COUNTY OF SANTA CLARA

Transcription

1 COUNTY OF SANTA CLARA BASIC AND SUPPLEMENTAL LONG-TERM DISABILITY PLAN BENEFIT BOOKLET Revised Effective December 26, 2011

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3 TABLE OF CONTENTS PAGE Long-Term Disability Plan Part One Article I Benefits 1.01 Amount of Benefits Benefits for Less than a Bi-Weekly Period Reductions because of Other Benefits Payable Commencement and Termination of Benefits Acts of Third Parties... 4 Article II Plan Costs 2.01 Participant Contributions Article III Eligibility for Benefits 3.01 Elimination Period Disability Defined Limitations and Exclusions Successive Periods of Disability... 5 Article IV Participation 4.01 Eligibility for Participation Commencement of Coverage Cessation of Participation... 6 Article V Definition Article VI Payment of Benefits 6.01 Application for Benefits Medical Examinations Non-Alienation of Benefits Payments are Made Payments to Representative... 9 Article VII Appeals 7.01 Claims Appeal Procedure

4 PAGE Long-Term Disability Plan Part Two Benefit Highlights Eligibility and Effective Date of Employee Insurance Termination of Employee Insurance Benefit Provisions Claim Provisions General Provisions Definitions Endorsement: Domestic Partner Coverage Certificate Endorsement: Partial Disability... 34

5 SANTA CLARA COUNTY LONG-TERM DISABILITY (LTD) BENEFIT PLAN The LONG-TERM DISABILITY (LTD) PLAN offered by Santa Clara County is comprised of two parts. The Plan is to financially aid Participants in the event of Disability which lasts longer than sixty (60) days. The Plan does not replace other disability benefit sources which are available to Participants, such as Social Security, Workers Compensation, State Disability Insurance or Public Employees Retirement System (P.E.R.S.). This booklet is separated into two sections. Each section details the eligibility, waiting periods, benefits available and all terms of each Part of the LTD Plan. Please refer to the applicable sections for complete plan details PART ONE of the LTD Plan has a maximum benefit period of 24 months for Sickness and 60 months for Accidental Injury. This Part became effective on August 6, 1979 and has been amended and restated to read as set forth herein, effective for Disabilities commencing on and after January 6, The payment of benefits for any Disability commencing prior to January 6, 1992 shall be governed by the terms of the Plan as in effect when such Disability commenced. PART TWO of the LTD Plan is coverage after all LTD Plan benefits under Part One are exhausted and is for disabilities commencing on or after June 1, This Part of the LTD Plan is underwritten by Sun Life Assurance Company of Canada. The information for Part Two of the LTD Plan is the Group Insurance Certificate Amount of Benefits LONG-TERM DISABILITY PLAN PART ONE ARTICLE I MAXIMUM BENEFIT The Benefit pays 66 2/3% of bi-weekly Regular Base Wages. If applicable, this maximum is reduced by the other benefit sources described in Section If you do not elect the benefit level at 66 2/3% of your bi-weekly Regular Base Wages, this benefit may be elected at any of the following benefit levels shown below provided the benefit elected does not exceed 66 2/3% of the employee s bi-weekly Regular Base Wages. Bi-Weekly Benefit Amount Bi-Weekly Covered Salary Bi-Weekly Cost ($.81 with SDI) Bi-Weekly Cost ($1.04 w/out SDI) $ 700 $ 800 $ 900 $1,000 $1,100 $1,200 $1,300 $1,500 $1,800 $2,000 $1,050 $1,200 $1,350 $1,500 $1,650 $1,800 $1,950 $2,250 $2,700 $3,000 $ 8.45 $ 9.66 $10.87 $12.08 $13.28 $14.49 $15.70 $18.11 $21.74 $24.15 $10.87 $12.42 $13.97 $15.53 $17.08 $18.63 $20.18 $23.29 $27.95 $31.05 This benefit is available only to employees enrolled under this benefit effective April 15, 1997 or after. MINIMUM BENEFITS ALL PLANS Effective January 6, 1992 the bi-weekly minimum benefit amount for all Plans is $ If the Plan benefit is Long-Term Disability Plan Part One 1

