emplnyef but m no cue beyond rh. er lr: Mm a:' a fi-tnH f ChtrCy litye fella fef >. Ckia. . - . aueh lay-of commenced. In the eiec of either of die forepeint eaeepnona, the Ptncnal Hospital Expente Inturanee and Dependent Hespial Expente Inturanee hereunder on tuch Em* ployee tfuJl autamenealfy ceajc on the date of euch tatnaianen of hu emptormam by the Employer, at evidenced to the Inturance Company by the Emplpyar, whether by nonficanon or try eiaaanen of premium payment an account of tuch Employ--t mtunnee hereunder. fa) The Frreonal Hoapnal Expente Imuranee hen- under on any Emplover thafl automatically caaat on the dare he becomet enntled to the Maximum Total Payment for Room and Beard an account of ha own hmpital confinement. The Fananal Hoapnal Expente Imumrce hanunder eat any such Employ-- may be reInnated only if and whan he mean* acorn wwrh far the Employer on full am*. An Employ--'* Dmaidant Ha--teal Expenea lnaur- anee hemundar with topeci ap any Drpandenl dull autamaocatty coma on the dt the Employaa btcomae anenlad ap the MtuBnuim Tool Ptrmem for Roam and Board on account af aiach Dcpendani't hapnil eondnamatu. The Eoptayat'a Dependant Hmptnl Eaperwe Inaoeanct hemundar wtch mam a audt Dependent may be miawated only altar tax giaiaiaiaai af Kh haapenl aeiinemeni and undo ary af die Dapendent Iram the etjary or nrlmn which cuaad auch human! eenfinemane, and anh provided da each Fmplnyaa a dien ei lane* (C) tf anr Employaa bnured berwoadat far ady Far--nol Hnpnel Ecpenae Itwtaaetae dad aadfy dee fmi linn dm ha Personal Haepaal Inane bmpanea hemirkirr it 10 be discontinued. tuch mtutancc thafl auiumaucaljy crate on m* . cote tuch nonce of discontinuance a rrcejred by the Em ployer. If inv Employee insured hetcunder foe both Pommel HcypnaJ Expente Inturanee and Dependcm Heapital Expente Imuranca thill notify the Empfuyrr thxr cither (i) hu PervertI Hotpiiai Expente Intuttnec hereunder, er (ill ho Personal Hocpuai Expente lmur* Inee and Deptndaa HotpttaJ Expense Inturance hem* under it to be duconratuad. then buth hu Pertonal HoapuaJ Expense Inturance and Dependent Hoapnal Eapenae Insurance henunder dull automenctllr crate on 'he et ta ------------------ - ------ , i, i airh nonce af dacannnuancr a neanred by the Employer, if any Employe* round hereunder for both Personal Hospital Expense Imuranee and Dependant Hoaptal Expente Inturance shall noafy the Employer diet only ha Dependent Hartal Experwe Insurance hereunder a to be diaoonnnutd. hu--XX - - *__________ a ry.p.dtn. Keepnal Expame insurance hereunder dull autamaneaily ccxte on * *-* --i- ............... ,, oirh nonce of dacaimumce raaatvad by dm Employer. Failure af any Empldrue a awke rannabunan whan due. at mputtad by die Employer. a the eat of either ha Personal Hoapnal Expanse imuranca henunder at ha Dependent Hartal Eratntr Imuranca henunder dull hsv* the tame after a nonet a the Employer, wtdiui the aeanog of tha pracedug pancraph, that dw assurance ler which tuch Employ-- ha laded a made cantribunal a e be darantmiiaf () An Emptar--'a Drpsndu Haptul Expente boom-- heiauraia wnh ra--t a any Dependent shall auaaatacaUr cease aa da day oanadattlr pew cade* tha daa aiach p--aoa oeaaa a he t Dependent of euch Employ--, at dadoed a Sanaa 1 bwenf. () bi any at--* all aaurenm haramda dwll ummenrallT ceaae aaaadaeeiy open da d--ennnu* nee ef due Surpismamay Agnail a af mad Group hUcy. X * _____ I.,............... JlS ______EII IS!------------------------------------ --JESI---------- _____ II!-----------------------------------_______________i________________ *______ Farm GAF. OH Mat* 1X2 - (& Srcno*. 