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KEEWATIN-PATRICIA DISTRICT SCHOOL
(CANADIAN UNION OF PUBLIC EMPLOYEES)
(C.U.P.E.)
Protecting Your Personal Information
At Great-West Life, we recognize and respect the
importance of privacy. When you apply for coverage or
benefits, we establish a confidential file of personal
information. We limit access to personal information in
your file to Great-West Life staff or persons authorized
by Great-West Life who require it to perform their
duties, to persons to whom you have granted access, and
to persons authorized by law.
We use the personal information to administer the
group benefit plan under which you are covered. This
includes many tasks, such as:
• determining your eligibility for coverage under the
plan
• enrolling you for coverage
• assessing your claims and providing you with
payment
• managing your claims
• verifying and auditing eligibility and claims
• underwriting activities, such as determining the cost
of the plan, and analyzing the design options of the
plan
• preparing regulatory reports, such as tax slips
Your employer has an agreement with Great-West Life
in which your employer has financial responsibility for
some or all of the benefits in the plan and we process
claims on your employer’s behalf. We may exchange
personal information with your health care providers,
your plan administrator, other insurance or
reinsurance companies, administrators of government
benefits or other benefit programs, other organizations,
or service providers working with us when necessary to
administer the plan.

All claims under this plan are submitted through you as
plan member. We may exchange personal information
about claims with you and a person acting on your
behalf when necessary to confirm eligibility and to
mutually manage the claims.
For more information about our privacy guidelines,
please ask for Great-West Life’s Privacy Guidelines
brochure.
Liability for Benefits
Your employer has entered into an agreement with The
Great-West Life Assurance Company whereby your
employer will have full liability for Pay-Direct Drugs,
Medi-Pack and Dental outlined in this booklet. This
means your employer has agreed to fund these benefits
and they are, therefore, uninsured. All claims will,
however, be processed by Great-West Life.
TABLE OF CONTENTS
BENEFIT DESCRIPTION . 2
Employee Life Insurance . 2
Optional Employee Life Insurance. 2
Optional Dependent Life Insurance . 3
Pay Direct Drugs . 3
Medi-Pack. 3
Dental . 4
Survivor Extension . 4
Changes In Coverage . 5
Termination of Benefits. 5
YOUR ELIGIBILITY. 6
Commencement of Your Coverage . 6
YOUR ELIGIBLE DEPENDENTS . 7
Commencement of Your Dependent's Coverage. 8
GENERAL HEALTH EXCLUSIONS. 9
TERMINATION OF INSURANCE. 9
EMPLOYEE LIFE INSURANCE BENEFIT. 10
Waiver of Premium . 10
Extension of Benefits . 10
Conversion of Your Life Insurance . 10
OPTIONAL EMPLOYEE LIFE INSURANCE. 11
Benefit Provisions . 11
OPTIONAL DEPENDENT LIFE INSURANCE . 12
Conversion of Your Spouse's Life Insurance. 12
PAY-DIRECT DRUG BENEFIT . 13
Eligible Charges. 13
Exclusion. 15
MEDI-PACK BENEFIT . 17
Accidental Dental . 21
Emergency Treatment. 22
Exclusions . 27
Extension of Benefits . 27
How to Submit a Claim. 28
How to make an out of province/country claim. 28
DENTAL BENEFIT. 29
Assignment of Benefits . 29
Important Note. 29
Pre-Authorization For Treatment Over $500. 30
How To Submit a Claim. 30
COORDINATION OF BENEFITS. 44
Order of Benefit Determination. 44
DEFINITIONS . 45
THIRD PARTY LIABILITY . 46
PHYSICAL EXAMINATION AND AUTOPSY. 46
LEGAL ACTION . 47
PURPOSE OF THIS BOOKLET. 47
BASIC ACCIDENTAL DEATH & DISMEMBERMENT
INSURANCE. 48
GROUP INSURANCE PLAN FOR EMPLOYEES OF
Keewatin-Patricia District School Board
Canadian Union of Public Employees (C.U.P.E.)
Group Life & Health Insurance Policy GH. 335020 & 335021
Division: 4
Administrative Services Only (ASO) Plan No. H. 56501
Division: 14 & 24
The following outlines the benefits available from June 1st, 2004. BENEFIT DESCRIPTION

Employee Life Insurance
Amount of Insurance


Optional Employee Life Insurance

You may elect Optional Employee Life coverage in multiples of $10,000 or
$25,000 to a maximum of $300,000. There will be a minimum of $5,000 per
insured employee when approved for insurance.
Optional Employee Life Insurance coverage is subject to satisfactory evidence of
good health before it becomes effective. Optional Employee Life Insurance is not
payable if you take your own life within the first two years of becoming insured.
Optional Employee Life Insurance will terminate on the employee's 65th birthday.

Optional Dependent Life Benefit
Spouse:

Benefits for children commence 24 hours after birth.
Spousal Optional coverage will terminate on the earlier of the employee's or the
spouse's 65th birthday
Pay Direct Drugs (Emergis Plan 84)
(Administrative Services Only)
Your deductible per prescription is nil with 100% reimbursement.
Your maximum Dispensing Fee is $6.00 per Drug Identification Number (DIN).
There is an overall lifetime maximum of $10,000 per covered person, and a
$1,000 reinstatement maximum per covered person per calendar year.
Medi-Pack
(Administrative Services Only)
Your deductible per calendar year is nil.
Reimbursement is 100% of covered charges.
There is an overall lifetime maximum of $10,000 per covered person, and a
$1,000 reinstatement maximum per covered person per calendar year.
Dental (CL670)
(Administrative Services Only)
Great-West Life will pay on the basis of each year's Dental Association Suggested
Schedule of Fees for General Practitioners as of the 1st of the month following the
month in which Great-West Life receives the new Schedule.
Your deductible per calendar year is nil.
Basic Services (Dental Charges 1 & 2)
Reimbursement is 100% of covered charges.
Major Restorative (Dental Charges 3)
Reimbursement is 50% of covered charges.
The overall maximum is unlimited per covered person in any calendar year.
Survivor Extension
In the case of your death, Pay-Direct Drugs, Medi-Pack and Dental coverage, if
applicable, will be extended to your eligible dependents until the earlier of the date
your spouse remarries or the date of the second anniversary of your death.

