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HomeMy WebLinkAboutNIS 2025_Life_Insurance_-_NIS_(1) Docusign Envelope ID:05525649-A25B-4328-AE00-96FCB8C6409A NATIONAL INSURANCE SERVICES OF WISCONSIN INSURANCE TRUST JOINDER AGREEMENT FOR GROUP TERM LIFE INSURANCE The below named Employer hereby requests application for participation in group term life insurance benefits under the Group Policy issued to the below named Group Policyholder(hereafter referred to as"Policyholder",and underwritten by Madison National Life Insurance Company, Inc. (hereafter referred to as"Insurer"). The term Group Policy means only the provisions of the Group Policy that apply to the Employer,based upon the coverage requested under this Joinder Agreement. Insurance and Benefit Information A. Administrative 1. Policyholder: National Insurance Services of Wisconsin Insurance Trust 2. Employer: City of Waterloo 715 Mulberry Street Waterloo, IA 50703 3. Employer Plan No: 3184 4. Nature of Business: Government 5. Initial Plan Effective Date: July 1, 1994 6. First Revised Joinder Effective Date: July 1,2014 7. Second Revised Joinder Effective Date: July 1,2025 8. Evidence of Insurability Requirements: Applies to Late Enrollees, Increases in Benefits and Amounts over Guarantee Issue Amounts 9. Enrollment Period: One-Time Open Enrollment Period for Supplemental Life Insurance: Madison National Life Insurance Company will offer a one-time open enrollment period for Supplemental Life Insurance per the following guidelines: • Employees must apply for Basic Insurance within the 31-day open enrollment period,which must be completed prior to 7/1/2025, as decided on by the Employer and Insurer • Employees not currently enrolled in Employee Supplemental Life Insurance may elect up to $100,000(not to exceed Guarantee Issue amount based on age)without Evidence of Insurability • Current Employee Supplemental Life Insurance enrollees may elect up to $200,000 without Evidence of Insurability. The combined amount(in force plus additional election during the open enrollment)is subject to the Guarantee Issue amount based on age. • Current Spouse Supplemental Life Insurance enrollees may add up to $5,000 without Evidence of Insurability. • Current Dependent Child Supplemental Life Insurance enrollees, and employees not currently enrolled in Dependent Child Supplemental Life Insurance,may elect up to $15,000 without Evidence of Insurability. • Prior declined/incomplete applications are ineligible for the open enrollment period. GTL-JA-0708 1 Docusign Envelope ID:05525649-A25B-4328-AE00-96FCB8C6409A Annual Open Enrollment Period for Employee Supplemental Life and AD&D Insurance. Madison National Life will agree to an Annual Open Enrollment period per the following guidelines: Employ: Annual Supplemental Life/AD&D increase of$10,000(applies to current enrollees). • Applies during a pre-designated annual 31-day period,with a future effective date. • Current Enrollees may elect$10,000 of additional coverage without Evidence of Insurability. • The combined Supplemental amount(in-force plus additional$10,000) is subject to the Supplemental Life Guarantee Issue Limit. • Those previously declined and incomplete applications are NOT eligible for this increase and must submit satisfactory Evidence of Insurability. • Retiree classes are not eligible for this increase. • Employees 70 and older by the time of the effective date of the increase are not eligible. 10. Employee Classes: 01 Non-Bargaining Employees excluding Non-Bargaining Employees who work 29 hours or less at the Cedar Valley SportsPlex 02 Bargaining Employees 11. Minimum Hourly Work Requirement: Classes 01,02: 20 hours per week 12. Waiting Period for Insurance Coverage: Classes 01,02: None 13. New Employee Eligibility Date: Classes 01,02: Upon completion of the Waiting Period 14. Leaves/Layoffs: Classes 01,02: Coverage with premium payment while on FMLA leave; Coverage with premium payment for up to 2 years while not Actively at Work due to Physical Disease or Injury; Coverage with premium payment for up to 15 days while on Military Leave 15. Employee Premium Contribution: Classes 01,02: Employee Basic Insurance: 0% Employee Supplemental Insurance: 100% Dependent Basic Insurance: 100% Dependent Supplemental Insurance: 100% GTL-JA-0708 2 Docusign Envelope ID:05525649-A25B-4328-AE00-96FCB8C6409A 16. Participation Requirements: Classes 01,02: Employee Basic Insurance: 100% Employee Supplemental Insurance: 15% Dependent Basic Insurance: None Dependent Supplemental Insurance: None 17. Insurance Reduction Schedule: Classes 01,02: Employee Basic Insurance: Basic Life and Basic AD&D Insurance does not reduce and terminates at retirement. Employee Supplemental Insurance: Supplemental Life Insurance reduces to 65% upon attainment of age 65,reduces to 45% upon attainment of age 70 and terminates at retirement. Dependent Basic Insurance: Dependent Child Basic Life Insurance terminates upon the earlier of the