6 reduced by the other benefit sources described in Section 1.03, to less than one hundred dollars ($100.00) biweekly, the Plan will still pay the one hundred dollars ($100.00) bi-weekly minimum amount. This benefit is payable on new disabilities and continuing disabilities which commenced prior to the amendment date. However, benefits are not retroactive prior to January 6, MAXIMUM BENEFIT PERIOD For Sickness - Benefit is limited to a maximum of 24 months Accidental Injury - Benefit is limited to a maximum of 60 months Refer to Section B, Termination of Benefits for additional details. AFTER ALL BASIC PLAN BENEFITS ARE EXHAUSTED, SEE PART TWO SUPPLEMENTAL LTD PLAN Benefits For Less Than a Bi-Weekly Period For each day of any period of disability for which benefits are paid and which is less than a full bi-weekly period, the amount of benefit payable shall be one-fourteenth (1/14) of the amount of the Bi-Weekly Benefit Reductions Because of Other Benefits Payable The Disability benefit as described previously under the heading Amount of Benefits shall be reduced by the amount of any benefits (expressed in comparable bi-weekly terms) which the Plan Administrator determines are available to the Participant for the same period of Disability as is payable hereunder, whether or not such benefits are applied for, and whether or not such benefits are contingent upon disability, from the following: 1) primary and dependent Disability benefits (as a result of such Disability) or old age retirement benefits under the Federal Social Security Act as now or hereafter in effect; provided, however that after the initial deduction for such benefits, the bi-weekly benefit shall not be further reduced by the amount of any increase in benefits as may thereafter become effective during a period for which Disability benefits are payable and which is due to a cost-of-living adjustment pursuant to Section 230, Title 11 of the Act; 2) disability benefits under a state Disability fund or a Company plan established in lieu thereof, or the County s Short-Term Disability Benefit Plan, Public Employees Retirement System (P.E.R.S.), or any other Countysponsored Retirement and/or Disability Plan; 3) benefits paid pursuant to any state or federal workers compensation or Disability law or other law of similar purpose; such benefits shall include, but shall not be limited to temporary Disability and permanent Disability payments (whether total or partial), vocational rehabilitation payments and any amounts awarded or allocated for future medical expenses - any amount awarded or paid in a lump sum, whether voluntarily or by operation of law, shall be deducted from the Plan benefit payable commencing from the date of the award of settlement and continuing for as many future months as is necessary to equal the amount of such lump sum; 4) benefits under any plan, fund or other arrangement, by whatever name called, providing Disability benefits pursuant to any compulsory benefit act or law or any government; 5) benefits under any Employer sponsored program which provides for a periodic Disability benefit or a lump sum Disability payout (only the portion of these benefits attributable to contributions made by the Employer will be integrated with the Plan benefits); and 6) amounts received or awarded because the Participant was injured by a third party (see Section 1.05), less any unreimbursed medical expenses awarded by a court and less reasonable expenses of collecting such amounts, including attorneys fees. If the Participant either chooses not to apply for, elects to defer or fails to request any of the above benefits, for Long-Term Disability Plan Part One 2

7 which he or she may be eligible, the Claims Administrator will reduce such benefits on the basis that the Participant had received the benefit on the earliest date of eligibility. If, however, a Participant does apply for and/or requests any of the above benefits for which he may be eligible and can provide the Claims Administrator with written evidence of these applications and/or requests, the Claims Administrator shall have the option of having the Participant sign a promise to repay the Plan the appropriate integrable amount of the other benefits payable. If the Participant signs the promise to repay, the Claims Administrator will pay the Participant the full Plan benefits while the Participant is waiting for other benefits payments. Otherwise, benefits will reduced as provided above Commencement and Termination of Benefits A) Commencement of Benefits Long-Term Disability benefits shall be payable as of the first day following sixty (60) days of continuous Disability. B) Termination of Benefit Disability benefits, once approved, shall be payable bi-weekly so long as eligibility for Long-Term Disability benefits continues. Eligibility for Long-Term Disability benefits shall terminate upon the earliest of any of the following events or dates: 1) the death of the Participant; 2) the cessation of the Participant s Disability as determined by the Plan Administrator; 3) the Participant s failure to cooperate in an independent medical examination within thirty (30) days following a written request by the Plan Administrator; 4) the Participant s failure to provide, within thirty (30) days following request, information reasonably requested in writing by the Plan Administrator for the purpose of determining whether he or she is entitled to benefits under the Plan; 5) the date on which the Participant ceases to be under the regular and continuous care and treatment of a licensed Physician, unless such regular and continuous care and treatment is not medically indicated (given the nature of the Disability), or the Participant refuses to follow or rejects the treatment plan recommended by the attending Physician, unless such treatment plan is disputed in good faith and on the advice of another Physician. 6(a) for a disability which arises out of, relates to, is caused by, or results from a sickness, eligibility shall terminate after 26 months of Continuous Disability. 6(b) for a disability which arises out of, relates to, is caused by, or results from an accidental injury, and the disability begins within 30 days from the date of the accident, eligibility shall terminate after 26 months of Continuous Disability if: i) a determination is made by the Social Security Administration that the condition for which the participant is claiming benefits is not or is no longer disabling within the meaning of the Federal Social Security Act as now or hereafter in effect; or ii) iii) a determination is made by the Plan Administrator that the condition for which the Participant is claiming benefits does not meet or no longer meets all of the required medical criteria ( listing of impairments ) as set forth in the Social Security regulations pertaining to Disability claims under Title II of the Social Security Act; or after an additional 36 months of Continuous Disability if i) or ii) above do not apply. Long-Term Disability Plan Part One 3