Changes In Coverage

Changes in coverage due to reclassification, dependency status or gross salary will
take effect on the date of the change. You must be actively at work in order for
your insurance to increase. In order for the change in benefit to occur, Great-West
Life must also be properly notified by the Employer.
Great-West Life will provide a revised certificate outlining your new coverage.
Please check each new certificate for accuracy.
Termination of Benefits

All benefits terminate at age 65 or date of retirement, if earlier.
YOUR ELIGIBILITY
If you are under age 65 you are eligible to be insured from the date of employment. This is provided you work at least 15 hours per week on a regular basis. Commencement of Your Coverage The date you will become covered depends on the date your application is completed, and your eligibility date: If you are not Actively at Work on the date your coverage should commence, you will be covered when you return to work. YOUR ELIGIBLE DEPENDENTS
Dependents eligible for benefits are either your spouse or common-law spouse and each unmarried child, step-child or common-law child who is under 21 years of age or under 25 years of age if attending an accredited educational institute, college or university on a full-time basis. Anyone who is in full-time service in any naval, military or air force will not be eligible as dependents. The attainment of any maximum age specified above will not terminate the coverage on your dependent child if at the time your child is incapable of self-support due to mental retardation or physical handicap and relies upon you for support and maintenance. A dependent who resides outside of Canada and the United States of America is not eligible for benefits. Commencement of Your Dependent's Coverage

Your dependent coverage will commence on the same date as your coverage if you
request dependent coverage on your application.
If you have no dependents when you become covered and later acquire a
dependent, you must complete an application for coverage. The earliest date this
coverage will commence depends on the date the application is completed:
Once you have dependent coverage, an additional child will automatically become
insured on the date the child qualifies as your dependent. Notification is required if
additional dependents are acquired.
If your dependent other than a new-born is confined in a hospital when health
coverage should commence, health coverage will not begin until your dependent's
discharge.
You must complete a new application if you wish to add or change a legally
married or common-law spouse.
R58-10/87
GENERAL HEALTH EXCLUSIONS
No amount of benefit will be payable for any charge that resulted either directly or indirectly from, or was in any manner or degree associated with, or occasioned by, any one or more of the following: a) intentionally self-inflicted injury while sane or insane, war, insurrection or hostilities of any kind whether or not you or your dependent were a participant in such action, participation in a riot or civil commotion, committing or attempting to commit a criminal offence or provoking an assault. Additional exclusions are found under the respective Benefit Descriptions in this booklet. TERMINATION OF INSURANCE
You are no longer insured from the date your employment terminates or the policy terminates. Insurance may terminate on the last day of the month that follows the month you began a temporary lay-off. Insurance terminates the day before you enter service in any naval, military or air force. For benefits on termination see Conversion of Your Life Insurance under your Life Insurance Benefit and Extension of Benefits on termination of employment following the health benefit description. EMPLOYEE LIFE INSURANCE BENEFIT

Your named beneficiary will be paid a lump sum amount in the case of your death.
You may appoint one or more beneficiaries or change your appointment at any
time by completing a change in Beneficiary Designation Form obtained from your
employer. Any amount of coverage for which there is no beneficiary will be
payable to your estate.
Waiver of Premium
Coverage on your life will continue if you become totally disabled for at least 6
consecutive months. You must become disabled while covered before your 65th
birthday. No premium payments will be required as of the date of disability.
This coverage will terminate without conversion privileges on your 65th birthday.
Totally Disabled means your complete inability to engage in any gainful
occupation for which you are reasonably fitted by education, training or
experience. Great-West Life must receive initial proof that you are totally disabled
no later than 12 months after the date of disability.
Extension of Benefits

The termination of the policy will not affect the continuation of your coverage
under the Waiver of Premium provision.
Conversion of Your Employee Life Insurance
You may convert your Group Life Coverage to an Individual Life Policy upon
termination of your employment or termination of the policy. You must be under
age 65 to convert but evidence of good health is not required. The form of any
individual life conversion policy will be one of the standard policy forms that
Great-West Life makes available from time to time. For limits on the amount of
coverage that may be selected please see your employer. It may not include any
provision for disability, accidental death or other special benefit.
An application and the first premium due for the individual policy must be
received by Great-West Life within 31 days after the termination of your group
coverage. In the case of your death during this 31 day period, the amount of
coverage, subject to any limits, will be paid to your named beneficiary.
C03-10/87
OPTIONAL EMPLOYEE LIFE INSURANCE
Your named beneficiary under the Basic Life Insurance will be paid in a lump sum amount in the case of your death. No payment will be made if you take your life in the first two years of coverage or increased coverage. Any amount of coverage for which there is no beneficiary will be payable to your estate. Benefit Provisions The Waiver of Premium, Extension of Benefits and Conversion Privileges are the same as those for Your Group Life Insurance. R111-11/87 OPTIONAL DEPENDENT LIFE INSURANCE

You will be paid a lump sum amount, if living, otherwise your estate, in the case
of your insured dependent's death.
If you have no Basic Group Life Insurance coverage in effect under the Plan, or
are retired your dependents are not eligible for this benefit.
Conversion of Your Spouse's Life Insurance
You, if living, otherwise your spouse, may ask Great-West Life to issue an
Individual Life Policy upon termination of your employment, death, or termination
of the policy. Evidence of good health is not required. The form of any individual
life conversion policy will be one of the standard policy forms that Great-West
Life makes available from time to time. For limits on the amount of insurance that
may be selected please see your employer. The policy may not include any
provision for disability, accidental death or other special benefit.
There is no provision for the conversion of the Group Life Insurance on an Insured
child.
An application and the first premium due for the Individual Policy must be
received by Great-West Life within 31 days after the termination of your group
coverage. In the case of your spouse's death during this 31 day period, the amount
of insurance, subject to any limits, will be paid to you.
C06-10/87
PAY-DIRECT DRUG BENEFIT (PLAN 84)
The Drug Coverage on your group is being administered by Emergis Inc. Any eligible drug charge will be paid if: 1. payment is not prohibited by a Government Sponsored plan in your Province or Territory of residence.
Eligible Charges
Medications, prescribed in writing by a Physician or Dentist bearing a Drug
Identification Number on their labels, listed as prescription requiring in Federal or
Provincial Drug Schedules and some other non-prescription requiring drugs are
covered. Included are injectable drugs, injectable vitamins, insulins, allergy
extracts, oral contraceptives, extemporaneous preparations or compounds,
disposable needles, disposable syringes, lancets and testing materials for
monitoring diabetes, fertility drugs limited to one period of 6 menstrual cycles,
smoking cessation products up to a lifetime maximum of $500, vaccines for
Hepatitis, Novasen drugs, Xenical drugs, and drugs in the following categories:
antimalarials
Drugs cards cannot be used to purchase fertility drugs. These claims must be submitted directly to Great-West Life for payment. Maintenance Drugs

