Mutual of Omaha Insurance Company





Voluntary
Accidental Death and Dismemberment Insurance
Program





Made Available By:


COLORADO HIGHER EDUCATION
INSURANCE BENEFITS ALLIANCE TRUST
(CHEIBA TRUST)















MC31649_1106 (51299)
Policy Form T66BA Series 13456




In spite of our best efforts, serious accidents can and do happen every day. If a serious accident occurs, your primary concern
should be recovering from the injury, not the financial burden such an accident can create.

Mutual of Omaha’s AD&D insurance is a voluntary program offered by the CHEIBA Trust. It is designed to help provide you
with peace of mind against the risk of covered injuries, or death. This coverage is so important because it offers both living and
death benefits. It can be used to cover the cost of hospitalization, rehabilitation, or to replace lost income in the case of an
accidental death. You can rely on Mutual of Omaha’s solid reputation and trusted name to provide security when you need it
most.


ELIGIBILITY
All exempt faculty and administrative personnel who are employed* by the colleges on a .50 full-time equivalent or more; or who
are eligible for insurance under the rules and regulations of the college by which they are employed and their eligible dependents.

Coverage is provided for your eligible family members only if you apply for coverage for them and pay the required premium.
Family members eligible include an Employee’s (a) legal spouse; and (b) an Employee’s unmarried child(ren) who are primarily
dependent upon the Employee for support and maintenance (i) until the end of the month of their 25th birthday, or (ii) of any age
who are medically certified by a physician as disabled. Dependents must satisfy the requirements of the Internal Revenue Code to
qualify as a tax dependent of the Employee and satisfy the eligibility requirements for coverage under a Benefit Plan. A
Dependent may also include a child for whom the Employee is required to provide health benefits pursuant to a court order or a
qualified medical child support order. Your eligible children shall include any legally adopted children and foster children
provided they are dependent on you for support and maintenance.

*”Employed” means all exempt faculty and administrative personnel of an Employer that are regularly scheduled to work at least
.5 FTE and that are included on the payroll records of the Employer. Leased Employees, independent contractors and part-time
Employees who work less than .5 FTE are not eligible. Eligible Employees on an authorized leave of absence not to exceed a 24
consecutive month period, including Employees on sabbatical and summer break, are included as eligible Employees until the
Employer notifies the Insurance Company of termination of eligibility.

Eligibility is extended to include the following named Colleges/Universities: Adams State College, Auraria Higher Education
Center, Colorado School of Mines, Colorado State University at Pueblo, Fort Lewis College, Metropolitan State College of
Denver, University of Northern Colorado and Western State College.

NOTE: No eligible person may be covered more than once under this plan. If they are covered as an employee, they
cannot, at the same time, be covered as a dependent of another employee.


COVERAGE
This plan offers protection on a worldwide basis, 24 hours a day, 365 days a year against any covered accident in the course of
business or pleasure, including accidents on or off the job, in or away from the home, commuting, traveling by train, airplane,
automobile or other private and public conveyances. It also covers accidents while riding as a passenger (not as a pilot or member
of a crew) and getting on or off: (a) any licensed civilian aircraft or its foreign equivalent; (b) any transport-type aircraft operated
by the Military Airlift Command, the Department of National Defence (Canada) and the Royal Air Force Air Transport Command
of Great Britain; or (c) any aircraft of the United States Department of Defense, other than a single-engine jet. The benefits
provided herein are payable in addition to any other insurance which may be in effect at the time of the accident.


EFFECTIVE DATE OF COVERAGE
Your insurance is effective on the later of: (a) the policy effective date; or (b) the first day of the month following the date the
Policyholder receives your completed enrollment form and payroll deduction authorization.


BENEFITS
Accidental Death and Specific Loss
When you or a dependent suffers any of the following specific losses because of injuries within 12 months from the date of the
accident, we will pay for loss of:
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Life .............................................................................................................................. Principal Sum
Both Hands or Both Feet or Both Eyes ........................................................................ Principal Sum
One Hand and One Foot .............................................................................................. Principal Sum
One Hand and One Eye or One Foot and One Eye ...................................................... Principal Sum
Speech and Hearing ..................................................................................................... Principal Sum
One Hand or One Foot or One Eye ............................................................... One-half Principal Sum
Speech or Hearing ......................................................................................... One-half Principal Sum
Thumb and Index Finger of the Same Hand .............................................. One-fourth Principal Sum

If you or your covered dependent suffers multiple losses due to the same accident, only one benefit amount – the largest to which
you are entitled – is payable. Loss of hand, hands, foot or feet means actual severance at or above the wrist or ankle joint. Loss of
eye or eyes, speech or hearing means total, uncorrectable and irrecoverable loss of the entire sight, speech or hearing.


