Accidental Death and Dismemberment summary Plan Description

Prudential’s Customer Service Office:
Prudential Group Life Claim Division
P.O. Box 8517
Philadelphia, PA 19176
1-800-524-0542

If Prudential fails to provide you with reasonable and adequate service, you may contact:

Arkansas Insurance Department
Consumer Services Division
1200 West Third Street
Little Rock, Arkansas 72201-1904
1-800-852-5494

The benefits of the policy providing your coverage are governed by the law of a state other than Florida.

If you need the assistance of the governmental agency that regulates the business of insurance, you can contact the Idaho Department of Insurance by contacting:

Idaho Department of Insurance
Consumer Affairs
700 W State Street, 3rd Floor
PO Box 83720
Boise ID 83720-0043
1-800-721-3272 or 208-334-4250 or www.DOI.Idaho.gov

Questions regarding your policy or coverage should be directed to: The Prudential Insurance Company of America (800) 524-0542

If you (a) need the assistance of the governmental agency that regulates insurance; or (b) have a complaint you have been unable to resolve with your insurer you may contact the Department of Insurance by mail, telephone or e-mail:

State of Indiana Department of Insurance
Consumer Services Division
311 West Washington Street, Suite 300
Indianapolis, Indiana 46204
Consumer Hotline: (800) 622-4461; (317) 232-2395
Complaints can be filed electronically at www.in.gov/idoi.

The Group Insurance Contract providing coverage under this Certificate was issued in a jurisdiction other than Maryland and may not provide all of the benefits required by Maryland law.

Notice: This Certificate of Insurance provides all of the benefits mandated by the North Carolina Insurance Code, but is issued under a group master policy located in another state and may be governed by that state's laws.

The Insurance Policy under which this certificate is issued is not a policy of Workers Compensation Insurance. You should consult your employer to determine whether your employer is a subscriber to the Workers' Compensation System.

Keep this notice with your insurance papers:

Problems with Your Insurance? – If you are having problems with your insurance company or agent, do not hesitate to contact the insurance company or agent to resolve your problem.

Prudential’s Customer Service Office:
The Prudential Insurance Company of America
Prudential Group Life Claim Division
P.O. Box 8517
Philadelphia, PA 19176
1-800-524-0542

You can also contact the OFFICE OF THE COMMISSIONER OF INSURANCE, a state agency which enforces Wisconsin’s insurance laws, and file a complaint. You can file a complaint electronically with the OFFICE OF THE COMMISSIONER OF INSURANCE at its website at http://oci.wi.gov/, or by contacting:

Office of the Commissioner of Insurance
Complaints Department
P.O. Box 7873
Madison, WI 53707-7873
1-800-236-8517
608-266-0103

Benefit Amounts Under Employee Insurance:

Amount For Each Benefit Class:

* Your Amount of Insurance will be equal to the amount for which you are insured under the Basic Employee Term Life Coverage under this Group Contract G-50757-NY. For this purpose only, that amount will be the amount as determined above, except that if your Basic Employee Term Life Coverage is reduced by any amount paid under the Option to Accelerate Payment of Death Benefits, that reduction will not apply to this Coverage.

The Definitions section explains what “Earnings" means.

Increases and Decreases: Your amount of insurance will be increased or decreased on the date your annual Earnings change. But, if you are not meeting the Active Work Requirement when your amount of insurance would be changed, that change will be deferred until the date you meet that requirement.

Amount Limit Due to Age: When you are age 70 or more, your amount of insurance is limited. It is the Limited Percent (for that Age) of the amount for which you would then be insured if there were no limitation. Each Age and the Limited Percent for that Age are shown below.

The Limited Percent for an Age takes effect on the day you become insured if you are then that Age. Otherwise, each Limited Percent for an Age takes effect on the first January 1 that occurs while you are that Age.

The Delay of Effective Date section does not apply to this Amount Limit Due to Age provision.

Benefit Amounts Under Employee Insurance:

You may enroll for one of the options below. The option for which you enroll will be recorded by your Employer and reported to Prudential.

Amount For Each Benefit Class:

*If this amount is not a multiple of $1,000, it will be rounded to the next higher multiple of $1,000. Maximum Amount: $750,000.

The Definitions section explains what “Earnings" means.

Automatic Increases and Decreases: Your amount of insurance will be increased or decreased on the date your annual Earnings change. But, if you are not meeting the Active Work Requirement when your amount of insurance would be changed, that change will be deferred until the date you meet that requirement.

Elective Increases and Decreases: You may elect to have your amount of insurance changed. You must do this on a form approved by Prudential and agree to make any required contributions.

This change will take effect on the date of your request if that date is a Contract Anniversary. If that date is not a Contract Anniversary, it will take effect on the next Contract Anniversary. But, if you are not meeting the Active Work Requirement when your amount of insurance would be changed, that change will be deferred until the date you meet that requirement.

Amount Limit Due to Age: When you are age 70 or more, your amount of insurance is limited. It is the Limited Percent (for that Age) of the amount for which you would then be insured if there were no limitation. Each Age and the Limited Percent for that Age are shown below.

The Limited Percent for an Age takes effect on the day you become insured if you are then that Age. Otherwise, each Limited Percent for an Age takes effect on the first January 1 that occurs while you are that Age.

The Delay of Effective Date section does not apply to this Amount Limit Due to Age provision.

BENEFIT AMOUNTS UNDER DEPENDENTS INSURANCE:

*If this amount is not a multiple of $1,000, it will be rounded to the next higher multiple of $1,000. Maximum Amount: $750,000

The Definitions section explains what “Earnings" means.

Your Children

Option 1: $10,000
Option 2: $20,000

Increases and Decreases for Your Spouse or Domestic Partner: The amount of insurance on your Spouse or Domestic Partner will be increased or decreased on the date your annual Earnings change. But, if you are not meeting the Active Work Requirement when the amount of insurance on your Spouse or Domestic Partner would be changed, that change will be deferred until the date you meet that requirement.