Any single purchase of drugs or medicines which would be considered reasonable
and customary to be consumed or used within a 100 day period.
Antiasthmatics
The Pay Direct drugs coverage is subject to a lifetime maximum of $10,000. There is an annual reinstatement of $1,000 on the lifetime maximum. Charges for the following are not covered whether or not they have been prescribed for medical reasons. 1. Atomizers, appliances, prosthetic devices, colostomy supplies, first aid kits or equipment, electronic diagnostic monitoring or testing equipment, non-disposable insulin delivery devices, delivery or extension devices for inhaled medications, spring loaded devices used to hold lancets, alcohol, alcohol swabs, disinfectants, cotton, bandages or supplies and accessories for the above. Oral vitamins, minerals, dietary supplements, infant formulas or injectable total parenteral nutrition solutions whether or not prescribed for a medical reason, except where Federal or Provincial law requires a prescription for their sale. jellies/foams/sponges/ suppositories, intrauterine devices, contraceptive implants or appliances normally used for contraception, whether or not prescribed for a medical reason. are registered under Division 10 of the Food and Drug Act, Canada, and bear a General Public (GP) number on their label Prescriptions dispensed by a physician, clinic, dentist or in any non-accredited hospital pharmacy, or for treatment as an inpatient or out patient in any hospital, including emergency status and investigational status drugs, unless otherwise approved by Great-West Life. All preventative immunization vaccines and toxoids except vaccines for Hepatitis. Items deemed cosmetic (even if a prescription is legally required) e.g. topical minoxidil, sunscreens etc. Any medication which the insured is eligible to receive under a Provincial Drug Benefit Plan. Supplies for recreation or sports, whether or not medically necessary.
Emergis Benefit

How Does Your Emergis Benefit Work?
Each time you use your Emergis (pay direct) drug card at a participating
pharmacy*, your drug claim will be checked for potential problems (such as
harmful drug interactions, duplication of medicines, or age associated risks). If a
problem is detected your pharmacist will be able to warn you of any dangers. In
some cases, where taking the prescribed medicine would be very dangerous to
your health, the claim may be declined for your safety. Emergis’ centralized claims
data base is available at participating pharmacies across Canada.
*Important Note: Pharmacies must be on-line with Emergis Inc. (our drug claim
adjudicators) and use the latest electronic software (called CPHA 3) for Emergis to
work.
Exclusion
This exclusion is in addition to those described under General Health Exclusions:
e)
any cause which entitles you or your dependent to apply for and receive indemnity or compensation under any Workers’ Compensation Act. Lost or Stolen Cards
Lost or stolen cards should be reported immediately, in writing, to the servicing
Great-West Life Regional office. Upon receipt of written notice, a replacement
card will automatically be issued with a new issue number. In most cases, the
pharmacist will not honour the lost or stolen card because the name on the
prescription will be different from that on the card. However, if you notify Great-
West Life immediately it will greatly reduce the risk of fraudulent claims being
paid.
SHNST-01/01/91
MEDI-PACK BENEFIT
You will be paid for any of the charges incurred by you or your dependent provided that the charge meets all of the following conditions. 1. It is medically necessary for the treatment of bodily injury, illness or disease. It is recommended and authorized by a physician or surgeon legally licensed to practise medicine. Payment for services covered under this plan is not prohibited by the Provincial Government (plan) in your province of residence. It is not more than the difference between the actual cost of the charge and the amount you are entitled to apply for and receive under any Government Sponsored plan in your province of residence. Nursing Care

The services of a registered nurse or registered nursing assistant at your residence,
subject to prior approval by Great-West Life.
Note:
The services will not be considered as eligible expenses while you or your dependent are residing in a nursing home, home for the aged, rest home or any other facility providing similar care, or confined in a Licensed Hospital.
Payment will not be made for services which are for custodial care and do not
require the skill of a registered nurse or registered nursing assistant.
The services will not be considered as eligible expenses if the RN or RNA is
normally resident in your home.
Ambulance

Licensed ambulance or other emergency service, when medically necessary, to
transport you or your dependent from the place where injury, disease, illness,
pregnancy or mental disorder is suffered to the nearest hospital where adequate
treatment can be rendered, from one hospital to another, and from a hospital to
your residence.
Charges for the fare of one attendant to accompany you or your dependent if
transportation is not provided by a licensed ambulance service.
- SP

Aids, Services & Supplies

Charges incurred in the Canadian Province or Territory in which you or your
dependent are resident for (i) services furnished by a Licensed Hospital and (ii)
supplies which are obtained from an out-patient department of a Licensed Hospital
or a surgical supply company, while you or your dependent are not confined to the
Hospital.
Purchase of braces, crutches, artificial limbs or eyes and prosthetic devices
approved by Great-West Life.
An initial pair of frames and one corrective prosthetic lens, for each eye, that is
prescribed after cataract surgery.
An initial breast prosthesis following a mastectomy plus a replacement every two
calendar years and two surgical brassieres per calendar year.
Rental of a wheelchair, hospital bed including mattresses or other approved
durable equipment for temporary therapeutic use. This equipment may be
purchased subject to Great-West Life's approval prior to the purchase.
Oxygen.
Orthopaedic shoes including modifications, as prescribed by a podiatrist or
physician up to a maximum of one pair per calendar year.
1 pair of foot orthotics per calendar year per covered person. The maximum
payable per covered person shall not exceed $300 per calendar year. To be eligible
for payment, the orthotic devices must be (i) prescribed by a physician, podiatrist or
chiropodist, (ii) made from a plaster cast, (iii) made at a professional podiatry
laboratory and (iv) Medically Necessary for the covered person’s regular daily
living activities and not solely for recreation or sports.
Two pairs of surgical stockings per calendar year.
Wigs and hairpieces purchased as a result of chemotherapy/radiation therapy up to a
lifetime maximum of $100. We will also reimburse up to $250 lifetime for wigs
purchased due to total hair loss from Alopecia Totalis.
- SP
The following are examples of items that are payable if they are recommended and authorized by a physician or surgeon legally licensed to practise medicine and approved by Great-West Life: glucometers, tens machine (chronic pain), crutches, casts, mozes detectors, apnea monitor, diabetic supplies, canes, grab bars, walker, colostomy supplies, aerochambers, oxygen equipment, compressors and braces. The following are examples of items that are not payable whether or not they have been recommended by a physician or surgeon: craftmatic or lifestyle beds, mattresses (except standard mattress with approved hospital bed), humidifiers, air conditioners or air purifiers, exercise machines or programs, home/automobile modifications (ex: ramps, lifts), breast pumps, contraceptive devices and spermicides/diaphragms/condoms, blood pressure kit, and obus forme/orthopaedic pillows. C28-12/91 Accidental Dental
Charges by a legally licensed dentist for dental treatment of injuries to natural
teeth, or replacement of natural teeth, for accidents suffered by you or your
dependent while insured under this benefit.
The charge will be subject to all of the following conditions:
-
the treatment is necessitated by a direct accidental blow to the mouth and not by an object or food placed wittingly or unwittingly in the mouth. the accidental blow occurs while the person is insured. the treatment is received within twelve months after the accidental blow. the treatment is the least expensive that will provide a professionally adequate treatment. no payment will be made for any part of the charge which exceeds the amount shown for the treatment in the current Dental Association Schedule of Fees for General Practitioners in your province of residence. if treatment is to be received more than 90 days after the accidental blow, a treatment plan must be submitted to Great-West Life within 90 days of the accident. Emergency Treatment
The following Emergency treatment required by you or your dependent while
temporarily absent from your Province or Territory of residence within the first 60
days while travelling because of business or vacation and not for health reasons
and will be reimbursed at 100%. This limitation is not applicable to in-Canada
emergency health care benefits.
Room and board in a Licensed Hospital up to the hospital's standard ward rate for
each day of confinement.
Hospital services and supplies furnished by a Licensed Hospital.
Diagnosis and treatment by a physician or surgeon legally licensed to practise
medicine.
The Travel Assistance provider must be notified within 48 hours, or when
reasonably possible, following an Emergency. Claims may be denied or reduced if
contact is not made with the Travel Assistance provider within 48 hours of
admission to Hospital.
If in the opinion of a physician or the Travel Assistance provider the patient can be
returned home or to another facility for immediate or continuing treatment and you
or your dependent chooses not to for whatever reason, coverage under this Charge
will terminate.
"Hospital" means an institution having diagnostic facilities that provides active,
chronic care or emergency treatment with physicians and registered nurses in
attendance 24 hours a day and is licensed by the appropriate governmental
authority. It does not include an institution providing convalescent care, a nursing
home for the aged, a rest home or any other facility providing similar care.
Note: If you are travelling and require medical care, please contact the
Assistance Centre using the telephone number on the Travel Assistance card. Travel Assistance Benefit

