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THIS POLICY/CERTIFICATE IS NOT A MEDICARE SUPPLEMENT
POLICY/CERTIFICATE.
If you are eligible for Medicare, review the Guide to Health Insurance for People
with Medicare available from the Company.
Note: The Guide to Health Insurance for People with Medicare is available from
our Customer Service Department.
MEDSP
Direct Response Division
Administrative Offices
100 Light Street
Baltimore, MD 21202
(referred to as we, us, our)
We certify that, subject to the terms of the Group Policy, the Member to whom this Certificate is
issued (referred to as you, your, and yours) is insured for the benefits described in this Certificate on
and following the effective date on which he is eligible.
In this Certificate, Transamerica Premier Life Insurance Company will be called we, our, or us. This
Certificate summarizes certain provisions of the Group Policy. All coverage and provisions are
subject to those in the Group Policy issued to the Policyholder.
Our President and Secretary witness this Certificate.
PLEASE READ YOUR ACCIDENTAL DEATH INSURANCE
CERTIFICATE CAREFULLY
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SCHEDULE OF BENEFITS
Insurance Benefits are determined by this schedule and the terms of the Group Policy.
ACCIDENT INSURANCE BENEFIT
Non-Contributory Accidental Death
Amount of Insurance
$2,500
Your Age at Death
Under 75
75 and over
Benefit Payable
100 %
50 %
* Benefit amounts payable will be doubled if accidental death occurs while at a Moose sanctioned
event or on Moose Lodge premises.
DEFINITIONS
When used in this Certificate the following words and phrases have the meaning given. The use of
any personal pronoun includes both genders.
INJURY means bodily injury caused by an accident. The accident must occur while your insurance is
in force under the Group Policy. The Injury must be the direct cause of the Loss and must be
independent of all other causes. The Injury must not be caused by or contributed to by Sickness.
PARTICIPATING ORGANIZATION means an Organization which has signed a Participation
Agreement adopting the Policyholder's plan of insurance.
PHYSICIAN means a person licensed by the state in which he is a resident to practice the healing
arts. He must be practicing within the scope of his license for the service or treatment given. The
Physician may not be you or a member of your immediate family.
SICKNESS means an illness or disease which results in a covered Loss while your insurance is in
force under the Group Policy.
ACCIDENTAL DEATH BENEFIT
When we receive due proof that you die, we will pay the benefit shown on the Schedule of Benefits to
your named Beneficiary; provided;
(1)
(2)
death occurs as a direct result of an Injury; and
death occurs within 365 days of the accident causing the Injury.
EXCLUSIONS
We will not pay a benefit for a Loss which is caused by, results from, or contributed to by:
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suicide, attempted suicide or intentionally self-inflicted Injury, while sane or insane
(in Missouri and Colorado while sane).
declared or undeclared war or any act of war.
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full-time military service.
participating in a riot; committing an assault or felony.
Sickness or its medical or surgical treatment, including diagnosis.
bacterial infection except through a wound accidentally sustained.
operating or riding in any aircraft except as a fare-paying passenger on a regularly
scheduled commercial flight or as a passenger in a transport plane operated by
the Air Mobility Command (AMC) of the United States of America.
alcohol intoxication, as defined in the state where the accident causing the Injury
occurred.
taking of any drug, medication, narcotic, or hallucinogen, unless as prescribed by
a Physician.
taking of alcohol in combination with any drug, medication, or sedative.
voluntary gas inhalation or poison voluntarily taken, administered, or inhaled.
riding or driving as a professional in any kind of race for prize money or profit.
WHEN COVERAGE ENDS
Your insurance automatically ends on the first of the following dates:
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The date the Group Policy is terminated.
The premium due date after you are no longer a member of the Participating
Organization.
The premium due date next following the date the Participating Organization
ceases to participate in this plan of insurance.
GENERAL PROVISIONS
BENEFICIARY. Your Beneficiary shall be as specified on the records of the Administrator.
RIGHT TO EXAMINE. The Policy is in the possession of the Policyholder; it will be available to be
inspected by you at any time during business hours at his office.
WHEN THERE IS A CLAIM
PAYMENT OF CLAIMS. Claims for benefits provided by the Group Policy will be paid as soon as
written proof is received. Benefits for Loss of life will be paid in accordance with the Beneficiary
designation in effect at the time of payment. All other benefits are paid directly to you.