In no event will the amount of Dependents Insurance on your Spouse or Domestic Partner be more than your amount of Employee Insurance.

Amount Limit Due to Age: When you are age 65 or more, your Spouse's or Domestic Partner's amount of insurance is limited. It is the Limited Percent (for that Age) of the amount for which your Spouse or Domestic Partner would then be insured if there were no limitation. Each Age and the Limited Percent for that Age are shown below.

The Limited Percent for an Age takes effect on the day you become insured if you are then that Age. Otherwise, each Limited Percent for an Age takes effect on the first January 1 that occurs while you are that Age.

The Delay of Effective Date section does not apply to this Amount Limit Due to Age provision.

Contract Holder: ROCHESTER INSTITUTE OF TECHNOLOGY

Group Contract No.: G-50757-NY

Associated Companies: Associated Companies are employers who are the Contract Holder’s subsidiaries or affiliates and are reported to Prudential in writing for inclusion under the Group Contract, provided that Prudential has approved such request.

Cost of Insurance: Insurance under the Coverage(s) listed below is Non-Contributory Insurance.

Basic Accidental Death and Dismemberment Coverage

Insurance under the other Coverage(s) in this Booklet is Contributory Insurance. You will be informed of the amount of your contribution when you enroll.

Prudential's Address:

The Prudential Insurance Company of America
80 Livingston Avenue
Roseland, New Jersey 07068

Each time a claim is made, it should be made without delay. Use a claim form, and follow the instructions on the form.

If you do not have a claim form, contact your Employer.

The coverage described in this Booklet provides only ACCIDENT coverage. It does NOT provide basic hospital, basic medical, or major medical insurance as defined by the New York State Department of Financial Services.

IMPORTANT NOTICE - THE COVERAGE DESCRIBED IN THIS BOOKLET DOES NOT PROVIDE COVERAGE FOR SICKNESS.

For all Full-time Employees, you are benefit eligible if you are scheduled to work for your Employer at least 1500 hours per year. If you are a partner or proprietor of the Employer, that work must be in the conduct of the Employer's business.

For all Employees classified as Part-time Employees, you are benefit eligible if you are scheduled to work for your Employer 750 hours or more per year. If you are a partner or proprietor of the Employer, that work must be in the conduct of the Employer's business.

For all Employees classified as Retirement Transition Employees, you are benefit eligible if you are scheduled to work for your Employer 750 hours or more per year. If you are a partner or proprietor of the Employer, that work must be in the conduct of the Employer's business.

These are the persons for whom you may obtain Dependents Insurance:

• A person who is your Spouse or Domestic Partner prior to their enrollment for Dependents Insurance.

  Your Spouse means your lawful Spouse.

  Your Domestic Partner is a person of the same or opposite sex who:

  1. Satisfies the requirements for being a domestic partner, registered domestic partner or party to a civil union under the law of your jurisdiction of residence; or
  2. Is a person of the same or opposite sex who satisfies all of the following:
     1. is age 18 or older; and
     2. is not related to you by blood or a degree of closeness that would prohibit marriage in the law of the jurisdiction in which you reside; and
     3. is mentally competent to consent to contract; and
     4. is not married to another person under statutory or common law nor in a domestic partnership, registered domestic partnership or civil union with another person; and
     5. is not otherwise a Qualified Dependent under the Program; and
     6. is in a single dedicated, serious and committed relationship with you; and
     7. has shared a single permanent residence with you for at least 12 consecutive months; and
     8. is financially interdependent with you.
     9.  
     Where requested by Prudential, you and/or your Domestic Partner certify that all of the above requirements are satisfied. Such certification shall be in a format satisfactory to Prudential.
     Either a Spouse or a Domestic Partner may be a Qualified Dependent under the Program at any one time, but not both at the same time.


• Your unmarried children from live birth to 26 years old.

  Your children include your legally adopted children, children placed with you for adoption prior to legal adoption, and each of your stepchildren and Domestic Partner's children who depend on you for support and maintenance. A child placed with you for adoption prior to legal adoption is considered your Qualified Dependent from the date of placement for adoption, and is treated as though the child was your newborn child. Your children also include each of your stepchildren who depends on you for support and maintenance.

Your Spouse, Domestic Partner or child is not your Qualified Dependent while:

1. on active duty in the armed forces of any country; or
2. insured under the Group Contract as an Employee.

A child will not be considered the Qualified Dependent of more than one Employee. If this would otherwise be the case, the child will be considered the Qualified Dependent of the Employee named in a written agreement of all such Employees filed with the Contract Holder. If there is no written agreement, the child will be considered the Qualified Dependent of:

1. the Employee who became insured under the Group Contract with respect to the child, while the child was a Qualified Dependent of only that Employee; and otherwise
2. the Employee who has the longest continuous service with the Employer, based on the Contract Holder's records.

The rules for obtaining Dependents Insurance are in the When You Become Insured section.

Your Employee Insurance under a Coverage will begin the first day on which:

• You have enrolled, if the Coverage is Contributory; and
• You are eligible for Employee Insurance; and
• You are in a Covered Class for that insurance; and
• Your insurance is not being delayed under the Delay of Effective Date section below; and
• That Coverage is part of the Group Contract.

For Contributory Insurance, you must enroll on a form approved by Prudential and agree to pay the required contributions. Your Employer will tell you whether contributions are required and the amount of any contribution when you enroll.

At any time, the benefits for which you are insured are those for your class, unless otherwise stated.