6. AMOUNT OF INSURANCE,--The trTKMim of frwwl H.*fial E*nn*e Inwrarve . Personal Hipital Emcm* Insurance and Dtrenderv H.*nral Earwnx Insurance arrihiHfc tn anr Emr.Unvc uvail frv m icmrdancc win the ichrduie *<i fourth Nrlow and any tncreix x .....-......-- * -- .....__ m tltc amounts of mch mujnrxt, m accordance with and achedulc. ahoJI become effective, pmwied 1N0 Emoiover then actively at work, on th.r__ __ ___^ - - ------ --- ----- ------ X________ __________ X..... .............. i/ wch Emoiovte is not then actively at wori. such chance the sirwumi of insurance thill breime elective xi the ne*t follow....... ............ ........... ......................x__________________________ X-........_ ............ ..... ...________ ___________ ____ - --.... _______ _____on which he aenveh ar *.vL ------------------ K-------------------------------------------------- X-------------------- --------------------------*-------------- ------------------------ E------------------------------------------------- X---------------------- --------------------------- *---------------------- -------------- -_X------------------------------------------------- X------------------------------------------------- S----------------------- SCHEDULE OF INSURANCE. EMPLOYEES' MAXIXfUM CONTRIBUTIONS, AND PREMIUM RATES cc::sn.ror li'r/nc: 2 r:njpr--r vr c-.-nna Clii 411 =plo7ea IkHeja Pri:- tatfli tapajrfaas ?areenal Ifeapitel Hero:tel Lxpcaaa Crpensa In-j-rw Irevrsncn lech -e.;c=it no.oo no.so n> roruni vfcieh as 2=ploroo ttj eontribita to tia eott of tha tasuraoea hall net axeoad the prorlsaa eiuirc*! ter tho roeuaia ei hie laauraac*. orsmt ff r tf' -za Initial .'testily ftrestai fjfe ->rr r-sluiaei Om ill tepl^oaa Paraoncl Henltal g-v-- iBJgfffftea C1.22 Bapdeat CocTltrl E~--r In-u_--neo 0.87 ha CAS. <JOI Ma*di)M2 |H]HlSMDQNl SccrttM 7. rVSURTNG CLAUSE.--Upon reetipt The Maatmum Dtilv BeneEt refined to In the pro af nnaict and lansfaetory pof. ti mruirai herein, iKit any Employer, white uuuted fot Tenon>1 HoapttaJ ceding table mill be taken ci the Maatmum Daily BencEt in force on account of the Employee or De Expenae Iruuranee hereunder, or nr Dependent of in pendent at the dait of ctnooianccment of hii hoapttal Employer, while luch Emptovee a iniurad for Depend- conEnoncnt. ent Hoaiaul Eapenae liuunnee hereunder, ihiU hive become conEned 11 a panenr in a legally caniotuted hoapttal ti i remit of. ___W urv injur;- ojt irlelnj out of or. in tie cjurae of ni euployreeBt, or..................................... .... For iU hen ltal confintci.iH.cr en.EipUyce exuaed if arty see > rL-giiancy or re ultiig childbirth cr eouj.iiepuoaa. the total of lb* ;a>-cat hctiuilcr Xtr ex-.. Fcaici. cUetvtd fee Ena .nod doerd cU... tot exceed fuarteun .licet the -cxiwia...... ___ eieertear. opt entitling hix to _____ benefit! uniar enjr vprixen'a cjs- Daily Beeefil, yr-vfotd, however, eo pay met ef ae> lied faeil lM. cJde fcr iuett ' .......... Wnaotlsn or pecu^-tl.-.di. diie-re coefiacoep I ..if..iae.+*e9ancx ..ex la ted. .*... l"'! ................................ .............. ....................t.b..e... effect He tie i*..#f..ibe ..Eaipl Heap 1 - end.jroviaed. In eltasr cue,. jrye!i lal Exyeaae 1 aiur,aee..her.eu"d*T.i_________ flneacnt esnunjee fjr . ferUw. of t lei.at_ilv,.?iar.ePBXicjt4Y..iBt.iiri1.eie^t ta._eto.te * 'elouj___________________________ .... Fbr..ill.l!paiHalcotficcttt..Af..a.JJ.fl-<*deat .which, li.ceaae(j.