Hemiplegia, Paraplegia and Quadriplegia Benefits
When you or your covered dependent suffer injuries which result in hemiplegia, paraplegia, or quadriplegia commencing within 60
days after the accident and continuing for one year, we will pay benefits as follows:

For hemiplegia ................................................................................................. 50% of Principal Sum
For paraplegia .................................................................................................. 75% of Principal Sum
For quadriplegia ............................................................................................ 100% of Principal Sum

Only one of the amounts (the largest applicable) named above or in the Benefits For Specific Loss provision, will be paid for
injuries from one accident.


Accident Only Coma Benefit
If as a result of Injuries due to a covered accident, the Insured or covered dependent becomes Comatose within the 7 day Loss
Period and remains Comatose beyond the 31 day Waiting Period, We will pay a benefit equal to 5% of their Principal Sum.
Benefits will end on the earlier of: (a) the end of the month in which the Insured or covered dependent dies; (b) the date on which
We have paid this benefit up to the 20 month benefit period; or (c) the end of the month in which the Insured or covered dependent
recovers from the Coma.


Seat Belt Usage
When you or a covered dependent receives injuries covered by the policy which result in loss of life, we will pay an additional
10% of the Principal Sum not to exceed $10,000 if, at the time of the accident, you were the operator of or a passenger in a private
passenger automobile and utilizing a seat belt. Seat belt usage must be verified by a doctor, coroner, traffic officer or other person
of competent authority.


Education Benefits
If a dependent child is enrolled in and attending either the 12th grade or an accredited college or university on the date of a covered
accident which results in your death, we will pay 5% of your Principal Sum or $5,000 per child per year, whichever is less, for
each year of full-time uninterrupted college or university attendance completed during the four consecutive years following the
child’s graduation from the 12th grade. If on the date of the accident no dependent children insured under the policy qualify for this
benefit, we will pay $1,000 to your beneficiary.


Surviving Spouse Training Benefit
If you have family coverage and suffer loss of life in a covered accident, we will pay your surviving spouse within 54 months from
the date of the accident, the expense incurred for any licensed professional or trade school training program not to exceed $5,000.
This benefit is payable provided the spouse has: (a) enrolled for the purpose of obtaining an independent source of support or
maintenance; (b) successfully completed the program; and (c) received a certificate or degree upon completion.

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Premium Waiver
If you, due to a covered injury, suffer loss of life, coverage for any insured dependents will continue without premium payment
until whichever of the following occurs first: (a) the date your spouse remarries; (b) the date the insurance terminates; (c) the date
an unmarried dependent child ceases to be eligible due to age or marriage; or (d) the date the 12 month Benefit Period ends.


Exposure and Disappearance
If, while insured under the policy, an Insured or a dependent is unavoidably exposed to the elements because of a covered accident
which results in the disappearance, sinking or damaging of a conveyance on which the Insured or dependent is covered by the policy
and in which the Insured or dependent was riding, and if as a result of such exposure the Insured or dependent suffers a loss for which
benefits are otherwise payable hereunder, such loss will be covered under the policy.

If, while insured under the policy, an Insured or dependent disappears because of a covered accident resulting in the sinking or
disappearance of a conveyance on which the Insured or dependent is covered by the policy and in which the Insured or dependent was
riding, and if the body of the Insured or dependent has not been found within 52 weeks after the date of such accident, it will be
presumed, subject to no evidence to the contrary, that the Insured or dependent suffered loss of life as a result of injuries covered by
the policy.


