Document rBxbnM7rX2b09YeLy93eE4nbV

PLAINTIFF'S EXHIBIT HCTROPOUTAN LIFE INSURANCE COMPANY Effective of lta dote of laaue, Supplementary Agreement fora C. 8297 attached to Qraip Policy No. P577-C is hereby endorsed to aubatitute for the aeeond paragraph of aubaeetlon (B) of Section 3 thereof, the following: If oa the effective date of the Dependent Inauronee of an teployee aa provided by the neat preceding paragraph, any Dependent of the Baployee la confined la a hoapltal or other lnatltutlon for care or treaasent, or la eoaflned at hone under the care of a phyalelaa or aurgeon becauae of a dlaabllag phyaleal or mental alekneaa or Injury, the Dependent Znaurance ob aeeouat of that Dependent aholl not become effective until that Dependent la no longer eoaflned la a hoapltal or other lnatltutloa or eoaflned at home under the eora of a phyalelaa or aurgeon." METROPOLITAN UTS XRSURANC* CCMPANT, --CV v`*!er (Reglatrar) Form 0. 8736 Auguat 1936 *I Effective >5 gf its <Ute of Issilg th< Sirrml--f o' hereby endorsed as follows: 2. to substitute for subsection (l) la Beetloo illowing: s thereof, the "(X) MEDICAL EXPEJSX PERIOD.-A 'Medical Expense Period', as used herein, mane period licr-in-tiar with nnv endlnr with the next foll^vinr Deeg-hcr 71st.. *t>a , the following; "PROVISIONS APPLICABLE IX CASE OF CESSATION OF HBUXAKCX OTHER TEAS PURSUANT TO ITEM ( 2 ) OF SECTION HEREOF.--If, at the date Of cassation of the insurance hereunder on account or aa Employee nr pPnc-^rt the Eeployee _ _______ is then under the care of a physician or Burgeon for treataent of aa injury or sleknese, the Ineuranee Conpony ahall pay beoeflte as If the la- suraaee hereunder on the Eeployee or TWicivivi.t. had continued la force, provided that (l) no benefits shall be payable on account of any Covered Medical Expenses Incurred after the date Uiruc iiiontha following the date of cessation of Insurance hereunder or after the date of recovery froa the Injury or olefc- ness for vbleb the Xa^loyee or Dependent ms being treated at the date of cessation of Ineuranee hereunder, whichever first occurs, unless the Eeployee or Dependent le totally disabled continuously froa the date of such cessation during the period sueh expenses are Incurred, and (11) If the Employee or Dependent is totally disabled continuously froa'the date of cessation of Insurance hereunder, benefits will continue to be provided during such disability under the eeae conditions aa if the Ineuranee bad ewitliiei la force, but la no eeae shall any benefits be payable oh aeoouat of any Oovered Medical Expenses lasurrod after the end of the calendar year folloulnr the cwlewdnr jrcur_in_whlcJi_fiueh_casatl^>n__occurs>;J____ii___^_______ wncFCLUA* un zmnua aoicux. (Registrar) m OiJftjA Strno* 3. EFFECTIVE DATES OF INSURANCE. effective J.ue of such Employee's Personal Surgical --An Employee msy become insured Wcrvuiidct fm Opet .moil In mu.-i me hereunder. whichever date is laier. Personal Surgical Operation Insurance only by making Tiie Dependent Surgical Operation Insurance on any written request to the Employer for tuch insurance on Employee who makes tuch request after the date of his forms furnished by the Insurance Company. The eligibility for tuch insurance and on or before the Personal Surgical Operation Insurance on any Employee thirty-first day following the date of hu eligibility for who makes such request on or before the date of his eligibility for such insurance shall become eifeenve on such insurance or on or before the thirty-first day following the date of his return to active work if he is the date of his eligibility for tuch insurance, provided not actively at work on the date of hu eligibility for XX.................................................... X........a..u...c..h... insurance, shall become effective with respect to X_____________________________X............................. X........t.h..o...s..e.. persons who are then Dependents of such X........................................... ........X...... ....... ............. X........E...m...p..l'oyee, on thex_*............................... .... ..... he is aenveiy at work on the date of his eligibility. The .................x.......................... x......... ..................x........ ........ Personal Surgical Operation Insurance on any Employee date of such request or on the effeenve date of the who makes tuch request after the date of bis eligibility Employee's Personal Surgical Operation Insurance here for such insurance and on or before the thirty-first under. whichever date it later. Any Employee making day followmc the date of hit eligibility for such insur auch request after such thiny-firtt day and any Em ance. or on or before the thirty-first day following the ployee requesting reinstatement of his Dependent date of his return to active work if he is not actively Surgical Operation Insurance hereunder after hit De at work on the date of his eligibility for such insurance, pendent Surgical Operation Insurance hereunder has shall become effeenve, provided he it then aenveiy at been discontinued in accordance with subdivision (c) wotk, on the*.................................................... _*.............. of Section 5 hereof, must furnish at hu own expense xx.................................... ............x.....e..v..i.d..e..nce tatufaetory to the Insurance Company of the __________x_______________ x............................x.............. good health of each person who is a Dependent of date of such request. Any Employee making tuch tuch Employee on the date of such request before the requett for Personal Surgical Operation Insurance after Dependent Surgical Operation Insurance with tespeet such thirty-first day and any Employee requesting to any such Dependant shall become effective. Such reinstatement of his Personal Surgical Operation Inaur- Dependent Surgical Operation Insurance shall become a nee after his Personal Surgical Operation Insurance effeenve with respect to each such Dependent whose hereunder has been dueonnnued in accordance with evidence of good health is accepted by the Insurance tubdiviaion (c) of Section 5 hereof, must furnish at his Company as satisfactory, on the....... ........ ...* own expense evidence of his insurability satisfactory to .............x...........................x___ _____________ x..... ......... th* Insurance Company before he may be insured x ... ...........x ...................... . dare of such hereunder. Any tuch insurance shall heroine effective, actcpiaiKr by the Insurance Company or mi the effec provided such Employee is then actively at wnrk, mi tive thin- of ilie Employee's Personal Surgical Operation the.____ *.................. ............* .............. x.. Imurame lietemslcr, wliielicvcr date is later. In the X............................... ..............x..........................x . e. v. ent that the evidence of good health of any tuch date the Insurance Company acrcrt* satisfactory person n not atn-pusl by ilie insurance Company as such evidence of tnsuraWhty. Tlic rctwmal Surgical saiisfat loiy, sts h is.