The following services with respect to medical and personal emergencies required
by you or your dependent while temporarily absent from your Province or
Territory of residence within the first 60 days while travelling because of business
or vacation and not for health reasons. This limitation is not applicable to in-
Canada emergency health care benefits.
-
assistance with lost documents or luggage return of dependent children or a travelling companion transmission and retention of urgent messages help to locate Embassy or Consulate services assistance in the event of death to transport the remains return of a vehicle to your home or nearest rental agency
Note: For specific details, please refer to your Great-West Life Travel
Assistance brochure which can be obtained through your employer. Diagnostic Test

Diagnostic tests, radium treatments and X-ray examinations, excluding dental
X-rays, that are incurred in the Canadian Province or Territory in which you or
your dependent are resident.
Hearing Aids

The purchase of hearing aids and repairs, excluding batteries, up to an individual
maximum of $500 every 5 consecutive years.
Hospital Accommodation
Hospital accommodation is the difference between the public ward allowance under
the Provincial Hospital Plan and the semi-private room rate in a Licensed Hospital.
Convalescent Hospital
Charges for a convalescent hospital when admitted immediately following a
minimum of 7 consecutive days of hospital confinement. Charges for convalescent
care services and supplies shall be subject to a daily maximum benefit equal to the
charge for ward accommodation for not more that 120 days of confinement of each
period of disability. Confinement must be of continued care of the same condition
for which the insured was hospitalized and must begin prior to the 65th birthday.
- SP
Eye Glasses
Prescription eye glasses or contact lenses and the fittings of such eyewear for the
purpose of correcting vision are subject to a combined maximum of $200 in any
two calendar years.
A pair of contact lenses up to a lifetime maximum of $200 if visual acuity is
improved to at least a 20/40 level and this level of acuity is not possible through
wearing eye glasses accompanied by a letter of verification. Otherwise, contact
lenses are subject to the $200 maximum as stated for eye glasses.
Note:
All charges must be recommended or approved by a legally licensed physician, surgeon, optometrist or ophthalmologist. All claims must be supported by an official receipt indicating name of patient and the date the eyewear was received. C32-10/87 Paramedical Services
The maximum amount payable is unlimited for services of a physiotherapist.
The services of any of these legally licensed classification of practitioners:
- Physiotherapists
-
Massage Therapists, to a maximum of $300 per calendar year. The maximum charge for each treatment will be as determined by the Schedule of Fees approved by the Association of which the practitioner is a member, and where there is no approved Schedule of Fees, an amount as determined by Great-West Life. Exclusions
These exclusions are in addition to those described under General Health
Exclusions:
e)
any cause which entitles you or your dependent to apply for and receive indemnity or compensation under the Workers' Compensation Act an examination by, or the services of, a physician or surgeon, if required solely for the use of a third party any treatment to correct temporomandibular joint dysfunction any service or treatment which you or your dependent would receive without being charged any service incurred under this plan for which payment is prohibited by the Provincial Government plan in your province of residence.

Extension of Benefits
If you or your dependent are disabled at the time of termination of your
employment, Medi-Pack charges as a result of such disability will continue to be
paid up to 90 days, provided the benefit remains in force.
How to Submit a Claim
Claim Forms are available from your employer. This form must be completed in
full and submitted with the original bills within 180 days after the end of the
calendar year in which the claim was incurred.
Note:
To ensure prompt claims service, any receipts should include: your name or your dependent's name receiving the service or treatment the date and the type of each service or treatment the prescription numbers for prescribed drugs and medicine How to make an out-of province/country claim: There are special rules for claiming the costs of emergency treatment outside of your home province or Canada. - For all medical expenses, you must contact the Travel Assistance provider at the time of the emergency. This will enable the Travel Assistance provider to co-ordinate payment directly with the hospital and/or medical provider involved. In addition, with your approval the Travel Assistance provider will co-ordinate payment with your Provincial Health Care plan. If a medical provider or hospital bills you directly, send the bill along with your claim form to the Travel Assistance provider. If your spouse has insurance with another carrier, please also refer to the Coordination of Benefits section for claim submission information. DENTAL BENEFIT
If you or your dependent require any insured treatments or services, you will be reimbursed for such charges but only to the extent: • that they are the least expensive service, supply or method of treatment which Great-West Life determines will produce a professionally adequate result, • that if the charge exceeds the least expensive service, Great-West Life may provide payment based on the cost of alternative services which are defined in this provision as eligible charges, • that the treatment for it has been performed, recommended or approved by a • that Great-West Life is not prohibited from paying it by any applicable law of the jurisdiction where you reside at the time the charge is incurred.
Assignment of Benefits
We reserve the right to refuse any assignment of benefit under this provision.
Important Note