Insured Child's attainment of the Limiting Age or the Insured Employee's retirement. Dependent Supplemental Insurance: Dependent Spouse Supplemental Life Insurance reduces to 65%upon the Insured Spouse's attainment of age 65 and terminates upon the Insured Spouse's attainment of age 70. B. Basic Life Insurance Employee Basic Life Class 01: 1 times Annual Salary,rounded to the next highest$1,000; Minimum$20,000 Guarantee Issue: $145,000 Maximum Issue: $145,000 Class 02: $20,000 Guarantee Issue: $20,000 Maximum Issue: $20,000 GTL-JA-0708 3 Docusign Envelope ID:05525649-A25B-4328-AE00-96FCB8C6409A Dependent Child Basic Life Classes 01,02: Age: 14 days to 6 months: $1,000 Guarantee Issue: $1,000 Maximum Issue: $1,000 Age: 6 months through Limiting Age: $10,000 Guarantee Issue: $10,000 Maximum Issue: $10,000 C. Supplemental Life Insurance Emplo, e�pplemental Life Classes 01,02: $1,000 increments Guarantee Issue: $200,000 under age 60; $50,000 age 60 and older Maximum Issue: $300,000,not to exceed 5 times Annual Salary Spouse Supplemental Life Classes 01,02: $500 increments Guarantee Issue: $30,000 Maximum Issue: $150,000,not to exceed 50%of Employee Supplemental Life amount Child Supplemental Life Classes 01,02: Age: Birth through 13 days: $0 Guarantee Issue: $0 Maximum Issue: $0 Age: 14 days to 6 months: $1,000 Guarantee Issue: $1,000 Maximum Issue: $1,000 Age: 6 months through Limiting Age: $15,000 Guarantee Issue: $15,000 Maximum Issue: $15,000 D. Additional Benefits 1. Conversion of Insurance Benefit: Included for all classes 2. Waiver of Premium Benefit: Included for all classes 3. Living Benefit: Included for all classes GTL-JA-0708 4 Docusign Envelope ID:05525649-A25B-4328-AE00-96FCB8C6409A E. Accidental Death and Dismemberment(AD&D)Insurance 1. Basic AD&D Insurance Employee Basic AD&D Insurance Class 01: 1 times Annual Salary,rounded to the next highest$1,000;Minimum$20,000 Guarantee Issue: $145,000 Maximum Issue: $145,000 Class 02: $20,000 Guarantee Issue: $20,000 Maximum Issue: $20,000 F. Premium 1. Rate: Classes: 01,02 Employee Basic Life Premium Rate: $0.21 per$1,000 of coverage Dependent Basic Life Premium Rate: $1.50 per dependent unit Employee Supplemental Life Premium Rate: See Table Below Dependent Spouse Supplemental Life See Table Below Premium Rate: Dependent Child Supplemental Life Premium See Table Below Rate: Employee Basic AD&D Premium Rate: $0.03 per$1,000 of coverage Employee/Dependent Spouse Supplemental See Table Below Life Portability Premium Rate: Dependent Child Supplemental Life Portability See Table Below Premium Rate: GTL-JA-0708 5 Docusign Envelope ID:05525649-A25B-4328-AE00-96FCB8C6409A Em to ee Supplemental Life Premium Rate Premium Age Rate per $1,000 of coverage 0 -24 $0.05 25 -29 $0.06 30- 34 $0.08 35 - 39 $0.09 40 -44 $0.12 45 -49 $0.20 50- 54 $0.30 55 - 59 $0.51 60- 64 $0.68 65 - 69 $1.27 70 - 74 $2.06 75 - 79 $3.56 80- 99 $5.37 De endent Spouse Supplemental Life Premium Rate Premium Age* Rate per $1,000 of coverage 0-29 $0.08 30 -34 $0.09 35 -39 $0.11 40 -44 $0.15 45 -49 $0.23 50 - 54 $0.36 55 - 59 $0.54 60 -64 $0.72 65 - 69 $1.30 *Spouse rates are based on Spouse's age GTL-JA-0708 6 Docusign Envelope ID:05525649-A25B-4328-AE00-96FCB8C6409A De endent Child Supplemental Life Premium Rate Premium Benefit Rate per Option dependent unit 1 $2.25 2 $2.25 Em to ee/De endent Spouse Sup lemental Life Portability Premium Rate Premium Age* Rate per $1,000 of coverage to age 29 $0.13 30 -34 $0.15 35 -39 $0.18 40 -44 $0.25 45 -49 $0.42 50 - 54 $0.66 55 - 59 $1.17 60 -64 $1.86 65 -69 $2.83 70 -74 $4.70 75 -79 $9.12 80+ $10.17 *Employee rates are based on Employee's age; Spouse rates are based on Spouse's age De endent Child Supplemental Life Portability Premium Rate Premium Benefit Rate per Option dependent unit 1 $2.25 2 $2.25 2. Rate Guarantee: 24 months until July 1,2027 3. Frequency of Billing Monthly GTL-JA-0708 7 Docusign Envelope ID:05525649-A25B-4328-AE00-96FCB8C6409A G. Benefits and coverage for Insured Persons are as agreed upon between the Insurer and the Policyholder. All coverages and actual benefit amounts in effect,with respect to each Insured Person, are described in the Certificates of Insurance issued by the Insurer to the Policyholder for distribution to the Insured Persons or,directly to the Insured Persons. This includes any applicable Riders or Endorsements which generally describe,without amending, superseding or changing the Policy in any way,the essential features of the coverages Insured Persons are entitled to under the Group Policy and this Joinder Agreement, and to whom the insurance benefits are payable in the event of a covered loss. TERMS AND DEFINITIONS All terms are as defined in the Certificates of Insurance(hereafter referred to as Certificate). PREMIUMS,PAYMENTS AND TERMINATION A. Payment of Premiums 1. Premiums are due on the 1St of the month of coverage for which the premium applies(e.g., premium for coverage in October would be due October 1 St) 2. The premium due on each Premium Due Date is the sum of the premiums for all Insured Persons under the Group Policy. Premium rates for each Employer covered under the Group Policy are shown in this Joinder Agreement. 