8 6(c) Notwithstanding 6(a) and (b) above, in no event will disability benefits be paid for a period in excess of 60 months from the commencement date of benefits Acts of Third Parties In the event that the Participant is injured through the acts or omissions of another person or organization, benefits shall be provided only on condition that the participant agrees in writing to the following: a) to reimburse the Plan for the full amount of payments made under the terms of this Plan, immediately upon receipt of the portion of the proceeds of any settlement of, or judgment in, an action at law, arbitration, claim or other proceeding to determine said Participant s right of recovery arising out of said injury, which are designated as reimbursement for past or future loss of Regular Base Wages (Note: in the absence of any specific allocation in the judgment or settlement, the total award, less the Participant s reasonable attorney s fees, shall be assumed to be reimbursement for loss of past or future Regular Base Wages); said Participant shall execute and deliver instrument and papers and do whatever is necessary to secure the rights of the Plan to reimbursement out of such proceeds; said Participant shall do nothing to prejudice such rights; b) to provide the Claims Administrator with a lien on the proceeds described above, to the extent of the full amount of payments made under the terms of this Plan; said lien may be filed with the person or organization whose act or omission injured the Participant, with his or hers (its) agents, or may be filed with the Court, and c) provide the Claims Administrator with a credit against payments to be made in the future under this Plan, said credit to be equal to the proceeds above described, less any amount paid to the Plan by way of reimbursement PARTICIPANT CONTRIBUTIONS The bi-weekly cost to you for either the Plan is: ARTICLE II PLAN COST 1. If covered by the State Disability Insurance Plan $.81 per $ of your bi-weekly salary. 2. If not covered by the State Disability Insurance Plan $1.04 per $ of your bi-weekly salary MAXIMUM APPLICABLE BI-WEEKLY SALARY The benefit pays 66 2/3% of bi-weekly Regular Base wages. EXAMPLE OF BENEFITS AND MONTHLY COST 1. For Employees covered by the State Disability Insurance Plan. If your bi-weekly Your bi-weekly Your bi-weekly salary is benefit will be contribution will be $1, $ $8.45 1, , , , , or over 2, Long-Term Disability Plan Part One 4

9 2. For Employees not covered by the State Disability Insurance Plan. If your bi-weekly Your bi-weekly Your bi-weekly salary is benefit will be contribution will be $1, $ $ , , , , , or over 2, Elimination Period ARTICLE Ill ELIGIBILITY FOR BENEFITS A Participant who sustains a Disability shall, subject to the provisions of the Plan, become eligible to receive the benefit described in Section 1.01 only after such Disability has lasted continuously for sixty (60) days Disability Defined Disability shall mean any physical or mental condition arising from an illness or injury, which renders a Participant incapable of performing work. During the first twenty-four (24) months of a Disability Benefit period, a Participant must be unable to perform the work of his regular occupation or any reasonably related occupation. After twenty-four (24) months of a Disability Benefit period, a Participant must be unable to perform the work of any occupation for which he is or becomes reasonably qualified by training, education or experience Limitations and Exclusions A. A Participant shall not be entitled to a Long-Term Disability benefit payment if his or her Disability arises out of, relates to, is caused by or results from: 1) an intentionally self-inflicted injury of any kind, while sane or insane; 2) an illness or injury to which a contributing cause was the commission or attempted commission of a felony, or the engagement in an illegal occupation; 3) an illness or injury due to war or any act of war, declared or undeclared, insurrection, rebellion or participation in a riot; 4) an illness or injury for which the Participant was or is not under the regular and continuous care and treatment of a medical doctor or doctor of osteopathy, unless such regular and continuous care and treatment are not medically indicated given the nature of Disability; B. Long-Term Disability benefits shall be payable only if the Participant s Disability commences while he or she is a Plan Participant Successive Periods of Disability After Plan benefits have become payable, successive periods of Disability separated by less than six (6) consecutive months of continuous active work on a Full-Time basis shall be considered one (1) period of Disability, unless the subsequent Disability is due to an illness or injury found by the Claims Administrator to be entirely unrelated to the cause of the previous Disability and commences after the return to active work with the County on a Full-Time basis. Long-Term Disability Plan Part One 5

10 ARTICLE IV PARTICIPATION 4.01 Eligibility for Participation If you are a classified or unclassified employee receiving a paycheck from the County and holding a code in provisional, probationary or permanent status, and are making a contribution to this Plan through payroll deduction, you are eligible for coverage under this Plan Commencement of Coverage If an eligible Employee was employed prior to the Effective Date of the Plan, and was also participating in the Santa Clara County Long Term Income Protection Plan prior to the effective date of this Plan, he or she will automatically be covered by this Plan on the Plan effective date, unless such Employee elects, in writing, to withdraw from the Plan. If an eligible Employee is employed on or after the Effective Date of the Plan, he or she will be covered as of the first date following the pay period for which the first payroll deduction is made provided that such Employee completes and signs the Enrollment Card and thereby elects to make contributions in accordance with Section Example: If the first payroll deduction was taken from your paycheck for the period December 23, 1991 through January 5, 1992, your effective date would be January 6, If an Employee was not enrolled in the Santa Clara County Long Term Income Protection Plan on the effective date of this Plan or initially rejected Plan coverage or withdrew from the Plan, or did not enroll within 60 days from the date he or she was first eligible and subsequently desires to be covered under this Plan, he or she will be required to provide acceptable proof of insurability, in accordance with procedures established by the Plan Administrator, before coverage will commence. If the evidence received is satisfactory, you will be advised by the Plan Administrator the date your coverage will become effective. If the Employee was not working full-time on the day or during the period he or she would ordinarily become covered by the Plan, coverage will not become effective until such Employee has returned to Full-Time work Cessation of Participation An Employee may voluntarily cease to participate in the Plan as of the last day of any payroll period by giving advance written notice to the Benefits Office, in accordance with the procedures established by the Plan Administrator. Participation shall automatically cease upon the earliest of the following dates: A. on the date of termination of employment by termination of Employer-Employee relationship; or B. on the last day of the month in which the Participant begins a County approved medical or non-medical leave of absence; or C. on the date a Participant is placed on layoff status; or D. on the date a Participant ceases to be an eligible Employee; or E. on the date of termination of the Plan. Long-Term Disability Plan Part One 6

