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Contract - Madison National Life - 9/13/2018 NATIONAL INSURANCE SERVICES OF WISCONSIN INSURANCE TRUST JOINDER AGREEMENT FOR SHORT-TERM DISABILITY INSURANCE City of Round Rock (the"Employer")hereby requests application for participation in National Insurance Services of Wisconsin Insurance Trust(the"Trust")for group short-term disability insurance benefits under a master group policy underwritten by Madison National Life Insurance Company, Inc. (the"Insurer").The"Group Policy"means only the provisions of the master group policy that apply to the Employer,based upon the coverage requested under this Joinder Agreement. A. Administrative 1. Employer: City of Round Rock 221 East Main Round Rock,TX 78664 2. Plan Number: 1654 3. Nature of Business: Government 4. Frequency of Billing: Monthly 5. Plan Effective Date: January 1,2019 6. Coverage Replaced: SHORT-TERM DISABILITY 7. Prior Carrier: AETNA 8. Term Date of Prior Coverage: January 1,2019 B. Class and Benefit Summary Class Number: 01 Class Description: All Eligible Employees Employer Premium Contribution: 0% Premium Rate: $0.34 per$10 of Weekly Benefit Premium Rate Guarantee: 24 months until January 1,2021 Elimination Period(Injury): 14 days Elimination Period(Physical Disease): 14 days Minimum Hourly Requirement: 30 hours per week Waiting Period: None Evidence of Insurability Requirement: Required for Late Enrollees,Increases and amounts exceeding the Guarantee Issue Employee Eligibility Date: First of month following completion of the Waiting Period Minimum Participation Required: 20% City of Round Rock 1654 Page 1 Class Number: 01 Class Description: All Eligible Employees Leaves and Sabbaticals: Coverage with premium payment while on FMLA leave; Coverage with premium payment for up to 12 months while not Actively at Work due to a Physical Disease or Injury Definition of Disability: Zero-Day Residual Own Occupation Period: From the end of the Elimination Period to the end of the Maximum Benefit Period 24 hour coverage: No;Non-Occupational Only Recurrent Disability: 30 days Definition of Predisability Earnings: Base pay plus Commissions averaged over 12 months; Shift Differential STD Benefit Percentage: 60% Maximum Weekly Benefit: $1,000 Guarantee Issue: $1,000 Maximum Benefit Period: Commencing at the end of the Elimination Period and continuing for the lesser of 26 weeks, or until LTD Benefits commence.No STD Benefits will be paid for periods of time for which LTD Benefits are payable. Integration with Sick Pay: Direct Social Security Integration: Full Family Freeze: General Freeze Integration With Work Earnings: Direct Pre-Existing Condition Exclusion: 3 months/12 months -Initial amounts and coverage increases Claim Payment Method: Biweekly C. Payment of Premiums 1. Premium Due Date.Premium is due on the 1 st of the month to which coverage for such premium applies (e.g.,premium for coverage in October would be due October 1st) 2. The premium due on each Premium Due Date is the sum of the premiums for all Insured Persons under the Group Policy. Premium rates for each Employer covered under the Group Policy are shown in this Joinder Agreement. City of Round Rock 1654 Page 2 3. The Employer determines the amount,if any,of each Insured Person's contribution toward the cost of insurance. 4. Premiums due under the Policy must be remitted by the premium payor as designated in the policy: (1) on or before the due date; or b)within any grace period specified in this Joinder. 5. Premium is due for an Insured Person for each month in which such employee is covered under the Group Policy. The Employer must notify the Insurer immediately whenever an employee becomes eligible or ceases to be eligible for coverage. Effective dates of coverage or termination dates which occur mid-month will be billed as follows: c) If the effective date of coverage is between the 1 st of the month and 15th of the month, premium for an entire month will be due to the Insurer. If the effective date of coverage is between the 16th of the month and the end of the month the Employer will be billed for the next full month of coverage. The Insurer does not prorate premium. d) If the date coverage ends is between the 1st of the month and the 15th of the month,no premium will be due for that month. If the date of termination is between the 16th of the month and the end of the month the Employer will be responsible for an entire month's premium. 6. All premiums will be based upon information provided by the Employer in the Census Reports. D. Changes in Premium Rates. Premium rates will not be changed during the initial rate guarantee period except if any of the following occur: 1. A change or clarification in a law or governmental regulation affects the amount payable under the Group Policy. Any such change in premium rates will reflect only the change in the Insurer's obligations 2. Factors material to the underwriting risk the Insurer assumed under the Group Policy with respect to the Employer, including,but not limited to, the number of persons insured,age,Predisability Earnings, gender and occupational classification change significantly. 