>jt..t!l_ttee _p|Mrkecj #r roaeltloa citlabirtb er centllcatiuaa, the tnaunnee Compinr ahall par luch Employee, aubiea to the tenu and liouraonna hereof, foi the expcaact charted for anr one or more of (ha fottoa ng throe type of aemce received dunn| luch canEnemcnt. provided (1) (hat the aervicaa rettnred were lecsmmended end approved br a phyaicun or autgeon letally bcenaad to praetica mediant. and (2) diet the total payment for aB cxpcnaei chirped for each auch type of aemce ahall in no event emceed die maximum determined in accordance endt the following tabic Tm or Scavtei Maximum Total fitment fee Any One Connnuoia fined of Hatpeel Coninimem. Vhether from One or Mote Ctmm, m tm Sacemetve fenoda of Heapirel Coo- Enmant From theSene or Related CwateCii-- oam end aoerd an exeunt egaei to tno -Hertain XciLf oosefIt for euch 007 bt men aea iitel ccfiteMst, out nut u exceed tnirv-ooe Lima tat tunlma i-ei-7 benefit -necthcUci (and Tea tlrnt L-te "ereSfin^eit-* "hW benefit Ptner ijecUl binlUl errieoe catr;ei tar if Luc hovpii-1 except aermlcet cf -JqrsteiaM IT expeeaea cUmcd for ell typea ef aerriccn U ad bitlAv .fiel 1 y* tj.rauiil_ncetTMLd.M.1ss inch cchiiacucit aaali .at t exc.aud_tea t.iuea the i'axl.aa Daily Ceaefit lafercc~ee accuuat ____ .<Wtif.d WheiM .a.ide). Subnet to due proof ef data, the Employee trill be paid each week during any period ef hoiptttl eonSn*ment for which beneia are payable. and any btlanee remaining unpaid at the teraitnetian of tuch petted will be paid waadiattlT upon receipt of proof. Section A HOSPITAL CONFINEMENT COMMENONO AFTER CESSATION OF INSURANCE.-- If to Employee, er t Dependent ef an Eitipleyee who ttiaut^ heteundet net Dependent Heepnal Expenae tnaunnee. at the date of the rantnon ef the Heepual Expenae tnaunnee an bn eetnunt, fa touBy ditabiad earn math ef tnfuty ot urlrnmi end, whaleedit eo lately dlaablad end eshfn_____ S&ESaaKJigI----------after neb caaaamn. btacnm canEnod aa a pattern la enaded m whatever beneto wauld have been payable in aamaqumee of tuch heepttel maiEmmem had much Hoapttd Expeaee buunaae been in Emce an the dan ef eemmancemanr ef aucb baminl eenEnaneot. gHjabt it tae exto of me ceetitlxa of tne EeiMui ix-eoae lneurcneo bwwitny cn her iccauat. M. o v impuit of waft , fU-----petlcmi U 4 I>.M^.gattUath________ i-nAj)unryo,t euiaeterrcit,iaelst-.wmtiyUftatUao*p>oiMTi|onono.f idiplui ejefEnemat yy st Itaet a I poteen owocuUvc mure xa-ai be i Uvcd. tj viatayw acscflt* void hove bean .U.vable nemte-tey ln tmreTxemp..;_rMfe. MalWi caafiarhoot od _V<LjKJaLi-- Xr StClisa 7. INSOUW; CUQSS UKT1NUE9 of >ueJi 0*}adeal praeidad, feotwoer. Idol oo of atj kiid odoll de sadc tor eb eeafiaaiocai If id* prtfaaaef tallied sa idc cficiit dole of id* Haipliol Exptai* Iaiuraae* lartaader aa acciaat of ouca lapeooaai. CNMMIIMCNV - - -P H Y O'er toon; Onrunff:* ..5afl.Ia.f4rrr..in. the... MLUjLt*ZLVi___ Stcrtopt 9. NOTICE AND fROOF OF CLAIMS.-- (a) Written notice of hospital confinement on which claim mar be based musi be given to the Imurine* Company vtthtm - - - - <^y liter the commencement of tuch hospnel confinement. Proof of tuch hospital confinement and of the receipt of any of the meciAed services must be furnished to the insur- imi Company not Jiter than...,, . . . day* after the lemunanm of the period of hospital confinement for which benefit* ire payable hereunder. The Intunrice Company, upon recent of the notice required by this Policy, mil fumoh tuch forms ei ere usually fumuhed by rt fir filmt proofs of daon. If such fenai m not received by the claimant withm fifteen day* after the Insurance Company receives such nonce, the claimant shall be deemed to have complied