AGE REDUCTION SCHEDULE
Principal Sum Benefits for Insureds age 70 and over shall be payable according to the following schedule:

Insureds ages 70 through 74 .......................................... receive 65% of their original Principal Sum
Insureds ages 75 through 79 .......................................... receive 45% of their original Principal Sum
Insureds ages 80 through 84 .......................................... receive 30% of their original Principal Sum
Insureds age 85 and over .............................................. receive 15% of their original Principal Sum


EXCLUSIONS
This plan does not cover: (a) expense or loss for suicide while snae; (b) expense or loss for intentionally self-inflicted injury while
sane; (c) loss caused by act of declared or undeclared war; (d) injuries received while participating in training exercises or
maneuvers of an armed service while a member of an armed service; (e) injuries received while traveling by air (except as
provided under the Coverage section); (f) injuries received because the insured person was under the influence of any controlled
substance unless administered on the advise of a physician; (g) injuries received because the insured person was intoxicated; or (h)
injuries received while traveling in any aircraft which is owned or leased by: (1) the Policyholder, subsidiary or affiliate of the
Policyholder; or (2) a director, officer or employee of the Policyholder, subsidiary or affiliate of the Policyholder.


PAYMENT OF CLAIMS
Indemnity for loss of life will be payable in accord with the beneficiary designation made in writing by the Insured and on file with
the Company. In the absence of such beneficiary designation, or in the event the designated beneficiary predeceases the Insured,
indemnity for loss of life will be paid to the first of the following surviving beneficiaries: the Insured's: (a) lawful spouse; (b) child
or children, jointly; (c) parents, jointly if both are living, or the surviving parent if only one survives; (d) brothers and sisters,
jointly; (e) estate. Any other accrued indemnities unpaid at the Insured's death may, at Our option, be paid either to the Insured's
beneficiary or to his or her estate.


TERMINATION DATE OF COVERAGE
Your insurance will end on the first of the following dates: (a) the date you cease to be eligible; (b) the date any premium is due
and unpaid, subject to the grace period; or (c) the date the policy terminates.


CONVERSION OPTION
Conversion coverage is available to you and a dependent in the event the insurance provided by the certificate should end because
your eligibility ends. You must send us a written application for conversion coverage and the initial premium within 31 days after
your coverage under the policy ends. The conversion coverage will be issued in accord with: (a) our rules; and (b) the conversion
law in effect when application is made.
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The conversion coverage: (a) shall provide indemnity for specific loss in an amount not to exceed the Principal Sum applicable to
you or a dependent under the certificate; and (b) may be substantially different from the certificate.


DEFINITIONS
“Coma” or “Comatose” means a state of unconsciousness in which the Insured or a covered dependent is wholly and totally
unresponsive and cannot be aroused. This condition must be diagnosed and regularly treated by a Physician.

“Injuries” means accidental bodily injuries received while insured under this policy, resulting independently of sickness and other
causes.

“Licensed Professional or Trade School Training Program” means a certificate or degree program of a professional or trade
school.

“Loss Period” within the Accident Only Coma Benefit means the period of time during which the insured person must seek initial
treatment for Injuries received in a covered accident.

Paralysis:
“Hemiplegia” means complete loss of function of one side of the body with involvement of the arm and leg.

“Paraplegia” means complete loss of function of the lower extremities of the body with involvement of the legs.

“Quadriplegia” means complete loss of function of both the upper and lower extremities of the body with involvement of both
arms and both legs.

“Seat Belt” means any factory-installed passive restraint device or any child passive restraint device which meets published
federal safety standards.

“Waiting Period” within the Accident Only Coma Benefit means the period of time during which benefits are not paid.


CHOOSE THE PROTECTION YOUR FAMILY NEEDS
The amount of insurance you select is called the “Principal Sum”. You may select a Principal Sum between a minimum of $10,000
and a maximum of $500,000 in increments of $10,000. Amounts over $250,000 are subject to ten (10) times your annual salary.

If you select a Family Plan, your spouse’s benefit will be 50% of your Principal Sum and the benefit for each child (no matter how
many) will be 10% of your Principal Sum. However, if no children are insured on the date of your covered accident, your spouse’s
benefit will increase to 60% of your Principal Sum. Likewise, if no spouse is insured on the date of your covered accident, each
child’s benefit will increase to 20% of your Principal Sum.

NOTE: Coverage for your Spouse and/or children cannot be purchased on a “stand alone” basis. Employee participation
in the program is required in order to purchase coverage for your eligible dependents.