3. The premium contribution arrangement for insured employees changes or varies from that stated in this Joinder Agreement when issued or last renewed. 4. Plan design changes are requested by the Employer. 5. The Insurer and the Employer mutually agree to change premium rates. After the rate guarantee has ended,rates may be changed at any time. In all cases the Insurer shall provide written notice to the Employer at least sixty(60)days prior to the effective date of any premium change. Such notice will state the amount of the change and the date on which the change is to take effect. E. Premium Adjustments.Premium adjustments involving a return of unearned premiums to an Employer will be limited to the 12 months just before the date the Insurer receives a request for premium adjustment. City of Round Rock 1654 Page 3 F. Information Required from Employer 1. The Employer will furnish all information reasonably necessary to administer the Group Policy, including but not limited to the following: a) At least one Census Report during each plan year,no later than six months prior to the next plan renewal date. The Census Report means a written report providing the following information for each Employee insured under the Group Policy: name,social security number,date of birth, gender, occupational class, annual Pre-disability Earnings as defined under the Group Policy and the amount of coverage. b) A list of all eligible employees and documentation supporting employee eligibility under the Group Policy. c) Information about employees who become eligible,whose amounts of coverage change and/or whose coverage ends. d) Occupational information and any other information that may be required to manage a claim. e) Notification of the Employer's change in legal status, expansion of business,dissolution, merger,buyout or any other significant business operational change. f) Notice of any additional eligible employee segment(s). g) Any other information that may be reasonably required. 2. The Employer must provide such information to the Insurer or its agents in a regular and timely manner as may be reasonably specified by the Insurer and/or its agents. The Insurer and its agents have the right at all reasonable times to inspect the payroll and other records of the Employer which relate to insurance under the Group Policy. G. Grace Period and Termination for Nonpayment 1. If a premium is not paid on or before its Premium Due Date,it may be paid during the Grace Period. The coverage under the Group Policy will remain in force during the Grace Period. 2. Grace Period means the 31 days following the Premium Due Date. 3. If the premium for coverage is not paid during the Grace Period,the coverage under the Group Policy will terminate automatically at the end of the Grace Period. 4. The Employer is liable for premium for coverage during the Grace Period. The Insurer may charge interest at the legal rate for any premium which is not paid during the Grace Period, beginning with the first day after the Grace Period. H. Termination for Other Reasons 1. The Policyowner may terminate the Group Policy and the Employer may terminate coverage under the Group Policy by giving the Insurer at least 60 days written notice. The effective date of termination will be the later of: a) The date stated in the notice; or b) The Premium Due Date immediately following the Insurer's receipt of the written notice. 2. The Insurer may terminate coverage under the Group Policy as follows: a) On any Premium Due Date if the number of persons insured is less than the minimum participation number or less than the minimum participation percentage provided for under this Joinder Agreement. City of Round Rock 1654 Page 4 b) On any Premium Due Date if the Insurer determines that the Employer has failed to promptly furnish any necessary information requested or has failed to perform any other obligations relating to the Group Policy or coverage under the Group Policy. c) On any Premium Due Date by giving the Employer at least 60 days advance written notice. d) On the date the Employer breaches any part of the Entire Contract. I. Certificates. The Insurer will prepare Group Short Term Disability Certificates of Coverage setting forth the main features of the Group Policy applicable to each Insured Person. The Insurer and Employer may agree to distribute the Certificates to Insured Persons in paper format,or to make the document available and accessible for review by Insured Persons on the Employer's website. The Employer will be responsible for providing sufficient notice to the Insured Person of the existence and availability of the Certificate, including instructions on how to view the document,and