Your Dependents Insurance under a Coverage for a person will begin the first day on which all of these conditions are met:

• You have enrolled for the person for Dependents Insurance under the Coverage, if the Coverage is Contributory.
• The person is your Qualified Dependent.
• You are in a Covered Class for that insurance. 83500 BEL 5126 (50757-43) 12
• You are insured for Employee Insurance under the Accidental Death and Dismemberment Coverage of the Group Contract, if any.
• Dependents Insurance under that Coverage is part of the Group Contract.

For Contributory Insurance, you must enroll your Qualified Dependent on a form approved by Prudential and agree to pay the required contributions. Your Employer will tell you whether contributions are required and the amount of any contribution when you enroll your Qualified Dependent.

At any time, the Dependents Insurance benefits for which you are insured are those for your class, unless otherwise stated.

Change in Family Status: It is important that you inform the Employer promptly when you first acquire or lose a Qualified Dependent, and when you no longer have a Qualified Dependent. Forms are available for reporting these changes.

Accidental Loss means your:

1. loss of life;
2. total and permanent Loss of Sight;
3. total and permanent Loss of Speech;
4. total and permanent Loss of Hearing;
5. permanent loss of arm or leg by severance at or above the elbow or the knee;
6. permanent loss of hand or foot by severance at or above the wrist or ankle;
7. permanent loss of thumb and index finger of the same hand or permanent loss of four fingers on the same hand by severance at or above the point at which they are attached to the hand;
8. permanent loss of all toes on the same foot or the big toe by severance at or above the point at which they are attached to the foot;
9. loss due to Quadriplegia, Paraplegia or Hemiplegia. 
10. Loss of Use of a hand, foot, arm or leg;

Loss of Sight means total and permanent loss of sight. Corrected visual acuity must be 20/200 or worse or the field of vision must be less than 20 degrees.

Loss of Speech means total and permanent loss of speech that continues for at least 12 consecutive months following the Covered Accident.

Loss of Hearing means a hearing loss of greater than 70 decibels at all frequencies or there is less than 50% speech discrimination at 70 decibels on an audiogram.

Quadriplegia means the total and permanent paralysis of both upper and both lower limbs.

Paraplegia means the total and permanent paralysis of both lower limbs.

Hemiplegia means the total and permanent paralysis of the upper and lower limbs on one side of the body.

Loss of Use means total and permanent loss of function.

Benefits for Accidental Loss are payable only if all of these conditions are met:

1. You sustain an Accidental Injury while a Covered Person.
2. The Accidental Loss results directly from that Accidental Injury and from no other cause.
3. You suffer the Accidental Loss within 365 days after the accident.

For the purposes of the Coverage:

1. Exposure to the Elements will be considered an Accidental Injury. Exposure to the Elements means exposure to severe hot or cold weather that results in actual significant physical injury including sun stroke, heat stroke and frostbite.
2. It will be presumed that you have suffered a loss of life if your body has not been found within one year of disappearance, stranding, sinking or wrecking of any vehicle in which you were an occupant.

Not all such Accidental Losses are covered. See Losses Not Covered below.

Benefit Amount Payable: The amount payable depends on the type of Accidental Loss as shown below. All benefits are subject to the Limits below.

Limits Per Accident: No more than the Amount of Insurance on a person at the time of the Accident will be paid for all Accidental Losses resulting from Accidental Injuries sustained in that Accident.

An Accidental Loss is not covered if it results from any of these:

1. Suicide or attempted suicide.
2. Intentionally self-inflicted Injuries.
3. Participation in any riot or insurrection.
4. War, or any act of war. War means declared or undeclared war. Terrorism is not considered an act of war.
   Terrorism means the deliberate use of violence or the threat of violence against civilians to create an emotional response through the suffering of victims or to achieve military, political, religious or social objectives.
5. An Accident that occurs while you are serving on full-time active duty for more than 30 days in any armed forces. But this does not include Reserve or National Guard active duty for training.
6. Participation in a felony.
7. Aviation (including getting in, out, on or off any vehicle used for aerial navigation), This does not include an Accidental Loss if: (a) it results from aviation as a fare-paying passenger on a scheduled or charter flight operated by a scheduled airline, or (b) you are riding as a passenger in an aircraft owned, operated, controlled or leased by or on behalf of the Contract Holder or any of its subsidiaries or affiliates.
8. Being legally intoxicated.

The Claim Rules apply to the payment of the benefits.

If a benefit is payable under the Coverage for a Loss an additional benefit may be payable. Any such benefit is payable in addition to any other benefit payable under this Coverage. The additional amount payable for each additional benefit and any additional conditions that apply to an additional benefit are shown below. An additional benefit is payable only if those conditions are met.

(1) Additional Benefit for Loss of life as a Result of an Accident in an Automobile While Using a Seat Belt:

This additional benefit for your loss of life only applies if you sustain the Accidental Loss while:

1. you are a driver or passenger in an Automobile;
2. you are wearing a Seat Belt in the manner prescribed by the vehicle’s manufacturer; and
3. the actual use of a Seat Belt at the time of the Injury is verified in an official report of the Accident, or is certified in writing by the investigating official(s).

Accidental Losses Not Covered under this Additional Benefit: An Accidental Loss is not covered under this additional benefit if it results from driving or riding in any Automobile used in a race or a speed or endurance test, or for acrobatic or stunt driving, as a professional.

Additional Amount Payable under this Additional Benefit: An amount equal to the lesser of:

1. 10% of your Amount of Insurance; and
2. $25,000

(2) Additional Benefit for Loss of life as a Result of an Accident in an Automobile While Using an Air Bag:

This additional benefit for your loss of life only applies if this test is met.

You sustain an Accidental Loss while:

1. you are a driver or passenger in an Automobile;
2. you are wearing a Seat Belt in the manner prescribed by the vehicle’s manufacturer;
3. the actual use of a Seat Belt at the time of the Injury is verified in an official report of the Accident, or is certified in writing by the investigating official(s);
4. the Automobile is equipped with a factory-installed Air Bag; and
5. a properly functioning Air Bag was deployed for the seat that you occupied.