A general overview of the services covered, along with the limitations that apply,
can be found on the following pages. Your plan covers these treatments and
services provided that the treatment is the least expensive that will produce a
professionally adequate result (as determined by Great-West Life). If the charge
exceeds the cost of the least expensive service, Great-West Life will pay the cost
of the least expensive service.
In some cases, such as undergoing extensive treatment, Great-West Life may
require proof from your dentist that the services to be performed meet this criteria.
This request is a normal cost control procedure and often just a copy of the x-rays
taken is considered acceptable proof.
Pre-Authorization For Treatment Over $500
If dental expenses are estimated to be greater than $500, you must submit a
"Pre-determination" to Great-West Life. A Pre-determination is simply an outline
of the proposed treatment which is prepared, by your dentist, prior to any work
being performed. Great-West Life will advise you of the portion that is covered by
your company dental plan, enabling you to determine your costs.
Note:
In order to determine benefits payable, Great-West Life may require additional information such as: A complete dental chart showing extractions, missing teeth, fillings, prostheses, periodontal pocket depths, and the date of any work previously done. An itemized claim form for all dental care. Pre-operative x-rays, study models, and laboratory reports.
Great-West Life cannot pay the dental claim until the additional information
requested is submitted to us.

How To Submit a Claim
Claims Forms are available from your employer. For prompt payment, it is
necessary that the claim form be completed in full.
Account bills or receipts for incurred covered charges in any calendar year under
the Dental Benefit should be mailed directly to the Group Health Claims
Department of The Great-West Life Assurance Company on a monthly basis
whenever possible.
A Standard Dental Claim Form, must be completed in full and submitted with
original bills within 180 days after the end of the calendar year in which the claim
was incurred for all covered charges. Your dentist will be required to complete a
section of the Form so it would be advisable to take the Form with you on your
appointment.
If a delay is anticipated in the submission of a claim, a notice should be sent to
Great-West Life with full details well in advance of the last day for filing proof.
If the Benefit Plan for your company terminates, no payment will be made with
respect to any claim unless proof is submitted within 90 days of termination of the
plan.
Exclusions