11 ARTICLE V DEFINITIONS General Wherever the following terms are used in this Plan, they shall have the meanings specified below, unless the context clearly indicates to the contrary Claims Administrator The words Claims Administrator shall mean United Administrative Services Disability The word Disability shall mean a disability as described in Section Effective Date The words Effective Date of the Plan shall mean August 6, Employee The word Employee shall mean a person who, on or after the Effective Date, is a classified or unclassified individual who performs a service for the Employer on a regular basis Employer The word Employer shall mean Santa Clara County Participant The word Participant shall mean an Employee who satisfies the eligibility requirements of Section 4.01 and who elects to participate in the Plan Physician The word Physician shall mean a medical doctor, a doctor of osteopathy, or any other licensed practitioner operating within the scope of his license and under the laws of the jurisdiction in which he operates Plan The word Plan shall mean the Santa Clara County Basic Long-Term Disability Benefit Plan Plan Administrator The words Plan Administrator shall mean Santa Clara County Definition of Regular Base Wages Regular Base Wages for the purposes of benefit computation and contribution determination, shall mean the product of the Employee s hourly rate of pay (excluding shift differential pay, call back pay, overtime, etc.) times the number regularly scheduled hours in a payroll period. The term regularly scheduled hours in a payroll period, as used above, means the number of such hours without regard to any temporary, mandatory reduction in work hours imposed by the County. For the purposes of benefit computation, Regular Base Wages shall be deemed to be that amount in effect on the date immediately prior to the date of the commencement of the period of Disability. Long-Term Disability Plan Part One 7

12 5.11 Sickness Sickness means illness or disease. It includes pregnancy and resulting childbirth, in addition to complications of pregnancy Accidental Injury Accidental Injury means physical harm which is the result of a specific unexpected incident caused by an outside force. The physical harm must have occurred at an identifiable time and place. Accidental injury does not include illness or infection, except infection of a cut or wound. Disabilities due to an accidental injury must start within 30 days from the date of the accident, and the accidental injury must have been incurred while the participant was covered under the Plan Application for Benefits ARTICLE VI PAYMENT OF BENEFITS I. Obtain a claim form by contacting the Claims Administrator s Office: United Administrative Services, telephone number (408) Fill out and sign the Claim Statement of Employee. Write or print clearly. Be sure all information is correct. Be especially careful with your Social Security Number, addresses and dates. 3. Give the form to your doctor for completion of the Attending Physician Statement. 4. Mail the claim form to: United Administrative Services P.O. Box 5057 San Jose, California Early filing will speed your payment. Please direct any questions regarding your claim to the Claims Administrator s Office: United Administrative Services P.O. Box 5057 San Jose, California Telephone Number: (408) Except for good cause, written notice of claim must be given to the Claims Administrator within ninety (90) days after the first (1st) day of a Disability. Failure to furnish such proof within the time required shall not invalidate nor reduce any claim if it was not reasonably possible to give proof within such time, provided such proof is furnished as soon as reasonably possible and in no event, except in the absence of legal capacity shall a claim be accepted more than twelve (12) months after commencement of Disability. A claim may be submitted by a representative of the Participant if the Participant is not reasonably able to do so. The Claims Administrator shall have the right to: (a) (b) require continued proof of Disability, at the Participant s expense, during the pendency of a claim; require written authorization for medical records and other information needed to document properly Long-Term Disability Plan Part One 8

13 the Participant s file; (c) (d) (e) require information with respect to the Participant s age, address, marital status, dependents, employment record and medical history; require any other information reasonably relevant to a determination of whether such Participant is eligible to receive Plan benefits; and personally contact and interview the Participant, the Participant s Physician, Employer or any other persons who can provide relevant information regarding the Participant s Disability. The Participant s failure to cooperate with the Claims Administrator in a reasonable investigation or processing of a claim will result in benefits being denied, suspended or terminated Medical Examinations The Claims Administrator may require that a Participant applying for Plan benefits submit to an examination by one or more Physicians or vocational specialists designated by the Claims Administrator. Reexaminations of a Participant receiving Plan benefits may be required by the Claims Administrator from time to time for the purpose of determining whether a Disability continues to exist. The fees of such Physician or vocational specialist and the expenses of such examination shall be paid by the Plan Non-Alienation of Benefits The interest and property rights of any person in the Plan or in any payment to be made under the Plan shall not be subject to option nor be assignable either by voluntary or involuntary assignment or by operation of law, including (without limitation) bankruptcy, garnishment, attachment or other creditor s process, and any act in violation of this Section 6.03 shall be void Payments Are Made Upon receipt of all the necessary information and determination of the Participant s eligibility for Plan benefits, the Claims Administrator will calculate the amount of the benefit payment and forward the initial check directly to the participant s residence. Subsequent benefit checks will be issued bi-weekly by the Claims Administrator, provided the claim is still approved and is complete in all respects at that time Payments to Representative In the event that a guardian, conservator, committee or other legal representative has been duly appointed for a Participant who is entitled to any payment under the Plan, any such payment due may be made, in good faith, to the legal representative making claim therefor, and any such payment so made shall be in complete discharge of the liabilities of the Plan therefor and the obligations of the Plan Administrator and the Claims Administrator Claims Appeal Procedure ARTICLE VII APPEALS The claimant and/or his or her representative may appeal a denied claim or a claim deemed to have been denied and may do the following: a. Request from the Claims Administrator a review of the eligibility status for any claim denied in whole. b. Request from the Claims Administrator a review of any benefit payments. Such requests must include Participant s name and Social Security Number. c. File a request for review in writing, stating in clear and concise terms the reason or reasons for the disagreement with the handling of his/her claim. Long-Term Disability Plan Part One 9