Accidental Losses Not Covered under this Additional Benefit: An Accidental Loss is not covered under this additional benefit if it results from driving or riding in any Automobile used in a race or a speed or endurance test, or for acrobatic or stunt driving, as a professional.

Additional Amount Payable under this Additional Benefit: An amount equal to the lesser of:

1. 5% of your Amount of Insurance; and
2. $5,000.

(3) Additional Benefit for Child Care Expenses for Your Dependent Child:

This additional benefit for child care expenses for your dependent child only applies if you suffer a loss of life.

This additional benefit is payable for each dependent child less than age 13 who:

1. is enrolled at a Child Care Center on the date of your death; or
2. becomes enrolled at a Child Care Center within 90 days after the date of your death. Proof of enrollment must be given to Prudential.

Additional Amount Payable under this Additional Benefit: An amount equal to the lesser of:

1. 5% of your Amount of Insurance; and
2. $5,000.

This benefit is payable annually for up to 4 consecutive years, but not beyond the date the child reaches age 13.

If there is no dependent child eligible for this benefit, a benefit of $500 will be paid.

(4) Additional Benefit for Return of Remains:

This additional benefit for return of remains only applies if you suffer a loss of life and such Accidental Loss occurs outside a 100 mile radius of your home. It is payable for Return of Remains Expenses incurred to return your body home to your country of residence.

Additional Amount Payable under this Additional Benefit: An amount equal to the lesser of:

1. the amount of Return of Remains Expenses; and
2. $5,000.

Accidental Loss means the person’s:

1. loss of life;
2. total and permanent Loss of Sight;
3. total and permanent Loss of Speech;
4. total and permanent Loss of Hearing;
5. permanent loss of arm or leg by severance at or above the elbow or the knee;
6. permanent loss of hand or foot by severance at or above the wrist or ankle;
7.  permanent loss of thumb and index finger of the same hand or permanent loss of four fingers on the same hand by severance at or above the point at which they are attached to the hand;
8. permanent loss of all toes on the same foot or the big toe by severance at or above the point at which they are attached to the foot;
9. loss due to Quadriplegia, Paraplegia or Hemiplegia.
10. Loss of Use of a hand, foot, arm or leg;

Loss of Sight means total and permanent loss of sight. Corrected visual acuity must be 20/200 or worse or the field of vision must be less than 20 degrees.

Loss of Speech means total and permanent loss of speech that continues for at least 12 consecutive months following the Covered Accident.

Loss of Hearing means a hearing loss of greater than 70 decibels at all frequencies or there is less than 50% speech discrimination at 70 decibels on an audiogram.

Quadriplegia means the total and permanent paralysis of both upper and both lower limbs.

Paraplegia means the total and permanent paralysis of both lower limbs.

Hemiplegia means the total and permanent paralysis of the upper and lower limbs on one side of the body.

Loss of Use means total and permanent loss of function.

Benefits for Accidental Loss are payable only if all of these conditions are met:

1. The person sustains an Accidental Injury while a Covered Person.
2. The Accidental Loss results directly from that Accidental Injury and from no other cause.
3. You suffer the Accidental Loss within 365 days after the accident.

For the purposes of the Coverage:

1. Exposure to the Elements will be considered an Accidental Injury. Exposure to the Elements means exposure to severe hot or cold weather that results in actual significant physical injury including sun stroke, heat stroke and frostbite.
2. It will be presumed that you have suffered a loss of life if your body has not been found within one year of disappearance, stranding, sinking or wrecking of any vehicle in which you were an occupant.

Not all such Accidental Losses are covered. See Losses Not Covered below.

Benefit Amount Payable: The amount payable depends on the type of Accidental Loss as shown below. All benefits are subject to the Limits below.

Limits Per Accident: No more than the Amount of Insurance on a person at the time of the Accident will be paid for all Accidental Losses resulting from Accidental Injuries sustained in that Accident.

An Accidental Loss is not covered if it results from any of these:

1. Suicide or attempted suicide.
2. Intentionally self-inflicted Injuries.
3. Participation in any riot or insurrection.
4. War, or any act of war. War means declared or undeclared war.
   Terrorism is not considered an act of war. Terrorism means the deliberate use of violence or the threat of violence against civilians to create an emotional response through the suffering of victims or to achieve military, political, religious or social objectives.
5. An Accident that occurs while the person is serving on full-time active duty for more than 30 days in any armed forces. But this does not include Reserve or National Guard active duty for training.
6. Participation in a felony.
7. Aviation (including getting in, out, on or off any vehicle used for aerial navigation), This does not include an Accidental Loss if:
   1. it results from aviation as a fare-paying passenger on a scheduled or charter flight operated by a scheduled airline, or
   2. the person is riding as a passenger in an aircraft owned, operated, controlled or leased by or on behalf of the Contract Holder or any of its subsidiaries or affiliates.
8. Being legally intoxicated.

The Claim Rules apply to the payment of the benefits

If a benefit is payable under the Coverage for a Loss an additional benefit may be payable. Any such benefit is payable in addition to any other benefit payable under this Coverage. The additional amount payable for each additional benefit and any additional conditions that apply to an additional benefit are shown below. An additional benefit is payable only if those conditions are met.

(1) Additional Benefit for Loss of life as a Result of an Accident in an Automobile While Using a Seat Belt:

This additional benefit for the person’s loss of life only applies if the person sustains Accidental Loss while:

1. the person is a driver or passenger in an Automobile;

2. the person is wearing a Seat Belt in the manner prescribed by the vehicle’s manufacturer; and

3. the actual use of a Seat Belt at the time of the Injury is verified in an official report of the Accident, or is certified in writing by the investigating official(s).