No amount of Benefit will be payable under this provision for any charge that resulted either directly or indirectly from, or was in any manner or degree associated with, or occasioned by, any one or more of: • Any cause for which the Insured may apply for and receive indemnity or compensation under any Workers' Compensation Act. War, insurrection or hostilities of any kind, whether or not the Insured was a participant in such actions. Participating in any riot or civil commotion. Committing or attempting to commit a criminal offence or provoking an assault. Any Group or Policyholder-Sponsored dental care or treatment. Any dental care or treatment for which the Insured is not Any dental care or treatment which is principally for cosmetic purposes. Any appointments not kept or for the completion of claims forms. Any dental treatment that has as its purpose the correction of temporomandibular joint dysfunction. Any endodontic treatment commencing prior to the date on which the Insured becomes insured under this provision, except as required to be consistent with the terms of the applicable Extension of Insurance on Replacement of this Policy section. Replacement of mislaid, lost or stolen appliances. Any crowns placed on teeth that are not functionally impaired by incisal or cuspal damage. Any crowns or bridges for which tooth preparations were made prior to the date on which the Insured becomes insured under this provision, except as required to be consistent with the terms of the applicable Extension of Insurance on Replacement of this Policy section. -SP Dental 1 Charges
01101, 01102, 01103, 01201, 01301, 01401, 01501, 01601, 01701, 01801, 01901, but not more than one examination in any period of 24 consecutive months. 01202 but not more than 2 examinations in any calendar year. 01203, 01204, 01302, 01402, 01502, 01602, 01702, 01703, 01802, 01902, but not more than one examination in any period of 6 consecutive months. 02101, 02102, but not more than once in any period of 24 consecutive months. 02111 to 02125 inclusive, 02131 to 02136 inclusive. 02201 to 02204 inclusive, 02209, 02401, 02402, 02409, 02601, 02701 to 02704 inclusive, 02709, 02931 to 02934 inclusive, 02939. 02141 to 02146 inclusive, but not more than twice in any calendar year. 04101, 04201, 04311 to 04313 inclusive, 04321 to 04323 inclusive, 04401, 04501, 04509. 05101 to 05104 inclusive, 05109, 05201, 05202, 05209. 11101, 11102, 11107, 11109, but not more than twice in any calendar year. Maximum of 1 unit per recall visit. 11111 to 11117 inclusive, 11119, but not more than twice in any calendar year. Maximum of 1 unit per recall visit. 11201 to 11203 inclusive, 11301 to 11303 inclusive, 11401 to 11403 inclusive, 11501 to 11503 inclusive, but not more than twice in any calendar year. 13211 to 13214 inclusive, 13219, 13231, 13232, 13239, 13241, 13242, 13249, but not more than once in any period of 6 consecutive months. 15101 to 15105 inclusive, 15201, 15202, 15301, 15302, 15401 to 15403 inclusive, 15501, 15601 to 15604 inclusive. 43311 to 43314 inclusive, 43317, 43319, but not more than 8 time units in any calendar year. Pit and Fissure Sealants (Limited to dependent children only): 20111, 20119, 20121, 20129, 20131, 20139. 21111 to 21115 inclusive, 21121 to 21125 inclusive, 21211 to 21215 inclusive, 21221 to 21225 inclusive, 21231 to 21235 inclusive, 21241 to 21245 inclusive. Stainless Steel, Plastic and Polycarbonate, applicable only to the Dependent children of an Employee while they are under 13 years of age: 22201, 22202, 22211, 22212, 22301, 22302, 22311, 22312, 22401, 22411, 22511. 23101 to 23105 inclusive, 23111 to 23115 inclusive, 23211 to 23215 inclusive, 23221 to 23225 inclusive, 23311 to 23315 inclusive, 23321 to 23325 inclusive, 23401 to 23405 inclusive, 23411 to 23415 inclusive, 23501 to 23505 inclusive, 23511 to 23515 inclusive. 71101, 71109, 71201, 71209, 72111, 72119, 72211, 72219, 72221, 72229, 72231, 72239. 72311, 72319, 72321, 72329, 72331, 72339. Anaesthesia, used in conjunction with an eligible dental expense. 92101, 92102, 92212 to 92219 inclusive, 92222 to 92229 inclusive, 92301 to 92309 inclusive, 92411 to 92419 inclusive, 92421 to 92429 inclusive, 92431 to 92439 inclusive. 93111, 93112, 93119, 94101, 94102, 94301, 94302. 41101 to 41104 inclusive, 41109, 41211 to 41214 inclusive, 41219, 41221 to 41224 inclusive, 41229, 41301, 41302, 41309. Surgical: The maximum Benefit payable will include charges for packing and post-surgical treatment. 42111, 42201, 42311, 42321, 42331, 42339, 42411, 42421, 42431, 42441, 42511, 42521, 42531, 42541, 42551, 42561, 42571, 42581, 42611, 42711. 42611, 42621, 42711, 42719, 42721 to 42723 inclusive, 42729, 42731 to 42734 inclusive, 42739, 42821 to 42823 inclusive, 42829, 42831 to 42833 inclusive, 42839, 43111, 43211, 43221, 43241, 43251, 43261, 43271, 43279, 49101, 49102, 49109, 49211, 49219. 11111 to 11117 inclusive, 11119, 43421 to 43427 inclusive, 43429. 43611, 43612, 43621 to 43623 inclusive, 43629, 43631, 43632. 33111 to 33114 inclusive, 33121, 33131, 33141, 33401 to 33403 inclusive. 33601 to 33604 inclusive, 33611 to 33614 inclusive. 34111, 34112, 34114, 34115, 34121 to 34123 inclusive, 34131 to 34134 inclusive, 34141, 34142, 34151 to 34153 inclusive, 34161 to 34164 inclusive, 34201 to 34203 inclusive, 34212 , 34215. Intentional Removal, Apical Filling and Reimplantation: 72511, 72519, 72521, 72529, 72531, 72539, 72641, 72649, however, that procedure codes 72531, 72539 will apply only if Orthodontic Treatment is covered under this policy. Alveoloplasty, Gingivoplasty, Stomatoplasty, Vestibuloplasty: 73111, 73121, 73141, 73142, 73151 to 73154 inclusive, 73161, 73171, 73172, 73181 to 73184 inclusive, 3211, 73221 to 73224 inclusive, 73231, 73241, 73411, 73421, 73431, 73441, 73451, 73461. 74111 to 74118 inclusive, 74121 to 74128 inclusive, 74211 to 74218 inclusive, 74221 to 74228 inclusive, 74401, 74611 to 74618 inclusive, 74621, 74631 to 74638 inclusive. 75111 to 75113 inclusive, 75121, 75122, 75211, 75212, 75221, 75301 to 75303 inclusive, 75401 to 75403 inclusive. 76201 to 76204 inclusive, 76301 to 76305 inclusive, 76911 to 76913 inclusive, 76921 to 76924 inclusive, 76931 to 76934 inclusive, 76941, 76949, 76951, 76952, 76959, 76961 to 76969 inclusive, 76971 to 76979 inclusive, 76981 to 76989 inclusive. 73511, 73521, 73611, 73621, 73631, 79101 to 79104 inclusive, 79111 to 79113 inclusive, 79311 to 79314 inclusive, 79321, 79322, 79331 to 79333 inclusive, 79341, 79343, 79401 to 79404 inclusive, 79601 to 79606 inclusive. If a covered person's insurance under this provision terminates due to one of the reasons shown below and he had commenced root canal treatment prior to such termination, he will continue to be insured for any charges incurred for such treatment during the 30 days after such termination: 1. Termination of an Employee's employment. The Employee ceases to qualify under the definition of Employee. Termination of this policy, except when this policy is replaced by a policy issued by another insurer. Dental 2 Extension of Insurance on Replacement of this Policy If a covered person is undergoing root canal treatment, the insurer with the policy in force at the date the canal is closed will be responsible for the charges incurred. 62101 to 62103 inclusive, 62501, 62502, 62701 to 62703 inclusive. 66111 to 66113 inclusive, 66119, 66211 to 66213 inclusive, 66219, 66301 to 66303 inclusive, 66309, 66711, 66719, 66731, 66739. 67101, 67102, 67121, 67129, 67131, 67139, 67201, 67202, 67211, 67212, 67301, 67302, 67311, 67312, 67321, 67322, 67331, 67341, 67501 to 67503 inclusive. Retentive Pins in Retainers and Abutments: Major Restorative – Limited to once every 4 year replacement 25111 to 25114 inclusive, 25121 to 25124 inclusive, 25131 to 25134 inclusive, 25141 to 25144 inclusive, 25511, 25521, 25531. Retentive Pins in Inlays, Onlays and Crowns: 27111 to 27114 inclusive, 27121, 27122, 27201, 27202, 27211, 27212, 27301, 27302, 27311, 27312, 27313, 27401, 27409. 25711 to 25713 inclusive, 25721 to 25724 inclusive, 25731 to 25733 inclusive, 25741 to 25743 inclusive, 25751 to 25756 inclusive, 25781 to 25784 inclusive, 25789. 