Virginia Surety Insurance Company - DOC

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					                                                                           Policy No:

                             1000 N. Milwaukee Avenue
                              Glenview, Illinois 60025

                       A Stock Company, herein called “We”, “Us”, “Our”

Group Policyholde r:

Delivered In:

Policy Effective Date:


We agree to insure the eligible Accountholders of the Group Policyholder against involuntary
loss of employment income. The coverage is subject to the terms and conditions of this Group
Policy (“Policy”).

This Policy becomes effective on the Policy Effective Date shown above at 12:01 a.m. The
Policy is terminated if it is terminated according to its Termination provision.


This Policy is issued in return for the Master Application for this Policy and for payment, when
due, of premiums.

The provisions on the following pages are a part of this Policy.

This Policy is signed by the President and Secretary of Combined Specialty Insurance Company.

                              INSERT SIGNATURES
                  Secretary                                          President

           Limited Benefit Group Involuntary Loss of Employment Income Insurance

                         Licensed Resident Agent (where required by law)
The complete contract consists of: (1) this Policy and any riders attached to it; (2) the Master Application; and (3)
any individual applications of Your Accountholder(s). A copy of the Master Application is attached to this Policy.
Only Our officers may agree to change or waive any of the Policy’s terms. The changes must be written, must be
signed by an officer and must be attached to this Policy. An agent or broker cannot change or waive Po licy terms.

We agree to pay the Creditor/Beneficiary/Accountholder the proportionate amount of the Monthly Account Payment
of the Accountholder for each day of continuous Involuntary Unemp loyment provided: (1) this Policy is in force,
(2) the Accountholder is covered by the Policy and (3) the terms, conditions, and limitations for this Po licy are met.

“Account” means the numbered account shown on the Schedule of the insured Accounth older.
“Accounthol der” means an eligible person, including a co-borrower, who has an Account with You and who is
insured under this Policy.
“Coverage Peri od” means the Coverage Period shown on the Schedule of the Accountholder.
“Creditor/Beneficiary” means the Creditor/ Beneficiary shown on the Schedule of the Accountholder.
“Effecti ve Date” means the Effective Date shown on the Schedule of the Accountholder. No coverage is provided
prior to the Effective Date.
“Involuntary Unempl oyment” means unemploy ment due to strikes, lockouts, individual and mass layoffs, or loss
of income due to business failure or bankruptcy. “Involuntary Unemploy ment” does not include: (1) mandatory or
involuntary retirement; (2) the Accountholder quitting or resigning from his employ ment; (3) the Accountholder
being terminated from employ ment as a result of willfu l misconduct, a transgression of some established and
definite ru le, a fo rbidden act, a derelict ion of duty, where such transgression is willfu l, improper or wrongful
behavior, which behavior is not mere negligence nor carelessness; (4) loss of income fro m self-emp loy ment for any
reason; (5) any period of time for which the Accountholder is being paid by contract for their efforts on behalf of
another; (6) any period of time fo r wh ich the Accountholder is receiving termination or severance pay; (7) the
Accountholder being terminated fro m emp loyment as a result of criminal misconduct (unlawful behavior as
determined by local, state or federal law); (8) the Accountholder being laid off as a result of a normal and routine
shutdown (i.e., an annual or regularly scheduled event where the Accountholder expects to be rehired) as
determined by the Accountholder’s occupation or place of emp loy ment; or (9) the Accounthold er is terminated
fro m or co mpleting seasonal or temporary work.
“Maxi mum Number of Benefit Payments ” means the Maximu m Nu mber of Benefit Pay ments shown on the
Schedule, that the accountholder may be eligib le to receive during the Coverage Period.
“Monthl y Account Payment” means the regularly scheduled monthly payment, determined at the time of the loan
closing, to the Creditor/ Beneficiary that the Accountholder is elig ible to receive as a benefit under the certificate.
“Relati ve” means immediate family members to include, but not limited to, spouses, parents, children, sib lings,
grandparents, parents-in-laws and grandparents-in-laws, aunts, uncles, step relatives, and half siblings.
“Unempl oyment Date” means the date of the Accountholder’s actual termination fro m their former employer not to
be determined by any period of time which the Accountholder received severance or termination pay.
“Vesting Period” means the Vesting Period shown on the Schedule of the Accountholder. If the Accountholder
becomes involuntarily unemployed (Unemploy ment Date) during the Vesting Period of the certificate, no benefits
will be paid for the duration of the unemploy ment occurrence. The Vesting Period begins on the Effective Date of
the certificate
“Waiting Period” means the Waiting Period shown on the Schedule of the Accountholder. Benefits for involuntary
loss of employment income begin only after the Waiting Period has expired. This Waiting Period is separate from
and not a part of the Vesting Period.
“You”, “Your”, or “ Yours” means the Group Po licyholder shown on the Schedule of the Accountholder who is a
resident of and employed in the United States or its territories. [In the event of a joint loan, Accountholder means
the two elig ible people who have an account and are insured under the certificate.]