Accidental Losses Not Covered under this Additional Benefit: An Accidental Loss is not covered under this additional benefit if it results from driving or riding in any Automobile used in a race or a speed or endurance test, as a professional.

Additional Amount Payable under this Additional Benefit: An amount equal to the lesser of:

1. 10% of the Amount of Insurance on the person; and
2. $25,000

(2) Additional Benefit for Loss of Life as a Result of an Accident in an Automobile While Using an Air Bag:

This additional benefit for your loss of life only applies if this test is met.

The person sustains an accidental bodily Injury resulting in the Loss while:

1. the person is a driver or passenger in an Automobile;

2. the person is wearing a Seat Belt in the manner prescribed by the vehicle’s manufacturer;

3. the actual use of a Seat Belt at the time of the Injury is verified in an official report of the accident, or is certified in writing by the investigating official(s);

4. the Automobile is equipped with a factory-installed Air Bag; and

5. a properly functioning Air Bag was deployed for the seat that the person occupied.

Losses Not Covered under this Additional Benefit: A Loss is not covered under this additional benefit if it results from driving or riding in any Automobile used in a race or a speed or endurance test, or for acrobatic or stunt driving, or for any illegal purpose.

Additional Amount Payable under this Additional Benefit: An amount equal to the lesser of:

1. 5% of the Amount of Insurance on the person;; and
2. $5,000.

(3) Additional Benefit for Tuition Reimbursement for Your Dependent Spouse or Domestic Partner:

This additional benefit for Tuition reimbursement for your dependent Spouse or Domestic Partner only applies if you suffer a loss of life.

This additional benefit is payable for the person who:

1. is your Spouse or Domestic Partner on the date of your death; and

2. enrolls in any professional or trades program within months after the date of your death for the purposes of obtaining an independent source of support or enriching that Spouse's or Domestic Partner's ability to earn a living.

Proof of enrollment must be given to Prudential.

Additional Amount Payable under this Additional Benefit: An amount equal to the lesser of:

1. the actual annual tuition charged for the program;

2. 5% of your Amount of Insurance; and

3. $5,000.

This benefit is payable for only one year.

If there is no dependent Spouse or Domestic Partner eligible for this benefit, a benefit of $500 will be paid.

(4) Additional Benefit for Tuition Reimbursement for Your Dependent Child:

This additional benefit for Tuition reimbursement for your dependent child only applies once. It applies if either: (a) you suffer a loss of life; or (b) your Qualified Dependent Spouse or Domestic Partner suffers a loss of life. Date of death, as used below, refers to your or your Spouse's or Domestic Partner's date of death depending upon whose loss of life this additional benefit is payable.

This additional benefit is payable for each dependent child less than age 23 who:

1.  is enrolled as a full-time student in a School on the date of death; or

2.  is a high school student on the date of death and becomes a full-time student in a School within 365 days after that date.

Proof of enrollment must be given to Prudential.

Additional Amount Payable under this Additional Benefit: An amount equal to the least of:

1. the actual annual Tuition, exclusive of room and board, charged by the School;

2. 5% of the Amount of Insurance on the person; and

3. $5,000.

This benefit is payable annually for up to 4 consecutive years, but not beyond the date the child reaches age 23.

If there is no dependent child eligible for this benefit, a benefit of $500 will be paid.

(5) Additional Benefit for Child Care Expenses for Your Dependent Child:

This additional benefit for child care expenses for your dependent child only applies once. It applies if either: (a) you suffer a loss of life; or (b) your Dependent Spouse or Domestic Partner suffers a loss of life. Date of death, as used below, refers to your or your Spouse's or Domestic Partner's date of death depending upon whose loss of life this additional benefit is payable.

This additional benefit is payable for each dependent child less than age 13 who:

1. is enrolled at a Child Care Center on the date of death; or

2. becomes enrolled at a Child Care Center within 90 days after the date of death.

Proof of enrollment must be given to Prudential.

Additional Amount Payable under this Additional Benefit: An amount equal to the lesser of:

(1) 5% of the Amount of Insurance on the person; and

(2) $5,000.

This benefit is payable annually for up to 4 consecutive years, but not beyond the date the child reaches age 13.

If there is no dependent child eligible for this benefit, a benefit of $500 will be paid.

(6) Additional Benefit for Return of Remains:

This additional benefit for return of remains only applies if the person suffers a loss of life and such Accidental Loss occurs outside a 100 mile radius of the person’s home. It is payable for Return of Remains Expenses incurred to return the person’s body home to their country of residence.

Additional Amount Payable under this Additional Benefit: An amount equal to the lesser of:

1. the amount of Return of Remains Expenses; and
2. $5,000.

Air Bag: An inflatable safety device that: (1) meets published federal safety standards; (2) is installed by the Automobile’s manufacturer or replaced by an organization sanctioned by the Automobile’s manufacturer; and (3) is not altered after that installation or replacement.

Automobile: A validly registered:

1. vehicle that may be legally driven with the standard issue class of motor vehicle driver's license and no additional class of license is necessary to operate this vehicle; or

2. four wheel, two axle private passenger motor vehicle.

But Automobile does not include: (1) a motor vehicle intended for off-road use; or (2) a motor vehicle being used without the owner’s permission.

Child Care Center: A facility or individual which:

1. operates pursuant to law, if locally required;

2. is not a family member; and

3. primarily provides care and supervision for children in a group setting on a regular, daily basis.

Return of Remains Expenses: Expenses for a coffin and transportation of the remains to return the person’s body home.

School: An institution of higher learning. The term includes, but is not limited to, a university, college or trade school.

Seat Belt: Any: (1) passive restraint device for an adult that meets published federal safety standards, is installed by the Automobile’s manufacturer or replaced by an organization sanctioned by the Automobile’s manufacturer; and is not altered or replaced after that installation; or (2) federally approved, properly installed child safety seat.