3. The Employer determines the amount, if any, of each Insured Person's contribution toward the cost of insurance. 4. Each premium is payable on or before its Premium Due Date directly to the Insurer at their home office. 5. Premium is due for an Insured Person for each month the Insured Person is covered under the Group Policy. The Employer must notify the Insurer immediately whenever an employee becomes eligible or ceases to be eligible for coverage. Effective dates of coverage or termination dates which occur mid-month will be billed as follows: a) If the effective date of coverage is between the 1st of the month and 15th of the month, premium for an entire month will be due to the Insurer. If the effective date of coverage is between the 16th of the month and the end of the month the Employer will be billed for the next full month of coverage. The Insurer does not prorate premium. b) If the date coverage ends is between the 1 st of the month and the 15th of the month,no premium will be due for that month. If the date of termination is between the 16th of the month and the end of the month the Employer will be responsible for an entire month's premium. 6. All premiums will be based upon information provided by the Employer in the Census Reports. B. Changes in Premium Rates. 1. Special Circumstances. The Insurer may change premium rates,to be effective on the next Premium Due Date,if any of the following occur: a) A change or clarification in a law or governmental regulation affects the amount payable under the Group Policy. Any such change in premium rates will reflect only the change in the Insurer's obligations. b) One or more changes occur in the factors material to the underwriting risk the Insurer assumed under the Group Policy with respect to the Employer,including,but not limited to,the number of persons insured, age, gender and occupational classification. GTL-JA-0708 8 Docusign Envelope ID:05525649-A25B-4328-AE00-96FCB8C6409A c) The premium contribution arrangement for insured employees changes or varies from that stated in this Joinder Agreement when issued or last renewed. d) Plan design changes are requested by the Employer. e) The Insurer and the Employer mutually agree to change premium rates. 2. In all other cases, and subject to a period for which the Insurer has provided the Employer with a written rate guarantee,the Insurer may change premium rates upon 90 days advance written notice to the Employer. Any such change in premium rates may be made effective on any Premium Due Date,but no such change will be made more than once in any Contract Year. Contract Years means successive 12-month periods computed from the end of the initial rate guarantee period, or from a time agreed to in writing by the Employer and Insurer. C. Premium Adjustments. Premium adjustments involving a return of unearned premiums to an Employer will be limited to the 12 months just before the date the Insurer receives a request for premium adjustment. D. Information Required from Employer 1. The Employer will furnish all information reasonably necessary to administer the Group Policy, including but not limited to the following: a) At least one Census Report during each plan year,no later than six months prior to the next plan renewal date. The Census Report means a written report providing the following information for each Employee insured under the Group Policy: name, social security number, date of birth, gender, occupational class,Annual Salary as defined under the Group Policy and Certificate, and the amount of coverage. b) A list of all eligible employees and documentation supporting employee eligibility under the Group Policy. c) Information about employees who become eligible,whose amounts of coverage change and/or whose coverage ends. d) Occupational information and any other information that may be required to manage a claim. e) Notification of the Employer's change in legal status,expansion of business,dissolution, merger,buyout or any other significant business operational change. f) Notice of any additional eligible employee segment(s). g) Any other information that may be reasonably required. 2. The Employer must provide such information to the Insurer or its agents in a regular and timely manner as may be reasonably specified by the Insurer and/or its agents. The Insurer and its agents have the right at all reasonable times to inspect the payroll and other records of the Employer which relate to insurance under the Group Policy. E. Grace Period, Termination for Nonpayment and Reinstatement. 1. If a premium is not paid on or before its Premium Due Date,it may be paid during the Grace Period. The coverage under the Group Policy will remain in force during the Grace Period. 