21301, 21302, 23601, 23602, 25781 to 25784 inclusive, 25789, 27401, 27409, 27501, 27502, 27711, 27721, 29101 to 29103 inclusive, 29109, 29301 to 29303 inclusive, 29309. If a covered person's insurance under this provision terminates due to one of the reasons shown below and he has had a tooth prepared for a crown, bridge or denture prior to such termination, he will continue to be insured for any charges incurred with respect to such crown or bridge during the 90 days after such termination: 1. Termination of an Employee's employment. The Employee ceases to qualify under the definition of Employee. Termination of this policy, except when this policy is replaced by a policy issued by another insurer. Dental 3 Extension of Insurance on Replacement of this Policy If a covered person is undergoing crowns or bridge work, the insurer with the policy in force at the date the appliance is installed will be responsible for the charges incurred. Dental 3 Limitations Charges for replacing an existing bridgework will only be paid if such replacement is for an equivalent bridgework and it meets one of the conditions shown below: 1. The existing bridgework was installed at least 3 years prior to its replacement and cannot be made serviceable. The existing bridgework is an immediate temporary bridgework, for which impressions were taken while the Insured is covered under this provision. The permanent replacement bridgework must be placed within 12 months from the date of installation of the immediate temporary bridgework. The existing bridgework is replaced because additional teeth have been extracted after the bridgework insertion, and while the Insured is covered under this provision. When payments for benefits provided under this plan are available to you or your dependent under any other insurance plan, benefits will be coordinated. The amount payable under this plan will be pro-rated and limited to the extent that the total amount available under all coverages will not exceed 100% of the allowable expenses. Order of Benefit Determination Payment of benefits will be decided in the following manner. 1. If another plan does not contain a Coordination of Benefits provision, the benefits of that plan will be deemed payable prior to the application of benefits under this plan. If another plan does contain a Coordination of Benefits provision, the benefits of that plan will be coordinated with our benefits as follows, if your spouse has coverage under another insurance plan, his/her charges must first be submitted under that plan. charges for dependent children should first be submitted to the plan of the parent whose month and date of birth comes earlier in the calendar year (excluding the year of birth). If priority cannot be established in the above manner, the benefits shall be pro-rated. C50-10/87 DEFINITIONS
Actively at Work means that you are (a) actually performing your normal duties, if it is a scheduled work day, or capable of performing your normal duties, if you were not at work due to a non-scheduled work day, holiday or vacation, at your normal place of employment or at some other location where your employer's business requires you to be. Common-law Spouse means a person of the same or opposite sex whom you publicly represent as your spouse and have been living with for 12 months. Common-law Child means a child of your common-law spouse from another relationship who resides with and is in the care and custody of you and your common-law spouse. Earnings means your gross base earnings from your employer, excluding any income you receive from your employer such as bonuses, dividends, overtime and profit sharing, etc. Licensed Hospital means a hospital that is licensed to provide active, convalescent or chronic care treatment by the government that is responsible for the issue of such licenses in the area that it is located. It does not include nursing homes, homes for the aged, rest homes or any other facility that provides similar care. Emergency means any sudden, critical, unforeseen or unexpected occurrence requiring immediate medical attention and takes place outside your Province or Territory of residence while the coverage is in force. THIRD PARTY LIABILITY
If you or your dependent have the right to recover damages from any person or organization with respect to which benefits are payable by Great-West Life, you will be required to reimburse Great-West Life in the amount of any benefits paid out of the damages recovered. The term damages will include any lump sum or periodic payments received with respect to: (1) past, present or future loss of income, and any other benefits, otherwise payable by Great-West Life. If you or your dependent receive a lump sum payment under judgement or settlement for benefits which would otherwise be payable by Great-West Life, no further benefits will be paid by Great-West Life until the benefits that would otherwise be payable equal the amount of the lump sum. If a claim for damages is settled before trial, you will be required to reimburse Great-West Life the amount that reasonably reflects the loss of benefits that would otherwise be payable by Great-West Life. You or your dependent must notify us of any action commenced against a third party and of any judgement or settlement in the circumstances described above. PHYSICAL EXAMINATION AND AUTOPSY
A physician of Great-West Life's choice may be required to examine anyone in respect to a claim. If required, payment will only be considered after the examination. Great-West Life will pay all expenses of such examination. In the case of death, an autopsy may be performed. LEGAL ACTION
No action or proceeding against Great-West Life concerning a claim may be started within sixty days of the date on which initial proof of the claim is given to Great-West Life, or more than one year (or longer by law) after the end of the period when initial proof of claim is required. PURPOSE OF THIS BOOKLET
These booklet pages are provided solely for the purpose of explaining the principal features of the Group Insurance Plan. All rights with respect to your benefits as a member of the plan will be governed by the Group Policy issued by The Great-West Life Assurance Company. R253-10/87 BASIC ACCIDENTAL DEATH & DISMEMBERMENT INSURANCE COVERAGE: This benefit is payable, in addition to any other insurance benefits, for paralysis, loss of life, limb, sight ,speech or hearing which is the result of accidental bodily injuries and which occur within 365 days from the date of the accident. This coverage applies 24 hours a day, 365 days a year, on or off the job, anywhere in the world, including while travelling (passenger only) in commercial or chartered aircraft. ELIGIBILITY If you are an active, permanent, full-time employee of Keewatin-Patricia District School Board, working a minimum of 15 hours per week and are under age 65, you will be covered for a benefit amount stated below: BENEFIT AMOUNT You will be covered for an amount equal to your Group Life Insurance benefit. Coverage ceases upon the earlier of the attainment of age 65, termination or retirement. In the event of your death, the Benefit Amount is payable to the beneficiary you have named under your Group Life Insurance Plan or in the absence of such designation, to your Estate. Schedule of Losses Accidental Death, Dismemberment, Loss of Sight & Paralysis If such injuries shall result in any one of the following specific losses within one year from the date of accident, ACE INA Insurance will pay the percentage of the Benefit amount specified below, which is equal to the amount stated in the Benefit amount section; provided, however, that not more than one (the largest) of such benefits shall be paid with respect to injuries resulting from one accident. Life 100% Both Hands, Both Feet, Entire Sight of Both Eyes, One Hand or One Foot and Entire Sight of One Eye Speech and Hearing One Arm or One Leg or Use of One Arm or One Leg One Hand or One Foot or Use of One Hand or One Foot "Loss" shall mean, with respect to hand or foot, actual severance through or above the wrist or ankle joint; with respect to arm or leg, actual severance through or above the elbow or knee joint; with respect to eye, the total and irrecoverable loss of sight; with respect to speech, the total and irrecoverable loss of speech which does not allow audible communication in any degree; with respect to hearing, the total and irrecoverable loss of hearing which cannot be corrected by any hearing aid or device; with respect to thumb and index finger, actual severance through or above the first phalange; with respect to fingers, the actual severance through or above the first phalange of all four fingers of the same hand; with regard to toes, the actual severance of both phalanges of all toes of the same foot. "Loss" as used with reference to Quadriplegia (paralysis of both upper and lower limbs), Paraplegia (paralysis of both lower limbs) and Hemiplegia (paralysis of upper and lower limbs of one side of the body), means the complete and irrecoverable paralysis of such limbs. "Loss of Use” shall mean the total and irrecoverable loss of function of an arm, hand or leg, provided such loss of function is continuous for twelve consecutive months and such loss of function is thereafter determined on evidence satisfactory to ACE INA Insurance to be permanent. Rehabilitation Benefit When injuries shall result in a payment being made by ACE INA Insurance under the Schedule of Losses excluding the Loss of Life benefit provided by the policy, ACE INA Insurance will also pay the reasonable and necessary expenses actually incurred up to a limit of $15,000 for special training provided: (a) such training is required because of such injuries and in order for you to be qualified to engage in an occupation in which you would not have been engaged except for such injuries; (b) expenses be incurred within two years from the date of the accident; (c) no payment will be made for ordinary living, travelling or clothing Repatriation