Tuition: The charge or fee for instruction, as at a private school, trade school or a college or university. Tuition does not include fees or charges other than for instruction.

A right under this section is subject to the rest of these provisions.

You will have the right to apply for accidental death and dismemberment coverage under the Portability Plan if you meet all of these tests:

1. Your Accidental Death and Dismemberment Coverage ends for any reason other than:

   1. your failure to pay, when due, any contribution required for it; or

   2.  the end of the Coverage for all Employees when such Coverage is replaced by group accidental death and dismemberment insurance from any carrier for which you are or become eligible within the next 45 days.

2. You are less than age 80.

3.  Your Amount of Insurance is at least $20,000 under the Accidental Death and Dismemberment Coverage on the day your insurance ends.

You have the right to apply for coverage under the Portability Plan during the Portability Application Period.

The Portability Application Period is the 45 day period after your Accidental Death and Dismemberment Coverage ends.

The form, amount, first premium, and effective date will be as stated below.

Form and Amount: The form of accidental death and dismemberment coverage that Prudential then makes available under the Portability Plan. The terms and conditions of that coverage will not be the same as the Accidental Death and Dismemberment Coverage under the Group Contract.

Amount: Not more than your amount of insurance under the Accidental Death and Dismemberment Coverage when your insurance ends, subject to these rules:

1. Minimum: The minimum amount of Accidental Death and Dismemberment Coverage that may be ported is $20,000, less the amount ported under Basic Accidental Death and Dismemberment Coverage.

2. Maximum: The maximum amount of Accidental Death and Dismemberment Coverage that may be ported is (a) the lesser of 5 times your annual Earnings and $1,000,000 minus (b) the amount ported under Basic Accidental Death and Dismemberment Coverage.

First Premium: The first premium is due to Prudential by the later of the end of the Portability Application Period and 31 days from receipt of the first bill.

Effective Date: The day after the Portability Application Period ends.

A right under this section is subject to the rest of these provisions.

You will have the right to apply for accident coverage under the Portability Plan for a Qualified Dependent if all of these tests are met:

1. The Accidental Death and Dismemberment Coverage on the dependent ends because your Accidental Death and Dismemberment Coverage for Employees under the Plan ends for any reason other than:

   1. your failure to pay, when due, any contribution required for it; or

   2. the end of the Accidental Death and Dismemberment Coverage for all Employees when such Coverage is replaced by group accidental death and dismemberment insurance from any carrier for which you are or become eligible within the next 45 days.

2.  You apply and become covered for accidental death and dismemberment coverage under the Portability Plan.

3.  With respect to a dependent Spouse or Domestic Partner, that Spouse or Domestic Partner is less than age 80.

4.   With respect to a dependent child, that child is less than age 26.

5.  The dependent is covered for Accidental Death and Dismemberment Coverage on the day your Accidental Death and Dismemberment Coverage for Employees ends.

6.  The dependent is not confined for medical care or treatment, at home or elsewhere on the day your Accidental Death and Dismemberment Coverage for Employees ends.

If you die, your Spouse or Domestic Partner will have the right to apply for accident coverage under the Portability Plan if that Spouse or Domestic Partner meets all of the tests in (3), (5) and (6) above.

If you die, your Spouse or Domestic Partner will also have the right to apply for accident coverage under the Portability Plan for a Qualified Dependent child if:

1. That Spouse or Domestic Partner applies and becomes covered for accident coverage under the Portability Plan; and

2. That child meets all of the tests in (4), (5) and (6) above.

If you divorce or your Domestic Partner ceases to be a Qualified Dependent, your Spouse or Domestic Partner will have the right to apply for accident coverage under the Portability Plan if:

1.  The Accidental Death and Dismemberment Coverage on your Spouse or Domestic Partner ends due to divorce or your Domestic Partner ceasing to be a Qualified Dependent; and

2.   That Spouse or Domestic Partner is less than age 80; and

3.   That Spouse or Domestic Partner is not confined for medical care or treatment, at home or elsewhere on the day the Accidental Death and Dismemberment Coverage on that Spouse or Domestic Partner ends.

You have the right to apply for accident coverage under the Portability Plan for your dependents during the Portability Application Period. In the case of your death or divorce or your Domestic Partner ceasing to be a Qualified Dependent, your Spouse or Domestic Partner has the right to apply for coverage under the Portability Plan during the Portability Application Period.

The Portability Application Period is the 45 day period after the Accidental Death and Dismemberment Coverage with respect to the dependent ends.

The form, amount, first premium, and effective date will be as stated below.

Form and Amount: The form of accident coverage for dependents that Prudential then makes available under the Portability Plan. The terms and conditions of that coverage will not be the same as those under the Group Contract.

Amount: Not more than the amount of insurance on the dependent under the Accidental Death and Dismemberment Coverage when that insurance ends. For each dependent, the maximum amount of accident insurance under the Portability Plan is the lesser of 5 times your annual Earnings and $1,000,000.

First Premium: The first premium is due to Prudential by the later of the end of the Portability Application Period and 31 days from receipt of the first bill.

Effective Date: The day after the Portability Application Period ends.

The rules in this section apply to insurance payable on account of your death, when the Coverage states that they do. But, if there is an assignment, these rules are modified by the Limits on Assignments section.

“Beneficiary" means a person chosen, on a form approved by Prudential, to receive the insurance benefits.

You have the right to choose a Beneficiary.

If there is a Beneficiary for the insurance under a Coverage, it is payable to that Beneficiary. Any amount of insurance under a Coverage for which there is no Beneficiary at your death will be payable to the first of the following: your (a) surviving Spouse or Domestic Partner; (b) surviving child(ren) in equal shares; (c) surviving parents in equal shares; (d) surviving siblings in equal shares; (e) estate. This order will apply unless otherwise provided in the Limits on Assignments.