wish the requirements cd thn Supplementary Agree* imm as to proof of claim upon submitting, vtthei the nme find m the Supplementary Agreement for fihng proofs of claim, wnrten proof covering the occurrence, character end extent of the hcepoal confinement for which clam is nude Failure to furnish notice or proof within the time provided in this Supplementary Agreement shall not invalidsrt nor reduce any claim if n shall be diown not to have been reasonably possible to lumuh such nonce or proof and that such nonce or proof was fumuhed as soon as was reasonably possible. (b) bln anion at lew or m equity shell be brought to focovor on this Supplementary* Agreement prior to the Optranon after proof of claim has been filed oi accordance with the require mm of dm Supplementary Apteawt. m dull such anion be brought at all unlaw brought within -- ------* from die opium of the rim widur whoh proof of dan a reqtarad by the Supple* Stems 10. DUE DATE. CONFUTATION AND PAYMENT OF ADDITIONAL HOSPITAL EX* PENSE JNSUEANCS FRE*0UM1-T>* srtdnwitl pndPH due * and after the data of mm f do Supplementary Agrumam for die ftmurB Mwndod hereunder dull be dmnmpod and dud be payable m cmifenia anti the fdlowmg pnerubs The bona) addmonaJ HoepmJ fapw iMumnce E It due on the data of Pm* f thee 1 i shall be dot. Hm ficjUuat ailed dtt due date) i TW Initial eddmenal Haed 1 pnaiuo due m the due of mm rf 4 FremCAf.OOl Mad 1M2 Agreement and ihe sUdmonaJ Hmpitsl Expense Jn*uf. ancs premium uuc on any due date after die date of uuc of tbih Supplementary Acrtemtnr ihall be (*> the asycgire of the rmortal Hpttal Expense Insurance premium* determined n to each Employre rhen insured hereunder for Pmcnsl Hiapttal Expense insurance from ihc^.^*!***.*..J*crsnnal Mutpnsl Es> pense Insurance premium rare then applicable k> such Employee m accordance with Section 6 hcrcuf. piu* ;*) the aggregate of the Dependent Hospital Expense Insurance premiums determined as to each Employee then insured hereunder for Dependent Hspttsl E** i Insurance from h--- Dependent Hospital Expense Insurance premium rare then applicable to such Empirysc in acceedaner with taid Section 6, subjoa, however, to premua adjust* menu, if any. Pnmosm edjuirmenu uivdwtg mum (4 unearned additional premiums (he Employer shall be lemtad to (he period of twelve months aimedlately preceding die daw of receipt by the Insuring Compony of evidence that sueh adjustments thouid be made. On written request of the Employer, approved by the Insurance Company, additional Hospital cy--*** Insurance premium paymana may, d not than to payable, be changed at any due date f thu Supple* mencory Agreement. to as to be payable anaually, serru annually, quarterly, or monthly, provided the frequency of premium paymau* atiected arwiser also to the payment of all other premiums due under (he Ctoup Falicy. Upon any renewal of mid Gmup Fobcy and f dus Supplementary Agreement, or whenever the terms of and Croup Fotscy m of this Supplementary Agreement art changed, the insurance Company my change either the Fenenal Hcepital Expense Insurance pro* i rates or the DependcM Hcapual fepenat btsur* t taies or afi of such premium, rates. _In iit.xgra?.oUa-af-lB-JZJUt?,a-- .a.ltlatt.: sat-im tBn Inrjr nt. -attiiiiaLtM.-<ai.~ .s&r. ___ x ,,tt n* cat* fc> v* sjst ,m.rrlhtd > jc*low, tn Iai. ir'ne. Casing/ a,r u> mrui sralin rttn - il*^ iff ta -rrJ.'tz t*.tt wwn 1b * ^!