REIMBURSEMENT AGREEMENT
GROUP DISABILITY INSURANCE BENEFIT

(Please read carefully)


When Madison National Life Insurance Company, Inc. (“MNL”) has made benefit payments to you in excess of the amount required by the provisions of this policy, or during periods of time for which you subsequently receive retroactive benefits from any source that may offset your benefits under the group policy, you must, in a timely manner, reimburse MNL for such payments, including duplicate or erroneous payments. In addition and upon request, you must execute and deliver to MNL such documents as may be required and do whatever else is necessary to secure our rights to recover any excess, duplicate, or erroneous payments. Such reimbursement will be due and payable immediately upon our notification to and demand of you. Or, at our option, the subsequent payment of benefits or the refund of any premium owed you by MNL may be reduced or refused as a setoff and applied toward such reimbursement. If you delay in notifying MNL of your receipt of a reimbursable income benefit or in making reimbursement to MNL, MNL will have the right to charge interest at a reasonable rate on the delinquent amount owed to MNL. Our acceptance of premium and other fees, or our providing or paying disability benefits, does not constitute a waiver of our right to enforce the provisions of this agreement and/or the group policy in the future. The provisions of this agreement are in addition to, and not in lieu of, any other rights or remedies available to MNL at law or in equity.

Agreement

If my application for group disability insurance benefits is approved, in consideration of the payment of benefits without reduction on account of other benefit payments to which I or my eligible dependents may become entitled under the United States Social Security Act or from any of the other income sources described and provided for in the group policy, I hereby agree to reimburse Madison National Life Insurance Company, Inc. for any and all overpayments made to me under the group disability plan provided by employer. I understand that MNL agrees to make payment in this manner in consideration of my agreement to promptly notify MNL of the amounts and effective dates of any such benefits. Further, I agree that any benefits due me, my beneficiaries, heirs, executors, administrators or assigns under the applicable group policy may be applied to any outstanding overpayment whether resulting from retroactive award of Social Security or any other income benefits as described in the applicable policy.

With respect to any group life insurance coverage provided me by MNL and in consideration of the foregoing, I hereby assign to MNL, as creditor beneficiary, an amount of such group life insurance equal to the amount of any overpayment which may be outstanding under any applicable group disability policy at the time of death.

In witness of the above, the parties hereto have caused this Agreement to be executed, as of the date indicated.

Printed Name of Claimant:
Email Address:
Printed Name of Spouse:
Signature of Claimant: You will be prompted for your signature at a later date.

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