You may change the Beneficiary at any time without the consent of the present Beneficiary. The Beneficiary change form must be filed through the Contract Holder. The change will take effect on the date the form is signed. But it will not apply to any amount paid by Prudential before it receives the form.

If there is more than one Beneficiary but the Beneficiary form does not specify their shares, they will share equally. If a Beneficiary dies before you, that Beneficiary's interest will end. It will be shared equally by any remaining Beneficiaries, unless the Beneficiary form states otherwise.

If you and a Beneficiary die in the same event and it cannot be determined who died first, the insurance will be payable as if that Beneficiary died before you.

The rules in this section apply to Accident Insurance payable on account of a Covered Person’s death. But these rules are subject to the Limits on Assignments section.

Insurance payable on account of a Covered Person’s death is normally paid to the Beneficiary in one sum. Subject to applicable law, where the amount of the benefit meets Prudential's current minimum requirement, payment in one sum will be made by establishing a retained asset account in the Beneficiary’s name, unless the Beneficiary elects another settlement or payment option available at the time of claim, including lump sum check, and the benefit distribution will be deemed complete when the account is established. The retained asset account is an interest-bearing draft account backed by the financial strength of Prudential. Funds are held in Prudential’s general account or elsewhere as Prudential may direct and an account in the Beneficiary’s name is credited interest at a rate set by Prudential’s discretion, subject to a minimum rate that will change no more than once every 90 days on advance notice to the Beneficiary. The Beneficiary is provided a draftbook and has immediate access to the entire amount by writing drafts for any amount up to the account balance. The retained asset account is not a bank account and is not insured by the Federal Deposit Insurance Corporation; it is a contractual undertaking between Prudential and the Beneficiary. Further information about the account is provided at the time of claim. Prudential may at its discretion provide other forms of payment in one sum. But another mode of settlement may be arranged with Prudential for all or part of the insurance, as stated below.

Arrangements for Mode of Settlement: You may arrange a mode of settlement by proper written request to Prudential.

If, at a Covered Person’s death, no mode of settlement has been arranged for an amount of the person’s Accident Insurance, the Beneficiary and Prudential may then mutually agree on a mode of settlement for that amount.

Conditions for Mode of Settlement: The Beneficiary must be a natural person taking in the Beneficiary's own right. A mode of settlement will apply to secondary Beneficiaries only if Prudential agrees in writing. Each installment to a person must not be less than $20.00. A change of Beneficiary will void any mode of settlement arranged before the change.

Choice by Beneficiary: A Beneficiary being paid under a mode of settlement may, if Prudential agrees, choose (or change the Beneficiary's choice of) a payee or payees to receive, in one sum, any amount which would otherwise be payable to the Beneficiary's estate.

Prudential has prepared information about the modes of settlement available. Ask the Contract Holder for this.

You may assign your insurance under a Coverage. Any rights, benefits or privileges that you have as an Employee may be assigned without restriction.

This includes any right you have to choose a Beneficiary or to convert to another contract of insurance. Prudential will not decide if an assignment does what it is intended to do. Prudential will not be held to know that one has been made unless it or a copy is filed with Prudential through the Contract Holder. This paragraph applies only to insurance for which you have the right to choose a Beneficiary, when that right has been assigned. If an assigned amount of insurance becomes payable on account of your death and, on the date of your death, there is no Beneficiary chosen by the assignee, it will be payable to:

1.  the assignee, if living; or
2.  the estate of the assignee, if the assignee is not living.

It will not be payable as stated in the Beneficiary Rules.

Active Work Requirement: A requirement that you be actively at work on a full time basis at the Employer's place of business or at any other place that the Employer's business requires you to go. You are considered actively at work during a normal vacation if you were actively at work on your last regularly scheduled workday.

Calendar Year: A year starting January 1.

Contributory Insurance, Non-contributory Insurance: Contributory Insurance is insurance for which the Contract Holder has the right to and may require your direct contribution to the cost of coverage. Non-contributory Insurance premiums are paid by the Contract Holder, usually without direct contribution from you. The rate for Non-contributory insurance may be determined, or in some cases, reduced, in part, based on your contributions for contributory insurance or other benefits offered to you under the Contract Holder benefit plan.

Coverage: A part of the Booklet consisting of: 

1. A benefit page labeled as a Coverage in its title.
2.  Any page or pages that continue the same kind of benefits.
3. A Schedule of Benefits entry and other benefit pages or forms that by their terms apply to that kind of benefits.

Covered Person under a Coverage: An Employee who is insured for Employee Insurance under that Coverage; a Qualified Dependent for whom an Employee is insured for Dependents Insurance, if any, under that Coverage.

Dependents Insurance: Insurance on the person of a dependent.

Doctor: A licensed practitioner of the healing arts acting within the scope of the license.

Earnings: This is the gross amount of money paid to you by the Employer in cash for performing the duties required of your job, determined as of January 1 of each year. Bonuses, overtime pay, Earnings for more than 40 hours per week, and all other benefits are not included.

Employee: A person employed by the Employer; a proprietor or partner of the Employer. The term also applies to that person for any rights after insurance ends.

Employee Insurance: Insurance on the person of an Employee.

The Employer: Collectively, all employers included under the Group Contract. Injury: Injury to the body of a Covered Person.

Injury: Injury to the body of a Covered Person.

Prudential: The Prudential Insurance Company of America.

Sickness: Any disorder of the body or mind of a Covered Person, but not an Injury; Sickness also includes pregnancy of a Covered Person, including abortion, miscarriage or childbirth.

You: An Employee.

These rules apply to payment of benefits under all accident Coverages

Notice of Claim: Prudential must be given written notice that a claim will be made. The notice must be given to Prudential within 20 days after the date of the loss. But failure to meet that time limit will not make the claim invalid if the notice is given as soon as reasonably possible.