-rs.Mi shall niM, for the |Mirpoevs of Operation Insurarvc on any Employee me actively at iiiMiraiuc hereunder, Ik deemed a Dependent and no work on the date when his Personal Surgical Operation Dependent Surgical O|viaiiott Insurance shall be pro Insurance hereunder would otherwise become effective vided hereunder with rc|s*t to auch person. shall become effective on the next following_______ __ -------------------- tex---------------------- The Dependent Surgical Operation Insurance with respect to any parson who becomes a Dependent of an Employee while auch Employee is insured for Depend __ which he k actively at work. ent Surgical Operation Insurance hereunder shall An Employee may knot hooted hereunder for become effective on the dan auch person becomes a Dependent Surgical Operation Insurance only by mak- Dependent of such Employee. ing wrlncn request to the Employet far both Personal Siennas 4- EMPLOYEES' CONTnmUTlONS.-- Surgical Operation lnatsranrc and Dependent Surgical No Employee insured hereunder may contribute to Operation Iroutenee hereondcr usi firma furnished by the cum of hia Surgiral Operation Insurance mure the Insurance Company. The Dependent Sumaral than the nusaimiun amount specified In Section 6 hereof Operation Insurance on any Employee who make* such in accordance with the frnonal Surgical Operation request on or before the date of hit eligibility far tuch Insurance and Dependent Surgical Operation Insur Insurance shall become effective with tespeet to those ance. if any, its ferae hereunder on hia account. persona who are then Dependents of tuch Employee, on Sacrum 5. CESSATION OF INSURANCE.--(a) the dan of hia eligibility (or such insurance or on the The Personal Surgical Operation Insurance and De. FomG&F. 6303 March 1942 eoaoimnoat sour <J * u pendent Surpeal Operation Insurance on inr Em ployee insurad Reminder shall automatically cease on the date ofthe termination of his employment. Tominetion of employment, for the purpose! of the Surpeal Operation insurance hereunder, mean* emmnon of active work a* an Employee a* defined in Section 1 hereof, except that (l) in css* of the abtence nf an Employee from active work because of sickness or miury, hi> employ* mem may, for the purposes of hi* Surgical Opera* non Imuranee hereunder, be deemed to continue until terminated by the Employe*, or (fi) in caae of the abaence of on Employee from active work beeauae of temporary lay-off, hi* employ* mem may, for the purpemes of hi* Surpeal Opera* non Inturance hereunder, be deemed to continue until termmeted by the Employer but In no caae beyond theS___ _5__________________ ___ X x uch lay-off commenced In the caae of cither of the above cxcepnons, the Per* aons! Surgical Operation Insurance end Dependent Surpeal Operation Insurance hereunder on such Em* ployce ahall automatically ceaae on the date of such termination of hi* employment by the Employer, a* evidenced to the Insurance Company by the Employer, whether by notthe*I ion or by cessation of premium payment on account of such Employee'* insurance hereunder, (I) The Persons! Surpeal Operation Inauranet hero* under on any Employee ahail automatically ceaae on the date he becomes entitled to the Maximum Surgical Operation Benefit applicable to him. The Personal Surpeal Operation Insurance hereunder on any such Employee may be reinstated only if and whan ha returns to active work for the Employer on full time. An Employee'! Dependent Surgical Operation iiwut* anet hereunder wuh respect to any Drpendent (hall automatically erase on the date the Employee heeomc* entitled to the Maximum Surgical Operation Benefit applicable to auch Dependent. The Employee's Do* pendent Surgical Operation Inauranca hereunder with respect to auch Dependent may be rasnasated only upon recovery of the Depcndcoe firm the lajaty or ncbiscaa which nictmirated auch surgical operation, and only provided the totonal Surgical Operation Insurance hereunder on auch Employee is than m lame. (e) If any Employee hmirad Hmaundcr far only Personal Surgical Operation Insurance dial! notify tho Employer that his Panonal Surgical Operation Insur* ante haraundtr h m be discontinued, such Insurance Pern OSJ. 003 March IMS shall automatically cum on the such notice of discontinuance is received by the Em ployer. If any Employee insured hereunder for both Personal Surgical Operation Insurance and Dependent Suruicsl Operation Insurance shall notify the Employer that either (i) hi* Personal Surgical Operation Iruutsnce hereunder, or (H) his Personal Surgical Operation Insur* anee and Dependent Surgical Operation Insurance here* under is to be discontinued, then both his Personal Surgical Operation Insurance and Dependent Surgical Operation Insurance hereunder (hail auteniancally Cease on the dote * such notice of discontinuance is received by the Employer. If sny Employee insured hereunder for both Persona! Surgical Operation Insurance and Dependent Surgical Opera tion Insurance ahail notify the Employer that only his Dependent Surgical Operation Insurance hereunder is to be discontinued, hia.-EES235i.l.'i'5i.9.*1.---------- JMVL&SSS Dependent Surgical Operation Inauranca hereunder, shall automatically cease on the date ______________ such notice of discontinuance is received by the Employer. Failure of any Employee so make contribution when due, at required by the Employer, to the coat of either hia Personal Surgical Operation Insurance hereunder or his Dependent Surgical Operation Insurance hereunder shall have the same effect at notice to the Employer, within the meaning of the preceding paragraph, that the insurance (or which auch Employee has failed to make contribution is to be discontinued. () An Employee's Dependent Surgical Operation Inauranca hereunder with respect to any Dependent shall automaticalty cease on the day immediately pre ceding the date such person ceases w be a Dependent of such Employee, e defined la Section 1 hereof. (t) la any event all insurance hereunder shall automatically ceaae immediately upon the diacanrinu* of this Supplementary Agreement or of mid (F) for the purpose of tho provlnlona of ub- arcU-aa, *of *r B^yeg:Kfa8^,:rsg^,^M^^gl5g^y Hu th. femtnuno. nnVl niimaallcally S<*13C " the .*** ruccdlnf. the date the hnployee bueo-.ee dibble or any euv.-m/r under *? Ib-nJth Tittiuruneu fr.r l,. A,.,i i.ruvlclanu nr Usn Unltml .'ituf; imuriuy Aet. An N|.liyv- `a 1 JJ.,r,U eui j i Ui rvuivet be uwy ttrmuotonfc dwll,e luii ` m- M Uw tiuy lived1 nyihfPMudln.' Utt uuw.^ ueh Dependent bccooea eligible mmst under the Health Xnaurtwee,. er M ,,, s ,, j m. rP be r *w f * * * * . w Stsnew i. AMOUNT OP INSURANCE.--'The amount of Personal Optfitlmi Insurance or Perianal Suisteal Operation Insurance and Dependent Sutuka) Operation lruurance applicable to any Employee (halt ba In eceoedanct with the achaduk act forth below and any Incrcaac x_______ ____x....... ... ......x_.......... te the amounts of such tiuunno. in accordance with aald schedule, shall become elective. provided cite Employee ia than aedveiy u work, an k - * * x ______xx______________ ___ ___ y V ................ X . - - -r-____________ ____ X . ____ xx_____ , tf such Employe* is men than aedvely at work, aueh eharv* In the amounts of Insurance ihall become tfcttln on the neat m--tnf dnv --___________________________________________________ ...... -I .i --... --I. X ... ................................. X -...... ............. -on which ha ia actively at work X XX XX XX X SCHEDULE OP INSURANCE. EMPLOYEES* MAXIMUM CONTRIBUTIONS. AND PREMIUM RATES SCHOULE OF DJSURANCE AND SXPL0TES5' MAXIMUM CONTRIBUTIONS Clasa Surgical Operation Insurance Maxlg.ua Benefit Dependent Personal Insurance Insurance Each Dependent All fcployees $600.00 $600.00 The asoust which an Ssployee may contribute to the coat of the Insurance shall not ex ceed the premium charged for the amounts of hit Insurance. Initial Monthly Premium Rate per Employee: Clasa All Employees fenoO&r.tMl Match IMS fUfflBPf UflJh 5 tmmaunnma* v-y SsertoM 7. INSURtWC CLAUSE.--Upon receipt if notice snd satisfactory proof, u required herein, hit any Employee, while insured lor Personal Surgical operation Insurance hereunder, or say Dependent of n Employee, while such Employee is insured for )cpendent Surreal Operation Insurance hereunder, hall have undercone any surcical operation specified n Section 9 hereof, as s result of: I A) any in.lury not arising out of or lnr_the course of any employment for wage or profit, or *T3 any tlcltness not entitling hla to " benefits under"any workmen's~ cocipeosatlon or" occupational "disease Law, rf,,lhc,,jregnnncy existed__ on the effec tive date of the Surgi cal Opera cl on_____ Insurance on account of such Dependent. Benefits hereunder ore not payable for a*nyJc^r^rl_c.ec vnleh, la ae'eordanee"~th I awe"or" reiul ation e~o?"nny~governai cnt, arc"o'r`m'iry`''B<r"l)uui'i'ncS''vrtHou'i~"co'si or"*' iT i'"rc2uce2"coot to a prson"cov*cre3 fTereua'der, exfcpfts provl'dugnBy'XR'e he Insurance Company shall pay such Employee, ubj'cct to the terms and limitations hereof, for the etual surcical fee charted for such surgical operation, eludes the Federal, State. Provincial or local" government or any. JoliticaL.au.b-... division thereof, of the Uni ted-States,. rovided (1) that such surgical operation was rteom* arJ*fccaAft.i icnded and performed by a physician or surccon tgally licensed to practice medicine, and (2) that the mount of such payment shall ia no event exceed the ___________ LnS.lny_^5!LZSXSE..JilAfii-- mount specified for such surgical operation in the Alt benefits provided in this Supplementary Agree* ichcdule ia Section 9 hereof applicable to the Employed mem will be paid to the Employe* immediately after r Dependent who has undercone such operation, as receipt of due proof. .etermiaed by Section 6 hereof. Tf_.lva-Or aaro xurglenl op-~s*fnns poclfled In Section 9 hereof are per orated upon on Bnployee or Dependent .urlng any one continuous period of dls- blllty. whether froa one or more causes, :r are performed during successive lerlods of disability'due to the some StCTioir 1 SURCICAL OPERATION PERFORMED AFTER CESSATION OF INSURANCE. --If an Employee, or a Dependent of an Employe* who is insured hereunder lor Dependent Surgical Operation Insurance at the dale of the cessation of the Surgical Operation Insurance on his sccount, is totally disabled as s mult ol injury or sickness and, while still to totally >r related eouse or causes, the "total disabled and withinK!.^r.?J!*.?.l?J?3y.5^.aftcr such laywent hereunder for all such opera- cessation, undergoes any surgical operation specified Ion6 shall not exceed the Maximum m Section 9 hereof, such Employer shall be entitled to urglcal Operation Bi-ncflt In foreo whatever benefits would have been payable hereunder ereunder ob isocount of such Bnployeo in consequence of such surgical operation had such r Dependent "who has undergone such Surgical Operation Insurance been in force on the date perations, as determined by Section 6" ereof. of such operation. If a female Eaployeo or Dependent lo pregnant n't" the date of the cessation Bo payment shall fee node hereunder for of the Insurance hereunder on her account ny surgical operation performed on an aployee which Is duo to promoney or esu I ting childbirth or aaamllcatlons f the pregnancy nlitil'ssths affoeivo date of the ftreloy--* luralctl and, no a result of such pregnancy and within nlmonths aftar aueft cossatlooT" undergoes say surgical operation spec1fltd in Section 9 hereof, the topioyoo ohall bo entitled to whatever benefits deration Insurance. wouli 'hawe been payahio kereuojier In consequence of ouen surgical operation Bo payment shall be mode hereunder for ay surgical operatloo performed on a hnd sucii Insurance bccn ln force on the date of such surgical operation. enendent vhleb is duo to weaaney or esultlng childbirth or complications Form G.S.F. 6303 March I9C mime m tuu. 7 StcnoM . MAXIMUM PAYMENTS FOR SURGICAL OPERATIONS--The (mount / payment tor any oparation (hall not acted the amount ipeoAcd (or tuch (urped operanan in the Schedule herein applicable to the Employee or Dependent who undergoo luch operation. orschedule surgical opsutiohs (Other Than Radiation Therapy) The maximum payment for any surgical operation aot (pacified in the following ehedule or for nay multi-stage operation, ahall ho detereviaed by tho Zaauroace Coapaay oa the baeie of tbo sorority of the type of operation, la sa aaouat consisteat with the maximum payments for operations listed. Zf soro than ens operation la performed at tbs sase operative session la tbo same operative field by tbe seas surgical team, the total payment for all such operations shall aot txeaed tbe maximum payment for tbat aae of sueb operation# for vbleb tbe largest amount Is payable. Zf more tbea one operation is performed st tbe seme operative session in separate operative fields by tbe ssat surgical teas, and through separate Incisions, tbe total payment for all sueb operations shall not exceed the maximum payment for tbat one of sueb operations for vbleb the largest amount Is payable, plus of the maxima payment for each of tbe ether operations, unless otherwise speeifled in tbs sebadule. Zf bilateral similar operations are performed at tba some operative session in separate operative fields, tbe total payment for both operations shall not exceed 150 of tbe maximum payment for tbe single operation, unless otherwise speeifled la tbe schedule. In no event, however, shall tbe maximum payment determined In mesordenee with any of tbe paragraph* Immediately preceding exceed tbe Maximum Surgical Operatioa Benefit in force hereunder cm eceount of tbe Employee or Pependent vbo bos undergone aueb operations. Surgical Operation CARDIOVASCULAR SYSTEM . Commissurotomy or valvulotoagr, mitral....................................... Aortle, pulmonic, or tricuspid.................................. .............................. Cardiotomy or pericardiotomy vith exploration, drainage, or removal of foreign body.................................................................... Arterletomy, simple, vltb oxploration or removal of embolism Zntratboraels ear iatre-abdomianl....................... .......................... .. Neck...................... .................................................. .. Extremities. ........................................................................ .......... . Veins Ligation and division off long saphenous vein nt eephemofemorml Junction, uith or without retrograde injection, or distal Interruptions Unilateral........ .................................. ............ .. Schedule Applicable to Employees and Pependenta Faymant 4510.00 600.00 1*20.00 330.00 2UO.OO 160.00 90.00 150.00 Fern CAF. SMI Match 1942 raiwTsejMiMke. 1500 Applicable to Employees Whose Maximus Surgical Operation Insurance Benefit Is 1600.00 Smtww t. MAXIMUM PAYMENTS FOR SURGICAL OPERATIONS--C~tim*'4 Surgical Operation abedula Applicable to Employees end Dependents Maximum Payment ' CARDIOVASCULAR SISTEM - (Coot'4) Vains - (Coat'd) Ligatioo and dlrlalon of abort aaphaaous rein at oapba&opopliteal Junction (independent procedure).................. Ligation and dlvlaion and eoapleta atripping Long or abort eapbenouo veins Unilateral........................... ....................................................... Bilateral.................................................... Long and abort aapbeooua reina Unilateral........................................................................ Bilateral.............................................. Injection of acleroaing solution, eaeb treatment (not nore than fire)........................................... ................. '.............. * 60.00 120.00 210.00 168.00 2UO.OO 12.00 DIGESTIVE STSTB4 Appendectomy (independent procedure).. Cholecystectomy.............. ................... ................................ Vith open exploration of aoanoc duet................. Colectomy Partial, vith nnnatomoala, vith or without eolootomy........ For malignant tumor vith regional lymph node diaaeotlon. Oectreetomy Total, for itoligncnoy vith roglonol lymph node diaacctioo.... Subtotal, vith or vlthout vagotomy........................................... .. Oeatroeaterostoay............................. ............. Enterectomy: reacetlen of email iAteatlna vith anaatomoale or entaroatomy.......... Tonsillectomy, vith or vlthout edenoideoto^r Age 1U or over.................................. Under age lh. Esophogoeeopy Diagnostic.................................... .................................................................. with biopsy, add........................................... ........................ with remoral of forelpi body or excision of tumor............ - Oaatrooeopy Dlngnootie, vith or vlthout biopsy................................. Proctosigmoidoscopy, dlajpostl* Initial..................... .................................................................................................. Subsequent...... Bamorrhoidectcmy (vith or vlthout flasurecto^r, vith or vlthout ophluotorotomar) External, ainglo......................................... Rultlpli, OOOpiOtO....................................... Internal, or internal and oxtomal............................................ Radical (Bulo or VhltohaoA)........ ................ . 180.00 2U0.00 300.00 330.00 600.00 600.00 330.00 2UO.OO 300.00 90.00 60.00 *.60.00 21 00 102.00 60.00 12.00 12.00 *8.00 61.00 120.00 100.00 FeonC.S-F.SJOJ March 1X2 ruimiwi *500 Sccrraw 9. MAXIMUM PAYMENTS FOR SURGICAL OPERATIONS^-C..''.<^ Surgical Operation .DIGESTIVE SYSTEM - (Cont`d> Enucleation or xelaloa of external throabotle teaerrbold...< Fistulotomy or flstulecto^ GubauieuitfitntxK................................ ............... ............................ ............. .................................................................................................................. ...................................................... ............ Coop lets proetectoagr, combined ebdaalneperlaaal, oea or two stages.............. ............................................ Schedule Applicable to Employees sad Dependents Hatimun Payaeat $ 12,00 160.00 42.00 420.00 JSOXKROfE SYSTEM Thyroidectomy Total or subtotal for mnllgnaacy with radical seek dissection. Subtotal or partial, benign condition. Total thyroid lobcetouy, unilateral............................ local excision of snail cyst or cdcaeoa of thyroid...**' HEMIC AND LYMPHATIC SYSTSMS Splenectomy.............................................. ...................... ...................... Biopsy or exelalon of lymph node (independent procedure), except anterior scalene...................................... .......................... SfTECUKZPiTANY SYSTEM (Skis, Subcutaneous, Areolar Tissues, Breast) Skin and subcutaneous tissue Incision and drainage, eysts (up to 5), earbmele or abaeess................................ ....................................... Excision of pilonidal cyst or ........................... .. Exolslon (including slapis repair) of histologically verified malignant neoplasas Trunk, arms or legs Dlasetcr up to 3A laeh............ Bsad, Beck, hands, fset or sealtals Disaster 1/2 Inch or less............................. .. Pinaster over 1/2 inch but lees than 3A lnh.......... . Eyelids, lips or nueeus acabraas Dloaeter 1/2 inch or less*............... .. Disaster over X/2 lash bat lass'than 3A lank................. Breast Excision, bealfa tuners (other thoa superficial), say ^rpe Unilateral.*.......... Bilateral. Mastectomy, complete (slspla).............. .............................................. Partial, unilateral............ ................................... vmmm* bilateral.... Radical for malignancy, laaludiag pectoral aneclas sad axillary lyaph aodes.......... 420.00 270.00 210.00 180.00 240,00 24.00 12.00 120.00 42.00 60.00 84.00 64.00 102.00 72.00 106.00 120.00 73*00 106.00 360.00 0 /&! Pwm6^.P.30a March 1942 nnmwvsA $900 Stemm . MAXIKuIz^PAWEKTS FOR StmCIOU. OPERATION*^- Surgical Operation ICJSCULQSKELETAL 8T3UM Ron** Osteoplasty Shortening of boat Fesur, tibia or huaoru*........................................................................ Radius or ulna.......................................................... Radical retention of bon* for tuaor with boa* graft Large bon*................................................................................. .......................... Snail bona.......................................................................... Sxeisloa of boo* spat, ehaadroaa or axastosis Large bone*................ ................. .. Snell boa**... Pisloeationa Closed reduction, slaple Shoulder.............................. .................................................................................. Elbow........................................................................................................................ Finger or thuab............................................................................... .. Hip............................................................................. ............................................ Knee (except patella)......................................... ....................................... .. Patella. ..................... .. .................... ........... .. Open reduction, simple or eeapeund Shoulder or elbow (fresh).................................. .. Hip........................................................................ ..................................... ............. Knee (except patella)........................................................................ Patella.......................................... ................. .. Fractures Closed reduction Other than chip or avulsion fractures Clavicle, slaple, eg* 14 or ever.................................... ............... Under age 14........................................................... Rib or rlbe, sleple, strapping................. ............. .......................... Humerus Surgical nsak, requiring aonlpulatloo................. ............. .. Shaft, slaple, aga 14 or .................................................... .. Under ags 14........ .......... .......... . Elbow, involving 2 or 3 boons, simple, sgs 14 or ovar.... Uodsr ago 14...... Radius, bead, Immobilisation only........ Radius, shaft, with or without manipulation Ago 14 or soar.......... ................................ . Undor sgs $*...................... Ulna, shaft/^Ml or without manipulation Undor age 14..**.....**.*.**...****.. gebedule Applicable to Employees and Dependents Maximus Payment $420.00 270.00 420.00 270.00 210.00 132.00 72.00 46.00 24.00 150.00 46.00 30.00 210.00 300.00 240.00 150.00 72.00 46.00 24.00 132.00 162.00 100.00 162.00 106.00 48.00 72.00 48.00 $4.00 36.00 Fern OS.F. *303 March 1942 roiwroiN coa 8 8500 . &CTM* 9. MAXIMUM PAYUSKTS FOR SURGICAL oreRATJOK&--dWWrf urgieal Operation KUSCVLOSXEUETAL SI5TEM - (Cont'd) Fractures - Closed reduction - (Cont'd) Radius and ulna, shafts, requiring naolpuletlOQ Age lb or over........................... ............... ...................................... Under ago lb................................................. .. Metacarpal, one, immobilisation only Age lb or over............................................... ................... ................. Under age lb................................................. ............................................ For each additional metacarpal, add................... .. Phalanx or phalanges, one finger or thumb, immobilisation only......................... ......................................... .. For each additional finger, add............................ Pelvis (except saenm), slapis, single............................. .. Complicated or sultlple........................................ .. Femur, simple, neeX or shaft, including supracondylar Age lb or over..................................................................... ................... Under age lb................................................................... femur, intertrochanteric, slaple, roduetion with fixation Age lb or over........................................................................... .. Under age lb........................................................ ................................... Patella, simple, lsnobllltatlon only................................. .. Tibia, shaft, a lapis, inoblllxatloa only Age lb or over..................................... ..................................... Under age lb............................ .. Fibula, shaft, elaple.................................. ........................................... Tibia and fibula, shafts, age lb or over.................................... Under ago lb............................ Ankle, blmalleolar or trimalleolar (laeluding Potts) Slmpl*......................... ............................ .......................... Tarsal, simple One (except astragalus and os oalelo)..................... Astragalus or os calcla............................................ Phalanx or phalanges, one too, oi^lo/ except groat ton.* Great toe......................................................................................... For each additional too, add......................... ........................ For debridement of any compound fracture- add 1/3 of the amount for eloeed reduction Insertion of Klrehacr wire nr natal pin# for traetloo or east fixation, add.... Chip or evulsion freoturea...................... Open reduction (except chip or evulsion freoturea) Pelvis (easapt aacrun), ana or none hones lapis sv astound.. teens* alanlo or sonsound.... Bunerua, shaft or nook, slaplo or eonpound................. Radius, hoed, slaplo or eonpound...i........................ debedule Applicable to Eaploysss ___and Dependent. Marinim Paymsat $160.00 76.00 36.00 2b. 00 6.00 2b. 00 12.00 120.00 210.00 2b0.00 lbb.00 30c.00 210.00 bS.OO lbb.00 72.00 bd.00 192.00 120.00 lbb.00 bS.OO 72.00 16.00 2b.00 12.00 2b.00 16.00 390.00 180.00 210.00 166.00 Form G.S.F. dJfll ' Msrch 1942 PUMTCSIM MiA s 6900 Sktiow *. MAXIMUM PAYMENTS ?0R SURGICAL OPZRAnOK&--C*''`* iurgleal Operation Schedule Applicable to Employee* and Pcocndents ___ Hatiana Payaaat OISCULOSKEISTAL SY8TTX - (Coat'd) Rraetures - Open reduction - (Coat'd) feaur, neck, alspla or compound, vlth internal fixation*... Feaur, shaft, staple or coapound, Age lb or over....................... Under age lb.................. Tibia, shaft, staple or eo^ound, Age lb or ever..................... Joints Under age lb................. Excision: Intervertebral disk vith spinal fusion................................. Semilunar cartilage of knoe Joint......... .......................................... gynoveetouy Wrist.................................................................................................................. finger or thumb, iaterphalaageal Joint............... for each additional, add...................... Sip....................................................................................................................... Knee............................ Canglioneetomy of wrist or hand........................................ Arthrotooy or capaulotooy with exploration, drainage, or removal of loose body Elbow or ankle................................... Shoulder or taaee..................... Arthroplasty Shoulder........................................... Elbow, wrist or ankle............................... Sip or knee........................................ Radical bunion operation vlth aatatarsal osteotoay Unilateral.,.. V........................................................................................... Bilateral.............................................................. Arthrodesis wrist....................................................................................................................... .................................................................................................... Knee.......................................................................................................................... Hammer toe One toe, exeept great to*................ .. Great toe, iaterphalaageal Joint................. for eaeh additional tee, add... Museles or Tendon# Muscle biopsy Superficial......................................................................... .. Deep............ ......................................................................................... . Tendons ZnclslOB Eip adduotors, epan, mllateral.................. Bilateral............................. Sever (or siadlar} procedure of the shoulder for Xrb's paley. $360.00 300.00 180.00 2b0.00 180.00 510-00 210.00 210.00 73*00 36.00 390.00 2U0.Q0 72.00 162.00 210.00 330.00 300.00 bSO.OO 270.00 ,, wo.oo 330.00 60.00 120.00 2b.00 18.00 30.00 106.00 lbb.00 300.00 Pena G.S.P. 6303 Match 1942 rsiNTeeiw vaa P 8500 TO SurtttH . MAXIMUM PAYMZNTS >OR SURGICAL OPHCvnONS^-C*-'--'* ffieal Operation Schedule Applicable to Employees and Dependents ISCULOSXELCTAL SYSTEM - (Coat'd) Muscles or Tcodoaa - (Coat'd) Excision Paseiotomy or fasclectomy for Dupuytrea's coatraotur* (open) Partial......................................................................................................... Radical................................. Repair or sutoire of extensor trying, single, forearm, leg, band or foot............................................... ................................. Each additional Poreara or !(.......................................... ................................. hot".................................. Spine Spinal fusion 2 vertebrae............. 3-7 vertobrao........................................ 6-15 vertebras, one or two atogas...................................... .. Coeeygectoay.................................................................................... HTVOUS SYSTEM Peripheral nerves Excision of histologically confirmed neuroma of the hand or foot Cutaneous................................................ .. Interdigital, ona.................................. Por eaeh additional, add................. ................... .. Stoefel'e neurectomy..................... ................... .. Sympathectomy Cervicotboracle (Smitbvieke type, eupra-end infradiaphragmatic) Unilateral............ ............... Bilateral, eoneemltaat or delayed............... Lumbar, unilateral....................................................................... .. Bilateral.................................... Brain and Spinal Cord Craniotomy, onteoplnstie, ter excision of brain tumor, abscess, or eyst, supratentorial.................... .............. Craniotomy, suboceipltal for brain turner......................... .. Craniotomy, tor doprmsood skull fracture............... With debridement Ot brain and repair Ot dutea.............. Burr holes with eentrlaulecraphgr.* Inniasctomgr for deeeqpreesiaa tf tbs epinal eord aad errs root*........*...*. OlUL.OO 330.00 72.00 T2.00 48.00 au.oo 330.00 400.00 600.00 96.00 30.00 60.00 6.00 160.00 300.00 420.00 240.00 300.00 940.00 600.00 330.00 420.00 64.00 460.00 PsnnC3.P.<309 Match 1942 nmawaui 6900 Scctiom 9. MAXIMUM PAYMENTS FOR SURGICAL OPERA*nONS^-Cs<"*4 Surgleal Operation Schedule Applicable to Employesa _ end Dependent* Maximum Payment ~~ RSSPDUTORT STSTEH Cheat Lobectomy or pneumoneetomy.................. ............ .. $1*20.00 Wedge rejection, Ingle or multiple........................................................ 330.00 Thoracotomy, with open drainage or empyema cavity by rib rejection (independent procedure)......................... Soee and Throat 163.00 Removal of naaal polyp, oae or more, unilateral or bilateral. 30.00 Frontal alnuootomy, external, almple (trephine operation).... Si*.00 Radical, obliterative, unilateral or bilateral.... Antrctomy, intranaaal Unilateral.................................. ..................... ................................... ............... 240.00 60.00 Bilateral............................................................................................... 102.00 Masai septus, submucous refaction............................ .. ' 120.00 With grafts................................................ 180.00 Bronchoscopy Diagnostic.............................................. 60.90 With biopsy, add............... 24.00 With removal of foreign body or excision of tumor... .............. 102.00 Laryngoaeopy, direct Diagnostic, independent procedure.. ............ .. 42,00 With biopsy, add............ 16.00 With removal of foreign body.........84.00 SPECIAL SENSE GROANS Bar Mastoidectomy, simple........................................ 23.0.00 Radical.300.00 8tapedectony, vltb or vlthout vela graft.................. 420.00 Ryv Cataract Discission: needling of lane Initial.............................................................................................................. 04.00 Subsequent................................................ 42.00 Extraction of lens, any type, unilateral......... 330.OO Excision of pterygium....<< 102.00 Reettaehmcnt of rotlae Electroeoagulatlom, melon! resection, Buokllng or partial tubing..... .............. 420.00 light coagulation, euparconic or any other extra oeular method.................................. Ocular mueeleoi any 9p* opentlco Involving erne sr 168.00 more muselee la emo ar Both eyee daoe la one stage........... . ako.oo Corneal transplant........................ 1*0.00 Perm G.S.F. 410J March 1942 Nimsia uaa. i dsoo S*ctjoh 9. MAXIMUM PAYMENTS FOR SURGICAL OPERATIONS^--C*n.,r* Surgical Operation Schedule Applicable to Employees end Dependent* MitIhb Fsymeat UROGENITAL SYSTEM Female Genital Repair of eystocele, vlth or vltbout urethrocele........................... Repair of eystocele and rectoccle, with perlaeoplssty, with or without repair of urethrocele...................... ...................... Repair of reetocele, independent procedure........................................ Salpingectomy, oophorectomy, or ealpingo-ooptaorectomy, complete or partial, unilateral or bilateral, ladepeadant procedure...................................... ..................................................................... Hysterectomy (with or without removal of tubea, with or without removal of ovarlea) Total, vaginal or abdominal............................. ................................ .. Supracervical or subtotal.......................................................... .. Radical for mnllsnont tumor with regional lymph node dlaacetlon........................................ ...................................................... .. Vlth removal of bladder and ureteral transplant................ Vlth reetal reaeetloa, with or without removal of bladder and ureteral transplant.............................................. Amputation of cervix (independent procedure).......................... Dilation and curettage (non-puerperal) (ladepeadant procedure).................................................................... .. Vlth local excision of lesion of cervix, or cauteri cation......................................................................................... Delivery of child or children.............................................................. Caesarean Section, including delivery, or abdaoinnl operctioa for extra-uterine pregnancy.......................... Miscarriage................................................................................................. Male Genital Clrcuaelsien Clamp or dorsal slit.......................................... ............................ Other than clomp or dorsal slit Age 14 or older............................. ............................................................ Under ago 14............................... ...................................................... Orchiectomy, simple, unilateral............................................................... Bilateral.................................................... Excision of varleoeele, hydrocele, car spermatocele, independent procedure........ ............ ............ .............................. Prostatectomy, with or without vasectomy............................ .. Urinary Cystotomy or BjfUtestnmy with drainage or removal of calculus. Vlth fulguratlgh, odd............................................................... nephrectomy, lernlgdlag pertlal ureterectomy through seme -t------------------- Vlth total ureterostomy, two Incisions, add............................ Cystoscopy, diagnostic Initial (ladepeadant procedure)................................................... Subsequent, within 30 days....................... ....... Vlth ureteral catheterisation, unilateral or bill add Vlth blppsy of Bladder, odd...................... * 1150.00 210.00 120.00 lSO.OO 2U0.00 210.00 420.00 430.00 600.00 84.00 60.00 72.00 125-00 250.00 62.50 12.00 42.00 30.00 84.00 102.00 120.00 330.00 210.00 90.00 330.00 90.00 30.00 l' .:o 12. CO e .:o Fsrei G.5.F. 630! March 190 rsiirrtsiwuaju 2 $90P /0/i v.V. ScrrtOM 9. MAXIMUM PAYMENTS FOR -SURGICAL OPZRATIONS--C#<;.,W rgicol Operation BUTTONS MOT ASSOCIATED WITH A SINGLE SYSTEM Beploretexy Itpcoteqr or edletany............................................. .. Hamit Hiatus or diaphragmatic.................................................................... Herniotomy, Inguinal, unilateral.......................... Bilateral................................................... Farteentoala.....*............... Schedule Applicable to Ebiployces tad Dependents Marlmum Payment $ 168.00 150.00 210.00 18.00 SCHHWLE OF RADZAXION THHIAFY Tor the purposes of Surgical Operation Insurance hereunder, Xrty, radium, cobalt, nd radioactive Isotope therapy shall be deemed surgical operations and toy benefits herefor aiiall be subject to the terns and limitations applicable to benefits for ur ictj. operations; but no benefits shall be payable hereunder for any charges mode by a oapital or other Institution for services In connection vltb such therapy. The maximum payment for any X-ray, radium, eohalt, or radioactive isotope therapy ot specified In the following schedule shall be determined by the Insurance Company li^ a amount consistent vlth the maximum payments for therapies listed. The amounts sped* led are the maximum payments far the treatments shown, including dosage calculate ns nd use of facilities. Schedule Applicable to Employeas rcatment end Dependents Payment -RAY AMD RADIUM THERAPY All treatment (except concealtoot surgical procedures) and retreatment vlthln a period of 12 eonsceutlvo months for the following conditions (subject to the maximum per treatment below): Histologically verified malignancies Skin, 1 eentlaetar diameter or less........................ .. Over 1 centimeter diameter................................ Other soft tissue end bone STeast (except postaasteetaqr).........................' Postmastectcegr....................................... Zntra-abdoalnal and Intrnthomele..< Head and neck... Central norvoua eyetan.. Benign TUmore.#. Per Treatment X-ray (500 XVF or Bee*) Histologically verified malignancies....................... Benign ............................................ ....................................... ............................ . Surface application at railmi or other scaled radioactive source.*....... X-rey (over 500 m), eohalt, radius.............. .................... 160.00 120.00 2U0.00 168.00 21*0.00 330.00 300.00 42.00 12.00 e.i*o 12.00 18.00 300.00 Penn G.&P. dJOJ March 1942 seiMTseisi voe 8500 /?/ Stem* 9. MAXIMUM PAYMENTS "TOR. SURGICAL OPERATIONS___fii, 4 reatment ADIOXCriVE ISOTOPE TME3UPI All treatment (except concomitant surgical procedures) and retreatment vithia a period of IS eoasecutlre swaths tor: Hyperthyroidism...... .............. Thyroid suppression (cardiac).............................. Interstitial or Intracavitary therapy with radioactive colloids Radioactive gold............................................................. Rodloaetlvo phosphorus........................................ All treatment (except coaccmitaat surgical procedures) and retreatment vithla a period of 3 consecutive months fori Polycythemia vera.......................................... Chronic leukemia.................................... Schedule ^ppldcable to Baployeoa and Dependent! Ham a in gaynaat""1"'" $210.00 210.00 120.00 64.00 42.00 42.00 If Surgical Operation Insurance Benefits are paid bereuader for a surgical operation performed outaids of a legally constituted hospital vfalls Hospital Zbepease Insurance inder the Croup Pollqr Is la force on account of the person who underwent such operation, the Insurance Company shall pay, in addition to the payments otherwise provided, the mount of the aotual expense, if any, charged for a general anesthesia and the adalniitratloa thereof la connection vlth such operation 19 to a marl win of $10. Penn G.5.P- 4304 March 1942 isinniwtiaa Secno*. 10. NOTICE AND I*KOOF OF CLAIMS, (a) Written nonet of surgical optfltmi no which claim may be baaed must be given to the Insurance Company wuhi .tugnty h* tfier the dare of tuch operation. Pmnf of tuch turret! opera- lion mutt bo furnished to the Insurance Company fete Uicr then-----HIni',la.--......deye after the date tuch Surgical operation waa performed. The Insurance Company, open receipt of the notice required by thii Supplementary Agreement, will furnuh auch forma aa arc uaually fumiahcd by it for Aline pnada of claim. If auch forma are net received by the claimant within ifrecn dare after the fneurance Company re* Obvet auch notice, the claimant aha!I be deemed to have complied with the requirement! of thia Supplementary Agreement aa to proof of claim upon submitting, within the time Seed in the Supplementary Aercement for Aline proofa of claim, written proof covcrinc the occur* tenet, character and extent of the eur|ical operation for which claim ia made. Failure to furnuh notice oe proof within the time provided in thia Supplementary Aercement aha11 not invalidate no* reduce any claim if it ahall be shown not to have been reaaonably poaubic to fumiah auch nonce or proof and that auch notice or proof waa fumiahcd aa aoon aa waa reasonably pnaatblc. (a) No action at law or in equity ahall be brouchi to recover on thia Supplementary Aercement prior to the cepiration of sixty day* after proof of clatm haa been hied in accordance with the require* menta of thia Supplementary Aercement, nor ahall auch action be brought at all unleaa brought within ......fflS'.SS--.... yeart from the eepiranon of the time within which proof of claim Is required by the Supple* mcmary Agreement. Seenow 11. DUE DATE, COMPUTATION AND PAYMENT OF ADDITIONAL SURGICAL OPERA* TJON INSURANCE PREMIUMS*-The additional premium due on and after the date of issue of thie Supplementary Agreement far the iiuursnce provided hereunder ahall be determined and ahall be payable in accordance with the following paragraphs. The initial additional Surgical Operation Insurance premium it due on tho dew of twist of this Supplo* manaary Agreement and nfaorquant additional Surgical Operation Inaurmnea ptomiumg shall be due PS Mil WlgnAur ________ rti...ie wlliil the due daw) thereafter. The initial additional Surgical Operanon Insurance premium due en the date of beue of this Supplementary Agreement and the additianil Surgical Operation Incur* aim premium due on any due daw after the daw of iwue af this Supplementary AgraeaicM dull be (a) the agpegatt af the Pewonal Surreal Operation Insurance premiums determined aa w eachEmployee then inauead hereunder far Personal Surgical Operatian InweaMe fcrmGJLF.SM) March 1M2 tWMTIPMUddU l 0 ftnm h* icpr,.SJ`,ly............. rt<*<al Si<ei*al Operation Insurance premium raie then arplicshle 10 auch Employee In accordance with Section 6 hereof, plus (b) the *ggrcg<t of the Dependent Surgical Opcra- tinn Inaurance premiunu determined i in each Em. ployee then inaured hereunder lor Dependent Sweatee) Operation Iniursnee from theTM.J.'