a statement that a paper copy of the document will be made available upon request. Upon receiving such a request from either the Employer or Insured Person,the Insurer will provide a written copy of the Certificate to the Employer for distribution to the Insured Person. If the terms of the Certificate of Coverage differ from the terms of the Employer's coverage under the Group Policy,the latter will govern. J. Agency and Release. Individuals selected by the Employer to secure coverage under the Group Policy or to perform their administrative function under it,represent and act on behalf of the person selecting them and do not represent or act on behalf of Madison National Life Insurance Company. The Policyowner,Employer and such individuals have no authority to alter,expand or extend the Insurer's liability or to waive,modify or compromise any defense or right the Insurer may have under the Group Policy. The Policyowner and Employer hereby release,hold harmless and indemnify Madison National Life Insurance Company from any liability arising from or related to any negligence,error, omission,misrepresentation or dishonesty of the Policyowner or Employer respectively, or any of their respective representatives, agents or employees. K. Notice of Suit.The Policyowner and Employer shall promptly give the Insurer written notice of any lawsuit or other legal proceedings arising under the Group Policy. L. Entire Contract and Changes 1. The Group Policy,the Group Short Term Disability Insurance Certificate of Coverage,the Employer Joinder Agreement,the applications of the Policyowner,Employers and employees and any applicable riders,addenda and/or amendments constitute the Entire Contract. 2. The Group Policy may be changed in whole or in part.No change in the Group Policy will be valid unless it is approved in writing by one of the Insurer's executive officers and given to the Policyowner for attachment to the Group Policy. No change in an Employer's coverage under the Group Policy will be valid unless it is approved in writing by one of the Insurer's executive officers and given to the Employer for attachment to their Joinder Agreement. No agent has authority to change the Group Policy or an Employer's coverage under the Group Policy or to waive any provisions thereof. M. Effect on Workers' Compensation, State Disability Insurance.The coverage provided under the Group Policy is not a substitute for coverage under a Workers' Compensation or state disability income benefit law and does not relieve the Employer of any obligation to provide such coverage. City of Round Rock 1654 Page 5 N. The undersigned Employer adopts and agrees to be bound by the terms and conditions of National Insurance Services of Wisconsin Insurance Trust Trust Agreement, as amended from time to time (the "Trust Agreement")and master group policy. Copies of these documents are available for employer review at Madison National Life Insurance Company, 1241 John Q. Hammons Drive,Madison,WI 53717. O. The Trust is a vehicle for obtaining group insurance plans in which employers join together as a single policyowner for the purchase and maintenance of group insurance policies. P. The Trust's Administrator shall provide participating employers the necessary information for applicable State and Federal compliance reporting requirements. Q. The signatures below constitute acceptance of the undersigned employer as a participating member of the Trust. Signed into effect this [S-Mday of 20� ova, 14&1 A Signature of Aut orized E oyee of Employer Prin"amele of Authorid Employee Signature of Authorized Employee of Employer Printed Name&Title of Authorized Employee Administrator: National Insurance Services of Wisconsin, Inc. Y Bruce A. Miller,President October 2,2018 City of Round Rock 1654 Page 6 Madison National Ufc nsurance Companv NOTICE OF PRIVACY PRACTICES AND PROTECTION This PrivacyNotice is provided for your information --keep a c0PY of it foryour records. No response is required or requested. ' Customer Pri-vary Is Our Business - INVe value our relationship with authorities,or as authorized or requested by an'nib-tired individual. Such our customers and are dedicated to providing them with exceptional disclosures include,but are not limited to-- service and competitive product offers- As part of our dedication to Affiliates—we may provide information to affiliated companies to servicing their insurance needs, ive are committed to protecting the p enable them to provide business services for us such as claims confidentiality of nonpublic personal information about our customers. processm.01,undenwitIng-,and maintenance of your accounts_and to This Privacy-Notice will help you understand what type of information offer products and services we provide. ,ve collect about insured individuals,how the information we collect.is Agents and Brokers­kve may provide information to enable agents used,and what measures Ave take to