If a Beneficiary is a minor and there is no parent or legal guardian, or if he cannot give a valid release,
the benefit will be paid as follows: to the person or institution we decide has assumed custody or
support of the Beneficiary.
Any payment that we make in good faith will fully discharge us to the extent of that payment.
LEGAL ACTIONS. No legal action may be brought to recover against the Group Policy within 60
days after written Proof of Loss has been given. No such action will be brought after three years from
the time written Proof of Loss is required to be given.
If a time limit of the Group Policy is less than allowed by the laws of the state where you live, the limit
is extended to meet the minimum time allowed by such law.
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NOTICE OF PRIVACY POLICY
Information Only – No Response Necessary
Protecting your privacy is very important to us. We want you to understand what information we
collect and how we use it.
What Information We Collect and From Whom We Collect It
We collect personal information about you from:
 Applications or other forms you complete;
 Your business dealings with us and other companies; and
 Other third parties such as consumer reporting agencies.
Categories of Information We Disclose and To Whom We Disclose It
We do not disclose any personal information about you to anyone unless allowed by law. We may
disclose personal information about you as authorized by law. This could include information to allow
for servicing of the product you have purchased or to prevent fraud. These are only examples and
there may be other disclosures authorized by law. You cannot prevent these disclosures.
Your Right to Verify Accuracy of Information We Collect
You have the right to access and correction with respect to the information collected, except
information that relates to a claim or a criminal or civil proceeding.
Your Choice to Limit Marketing
You may limit our affiliates from marketing their products and services to you based on your personal
information that we collect and share with them. This information may include the products you own
and your account history. To limit marketing offers, contact us at 1-800-957-3195.
Our Security Procedures
We protect your personal information. The only employees who have access to that information are
those who must have it to provide products or services to you. Should your relationship with us end,
we would not disclose any personal information about you to anyone except in accordance with this
Privacy Policy.
Request for More Detailed Information
This Notice is a summary of our Privacy Policy. If you would like more detail, please send your
request in writing to us at Transamerica Premier Life Insurance Company, 100 Light Street,
Baltimore, MD 21202 or call 1-800-957-3195.
Special Notice for Nevada Residents
We are providing you this notice pursuant to Nevada law. If you prefer not to receive marketing calls
from us, you may be placed on our Internal Do-Not-Call list by calling 1-800-957-3195. For more
information contact us at the address above with "Nevada Annual Notice" in the subject line. You
may also contact the Nevada Attorney General's office: Bureau of Consumer Protection, Office of the
Nevada Attorney General, 555 E. Washington St., Suite 3900, Las Vegas, NV 89101; telephone
number: 702-486-3132; e-mail: [email protected].
CA AM Privacy 08/14
This Notice applies to the following companies and any separate accounts established for the
products they may offer.
Monumental Life Insurance Company
Stonebridge Casualty Insurance Company
Stonebridge Life Insurance Company
Transamerica Advisors Life Insurance Company
Transamerica Advisors Life Insurance Company of New York
Transamerica Casualty Insurance Company
Transamerica Financial Life Insurance Company
Transamerica Life Insurance Company
Transamerica Premier Life Insurance Company
Transamerica Series Trust
Western Reserve Life Assurance Co. of Ohio
CA AM Privacy 08/14
NOTICE OF PROTECTION PROVIDED BY
CALIFORNIA LIFE AND HEALTH INSURANCE GUARANTEE ASSOCIATION
This notice provides a brief summary regarding the protections provided to policyholders by the
California Life and Health Insurance Guarantee Association ("the Association"). The purpose of the
Association is to assure that policyholders will be protected, within certain limits, in the unlikely event
that a member insurer of the Association becomes financially unable to meet its obligations.
Insurance companies licensed in California to sell life insurance, health insurance, annuities and
structured settlement annuities are members of the Association. The protection provided by the
Association is not unlimited and is not a substitute for consumers' care in selecting insurers. This
protection was created under California law, which determines who and what is covered and the
amounts of coverage.
Below is a brief summary of the coverages, exclusions and limits provided by the Association. This
summary does not cover all provisions of the law; nor does it in any way change anyone's rights or
obligations or the rights or obligations of the Association.
COVERAGE
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Persons Covered
Generally, an individual is covered by the Association if the insurer was a member of the Association
and the individual lives in California at the time the insurer is determined by a court to be insolvent.
