Assurity Life Insurance Company of New York Group Credit Life Certificate

Policyholder: Nelnet Business Solutions, Inc.
3 Columbia Circle, Suite 205
Albany, New York 12203-5158 (518) 869-8154 • www.nelnet.com

Policy Number: G80004

This Certificate is a part of the Policy that is a legal contract between the group Policyholder and Us (Assurity Life Insurance Company of New York, a stock company), and may be amended, changed or terminated without Your consent or notice to You. Nothing in the Policy invalidates or impairs rights granted to the Member by the Certificate.

RIGHT TO EXAMINE

This Certificate may be cancelled within 30 days of the Issue Date by returning this Certificate to Our administrative office. As soon as this Certificate is received by Us, it is treated as if it was never issued. Any premium payment will be refunded when We receive this Certificate.

RIGHT TO CANCEL

After the 30-day period specified in the Right to Examine section, You may cancel this Certificate by notifying Us in writing that You wish to do so. This Certificate will be cancelled effective as of the date We receive Your written request, unless the notice specifies a later date.

This Certificate replaces any certificate previously issued under the Policy.

Assurity Life Insurance Company of New York has signed this Policy on the Effective Date.

                                                                                                

Tom Henning, President                                                                           John Sharp, Secretary

Assurity Life Insurance Company of New York Home Office: 121 State Street, Albany, NY 12207 (844) 401-7585 • FAX (888) 255-2060
Admin. Office: P.O. Box 82533, Lincoln, NE 68501-2533 (844) 401-7585 • FAX (888) 255-2060

GROUP CREDIT LIFE INSURANCE POLICY

STUDENT TUITION PERIODIC PAYMENT PROGRAM

CONTRIBUTORY PLAN NON-PARTICIPATING

RENEWABLE AT THE OPTION OF ASSURITY LIFE INSURANCE OF NEW YORK

READ YOUR CERTIFICATE CAREFULLY.

SCHEDULE

CLASSIFICATION

Class III All Members enrolled in the CollegeInsure Plan

MAXIMUM BENEFIT AMOUNTS

Class III CollegeInsure $40,000

Policyholder: Nelnet Business Solutions, Inc.
3 Columbia Circle, Suite 205
Albany, New York 12203-5158 (518) 869-8154 • www.nelnet.com

Insured
Person(s): CollegeInsure Plan Member

Premium: $17.00

Certificate No.: 9999999999

Issue Date: The date the Tuition Payment Agreement is signed.

DEFINITIONS

Beneficiary means the Educational Institution designated by the Member on each Tuition Payment Agreement for the current school year. For any portion of the Proceeds, as of the date of payment, in excess the outstanding tuition balance then owed to the Beneficiary designated on Your Tuition Payment Agreement, any excess of Proceeds (including not more than two months of delinquent payments) shall be payable to the Beneficiary or Beneficiaries designated by the Member on the enrollment form or to the estate of the Member, if no Beneficiary is designated.

Certificate means this document that describes the benefits, terms, conditions, exclusions and limitations of the insurance provided under the Policy.

Educational Institution means an elementary school, middle school, secondary school or college that has entered into a contract with the Policyholder for management of the school’s periodic tuition payment program.

Tuition Payment Agreement means the agreement between You and the Policyholder authorizing the Policyholder to process tuition payments.

Member(s) means a person who:

— has signed, or is the Spouse of a person who has signed, the Tuition Payment Agreement under which tuition payments are outstanding for the current school year; and
— is under the age of 70 on the later of the day insurance is elected or the Tuition Payment Agreement is signed.

Policy means the group master Policy issued to the Policyholder by Us.

Proceeds means the amount payable upon the death of an Insured Person.

Spouse means the person to whom You are legally married as recognized and allowed by federal law, or by state law in Your state of residence.

We, Us, Our mean Assurity Life Insurance Company of New York.

You, Your, Insured Person mean the Member who is insured under this Certificate.

ELIGIBILITY

Date a Person’s Insurance Takes Effect

You will become covered on the date (a) You sign the Tuition Payment Agreement and (b) You enroll for insurance; provided you are under the age of 70 on the later of the day you sign the Tuition Payment Agreement or you enroll for insurance.

Date an Insured Person’s Insurance Ends

Insurance coverage under this Certificate will terminate on the earliest of the following:

— the date that the last scheduled tuition payment for the current Tuition Payment Agreement is due;
— the day the Tuition Payment Agreement terminates for any reason; or
— the day of the Insured Person’s death.

In the event of termination of such Policy by the insurer or Policyholder, insurance coverage with respect to any insured Member shall be continued under such Policy for the remainder school year, unless such coverage is immediately assumed by the same or another insurer.

The Policyholder has the sole responsibility to notify the Insured Person of such termination.