>>*- ta ar in ICTTITMCI ltt _________ 4m 4m. aunt m mmT4t4 m tbt I f A grace period N thimine dan, wttNiur mimv chargr, dull be grtmcd ti* the Employer lot the pay ment of any additional HoapuaJ Expense insurance premium due after the mmaJ additional Hospital E* pom insurance premium. prmndod the Employer ha* not previously ci\n written nonce to the Insurance Company that this Supplementary Aqicment u rn he doeonmueO as d the due date <W luch premium, end dunnt any such pet enod this Suppiememary Acreement shall rtvwmuc ui force. If the Employer fails to rev mv additional Hospital Expense Insurance prrrruum within the greet period, this Supplementary Aerrement shall be discontinued on the last day nf such trace period, but the Employer shell, nevertheless, be liable to the Insurance Company fee the payment of all addmonai Hcapital Expense Iiuunnca premiutfu then due and unpaid, together with the additions! Hospital Expense Insurance pee* mtums for the pace period. If. however, wnrten nonet given by the Employer to rhe insurance Company, during rhe grace period, that this Supplementary Averment ro be dtacnmimied before the exptranon oi the greet period, thu Supplementary Agreement dull he dtacnnimued as of the date of receipt of such wnrten nonce by the insurance Company or the cart cpeciAcd by the Employer for such ducotvmuanee. whichever date a later, and the Employer shall be liable ro the Insurance Company for the payment of the pKKita additional Hospital Expense Insurance premium lor the period cummencmg with the last due dare and ending with such date of discontinuance. * StcnoN n. INCORPORATION IN CROUP POLICY AND RENEWAL--This Supplementary Agreement u attached to and made a pan of said Croup Policy for a period commencu* -- October 13. 1951 w ending with the day onmadtataiy f*uwy July V I*** ------- , on which last date and on rash aanrveraary ol which iasr das due Supptonmtfy Agreement mey be ra* newed to continue tn eflecr as a p*" t*f uid Cmuo Policy lot a further term uf one year, provided (1) the number of Employees then insured hereunder for Personal H,*pital Expense Insurance n, m the ease of Contrtbuinry iwuratwe, net Jess than Kveftty^ve porter the number ni eligible EmpWcta and. in the ease of Nun-Contnbunvy Insurance, nor less than the total number of eligible SmrLweet, and provided, tn either eaw. the number of Employees then insured hereunder fur Personal Huspual Expense Insurance a not leas than ftfrr snd (2) the number of Employees insured hereunder for Dependent Hospital Exreive Insurance is, m the ease of Cnambufory Insurance. njt leas than srrenrv-fSic percent of the number of eiic<bl Employees with Dependent! and, <n the ease of Sort' Contributory Insurance, not lew than the local number of elibic Employee! with Dependents. Such renewal a conditioned ucvn the renewal o< aid Croup Policy and upoi the payment of the additional Hospital Expense insurance premium then due m computed m the manner set forth m Snhot 10 heraof and baaed upon such premium rate* as may dun be determmd by tbs Insurance Company. Stetson 1L AGENTS; ALTERATIONS.--No agam has awrhrawT <o change dua Supplementary Agracmcnt ar m waive any of m provsnona No dhangi m this Supplementary Agraemcm dull be valid unless approved by an eiacunvt o&cer of the liuurance Compw and evidenced by endorsement hereon, or bp amendment herero agned by the Em ployer and bp the Ineurane* Compeny. Ssenon 13. ADDITIONAL PROVISIONS.-- -*------- - - - * -I,____________ X A.---, * - - * --------- ^--------- -- *------------- - ------ * S - . .,at vmtm Mrazof. * A.IHHIHII m hi tnctmd i W lilahtr Jiai Cmihwit hw . m ah. aMaci uai tka t du* a di* dm at mm*t du. S*p*kracnnr Y imrtmy. Fmoxr.aot |J*C V IPMJJdk If_____ i 1 l l i