CSIC-IUI-POL-1(7/02)                                                                                                  2
“Gainfully Empl oyed” means employed for wages, salary, or other monetary reward. “Gain fully Emp loyed” does
not include self-employ ment inco me (1099 inco me), barter-for-t rade compensation such as room and board or any
other non-monetary payment.

You will remit the premiu ms fo r the Accountholders. You will be charged the premiu m rate shown in the Master
Application for this Po licy.
The premiu m rate in Your Master Application for this Policy is subject to change. Any change in the premiu m rate,
will be made to all certificates issued under this Policy.
If We change the premiu m rate, You will be notified in writing at least sixty (60) days prior to the effective date of
the change.

What We Will Pay
After the Vesting Period and Waiting Period for unemploy ment has been satisfied, We will pay the
Cred itor/Beneficiary/Accountholder the lesser of the eligible proportionate amount of the Monthly Account
Payment (determined as of the date of loan closing) or the maximu m allo wable benefit amount, subject to the
Maximu m Nu mber of Benefit Pay ments, for each day of continuous Involuntary Unemploy ment, beginning with the
[_XXX_] day of Involuntary Unemploy ment provided the Accountholder meets the followin g:
   (1)   Accountholder is eligible for the involuntary loss of employ ment inco me benefit as described herein; and
   (2)    Accountholder is insured by       the certificate on the date the Accountholder became involuntarily
         unemployed; and
   (3)   on the day the Accountholder became involuntarily unemp loyed, had attained the age of 18 years and the
         Accountholder had not reached their sixty-sixth (66th ) birthday; and
   (4)   Accountholder was Gainfully Emp loyed on a regular fu ll-time basis at least 30 hours per week for the 12
         consecutive weeks immed iately prior to the date the Accountholder became involuntarily unemp loyed; and
   (5)   Accountholder earned income, disclosed on the application, on a W -2 basis; is not self-emp loyed; not a
         10% or greater owner of the company from wh ich the Accountholder earns their W-2 income; and/or is not
         receiving W-2 income wh ile working for a Relative; and
   (6)   Prior to the Effective Date of the certificate, the Accountholder had no prior knowledge of any pending
         Involuntary Unemp loyment; and
   (7)   Accountholder is eligible for resident state or local government unemployment benefits or is involuntarily
         unemployed due to strike or lockout;
   (8)   Accountholder has satisfied the required Vesting Period and the required Waiting Period as shown on the
         Schedule of the Accountholder; and
   (9)   Accountholder is not totally disabled due to sickness or accidental bodily injury.
If involuntary loss of employ ment inco me benefits have been previously paid on the Accountholder’s behalf to the
Cred itor/Beneficiary/Accountholder under the certificate and this benefit payment stopped, then requirement (4)
above changes so that the Accountholder must have returned to gainful emp loyment on a regular full-t ime basis of at
least thirty (30) hours per week for eight (8) consecutive weeks immed iat ely prior to any new period of Involuntary
Unemploy ment for wh ich the Accountholder wishes considered by Us for payment of benefits. A new Waiting
Period will apply in the event of subsequent Involuntary Unemploy ment. If the Accountholder becomes
Involuntarily Unemployed during the Vesting Period and no benefit is paid, any subsequent unemployment
occurrence will only be elig ible for benefit pay ment if requirement (4) above is met.