14 The request for review should be directed to the Claims Administrator within twenty (20) days after the claim payment date or the date of the notification of denial of benefits. A copy of your appeal will be filed with the Plan Administrator s office, Personnel Department. Your request will be submitted to the appeals panel. You are entitled to a hearing before the panel if you should so request. You may bring a representative of your choice to the hearing. Information regarding your claim will be kept confidential except for the purposes allowed by law. The appeals panel will review the denial and the Plan Administrator will provide the claimant with a written response with sixty (60) days of the date the Plan Administrator receives the written request for review. If because of extenuating circumstances the Plan Administrator is unable to complete the review process within sixty (60) days, the Plan Administrator shall notify the claimant of the delay within the sixty (60) day period and shall provide a final written response to the request for review within one hundred twenty (120) days of the date the Claims Administrator received the written request for review. If no notice of denial or notification of extenuating circumstances requiring a delay is provided as herein described, the claimant may appeal the claim as though the claim had been denied. The Plan Administrator s written response to the claimant shall, if the denial is upheld, cite the specific Plan provision(s) upon which the denial is based. Long-Term Disability Plan Part One 10

15 Employee Group Benefits UNDERWRITTEN BY SUN LIFE ASSURANCE COMPANY OF CANADA County of Santa Clara Long Term Disability Income Insurance GROUP POLICY NUMBER BOOKLET EFFECTIVE DATE - December 26, 2011 Long-Term Disability Plan Part Two 11

16 Welcome to Sun Life Assurance Company of Canada ( Sun Life ). Sun Life is pleased to be your Employer s insurance carrier for the benefits provided in the Group Policy. The description of Eligible Classes in the Benefit Highlights will help you determine what benefits apply to you. The booklet is intended to provide a summarized explanation of the current Group Policy Benefits. However, the Group Policy is the document which forms Sun Life's contract to provide benefits. If the terms of the booklet and the Group Policy differ, the Group Policy will govern. A complete copy of the Group Policy is in the possession of your Employer and is available for your review. In the event of any changes in benefits or Group Policy provisions, you will be provided with a new booklet or a supplement which describes any changes. Possession of this booklet does not necessarily mean you are insured under the Group Policy. The requirements for becoming eligible for insurance and the dates your insurance begins or ceases are explained within this booklet. This booklet uses insurance terms and phrases that are listed in the Definitions Section. For information, call the Sun Life Group Customer Service Center toll free at (800) Long-Term Disability Plan Part Two 12

17 NOTICE TO CERTIFICATEHOLDER THIS NOTICE IS TO ADVISE YOU THAT SHOULD YOU HAVE ANY QUESTIONS OR COMPLAINTS REGARDING YOUR SUN LIFE GROUP INSURANCE PLAN, YOU MAY CONTACT THE FOLLOWING: SUN LIFE ASSURANCE COMPANY OF CANADA GROUP CUSTOMER SERVICE CENTER SC1219 U.S. HEADQUARTERS OFFICE ONE SUN LIFE EXECUTIVE PARK WELLESLEY HILLS, MA (800) ALSO AVAILABLE TO YOU IS THE CONSUMER SERVICES DIVISION OF THE CALIFORNIA INSURANCE DEPARTMENT, 300 SOUTH SPRING STREET, SOUTH TOWER, 11TH FLOOR, LOS ANGELES, CALIFORNIA 90013, (800) THE INSURANCE DEPARTMENT SHOULD BE CONTACTED ONLY AFTER DISCUSSIONS WITH THE INSURER HAVE FAILED TO PRODUCE A SATISFACTORY RESOLUTION TO THE PROBLEM Long-Term Disability Plan Part Two 13