PREMIUM
The monthly premium for each unit of Principal Sum shall be:
Employee Only .......................................................................... $0.036 per $1,000.00 Principal Sum
Employee & Family ................................................................... $0.052 per $1,000.00 Principal Sum








This outline summarizes the provisions of the policy issued to the CHEIBA Trust.
Should there be any discrepancy between the policy and this outline, policy provisions will prevail.

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CHEIBA TRUST
Voluntary AD&D Insurance
How Do I Enroll?



1. Complete the Employee Section on the enclosed Voluntary Enrollment Form.


2. Complete the Employee Coverage Election section by placing an [X] in the Employee Only or the Employee and Family
box and indicate the insurance amount in the appropriate area.


3. If you have chosen to purchase Spouse and/or Dependent Children coverage please complete the Dependent Information
section of the Voluntary Enrollment Form.


4. Complete the Beneficiary section on the Voluntary Enrollment Form.


5. Sign and date the Voluntary Enrollment Form.


6. Return your Voluntary Enrollment Form to your benefits manager.



The premiums for this coverage will be withdrawn automatically by payroll deduction on a monthly basis.



Note: If you decide not to enroll, you must sign the “Waiver of Group Voluntary Insurance” section on the form and return it to
your benefits manager.











Underwritten by:
Mutual of Omaha Insurance Company
Home Office: Omaha, Nebraska






MC31649_1106 (51299)
Policy Form T66BA Series 13456

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Voluntary Enrollment Form







Underwritten by:
Mutual of Omaha Insurance Company

Employer Section
Company Name:





CHEIBA TRUST
City:
State:
Zip Code:


Sub Group Name:
Location Code:

Group I.D.:
Sub-group I.D.:
Class:
Effective Date:
Hours worked per week:


Current Base Pay
 Hourly
 Weekly
 Biweekly
Full-Time Employment
Occupation:

$
 Monthly  Semimonthly  Annually
Date:




Employee Section (Please Print)
Social Security:
Name:
Last
First
M.I.




Birth Date:
Mo.
Day
Yr.
Gender:
Marital Status:




 Male
 Female
Street Address:

City:


State:
Zip Code:




Voluntary AD&D Coverage Election





Review & Check As Applicable





Yes
No

Benefit Amount
Premium Amount
Voluntary AD&D
Employee Only



$__________

$__________
Voluntary AD&D
Employee & Family



$__________

$__________

Dependent Information (Please Print)
Birth Date
Name of Dependent(s)
Gender
Relationship
Mo.
Day
Yr.
Social Security Number
Spouse:




Child(ren):



















Beneficiary for Death Benefits – Right to Change Beneficiary is Reserved to the Insured.
(If more than one beneficiary is named, the beneficiaries shall share equally unless otherwise stated below.)
Primary Beneficiary
Relationship
Secondary Beneficiary
Relationship
Last Name
First
M.I.
to Insured
Last Name
First
M.I.
to Insured


__________________ ________________ ____ __________
__________________ ________________ ____ __________


__________________ ________________ ____ __________
__________________ ________________ ____ __________



Instructions: Application must be made within 31 days from the date the employee becomes eligible (or as otherwise stated in the plan). If plan is contributory,
form MUST be signed and dated to authorize payroll deductions. Should you decline coverage(s) for either yourself or your eligible dependent(s), you MUST
complete the Waiver of Group Voluntary Insurance on the back of this form.

I represent that the information I have provided in this Enrollment Form is complete, true and accurate, to the best of my
knowledge.

Signature of Employee_________________________________________________________Date________/________/________


MUG6673


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Waiver of Group Voluntary Insurance
I have been given the opportunity to apply for Group Voluntary AD&D Insurance as offered by the Policyholder, and after careful
consideration have decided not to enroll:

For:
 Myself (and all eligible dependents, if applicable)
 My eligible dependent spouse only

 My eligible dependent spouse and children only
 My eligible dependent children only


I understand and accept the Waiver of Group Insurance provisions.

Signature of Employee_________________________________________________________Date________/________/________


Insurance Company Use Only

Acknowledgement______________________________________________________Date Recorded _______/________/________








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Document Outline