Coverage is also provided to policy beneficiaries, payees or assignees, whether or not they live in
California.
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Amounts of Coverage
The basic coverage protections provided by the Association are as follows:
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Life Insurance, Annuities and Structured Settlement Annuities
For life insurance policies, annuities and structured settlement annuities, the Association will
provide the following:
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Life Insurance
80% of death benefits but not to exceed $300,000
80% of cash surrender or withdrawal values but not to exceed $100,000
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Annuities and Structured Settlement Annuities
80% of the present value of annuity benefits, including net cash withdrawal
and net cash surrender values but not to exceed $250,000
The maximum amount of protection provided by the Association to an individual, for all life
insurance, annuities and structured settlement annuities is $300,000, regardless of the
number of policies or contracts covering the individual.
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Health Insurance
The maximum amount of protection provided by the Association to an individual, as of April 1,
2011, is $470,125. This amount will increase or decrease based upon changes in the health
care cost component of the consumer price index to the date on which an insurer becomes an
insolvent insurer.
COVERAGE LIMITATIONS AND EXCLUSIONS FROM COVERAGE
The Association may not provide coverage for this policy. Coverage by the Association generally
requires residency in California. You should not rely on coverage by the Association in selecting an
insurance company or in selecting an insurance policy.
The following policies and persons are among those that are excluded from Association coverage:
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A policy or contract issued by an insurer that was not authorized to do business in
California when it issued the policy or contract
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A policy issued by a health care service plan (HMO), a hospital or medical service
organization, a charitable organization, a fraternal benefit society, a mandatory state
pooling plan, a mutual assessment company, an insurance exchange, or a grants and
annuities society
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If the person is provided coverage by the guaranty association of another state
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Unallocated annuity contracts; that is, contracts which are not issued to and owned by an
individual and which do not guaranty annuity benefits to an individual
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Employer and association plans, to the extent they are self-funded or uninsured
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A policy or contract providing any health care benefits under Medicare Part C or Part D
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An annuity issued by an organization that is only licensed to issue charitable gift annuities
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Any policy or portion of a policy which is not guaranteed by the insurer or for which the
individual has assumed the risk, such as certain investment elements of a variable life
insurance policy or a variable annuity contract
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Any policy of reinsurance unless an assumption certificate was issued
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Interest rate yields (including implied yields) that exceed limits that are specified in
Insurance Code Section 1607.02(b)(2)(C).
--------------------------------------------------------------------------------------------------------------------------------NOTICES
Insurance companies or their agents are required by law to give or send you this notice.
Policyholders with additional questions should first contact their insurer or agent. To learn more
about coverages provided by the Association, please visit the Association's website at
www.califega.org, or contact either of the following:
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California Life and Health Insurance
Guarantee Association
P.O. Box 16860
Beverly Hills, CA 90209-3319
(323) 782-0182
California Department of Insurance
Consumer Communications Bureau
300 South Spring Street
Los Angeles, CA 90013
(800) 927-4357
Insurance companies and agents are not allowed by California law to use the existence of the
Association or its coverage to solicit, induce or encourage you to purchase any form of insurance.
When selecting an insurance company, you should not rely on Association coverage. If there is any
inconsistency between this notice and California law, then California law will control.
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IMPORTANT INFORMATION TO POLICYHOLDERS
In the event you need to contact someone about this policy for any reason, please contact
your Insurance Agent who sold you your policy.
If you have additional questions, you may contact the insurance company issuing this policy
at the following address and telephone number:
AGIA, INC.
1155 EUGENIA PLACE
CARPINTERIA, CA 93013-2062
Telephone Number:
1-800-337-3140
If you have been unable to contact or obtain satisfaction from the company or the agent, you
may contact the California Department of Insurance at:
California Department of Insurance
Consumer Services Division
300 South Spring Street, South Tower
Los Angeles, CA 90013
Telephone Number:
In state toll-free calls: 1-800-927-4357 (HELP)
Out of state calls: 213-897-8921
For TDD (Telecommunication Devices for the Deaf),
please call: 800-482-4833
http://www.insurance.ca.gov/0500-about-us/02-department/01-csmcb/consumer-services.cfm
If in the future you consider making changes to the status of your policy, you should consult
with a licensed insurance or financial advisor.
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