protect that information- and brokers to prc"Ade business services for us and to offer products and:services we provide. What Information We Collect And How NVe Collect It-Depending a Joint IMarketig — we may provide Uilforniation to non-affiliated on the type of product,-,ve collect nonpublic personal information about insured individuals that may-include: third parties to jointly market-insurance products or services. ■ 0 Lending Institutions­kve may,provide information to non-affiliated address, telephonenumber, lendin'a institutions, such as banks and credit unions, to offer social:security number- for and services ,ire provide, and to provide business services for us- account information, Government Entitles a income. les —we may. provide information upon request from a State Department of Insurance or other government ent1tv & employment- The purpose for the request may be to prevent fraud,- , conduct an health status,and audit of our business practices,or for ani reason for which the other personal information relevant to their coverage. government entity is legally permitted to request information Servicingorganizations- .are may provide information ic' We collect such inforriiation primarily from information we receive from organizations Ion to servi ing organiz: ions such as TPAs. reinsurers, attorneys, accountants, individuals on applications or other forms. «re may also collect actuaries,undenwiters,and other such organizations to enable them information through telephone conversations or other electronic means- to provide business seri;ices for us- such as Internet "cookies-' (data stored on a computer bar an Internet browser,ashen you use the internet to access our kvebsite) that may be We do not share, trade. sell, exchange or in any other way disclose used to track-website usage,remember passwords customers create, and nonpublic personal information except as stated abave or to otherwise ic provide customers with website content specific to their needs and conduct the business of insurance. interests. We may also obtain information from third parties such as employers. non-affiliated -insurers, physicians, hospitals and other About this Pri a Notice - examples contained in this Privacv 'v' cN 'NO The e am s co aine medical providers- Notice are provided as illustrations and are not a comprehensive account of the rights of any party under applicable federal and state laws. The How Information Is Protected - 11.7p, restrict access to nonpublic policies and protections indicated in this Privaq,! -Notice w-11 remain personal information I emain inf rination to those employees who need to know that effective even after an jndivldual�s coverage is terminated.to the extent information to provide products or services to our customers. Fire we retain information about that individual. We may change this Pnivacn, maintain physical, electronic, and procedural safeguards that comply Notice at any time and ivill 'uformyou of any changer, as required by il.'Ith federal and state regulations to guard such information- law- Other applicable privacy ons may under state]a-,vs and Information about'insured individuals is accessed by our employees only -%-e will comply v exi with all applicable state laws 1,vhen we disclose wlien such access is necessan,to conduct our business. For example,we information about individual insureds. may access information to offer other compatible products or services we Qrol4de-to process customer requests,and to administer our products or This Privaev Notice is distributed on behalf of the followmi services. All employees are required to maintain the confidentiality, of Independence Holding Company entities and their affiliated nonpublic personal information and to follow policies we establish to organizations: secure such confidentiality. Additionally, we require third parties to tvhom we disclose nonpublic -'Standard SecurityLife Insurance Company of New York personal.information, or who receive or handle such information on our -Madison National Life Insurance Company,Inc. behalf to adhere to our standard of i i n and to establish Independence American Insurance Company information security procedures.. Privacy protectio For additional information,contact us at: Disclosure-11-Te do not disclose any nonpublic personal a'iforination about our customers of former customers to anyone,except as permitted Attn-Privacy Officer by law. Information will only'be disclosed for such purposes as Post Office Box 5008 conducting and auditing,our business,administering the business of Madison,Ison.WI 53705 affiliated organizations.responding to requests from goverment NATIONAL INSURANCE SERVICES OF WISCONSIN INSURANCE TRUST JOINDER AGREEMENT FOR LONG-TERM DISABILITY INSURANCE City of Round Rock (the"Employer")hereby requests application for participation in National Insurance Services of Wisconsin Insurance Trust(the"Trust")for group long-term disability insurance