BENEFITS

Payment of Proceeds

If the Insured Person dies while this Certificate is in force and all provisions have been met, Proceeds will be paid to the Beneficiary designated by the Member on the Tuition Payment Agreement for the current school year. Payment will be made in a lump sum after receiving due proof of loss.

Proceeds are equal to the outstanding tuition balance owed to the Educational Institution identified on the Tuition Payment Agreement that You have signed for the current school year. Proceeds will not include any tuition payments that are in arrears (past due) by more than two months. In no event will the Proceeds payable for each Tuition Payment Agreement be more than the Maximum Benefit Amount.

Proceeds are payable only once for each Tuition Payment Agreement.

If any portion of the Proceeds, as of the date of payment, exceeds the outstanding tuition balance then owed to the Beneficiary designated on Your Tuition Payment Agreement, any excess of Proceeds (including not more than two months of delinquent payments) shall be payable to the Beneficiary or Beneficiaries designated by the Member on the enrollment form or to the estate of the Member, if no Beneficiary is designated.

Premium Refund

If the Certificate terminates prior to the end of the tuition period the Member may be eligible for a Premium Refund. Premium Refunds are calculated as the present value of the outstanding tuition balance remaining at termination, divided by the present value of the outstanding tuition balance at issue, multiplied by the premium. The number of elapsed months will be equal to the number of completed months. The outstanding tuition balance will not include any tuition payments that are in arrears (past due) by more than two months.

Overpayment Refund

If it is found that We paid more benefits than We should have paid under the Policy due to misrepresentation, error or any other reason, We will have the right to a refund from the recipient of benefits. The recipient of benefits must reimburse Us in full. We will determine the method by which the repayment is to be made.

CLAIM PROCEDURES

Notice of Claim

Written notice of claim must be given to:
Nelnet Business Solutions, Inc.
3 Columbia Circle, Suite 205
Albany, New York 12203-5158 (518) 869-8154

Claim Forms

When the notice of claim is received, the form(s), if any, and instructions for filing a claim will be sent to the claimant.

Proof of Loss

Satisfactory proof of loss must be submitted which may consist of a copy of the Insured Person’s certified death certificate or other lawful evidence providing equivalent information and any other necessary documentation.

Time of Payment of Claim

Benefits covered by this Certificate will be paid after written proof of loss is received and all other provisions herein are met.

GENERAL PROVISIONS

Assignments

Assignments are prohibited in this Policy and Certificate.

Conformity with State and Federal Law

The laws of the federal government and Your state of residence on the Certificate Issue Date apply. If the Policy or this Certificate contains any provision in violation of any law of the federal government or the state in which the Insured Person resides on the Certificate Issue Date, such provision shall be enforceable as if it conformed with such requirements or prohibitions unless the actual provision is more favorable to Member(s) or not less favorable to the Member(s) and more favorable to Policyholders at the date when the Policy or contract was issued.

Contestable Period

We will not contest the validity of the Policy or this Certificate after it has been in force during the Insured Person’s lifetime for two years from this Certificate’s Issue Date, except for non-payment of premium. We have the right to contest the validity of this Certificate based on material misrepresentations made in the Certificate’s enrollment form.

No statement made by any person insured under the Policy relating to his or her insurability shall be used in contesting the validity of the insurance with respect to which such statement was made after such insurance has been in force prior to the contest for a period of two years during such person’s lifetime and in no event unless it is in a written instrument signed by him, a copy of which is or has been furnished to such person or to his Beneficiary.

We have the right to contest the validity of a change or reinstatement of this Certificate based on material misrepresentations made in the application for change or reinstatement. However, We cannot contest any such change or reinstatement of the Certificate after it has been in force during an Insured Person’s lifetime for two years from the change effective date or reinstatement date.

Entire Contract; Changes

The Entire Contract consists of the Policy and this Certificate, which includes the Policyholder’s application for credit insurance and the Insured Person’s enrollment form for credit insurance, any endorsements or amendments attached to the Policy or this Certificate on the Issue Date. The rights of the Policyholder or of any Insured Person(s) or Beneficiary thereunder shall not be affected by any provision other than one contained in the entire contract. All statements made on the application for credit insurance by the Policyholder or by any Insured Person(s) shall be deemed representations and not warranties. No change in the Policy or this Certificate will be effective until approved by one of Our officers and such approval is endorsed and attached to the Policy or this Certificate. No sales representative has authority to change the Policy or this Certificate or to waive any of its provisions.

Misstatement of Age

If the age of all Insured Persons have been misstated and according to the correct age of both Insured Persons the coverage provided would not have become effective, Our liability during that period shall be limited to a refund of premiums paid for such period. However, if the age of one such Insured Person is under the age of 70 on the later of the day insurance is elected or the Tuition Payment Agreement is signed, then coverage will remain in effect for such Insured Person.

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