Proof of Loss: Prudential must be given written proof of the loss including any requested documentation, such as a death certificate, for which claim is made under the Coverage. This proof must cover the occurrence, character and extent of that loss. A claim form will be furnished for submitting proof of loss. But, if you are not given a claim from within 15 working days after providing notice of claim, you must still submit the proof of loss.

Proof of loss must be furnished within 120 days after the date of the loss. But, if any Coverage provides for periodic payment of benefits at monthly or shorter intervals, the proof of loss for each such period must be furnished within 120 days after its end.

A claim will not be considered valid unless the proof is furnished within these time limits. However, it may not be reasonably possible to do so. In that case, the claim will still be considered valid if the proof is furnished as soon as reasonably possible.

When Benefits are Paid: Benefits are paid when Prudential receives written proof of the loss including any requested documentation, such as a death certificate. But, if a Coverage provides that benefits are payable at equal intervals of a month or less, Prudential will not have to pay those benefits more often.

To Whom Payable: Benefits are payable to you with these exceptions:

1. Benefits for Tuition reimbursement for your Spouse or Domestic Partner will be paid to:
   1.  your Spouse or Domestic Partner, if living; or
   2.  your Spouse's or Domestic Partner's estate, if your Spouse or Domestic Partner is not living.
2. Benefits for Tuition reimbursement for your child or child care expenses will be paid to the person or institution appearing to Prudential to have assumed the main support of your dependent children.
3. Benefits for any other of your Accidental Losses that are unpaid at your death or become payable on account of your death will be paid to your Beneficiary or Beneficiaries. (See Beneficiary Rules.)
   If you and a Beneficiary die in the same event and it cannot be determined who died first, benefits will be payable as if that Beneficiary died before you.
4.  If you are not living, benefits for a dependent’s Accidental Losses are payable to your Spouse or Domestic Partner if your Spouse or Domestic Partner is living.If neither you nor your Spouse or Domestic Partner is living, then:
   1. benefits for a Spouse's or Domestic Partner's Accidental Losses will be paid to your Spouse's or Domestic Partner's estate.
   2. benefits for any other dependents Accidental Losses will be paid to the dependent who suffered the Accidental Loss. If that dependent is not living, the benefits will be paid to that dependent’s estate.

Physical Exam and Autopsy: Prudential, at its own expense, has the right to examine the person whose loss is the basis of claim. Prudential may do this when and as often as is reasonable while the claim is pending. Prudential also has the right to arrange for an autopsy in case of accidental death, if it is not forbidden by law.

Legal Action: No action at law or in equity shall be brought to recover on the Group Contract until 60 days after the written proof described above is furnished. No such action shall be brought more than three years after the end of the time within which proof of loss is required.

This limits Prudential's use of a person’s statements in contesting an amount of that insurance for which the person is insured. These are statements made to persuade Prudential to effect an amount of that insurance. They will be considered to be made to the best of the person’s knowledge and belief. These rules apply to each statement:

1. It will not be used in a contest to avoid or reduce that amount of insurance unless:
   1.  It is in a written instrument signed by the person; and
   2. A copy of that instrument is or has been furnished to the person.
2. It will not be used in the contest after that amount of insurance has been in force, before the contest, for at least two years during the person’s lifetime.

It is the Plan Sponsor’s intention and direction that The Prudential Insurance Company of America as Claims Administrator has the sole discretion to interpret the terms of the plan, to make factual findings, and to determine eligibility for benefits. The Plan Sponsor has determined that benefits are payable under the plan only if The Prudential Insurance Company of America, in its sole discretion, determines that they are due. The decision of the Claims Administrator shall not be overturned unless arbitrary and capricious. *

* This paragraph does not apply to residents of AK, AR, CA, CO, DC, IL, KY, MD, ME, MI, NJ, NY, OR, PR, RI, SD, TX, VT, WA

The Group Contract underwritten by The Prudential Insurance Company of America provides insured benefits under your Employer/Policyholder/Plan Sponsor's ERISA plan(s). For all purposes associated with the plan or the Group Contract under which The Prudential Insurance Company of America provides benefits, the Employer/Policyholder/Plan Sponsor acts on its own behalf or as an agent of its employees. Under no circumstances will the Employer/Policyholder/Plan Sponsor be deemed the agent of The Prudential Insurance Company of America, absent a written authorization of such status executed between the Employer/Policyholder/Plan Sponsor and The Prudential Insurance Company of America. Nothing in these documents shall, of themselves, be deemed to be such a written authorization.

The insurance benefit coverages described in this Booklet are being offered to you under a single ERISA plan. Coverages described as non-contributory or as being paid entirely by the Employer/Policyholder/Plan Sponsor (if any) are those paid for directly by the Employer/Policyholder/Plan Sponsor such that you have no out of pocket expense for such coverages. However, the premium rate that the Employer/Policyholder/Plan Sponsor pays for insurance coverage offered to you under the Plan may be determined, or in some cases, reduced, in part, based on your contributions for other coverages or other benefits offered under the Plan. When this occurs, your contributions for one benefit coverage may cover some or all of the costs or plan expenses for another benefit coverage offered to you under the Plan.

You must continue to be a member of a class of eligible employees or beneficiaries to which the plan pertains and continue to make any contributions or payments that are due, including those you agreed to when you enrolled for coverage. Failure to make required contributions may result in partial or total loss of your benefits.

It is intended that this plan will be continued for an indefinite period of time. But, the Plan Sponsor reserves the right to change or terminate the plan at any time. This Booklet elsewhere describes your rights upon termination of the plan.

If your claim for benefits and any required appeals are denied (or not decided within the time periods discussed above), you may file suit as discussed below. If you elect to file suit, you should do so as soon as possible. However, you must file suit no later than three SPD (50757-43) years after proof of your claim was first due as explained elsewhere in this Booklet, regardless of whether your claim is still pending in the claim or appeal process.