benefits under a master group policy underwritten by Madison National Life Insurance Company, Inc. (the"Insurer").The"Group Policy"means only the provisions of the master group policy that apply to the Employer,based upon the coverage requested under this Joinder Agreement. A. Administrative 1. Employer: City of Round Rock 221 East Main Round Rock,TX 78664 2. Plan Number: 1653 3. Nature of Business: Government 4. Frequency of Billing: Monthly 5. Original Plan Effective Date: January 1,2019 6. Coverage Replaced: LONG-TERM DISABILITY 7. Prior Carrier: AETNA 8. Term Date of Prior Coverage: January 1, 2019 B. Class and Benefit Summary Class Number: 01 Eligible Class: All Eligible Employees Employer Premium Contribution: 100% Initial Premium Rate: $0.14 per$100 of covered payroll Initial Premium Rate Guarantee: 36 months until January 1,2022 Elimination Period: 180 consecutive calendar days Minimum Hourly Work Requirement: 30 hours per week Waiting Period: None Evidence of Insurability: Required for Late Enrollees, Increases and amounts exceeding the Guarantee Issue New Employee Eligibility Date: First of month following completion of the Waiting Period Minimum Participation Required: 100% Leaves and Sabbaticals: Coverage with premium payment while on FMLA leave; Coverage with premium payment for up to 12 months while not Actively at Work due to a Physical Disease or Injury City of Round Rock 1653 Page I Class Number: 01 Eligible Class: All Eligible Employees Definition of Disability: Zero Day Own Occupation Period: 24 months following the end of the Elimination Period Any Occupation Period: From the end of the Own Occupation Period to the end of the Maximum Benefit Period Cumulative Elimination Period: 30 Working Days Recurrent Disability: 6 months Predisability Earnings: Base pay plus Commissions averaged over 12 months; Shift Differential Maximum Monthly Covered Salary: $8,333 LTD Benefit Percentage: 60% Maximum Monthly Benefit: $5,000 Guarantee Issue: $5,000 Work Incentive Period: First 12 months of Disability with Work Earnings LTD Benefit Calculation: Standard-Non-Contract Day Social Security Integration: Full Family Freeze Type: General Freeze Pre-Existing Condition Exclusion: 3 months/12 months-Initial amounts and coverage increases Mental Disorder Limitation: 24 Months unless hospital confined, with recovery Substance Abuse Limitation: 24 Months unless hospital confined,with recovery Claim Payment Method: Monthly Rehabilitation Benefit: Included Survivor Benefit: Included City of Round Rock 1653 Page 2 Maximum Benefit Period: Age at Benefit Disablement Duration* 61 or younger to age 65 62 3-1/2 years 63 3 years 64 2-1/2 years 65 2 years 66 1-3/4 years 67 1-1/2 years 68 1-1/4 years 69 or older 1 year *To the later of. 1)the specified length of time as stated above,or 2)the day before attaining the Social Security Normal Retirement Age under the United States Social Security Act,as revised. C. Payment of Premiums 1. Premium Due Date.Premium is due on the 1st of the month to which coverage for such premium applies(e.g.,premium for coverage in October would be due October 1S) 2. The premium due on each Premium Due Date is the sum of the premiums for all Insured Persons under the Group Policy. Premium rates for each Employer covered under the Group Policy are shown in the Employer's Joinder Agreement. 3. The Employer determines the amount, if any, of each Insured Person's contribution toward the cost of insurance. 4. Each premium is payable on or before its Premium Due Date directly to the Insurer at their home office. 5. Premium is due for an Insured Person for each month in which such employee is covered under the Group Policy. The Employer must notify the Insurer immediately whenever an employee becomes eligible or ceases to be eligible for coverage. Effective dates of coverage or termination dates which occur mid-month will be billed as follows: a) If the effective date of coverage is between the 1st of the month and 15th of the month, premium for an entire month will be due to the Insurer. If the effective date of coverage is between the 16th of the month and the end of the month the Employer will be billed for the next full month of coverage. The Insurer does not prorate premium. City of Round Rock 1653 Page 3 b) If the date coverage ends is between the 1 st of the month and the 15th of the month,no premium will be due for that month. If the date of termination is between the 16th of the month and the end of the month the Employer will be responsible for an entire month's premium. 6. All premiums will be based upon information provided by the Employer in the Census Reports. D. Changes in Premium Rates. 