2. Grace Period means the 31 days following the Premium Due Date. 3. If the premium for coverage is not paid during the Grace Period,the coverage under the Group Policy will terminate automatically at the end of the Grace Period. GTL-JA-0708 9 Docusign Envelope ID:05525649-A25B-4328-AE00-96FCB8C6409A 4. The Employer is liable for premium for coverage during the Grace Period. The Insurer may charge interest at the legal rate for any premium which is not paid during the Grace Period, beginning with the first day after the Grace Period. 5. Reinstatement. If any renewal premium is not paid and coverage is terminated,the Employer may request a reinstatement by reapplying with the Group Policyholder and submitting the required premium. Coverage will be reinstated upon the Insurer's approval, if the Employer requests reinstatement within 31 days of termination date. The Insurer shall approve or disapprove the reinstatement within 15 calendar days following receipt of the reinstatement request and premium. The Insurer and Employer shall have the same rights hereunder as they did under the Policy immediately before the due date of the defaulted premium, subject to any provisions endorsed hereon or attached hereto in connection with the reinstatement. F. Termination for Other Reasons 1. The Policyholder may terminate the Group Policy and the Employer may terminate coverage under the Joinder Agreement by giving the Insurer at least 60 days written notice. The effective date of termination will be the later of- a) £a) The date stated in the notice; or b) The Premium Due Date immediately following the date the Insurer receives the notice. 2. The Insurer may terminate coverage under the Group Policy as follows: a) On any Premium Due Date if the number of persons insured is less than the Minimum Participation requirements provided for under this Joinder Agreement. b) On any Premium Due Date if the Insurer determines that the Employer has failed to promptly furnish any necessary information requested or has failed to perform any other obligations relating to the Group Policy or coverage under the Group Policy. c) On any Premium Due Date by giving the Employer at least 60 days advance written notice. d) On the date the Employer breaches any part of the Entire Contract. GENERAL PROVISIONS A. Certificates. The Insurer will prepare the Certificates setting forth the main features of the Group Policy applicable to each Insured Person. The Insurer and Employer may agree to distribute the Certificates to Insured Persons in paper format, or to make the document available and accessible for review by Insured Persons on the Employer's website. The Employer will be responsible for providing sufficient notice to the Insured Person of the existence and availability of the Certificate, including instructions on how to view the document,and a statement that a paper copy of the document will be made available upon request. Upon receiving such a request from either the Employer or Insured Person,the Insurer will provide a written copy of the Certificate to the Employer for distribution to the Insured Person. If the terms of the Certificate differ from the terms of the Employer's coverage under the Group Policy,the latter will govern. B. Limitation of Liability. Individuals selected by the Employer to secure coverage under the Group Policy or to perform their administrative function under it,represent and act on behalf of the person selecting them and do not represent or act on behalf of Madison National Life Insurance Company, Inc. The Policyholder and Employer hereby release,hold harmless and indemnify Madison National Life Insurance Company,Inc. from any liability arising from or related to any negligence,error, omission,misrepresentation or dishonesty of the Policyholder or Employer respectively,or any of their respective representatives, agents or employees. GTL-JA-0708 10 Docusign Envelope ID:05525649-A25B-4328-AE00-96FCB8C6409A C. Agency. The Policyholder and Employer are not agents of the Insurer for any purpose under the Policy. D. Entire Contract, Changes: This Joinder Agreement,the Policy, including the Certificates and any Riders,Amendments or attached papers,if any, constitutes the entire contract of Insurance.No change in the Group Policy will be valid unless it is approved in writing by one of the Insurer's executive officers and given to the Policyholder for attachment to the Group Policy. No change in an Employer's coverage under the Group Policy will be valid unless it is approved in writing by one of the Insurer's executive officers and given to the Employer for attachment to the Joinder Agreement. No agent has authority to change this Policy or waive any of its provisions. We have authority to determine all questions arising in connection with the Policy, including its interpretation. Our failure to enforce any provision shall not waive,modify or render such provision unenforceable at any other time; at any given time; or