In the event of a joint loan, if one of the Accountholders becomes involuntarily unemp loyed, this Policy will pay a
proportionate share of the involuntary loss of employ ment income benefit that would otherwise be payable. The
proportion is determined by dividing (1) the amount of the involuntarily unemployed Accountholder’s income

CSIC-IUI-POL-1(7/02)                                                                                                  3
immed iately prior to the Involuntary Unemployment by (2) the amount of both Accountholder’s income (including
the involuntarily unemployed Accountholder’s income immed iately prior to the Involuntary Unemploy ment.]

We will stop paying this benefit when any of the following occur:
   (1)   the Accountholder is no longer involuntarily unemp loyed; or
   (2)   We have paid the Maximu m Nu mber of Benefit Pay ments for the Accountholder; or
   (3)   state or local unemploy ment governmental agency fro m wh ich the accountholder is receiving benefits stops
         paying benefits due to the accountholders failure to continue to qualify for those benefits; or
   (4)    the Accountholder is Gainfully Emp loyed for wages, salary or other monetary reward in any amount
         reportable on a W-2; or
   (5)   the accountholder is self-emp loyed in any new occupation; or
   (6)   the Coverage Period has expired.

If the Accountholder is involuntarily unemployed fro m other than a strike or lockout, the insured Ac countholder
must provide Us with verification of reg istration with a state unemployment governmental agency and is receiving
benefits from this office or agency. The Accountholder must have registered with the state unemployment office or
the recognized unemploy ment governmental agency within thirty (30) days of the start of his Involuntary
Unemploy ment. The Accountholder must be registered during the entire period of the claim to receive involuntary
loss of emp loyment inco me benefits under the certificate and be receiving state benefits for the entire period of the
claim. In addition, the accountholder must provide the following:
    1.     A signed original letter (on emp loyer letterhead), fro m the Accountholders former emp loyer verifying the
           date of unemploy ment, the reason for unemploy ment, gross annual inco me on the termination date and
           any severance pay received, as well as verification of the accountholders length of employ ment, the
           weekly hours worked, immediately prior to the termination date.
    2.     A legible copy of the Accountholders loan instrument or similar contract wh ich identifies the Effect ive
           Date of the original contract, length of contract, monthly payment amount, lender o r dealer name,
           description of collateral, etc.
    [3. If there is a co-borrower on the original instrument, please provide copies of each Accountholder’s W -2 or
    pay stub at the time of Involuntary Unemp loy ment.]
Should the insured Accountholder become involuntarily unemployed as a result of a lock out or strike, the insured
Accountholder must provide Us with continuing proof of Involuntary Unemp loy ment due to the lockout or strike.
The Accountholder must notify Us at the address shown on the Schedule about Involuntary Unemployment no later
than sixty (60) days after the beginning of the Accountholder’s Involuntary Unemployment. We will send claim
forms to the Accountholder within fifteen (15) days of Our receipt of the Accountholder’s notice of claim. The
claim form will require informat ion fro m the Accountholder that will allo w the Accountholder to prove eligib ility
for coverage herein. If We do not send the claim forms within 15 days, the Accountholder can simply send Us the
informat ion requested earlier in this section.

The Accountholder’s certificate will end at the earliest of the following:
   (1) We or the Group Policyholder write to the Accountholder at least thirty (30) days prior to the termination
       date of the certificate, informing the Accountholder of the termination of the Grou p Policy or the certificate;
   (2) The date the Accountholder’s account had been closed or refinanced; or
   (3) The first billing date of the Accountholder’s account which immed iately follows the date the Accountholder
       has reached their 66th birthday; or
   (4) The Accountholder dies.