1. Special Circumstances. The Insurer may change premium rates,to be effective on the next Premium Due Date,if any of the following occur: a) A change or clarification in a law or governmental regulation affects the amount payable under the Group Policy. Any such change in premium rates will reflect only the change in the Insurer's obligations. b) One or more changes occur in the factors material to the underwriting risk the Insurer assumed under the Group Policy with respect to the Employer, including,but not limited to, the number of persons insured, age,Predisability Earnings,gender and occupational classification. c) The premium contribution arrangement for insured employees changes or varies from that stated in the Employer's Joinder Agreement when issued or last renewed. d) Plan design changes are requested by the Employer. e) The Insurer and the Employer mutually agree to change premium rates. 2. In all other cases, and subject to a period for which the Insurer has provided the Employer with a written rate guarantee,the Insurer may change premium rates upon 90 days advance written notice to the Employer. Any such change in premium rates may be made effective on any Premium Due Date,but no such change will be made more than once in any Contract Year. Contract Years means successive 12-month periods computed from the end of the initial rate guarantee period, or from a time agreed to in writing by the Employer and Insurer. E. Premium Adjustments.Premium adjustments involving a return of unearned premiums to an Employer will be limited to the 12 months just before the date the Insurer receives a request for premium adjustment. F. Information Required from Employer 1. The Employer will furnish all information reasonably necessary to administer the Group Policy, including but not limited to the following: a) At least one Census Report during each plan year,no later than six months prior to the next plan renewal date.The Census Report means a written report providing the following information for each Employee insured under the Group Policy: name,social security number, date of birth,gender, occupational class,annual Pre-disability Earnings as defined under the Group Policy and the amount of coverage. b) A list of all eligible employees and documentation supporting employee eligibility under the Group Policy. c) Information about employees who become eligible,whose amounts of coverage change and/or whose coverage ends. d) Occupational information and any other information that may be required to manage a claim. e) Notification of an Employer's change in legal status, expansion of business, dissolution, merger,buyout or any other significant business operational change. City of Round Rock 1653 Page 4 f) Notice of any additional eligible employee segment(s). g) Any other information that may be reasonably required. 2. The Employer must provide such information to the Insurer or its agents in a regular and timely manner as may be reasonably specified by the Insurer and/or its agents.The Insurer and its agents have the right at all reasonable times to inspect the payroll and other records of the Employer which relate to insurance under the Group Policy. G. Grace Period and Termination for Nonpayment 1. If a premium is not paid on or before its Premium Due Date,it may be paid during the Grace Period. The coverage under the Group Policy will remain in force during the Grace Period. 2. Grace Period means the 31 days following the Premium Due Date. 3. If the premium for coverage is not paid during the Grace Period,the coverage under the Group Policy will tenninate automatically at the end of the Grace Period. 4. The Employer is liable for premium for coverage during the Grace Period. The Insurer may charge interest at the legal rate for any premium which is not paid during the Grace Period, beginning with the first day after the Grace Period. H. Termination for Other Reasons 1. The Policyowner may terminate the Group Policy and the Employer may terminate coverage under the Group Policy by giving the Insurer at least 60 days written notice. The effective date of termination will be the later of- a) fa) The date stated in the notice; or b) The Premium Due Date immediately following date the Insurer receives the notice. 2. The Insurer may terminate coverage under the Group Policy as follows: a) On any Premium Due Date if the number of persons insured is less than the minimum participation number or less than the minimum participation percentage provided for under Employer's Joinder Agreement. b) On any Premium Due Date if the Insurer determines that the Employer has failed to promptly furnish any necessary information requested or has failed to perform any other obligations relating to the Group Policy or coverage under the Group Policy. c) On any Premium Due Date by giving the Employer at least 60 days advance written notice. d) On the date the Employer breaches any part of the Entire Contract. I. Certificates.The Insurer will prepare Group Long Term Disability Certificates of Coverage setting forth the main features of the Group Policy applicable to each Insured Person. The Insurer and Employer may agree to distribute the Certificates to Insured