Benefit When injuries covered by this policy result in a loss of life outside 150 km from your city of permanent residence or outside of Canada and occurs within 365 days from the date of the accident, ACE INA Insurance will pay the actual expense incurred for preparing the deceased for burial and shipment of the body to the city of residence of the deceased, but not to exceed $15,000. Family Transportation Benefit When injuries covered by this policy, result in your confinement as an inpatient in a hospital outside 150 km from your city of permanent residence or outside of Canada and requires personal attendance of a member of your immediate family as recommended by the attending physician, in writing, ACE INA Insurance will pay for the expense incurred by the member of your immediate family, for the transportation by the most direct route by a licensed common carrier to you while confined, but not to exceed an amount of $15,000. "Member of your immediate family" means your spouse, legal or common-law, parents, grandparents, children over age 18, brother or sister. Spousal Occupational Training Benefit When injuries to you result in a payment being made by ACE INA Insurance under the Loss of Life benefit, ACE INA Insurance will pay in addition: the expenses actually incurred, within 365 days from the date of the accident, by your spouse for a formal occupation training programme for the purpose of specifically qualifying your spouse to gain active employment in an occupation for which your spouse would otherwise not have sufficient qualifications. The maximum payable hereunder is $15,000. Home Alteration and Vehicle Modification In the event you sustain an injury which results in a payment being made under the Schedule of Losses excluding the Loss of Life Benefit and such injury subsequently requires the use of a wheelchair to be ambulatory, ACE INA Insurance will pay the reasonable and necessary expenses actually incurred within 365 days from the date of accident for: 1. the one-time cost of alterations to your principal residence to make it the one-time cost of modifications necessary to a motor vehicle utilized by you to make the vehicle accessible or driveable for you. Benefit payments herein will not be paid unless: (i) home alterations are made by a person or persons experienced in such alterations and recommended by a recognized organization, providing support and assistance to wheelchair users; and (ii) vehicle modifications are carried out by a person or persons with experience in such matters and modifications are approved by the Provincial vehicle licensing authorities. The maximum payable under both Items 1. and 2. combined will not exceed $15,000. Day Care Benefit If you suffer a loss of life in a covered accident while the policy is in force, ACE INA Insurance will pay, in addition to all other benefits payable under the policy a "Day Care Benefit" equal to the reasonable and necessary expenses actually incurred, subject to the lesser of 5% of your Benefit amount or a maximum of $5,000 per year, on behalf of your dependent child who is enrolled in a legally licensed Day Care centre on the date of the accident or who enrolls in a legally licensed Day Care centre within 365 days following the date of the accident. The "Day Care Benefit" will be paid each year for 4 consecutive years, but only upon receipt of satisfactory proof that your child is enrolled in a legally licensed Day Care centre. "Dependent Child" means either a legitimate or illegitimate child, adopted child, step-child or any child who is in a parent-child relationship with you and who is unmarried, twelve (12) years of age and under and dependent upon you for maintenance and support. Special Education Benefit If you suffer a loss of life in a covered accident while the policy is in force, ACE INA Insurance will pay, in addition to all other benefits payable under this policy, a “Special Education Benefit” equal to 5% of your Benefit amount, (subject to a maximum of $5,000 per year), on behalf of any dependent child who, on the date of the accident, was enrolled as a full-time student in any institution of higher learning beyond the 12th or 13th grade level, or was at the 12th or 13th grade level and subsequently enrolls as a full-time student in an institution of higher learning within 365 days following the date of the accident. The ”special education benefit” is payable annually for a maximum of four consecutive annual payments but only if the dependent child continues his/her education as a full-time student in an institution of higher learning. Continuance of Coverage If you are (1) laid off on a temporary basis, (2) temporarily absent from work due to short-term disability, (3) on leave of absence, or (4) on maternity leave, coverage shall be extended for 12 months, subject to the payment of premiums. If you assume other occupational duties during the leave or lay-off period, no benefits shall be payable for a loss occurring during the performance of such other occupation. Seat Belt Benefit In the event you sustain an injury which results in a payment being made under the Schedule of Losses, your Benefit amount will be increased by 10%, if, at the time of the accident, you were driving or riding in a Vehicle and wearing a properly fastened Seat Belt. Due proof of Seat Belt use must be provided as part of the written proof of loss. “Vehicle” means a private passenger car, station wagon, van, or jeep-type automobile. “Seat Belt” means those belts that form a restraint system. Conversion Privilege On the date of termination of employment or during the 31-day period following termination of employment, you may convert your insurance to an individual insurance policy of ACE INA Insurance. The individual policy will be effective either as of the date that the application is received by ACE INA Insurance or on the date that coverage under the group policy ceases, whichever occurs later. The premium will be the same as a person would ordinarily pay when applying for an individual policy at that time. Application for an individual policy may be made at any office of ACE INA Insurance. The amount of insurance benefit converted to shall not exceed that amount issued during employment. Waiver of Premium If you are under age 65 and become totally disabled* while you are insured under this plan and satisfactory evidence of your total disability is provided to ACE INA Insurance on an annual basis, payment of premium will be waived until the earlier of the following occurs: (a) you return to active employment with the Keewatin-Patricia District School (b) you attain age 65; (c) the master policy underwritten by ACE INA Insurance is terminated. Once you return to active employment with the Keewatin-Patricia District School Board, your coverage will continue only upon the commencement of premium payments. *You will be considered totally disabled if you are unable to engage in any business or occupation and perform in any work for compensation or profit for a time period in accordance with the waiver of premium requirements under the Group Life Insurance policy issued to the Keewatin-Patricia District School Board. Exclusions The plan does not cover any loss which is the result of: 1. intentionally self-inflicted injuries, suicide or any attempt thereat, while 2. war or any act thereof; 3. flying in aircraft owned or leased by your employer, yourself or a member of your household, or aircraft being used for any test or experimental purpose, firefighting, powerline inspection, pipeline inspection, aerial photography or exploration; 4. flying as pilot or crew member in any aircraft or device for aerial 5. full-time, active duty in the armed forces. Exposure and Disappearance: Loss resulting from unavoidable exposure to the elements and arising out of hazards described above shall be covered to the extent of the benefits afforded you. If your body has not been found within one year of the disappearance, stranding, sinking or wrecking of the conveyance in which you were riding at the time of the accident it shall be presumed, subject to all other conditions of this policy, that you suffered a loss of life resulting from bodily injuries sustained in an accident covered under this policy. HOW TO CLAIM NOTE: In the event of a claim, notice of claim must be given to ACE INA Insurance within 30 days from the date of accident and subsequent proof of claim must be submitted to ACE INA Insurance within 90 days from the date of the accident. A claim form can be obtained from the benefits administrator. This wording has been prepared in connection with a group plan underwritten by ACE INA Insurance, For ease of reference it contains a brief description only and does not mention every provision of the contract issued. Please remember that rights and obligations are determined in accordance with the contract and not this wording. For the exact provisions applicable, please consult your Human Resources Department. Printed on: October 5 2005

Source: http://www3.kpdsb.on.ca/departments/humanResources/docs/benefits/CUPE.pdf