!.9^.h'ii^_................. Dependent Suraical Operation Iniursnrt prmwm rate then applicable to auch Employer in accordance with taid Section 6, subject, hpwever, to premium adiuit- menta, if any. Premium sdjutmttma Involving return of unearned additional premium! to the Employer ihall be limned to the period of twelve monthe immediately preceding the date of receipt by the Inaurance Company of evidence that auch adjustment! should be made. On written request of the Employer. approved Mr the Inaurance Compony, additional Sunncsl OreraiNvi Inaurance premium payments may, if not then an payable, be changed at any due date of this Supple* mcmary Agreement, so aa to be payable annually, semiannually, quarterly, or monthly, provided the frequency of premium payment! selected applies aim to the payment of all other premiums due under the Croup Policy. Upon any renewal of aaid Croup Policy and of this Supplementary Agreement, or whenever the terms af Mid Croup Policy or of thia Supplementary Agreement ate changed, the Inaurance Company may change either the Personal Surgical Operation Insurance pre mium rates ar the Dependent Surgical Operation In* surance premium mica or all of auch premium rates. ,siii XiSDii,, Jj?.suranc,,e A rrreror.t on ar.v due >l3tc lr, the manner JCK8Egi!3gLJgJBA^ ,-inrv Crrn t.-my ir-uy use nvm'X nrci-lui. aweaeacaaeaaaoawaaat<bao*M*MaaoaMiaoeaeteoaaaOaeaaPeoao * jnu-s insc*l on Uic prc.nl uv- rates shown In Suction da. subject ^^Tny"1et)a)Vge`*ifi' nceord'itiee with Utls Suction 11. ......... All additional Surgical Operation Inaurance pre miums failing due under thie Supplementary Agree* went, including adjustments thereof, if any, arc payable by the Employe!, on at before their respective due dawn direct to tho Insurance Company at ha Home OfBcc or one of iaa Head Oita. Tho payment of any additional Surgical Operation Inaurance premium shall not oiainrein the incuranea under thia Supplementary Agreement In farce beyond die day immediately pre ceding the now data daw, ewept aa petidad in the am paragraph. A frees period of thirty one days, without inwrcai choigt, ahall be granted aa the Employer far the pay* ment of any additional Surgical Operation lnautanc* ptcofaaw due after the initial additional Surgical Opera tion Inaurance premium, provided the Employer baa not previosniy pnn written notice to the Insurance Company that this Supplementary Agreement J to be dwermtmuad M of the due date of such premium, end during any euch (race period thu Supplementary Agreement shall continue in force. If the Empioyer fail* to pay any additional Surgical Operation Insurance premium within the price period, this Supplementary Agreement thall be diacominued on the last day of auch put period, but the Employer shall, nrrenheleai, be liable to the Inaurance Company for the payment of all additional Surgical Operation Inaurance premium! then due and unpaid, toyether with the additional Surgical Operation Inaurance premhima for the grace period. If, howmer, written notice is given by the Employer to the Insurance Company, during the grace period, that this Supplementary Agreement ir to be discontinued before the expiration of the grace period, this Supplementary Agreement shell be discontinued u of the date of receipt of auch written nonce by the Insurance Company or the date specified by the Employer for auch discontinuance, whichever date later, and the Employer shall bt liable to the Insurance Company for the payment of the pro-rsts additional Surgical Operation Inaurance premium for the period commencing wtih the lest due date and ending with Mich date of discontinuance. StenoN a INCORPORATION IN CROUP POLICY AND RENEWAL.--This Supplementary Agreement is attached to and made a part of aaid Croup Policy for a period commencing with........... ---lu.-LSftL _______and ending with the day immediately preceding.--........ . on which Ian date and on each annivenary of which last date this Supplementary Agreement may be re* newod to continue in effect as a pen of said Croup Policy for a further term of one year, provided (I) the number of Employees then insured hereunder lor Personal Surgical Operation Insurance is, in the cast of Contributory Insurance, not less than seventy-Avt per* cent of the number of eligible Employres and, in the ease of NonCentributory Inaurance, not leas than the total number of eligible Employees, and provided, in either esse, the number of Employes 'hen insured hereunder for Personal Surgical Operation Insurance it not less than fifty and (2) the number of Employees Insured hereunder for Dependent Surgical Operation Insurance is, in the case of Contributory Insurance, not leas than seventy-five percent of the number of eligible Employees with Dcpendcntt and, bt the case of Non. Contributory Insurance, nor less than the total number of eligible Employees with Dependents. Such renews! a conditioned upon the renewal of said Croup Policy end upon the poyment of the additional Surgical Operation Inaurance premium then due as computed In the manner act forth in Section 11 hereof and baaed upon such premium rates si may then be determined by the Inaurance Company. SctmoN 13. AGENTS: ALTERATIONS--No agent hsa authority to change this Supplementary Agreement or to waive any of in provisions. No change in this Supplementary Agreement that! be valid unless approved by an executive officer of the Insurance Company and evidenced by andianunainr hereon, or by amendment hereto signed by the Employer and by the Insurance Company. Scenow 14. ADDITIONAL PROVISIONS-- XXX x--------------------- ------------------------------------ r------ -------- .................................................. .. x------X..... . -- ................ 1------------""X---------------'*...........*----- ----X ' r' ' X------X.........................*""K........... .............-------------- IN WITNESS WHEREOF, the Metropolitan Ufa Imurenca Company haa ceosed this Supplementary Agreement id be panned this -- ...... day of. -- --i... -- tomltarfoasoof the firs* -t-y T* Mnv- -------- , which hat data b dta darn of hetso of this Supplamontary J(/)trzr. AotObai Farm OS.F. 003 March 2P42 i