Persons in paper format,or to make the document available and accessible for review by Insured Persons on the Employer's website. The Employer will be responsible for providing sufficient notice to the Insured Person of the existence and availability of the Certificate, including instructions on how to view the document, and a statement that a paper copy of the document will be made available upon request. Upon receiving such a request from either the Employer or Insured Person,the Insurer will provide a written copy of the Certificate to the Employer for distribution to the Insured Person. If the terms of the Certificate of Coverage differ from the terms of the Employer's coverage under the Group Policy,the latter will govern. City of Round Rock 1653 Page 5 J. Agency and Release. Individuals selected by the Employer to secure coverage under the Group Policy or to perform their administrative function under it,represent and act on behalf of the person selecting them and do not represent or act on behalf of Madison National Life Insurance Company. The Policyowner,Employer and such individuals have no authority to alter,expand or extend the Insurer's liability or to waive,modify or compromise any defense or right the Insurer may have under the Group Policy. The Policyowner and Employer hereby release,hold harmless and indemnify Madison National Life Insurance Company from any liability arising from or related to any negligence,error, omission,misrepresentation or dishonesty of the Policyowner or Employer respectively, or any of their respective representatives, agents or employees. K. Notice of Suit. The Policyowner and Employer shall promptly give the Insurer written notice of any lawsuit or other legal proceedings arising under the Group Policy. L. Entire Contract and Changes 1. The Group Policy,the Group Long Term Disability Insurance Certificate of Coverage, the Employer Joinder Agreement, the applications of the Policyowner,Employers and employees and any applicable riders,addenda and/or amendments constitute the Entire Contract. 2. The Group Policy may be changed in whole or in part. No change in the Group Policy will be valid unless it is approved in writing by one of the Insurer's executive officers and given to the Policyowner for attachment to the Group Policy. No change in an Employer's coverage under the Group Policy will be valid unless it is approved in writing by one of the Insurer's executive officers and given to the Employer for attachment to their Joinder Agreement. No agent has authority to change the Group Policy or an Employer's coverage under the Group Policy or to waive any provisions thereof. M. Effect on Workers' Compensation, State Disability Insurance. The coverage provided under the Group Policy is not a substitute for coverage under a Workers' Compensation or state disability income benefit law and does not relieve the Employer of any obligation to provide such coverage. N. The undersigned Employer adopts and agrees to be bound by the terms and conditions of National Insurance Services of Wisconsin Insurance Trust Trust Agreement,as amended from time to time(the "Trust Agreement")and master group policy. Copies of these documents are available for employer review at Madison National Life Insurance Company, 1241 John Q.Hammons Drive,Madison,WI 53717. O. The Trust is a vehicle for obtaining group insurance plans in which employers join together as a single policyowner for the purchase and maintenance of group insurance policies. P. The Trust's Administrator shall provide participating employers the necessary information for applicable State and Federal compliance reporting requirements. City of Round Rock 1653 Page 6 Q. The signatures below constitute acceptance of the undersigned employer as a participating member of the Trust. Signed into effect this 13�day of �Pr�*"9-Z L ,20�. Signature of Authori d mp yee of Employer Printed ame&Tit e of uthoriz d Employee Signature of Authorized Employee of Employer Printed Name&Title of Authorized Employee Administrator: National Insurance Services of Wisconsin,Inc. r Ey. Bruce A.Miller,President October 1,2018 City of Round Rock 1653 Page 7 Madison National Liffe Insurance Company A Member of The 1HC1 GirOUP NOTICE OF PRIVACY PRACTICES AND PROTECTION This Privacy Notice is provided for your information—keep a copy of it for your records. No response is required or requested. Customer Privacy Is Our Business-a't'e value our relationship with authorities,or as authorized or requested by an insured individual. Such our customers and are dedicated to providing them. vrith exceptional disclosures include,but are not limited to: service and competitive product offers. As part of our dedication to * AHiliates—we may provide information to affiliated companies to servicing their insurance needs, we are committed to protecting the enable them to provide business services for us such as claims confidentiality of nonpublic