under any given set of circumstances,whether the circumstances are or are not the same. E. Incontestability.All statements made by the Employer in the Application are, in the absence of fraud, representations and not warranties. The Insurer cannot contest the Policy or this Joinder Agreement after it has been in force for 2 years from its Date of Issue. No statement shall be used to contest the validity of coverage or reduce benefits,unless it is in writing, signed by the Employer, and a copy of such statement is furnished to the Employer. F. Non-Participating: The Policy is non-participating. It does not share in Our profits or surplus earnings. G. Conformity With State Laws: If any provisions of Our forms are contrary to any law to which it is subject, such provision is hereby amended to conform to the minimum requirements of such law. H. Workers'Compensation. The Policy is not in lieu of and does not affect any requirements for coverage by any Workers' Compensation Act or similar law. I. Misstatement. If Policyholder or Employer premiums for the Insured Person are based on age or gender and the Insured Person's age or gender has been misstated,there will be a fair adjustment of premiums based on his or her true age or gender. If benefits for the Insured Person is based on age or gender and the Insured Person's age or gender has been misstated,there will be an adjustment of said benefits based on his or her true age or gender. We may require satisfactory proof of age or gender before paying any claim. J. Clerical Error. A clerical error may be made by the Insurer,Employer or Policyholder in keeping data. If so,when the error is found the premium and/or benefits will be adjusted according to the correct data. An error will not end insurance validly in force,nor will it continue insurance validly ended. GTL-JA-0708 11 Docusign Envelope ID:05525649-A25B-4328-AE00-96FCB8C6409A ACCEPTANCE AND SIGNATURES The undersigned Employer adopts and agrees to be bound by the terms and conditions of this Agreement, as amended from time to time and Group Policy. Copies of these documents are available for Employer review at the Policyholder's place of business. The Employer may also contact the Insurer for further information. The Group Policy is a vehicle for obtaining group insurance plans in which Employers join together as a single policyholder for the purchase and maintenance of group insurance policies. The Insurer,in performing its obligations under the Group Policy,is acting only as a life insurer with respect to the Group Policy. The Trust Administrator, in performing its obligations under the Group Policy, is acting only as a trust administrator with respect to the Group Policy. The Insured and Trust Administrator are not in any way acting as a plan administrator, a plan sponsor or a plan trustee for the purposes of the Employee Retirement Income Security Act of 1974(ERISA), as amended, or any other federal or state laws. The signatures below constitute acceptance of the undersigned Employer as a participating member under the Group Policy. Signed into effect this 5th day of May 20 25 DocuSigned by: t,ln ilt Rof Quentin Hart , Mayor SigAA nature o Authorized Signer for Employer Printed Name& Title of Signer Signature of Authorized Signer for Employer Printed Name&Title of Signer Administrator: AP/National Insurance Services Q) - By: - Hank Ehrsam,President January 27,2025 GTL-JA-0708 12 Docusign Envelope ID:05525649-A25B-4328-AE00-96FCB8C6409A MADISON NATIONAL LIFE INSURANCE COMPANY, INC. NOTICE OF PRIVACY PRACTICES AND PROTECTIO This Privacy Notice is provided for your inforination — keep a copy of it for your records. No response is required or requested. Customer PrivacF Is Our Business - We value our relationship with authorities,or as authorized or requested by an insured individual. Such our customers and are dedicated to providing them with exceptional disclosures include,but are not limited to- service and competitive product offers_ As part of our dedication to ■ Affiliates—we may provide information to affiliated companies to servicing their insurance needs, we are committed to protecting the enable them to provide business services for us such as claims confidentiality of nonpublic personal information about our customers. processing,underwriting, and maintenance of your accounts, and to This Privacy Notice w iii help you understand what type of information offer products and services we provide. we collect about insured individuals,how the information we collect is ■ Agents and Brokers—we may provide infonnation to enable agents used,and what measures we take to protect that information. and brokers to provide business services for us and to offer products and services we provide- What Information We Collect And Hose We Collect It - Depending ■ Joint Marketing — we may provide information to non-affiliated on the type of product: we collect nonpublic personal information about third parties to jointly