18 LONG TERM DISABILITY INCOME INSURANCE ELIGIBLE CLASSES BENEFIT HIGHLIGHTS All United States Employees working in the United States regularly scheduled to work at least 40 hours per biweekly pay period. CLASSIFICATION All Eligible Employees AMOUNT OF INSURANCE You may elect one of the following Options: Option I 66.67% (Benefit Percentage) of your Total Monthly Earnings, not to exceed the Maximum Monthly Benefit, less Other Income Benefits. - the Maximum Monthly Benefit is: $15,000. Option II 66.67% (Benefit Percentage) of your Total Monthly Earnings, not to exceed the Maximum Monthly Benefit, less Other Income Benefits. - the Maximum Monthly Benefit is: $1, Option III 66.67% (Benefit Percentage) of your Total Monthly Earnings, not to exceed the Maximum Monthly Benefit, less Other Income Benefits. - the Maximum Monthly Benefit is: $1, Option IV 66.67% (Benefit Percentage) of your Total Monthly Earnings, not to exceed the Maximum Monthly Benefit, less Other Income Benefits. - the Maximum Monthly Benefit is: $1, Option V 66.67% (Benefit Percentage) of your Total Monthly Earnings, not to exceed the Maximum Monthly Benefit, less Other Income Benefits. - the Maximum Monthly Benefit is: $2, Option VI 66.67% (Benefit Percentage) of your Total Monthly Earnings, not to exceed the Maximum Monthly Benefit, less Other Income Benefits. - the Maximum Monthly Benefit is: $2, Long-Term Disability Plan Part Two 14

19 Option VII 66.67% (Benefit Percentage) of your Total Monthly Earnings, not to exceed the Maximum Monthly Benefit, less Other Income Benefits. - the Maximum Monthly Benefit is: $2, Option VIII 66.67% (Benefit Percentage) of your Total Monthly Earnings, not to exceed the Maximum Monthly Benefit, less Other Income Benefits. - the Maximum Monthly Benefit is: $2, Option IX 66.67% (Benefit Percentage) of your Total Monthly Earnings, not to exceed the Maximum Monthly Benefit, less Other Income Benefits. - the Maximum Monthly Benefit is: $3, Option X 66.67% (Benefit Percentage) of your Total Monthly Earnings, not to exceed the Maximum Monthly Benefit, less Other Income Benefits. - the Maximum Monthly Benefit is: $3, Option XI 66.67% (Benefit Percentage) of your Total Monthly Earnings, not to exceed the Maximum Monthly Benefit, less Other Income Benefits. - the Maximum Monthly Benefit is: $4, If you do not make an election, you will not be insured. Your Evidence of Insurability, satisfactory to Sun Life will be required if: - you elect no coverage and later elect Long Term Disability Income Insurance; or - you elect to increase your amount of Long Term Disability Income Insurance. Note: your amount of insurance is also subject to reductions for your employment earnings. The Minimum Monthly Benefit for all Options is $100. Elimination Period (The period of time you need to be continuously Totally Disabled before LTD benefits are payable) 62 months - for Injury 26 months - for Sickness Maximum Benefit Period (The longest period of time Sun Life will pay you an LTD benefit while you are Totally or Partially Disabled) Long-Term Disability Plan Part Two 15

20 Your Maximum Benefit Period is the period shown below or your Normal Retirement Age under the 1983 amendments to the Federal Social Security Act, whichever is longer. Age at Disability Maximum Benefit Period Less than age 60 To age 65, but not less than 60 months Months Months Months Months Months Months Months Months Months 69 and over 12 Months Year of Birth Normal Retirement Age Before 1938 Age Age 65 and 2 months 1939 Age 65 and 4 months 1940 Age 65 and 6 months 1941 Age 65 and 8 months 1942 Age 65 and 10 months 1943 through 1954 Age Age 66 and 2 months 1956 Age 66 and 4 months 1957 Age 66 and 6 months 1958 Age 66 and 8 months 1959 Age 66 and 10 months After 1959 Age 67 Applicable to All Hourly Employees who do not have regularly scheduled hours Total Monthly Earnings Your hourly rate of pay multiplied by your average hour workweek in the previous calendar year not to exceed 40 hours per week multiplied by 4.333, or the average weekly earnings for the period of employment if employed for less than a full calendar year multiplied by If your current monthly earnings includes commissions, your commissions will be averaged over the previous calendar year prior to the first date Total Disability begins or the average monthly earnings received to date to the above calculation. Applicable to All Hourly Employees who do have regularly scheduled hours Total Monthly Earnings Your hourly rate of pay multiplied by hours worked multiplied by Applicable to All Other Eligible Employees Long-Term Disability Plan Part Two 16

21 Total Monthly Earnings Your average monthly earnings as reported by your Employer for the previous calendar year immediately prior to the first date Total Disability begins. Total Monthly Earnings includes commissions and deductions made for pre-tax contributions to a qualified deferred compensation plan, Section 125 plan, or flexible spending account, but does not include income received due to bonuses, overtime pay or any other extra compensation. If you have been employed for less than a full calendar year, Total Monthly Earnings will be your average monthly earnings from the date of employment. If you are paid on an hourly basis, Total Monthly Earnings will be based on your hourly rate of pay, but will not exceed 40 hours per week. WAITING PERIOD (The period of time you must be employed in an Eligible Class before you can apply for benefits) Until the first day following the pay period for which the first payroll deduction is made. CONTRIBUTIONS The cost of your Long Term Disability Income Insurance is paid for by you. This is your contributory insurance. The following Questions and Answers will help you to better understand your benefits. Please read them carefully and refer any questions to your Employer or call the Sun Life Group Customer Service Center toll free at Long-Term Disability Plan Part Two 17