CSIC-IUI-POL-1(7/02)                                                                                                 4
This Policy may be terminated by You or by Us by giving the other party thirty (30) days prior written notice. The
Policy will end on the date given in the written notice. Th is date for termination must be at least thirty (30) days
after the written notice is given. Notice can be delivered by one party to the other or mailed by Cert ified or
Registered Mail to their last known address. The coverage of an Accountholder will continue for as long as the
premiu m is paid, even if that is past the termination date. No new coverage may become effective after the
termination date.

Entire Contract: This Policy, the certificate, the Schedule, the Master Application, all applications (if any) of the
Accountholder and any attached papers, is the entire contract between the parties. All statements made by You, or
the Accountholder, shall be deemed representations and not warranties. No change in the Policy and certificate will
be effective until approved in writ ing by one of Our officers. This approval must be noted on or attached to the
Policy and certificate. No one (including any agent or broker) may change or waive any of the provisions of the
Policy or cert ificate.
Ti me Li mit on Certain Defenses: Misstatements in the application of any kind may be used to void Your or the
Accountholder’s coverage or deny any claim for loss for the first two (2) years from the Effective Date. Fraudulent
misstatements in the application may be used, at any time after the Effect ive Date, to void Your or the
Accountholder’s coverage or deny an claim for loss.
Grace Peri od: This Po licy and the certificates issued under this Policy have a ninety (90) day grace period. This
means that if a renewal premiu m is not paid on or before the date it is due, it may be paid during the following
ninety (90) days. During the grace period, the policy and the certificates issued under this Policy will stay in force;
unless otherwise terminated.

Notice of Clai m: The notice can be given to Us at Our ho me office address shown on the Accountholder’s
Schedule. This notice should include the Accountholder’s name, cert ificate number and Account number. The
Accountholder’s failure to give notice within the time allowed will not invalidate or reduce any claim fo r benefits if
it can be shown that it was not reasonably possible for the Accountholder to give notice and that the notice was
given as soon as reasonably possible. Otherwise, the Accountholder’s failure to report th e claim in accordance with
the procedures in the certificate may reduce or invalidate the claim.
Proof of Loss: The proof o f loss forms are a request for in formation on the Accountholder’s Involuntary
Unemploy ment. These forms must be returned to Us with in ninety (90) days of receipt. If the Accountholder does
not get the forms fro m Us within fifteen (15) days, the Accountholder should send Us the informat ion requested in
the CLAIM FILING REQUIREM ENTS section of this document. The Accountholder’s failu re to g ive proof of loss
acceptable to Us within the time allowed will not invalidate or reduce any claim for benefits if it can be shown that it
was not reasonably possible to give the proof of loss and that proof of loss was provided to Us as soon as rea sonably
possible. However, if the Accountholder cannot provide proof the inability to file his claim according to the
certificate was as a result of an event or happening out of the Accountholder’s control, then the claim for benefits
may be reduced or denied. In any event, except in the absence of legal capacity, proof of loss must be given to Us
no later than one (1) year fro m the time it is otherwise required.
Ti me Payment of Cl ai ms: After receiving written proof of loss, and all information necessary to substantiate the
Accountholder’s claim, We will pay all claims pro mptly.
Legal Actions: No legal action may be brought to recover under this Policy or a certificate issued under this Policy
within sixty (60) days after written proof of loss has been g iven as required by the Policy and the certificate. No
such action may be brought after three (3) years fro m the date written proof of loss is required to be given.
Misstatement of Age: If the Accountholder’s age or date of birth has not been stated correctly on the application
and the Accountholder was under the age of 18 years or older than 65 years of age when the Accountholder applied
for this insurance, then the certificate is void and We have no obligation; except to return any premiu m paid for this
insurance coverage.
Conformity with State Statutes: We amend through this provision to conform with the min imu m standards, any
part of the Policy that conflicts on its Effective Date with the Statutes of the State where the Policy is delivered.

CSIC-IUI-POL-1(7/02)                                                                                                  5

Description: Virginia Surety Insurance Company document sample