market insurance products or services_ insured individuals that may include= ■ Lending Institutions—we may provide information to non-affiliated ■ address, lending institutions, such as banks and credit unions, to offer ■ telephone number, products and services we provide, and to provide business services ■ social security number. for us. ■ account inforniation, ■ Government Entities —we may provide information upon request ■ income, from a State Department of Insurance or other govenmment entity. ■ employment, The pupose for the request may be to prevent fraud, conduct an ■ health status,and audit of our business practices,or for any other reason for which the ■ other personal information relevant to their coverage. goveramen#entity is legally permitted to request information. ■ Servicing organizations -we may provide information to servicing We collect such information primarily from infommation we receive from organizations such as TPAs, reinsurers, attorneys, accountants, individuals on applications or other forms. We may also collect actuaries,underwriters;and other such organizations to enable them information through telephone conversations or other electronic means, to provide business services for us- such as internet "cookies" (data stored on a computer by an internet browser when you use the internet to access our website) that may be We do not share, trade, sell, exchange or in any other way disclose used to track website usage, remember passwords customers create, and nonpublic personal information except as stated above or to otherwise provide customers with website content specific to their needs and conduct the business of insurance_ interests_ We may also obtain information from third parties such as employers, non-affiliated insurers, physicians; hospitals and other About this Privacy- notice - The examples contained in this Privacy medical providers_ Notice are provided as illustrations and are not a comprehensive account of the rights of any party under applicable federal and state laws. The How Information Is Protected - We restrict access to nonpublic policies and protections indicated in this Privacy Notice will remain personal information to those employees who need to know that effective even after an individual's coverage is ternunated, to the extent information to provide products or services to our customers. we we retain information about that individual_ We may change this Privacy maintain physical, electronic: and procedural safeguards that comply Notice at any time and will infomm you of any changes as required by with federal and state regulations to guard such information. law_ Other applicable privacy protections may exist under state laws and Information about inswed individuals is accessed by our employees only we will comply with all applicable state laws when we disclose when such access is necessary to conduct our business_ For example,we information about individual insureds. may access information to offer other compatible products or services we provide,to process customer requests,and to administer our products or services. All employees are required to maintain the confidentiality of For additional infoluiation.contact rots at: nonpublic personal information and to follow policies we establish to secure such confidentiality. Aftn: Privacy'Officer Madison National Life Insurance Company-,Inc. Additionally, we require third parties to whom we disclose nonpublic Post Office Box 50,08 personal information, or u�ho receive or handle such infoinmation on our p Madison,I'VI 537Ua behalf, to adhere to our standard of privacy protection and to establish information security procedures_ Disclosure-We do not disclose any nonpublic personal infornmation about our customers or formes customers to anyone,except as permitted by law. Inforriation will only be disclosed for such purposes as conducting and auditing our business,administering the business of affiliated organizations,responding to requests from government MNLpn-IND-0721 Docusign Envelope ID:05525649-A25B-4328-AE00-96FCB8C6409A NOTICE This notice describes identities of and relationships among the Insurer,Administrator,and Policyowner of this insurance. Insurer: Madison National Life Insurance Company,Inc. (MNL)is the insurance underwriter of this insurance. Third Party Administrator: National Insurance Services (NIS)is the administrator for this group insurance. NIS provides administrative services for insurance issued to groups,including,but not limited to underwriting,premium billing,premium collection,client services,and policy and certificate issuance. There is no ownership affiliation between MNL and NIS. Policyowner: The Policyowner of your policy/certificate of insurance is the National Insurance Services of Wisconsin Insurance Trust(Trust). Employer: Your Employer participates in the group insurance under the group policy issued to the Trust. NIS is the Administrator of the Trust. Notice/NIS(NISW)0320