22 ELIGIBILITY AND EFFECTIVE DATE OF EMPLOYEE INSURANCE When am I eligible for insurance? If you are in an Eligible Class shown in the Benefit Highlights, you are eligible on the later of: - December 26, 2011; or - the day after you complete the Waiting Period. When do I need to apply for insurance? You must apply within 31 days of the date you become eligible. When does my insurance start? Your insurance starts on the later of: - the date you apply; or - the date you are eligible; if you are Actively at Work on that date. What happens if I do not apply within 31 days? Your insurance will start on the date Sun Life approves your Evidence of Insurability, if you are Actively at Work on that date. What if I am not Actively at Work on that date? If you are not Actively at Work on the date your insurance would normally start, your insurance will not start until you are Actively at Work. What happens if I do not want my insurance? You need to sign a form refusing your insurance. This form is available from your Employer. If you decide later you want to enroll for insurance, Sun Life must first approve your Evidence of Insurability. When do changes in my amount of insurance occur? If your amount of insurance increases, your increase will take effect immediately upon the date of change, as long as: - you are Actively at Work on that date; and - Evidence of Insurability is not required for the increase in your amount of insurance. If your amount of insurance decreases, your decrease will take effect immediately upon the date of change. If Evidence of Insurability is required for any increase in your amount of insurance, the increase in your insurance will not start until Sun Life approves the increase, but you need to be Actively at Work on that date. If you are not Actively at Work on the date an increase in your insurance would normally start, the increase in your insurance will not start until you are Actively at Work. Long-Term Disability Plan Part Two 18

23 When does my insurance cease? TERMINATION OF EMPLOYEE INSURANCE Your insurance ceases on the earliest of: - the date the Group Policy terminates. - the date you are no longer in an Eligible Class. - the date your class is no longer included for insurance. - the last day for which any required premium has been paid for your insurance. - the last day of the pay period in which you retire. - the date you request in writing to terminate your insurance. - the date you enter active duty in any armed service during a time of war (declared or undeclared). - the last day of the pay period in which your employment terminates. - the date you cease to be Actively at Work. Are there any conditions under which my insurance can continue? Yes. Your insurance will continue during any Elimination Period or any period the premium for your insurance is waived under the Group Policy. If you are on temporary layoff, leave of absence or vacation, your Employer may continue your insurance by paying the required premium for the length of time specified below. Layoff up to 24 months. Leave of Absence up to 24 months (including Family and Medical Leave of Absences.) Vacation up to 3 months If you are absent from work due to an injury or sickness, your Employer may continue your insurance, by paying the required premium, for up to 3 months. You may be eligible to continue your insurance coverage pursuant to the Family and Medical Leave Act of 1993, as amended or continue coverage pursuant to a state required continuation period (if any). You should contact your Employer for more details. You may be eligible to continue your insurance coverage pursuant to the Uniformed Services Employment and Reemployment Rights Act (USERRA). You should contact your Employer for more details. Long-Term Disability Plan Part Two 19

24 What is the Long Term Disability Benefit? BENEFIT PROVISIONS LONG TERM DISABILITY INCOME INSURANCE Long Term Disability Benefits (LTD) partially replace your income if you become Totally or Partially Disabled while insured. When do LTD benefits become payable? Sun Life will pay a monthly LTD benefit after the end of your Elimination Period, if Sun Life receives proof that you are: - Totally Disabled due to an Injury or Sickness; or - Partially Disabled due to the same Injury or Sickness that caused Total Disability, within 31 days after Total Disability Benefits cease; and - under the regular and continuing care of a Physician that provides appropriate treatment in accordance with your disabling condition. What conditions must be met for LTD benefits to continue? Sun Life will pay you an LTD benefit, up to the Maximum Benefit Period, if you provide proof that you continue to be Totally or Partially Disabled and you require the regular and continuing care of a Physician. You need to provide proof when Sun Life asks for it, but the proof is at your expense. You need to provide Sun Life with proof of your monthly earnings (if applicable) on a quarterly basis. What is the Total Disability Benefit? If you are Totally Disabled, your Net Monthly Benefit will be calculated based on the Total Disability Benefit formula. You will qualify for this benefit if: - you are not working or you are working but you are earning less than 20% of your Indexed Total Monthly Earnings; and - you, because of your Injury or Sickness, are unable to perform with reasonable continuity any Gainful Occupation for which you are or become reasonably qualified for by education, training or experience. How is the Total Disability Benefit calculated? To determine your Total Disability Benefit: 1. Take the lesser of: a. your Total Monthly Earnings multiplied by the Benefit Percentage (shown in the Benefit Highlights); or b. your Maximum Monthly Benefit elected by you (shown in the Benefit Highlights); then 2. Subtract Other Income Benefits from the amount determined in Step 1. What is the Partial Disability Benefit? If you are Partially Disabled, your Net Monthly Benefit will be calculated based on the Partial Disability Benefit formula. Long-Term Disability Plan Part Two 20

