55A - HARTFORD INSURNACE - Laserfiche WebLink

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HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY One Hartford Plaza, Hartford, Connecticut 06155 (A stock insurance company, herein called The Company) will pay benefits according to the terms and conditions of The Policy. Name of Policyholder: CITY OF SANTA ANA Policy Number: GUGLT-803893 Anniversary Date: January 1 of each year, beginning in 2020 Policy Effective Date: September 1, 2019 Premium Due Dates: Monthly, on the first day of each policy month Signed for The Company: Lisa Levin, Secretary Place of Delivery: California Michael Concannon, President Countersigned by..................................................................... Licensed Resident Agent or Registrar RIGHT TO RETURN THE POLICY: YOU HAVE THE RIGHT TO RETURN THE POLICY WITHIN 30 DAYS AFTER ITS RECEIPT VIA REGULAR MAIL OR OTHER DELIVERY METHOD AND TO HAVE THE FULL PREMIUM AND MEMBERSHIP FEES REFUNDED. THE RETURN VOIDS THE POLICY FROM THE BEGINNING. THE PARTIES SHALL BE IN THE SAME POSITION AS IF NO CONTRACT HAD BEEN ISSUED. ALL PREMIUMS PAID AND ANY POLICY FEE SHALL BE FULLY REFUNDED BY US, AND ANY MEMBERSHIP FEE SHALL BE FULLY REFUNDED BY THE ENTITY CHARGING THE FEE, WITHIN 30 DAYS OF OUR RECEIPT OF THE RETURNED POLICY. IF, AT THE TIME OF APPLICATION OR AT THE TIME OF DELIVERY OF A GROUP TERM LIFE INSURANCE POLICY OR CERTIFICATE, AN INSURER, ITS AGENT, GROUP MASTER POLICYOWNER, OR ASSOCIATION COLLECTS MORE THAN ONE MONTH'S PREMIUM FROM AN INDIVIDUAL WHO IS 60 YEARS OF AGE OR OLDER ON THE DATE HE OR SHE PURCHASED COVERAGE, THE INSURER SHALL PROVIDE THE INDIVIDUAL WITH A PRORATED REFUND OF THE PREMIUM IF THE INDIVIDUAL DELIVERS A CANCELLATION REQUEST TO THE INSURER DURING THE FIRST 30 DAYS OF THE POLICY PERIOD. Form GBD-1000 A (10/08) (CA) Table of Contents Schedule of Insurance 3 Premium Provisions 4 Policy Provisions 8 y