personal information about our customers. processing,underwriting,and maintenance of your accounts,and to This Privacy Noticetvill help you understand what type of information offer products and sen ices we provide. %ve collect about insured individuals, how the information we collect is a Agents and Brokers—we may provide information to enable agents used,and u--hatmeasureswe take to protect that information. and broken to provide business services for us and to offer products and services we provide. '%Nlat Information Nile Collect And How We Collect It-Depending aJoint Marketing — %ve may provide information to non-affiliatedon the type of product,we collect nonpublic personal information about third parties to jointly market insurance products or services. insured individuals that may include. Lendmig Institutions—we may provide injf6nnation to non-affiliated • address, lending institutions, such as banks and credit unions, to offer • telephone number, products and services we provide,and to provide business services • social security number, for us, • account infbrluation, Government Entities—we may provide informati ton upon request income, from a State Department of Insurance or other government tntiq,, emplo)vient- The purpose for the request may be to prevent fraud, conduct an health status,and audit of our business practices,or for any other reason for which the other personal information relevant to their co^c erage. goy em entity is legally permitted to request inforruation. 3ervicing organizations-we may Provide information.to servicing We collect such information primarily from information we receive from organizations such as TPAs, reinsurers, attorneys, accountants, individuals onapplications or other forms. lVe may also collect actuaries,undenwiters,and other such organizations to enable them information through telephone conversations or other electronic means, to provide business services for us, such as internef "cookies" (data stored on a computer by an intemet browser when you use the internee to access our website)that may be NVe do not share, trade, sell, exchange or in any other uray disclose used to track website usage,remember passwords customers create, and nonpublic personal information except as stated above or to othenNise provide customers with website content specific to their needs and conduct the business of insurance, interests. We may also obtain information from third parties such as employers, non-affiliated insurers, physicians, hospitals and other About this Privacy Notice - The examples contained in this Privacy medical providers. Notice are provided as illustrations and are not acomprehensive account of the rights of any,party.=under applicable federal and state laws. The How Information Is Protected - NVe restrict access to nonpublic policies and protections indicated in this Privacy Notice will remain personal information to those employees who need to know that effective even after an individual's coverage is terminated,to the extent information to provide products or services to our customers. We we retain information about that individual. We may change this Privacy maintain physical, electronic, and procedural safeguards that comph- '.Notice at any time and v611 inform you of any changes as required by with federal and state regulations to -guard such information. law- Other applicable Privacy protections may exist under state laws and Information about insured individuals is accessed by our employees only we *will comply with all applicable state laws when, we disclose when such access is necessary to conduct our business. For example,we information about individual insureds. may, access information to offer other compatible products or services we provide,to process customer requests,and to administer our products or This Privacy Notice is distributed on behalf of the follolving services. All employees are required to maintain the confidentiality of Independence Holding Company entities and their affiliated nonpublic personal information and to follow policies we establish to or anizatio secure such confidentiality. % Ly ns Additionally, we require third parties to NA-hom we disclose nonpublic Standard Security Life Insurance Company of New York Madison National Life Insurance Company,Inc. personal infomiation,or who receive or handle such information on our Independence American Insurance Company behalf,to adhere to our standard of Privacy protection and to establish information security procedures. For additional 'mformation,contact us at: Disclosure-We do not disclose any nonpublic personal information Attn:Privacy Officer about our customers or former customers to anyone,except as permitted by,law. Information'"ill only be disclosed for such purposes as Post Office Box 5008 conducting and auditing our business,administering the business of Madison,All 53705 affiliated organizations,responding to requests from government