25 You will qualify for this benefit if: - you are working and have Disability Earnings of more than 20% but less than 60% of your Indexed Total Monthly Earnings; and - you, because of your Injury or Sickness, are unable to perform with reasonable continuity any Gainful Occupation for which you are or become reasonably qualified for by education, training or experience and you have Disability Earnings of less than 60% of your Indexed Total Monthly Earnings. How is the Partial Disability Benefit calculated? To determine your Partial Disability Benefit: where: (A divided by B) multiplied by C A = your Indexed Total Monthly Earnings minus your monthly Disability Earnings. B = your Indexed Total Monthly Earnings. C = your Total Disability Benefit. What are Other Income Benefits? Other Income Benefits are those benefits provided to you while your monthly LTD benefit is payable. These Other Income Benefits must be provided to you as a result of the same Total or Partial Disability payable under the Group Policy. Other Income Benefits include: 1. The amount you are paid under: a. Workers Compensation Law as temporary disability benefits; or b. Occupational Disease Law; or c. Unemployment Compensation Law; or d. Compulsory Benefit Act or Law; or e. any other act or law of like intent. 2. The Railroad Retirement Act (including any dependent benefits). 3. Any labor management trustee, union or employee benefit plans that are funded in whole or in part by your Employer. 4. Any disability income benefits you are paid under any governmental retirement system as a result of your job with your Employer. 5. The disability benefits you receive under your Employer s Retirement Plan. (This applies only if the benefits do not reduce your accrued retirement benefit and does not include any amount rolled over or transferred to any other retirement plan as defined in Section 402 of the Internal Revenue Code.) 6. The disability benefits under the United States Social Security Act, or any similar plan or act, as follows: a. Disability benefits you receive. b. Disability benefits your spouse, child or children receive because of your Total or Partial Disability, unless the dependent benefits are paid directly to your divorced spouse or to your children in custody of your divorced spouse. Long-Term Disability Plan Part Two 21

26 7. The amount you receive from any accumulated sick leave. 8. Any salary continuation paid to you by your Employer which causes your Net Monthly Benefit, plus Other Income Benefits and any salary continuation, to exceed 100% of your Total Monthly Earnings. The amount in excess of 100% of your Total Monthly Earnings will be used to reduce your Net Monthly Benefit. 9. Any amount you receive due to lost wages paid to you by compromise, settlement or other method as a result of a claim for any Other Income Benefit. 10. Any amount you receive from a voluntary separation of employment agreement from your Employer including severance pay or any other income settlement of an employment contract. What if I receive payment of Other Income Benefits in a lump sum? If you receive a lump sum payment for any Other Income Benefits, Sun Life will prorate the lump sum on a monthly basis over the time period specified for the lump sum payment. If no time period is stated, the lump sum payment will be prorated on a monthly basis over a reasonable period of time as determined by Sun Life. Am I required to apply for Other Income Benefits? You must apply for any Other Income Benefits for which you may be eligible and have a reasonable expectation of receiving benefits. If such benefits are denied, Sun Life will assist you with an appeal of the denial to any administrative level. Sun Life has the right to receive from you written documentation of your pursuit of Other Income Benefits. What is the Social Security Disability Income Assistance Program? At your request, Sun Life will assist you (if appropriate) through the various levels of the Social Security claims process. Sun Life will assist you with your application and also through the appeals process. What happens when the Other Income Benefits have been awarded or have been denied? You must notify Sun Life in writing, within 31 days of receipt of notice, of the amount of Other Income Benefits when it is approved or if the amount is adjusted (other than for cost of living increases). Sun Life will make an adjustment to the Net Monthly Benefit when Sun Life receives written notice of the amount of the Other Income Benefit. If after Sun Life makes an adjustment to your Net Monthly Benefit you have been underpaid, Sun Life will immediately make a lump sum refund to you of the amount that has been underpaid. If after Sun Life makes an adjustment to your Net Monthly Benefit you have been overpaid, you must reimburse Sun Life the amount of the overpayment within 31 days of the award. Sun Life has the right to reduce your future LTD benefit payments until the amount of the overpayment has been repaid. What happens if I receive increases in my Other Income Benefits? After the first deduction for each of your Other Income Benefits, Sun Life will not reduce your monthly LTD benefit payments due to cost of living increases you receive from any sources described as Other Income Benefits. This does not apply to any increase in earnings you receive from employment. Long-Term Disability Plan Part Two 22

27 When does my monthly LTD benefit cease? Your monthly LTD benefit will cease on the earliest of: - the date you are no longer Totally or Partially Disabled. - the date you die. - the end of your Maximum Benefit Period. - the date you do not provide adequate employment earnings information or proof that you continue to be Totally or Partially Disabled. - the date your Disability Earnings are more than 60% of your Indexed Total Monthly Earnings. - the date you are able to perform, on a full-time basis, any Gainful Occupation for which you are or become reasonably qualified for by education, training or experience, even if you choose not to work.. Full-time basis means you are able or have the capacity to perform any Gainful Occupation for the number of hours that you normally performed your Own Occupation prior to your Total or Partial Disability. However, if you normally performed your Own Occupation on an average in excess of 40 hours per week, Sun Life will consider you as being able to perform that requirement if you work or have the capacity to work 40 hours per week. What happens if I return to work and become Totally Disabled again? Sun Life will treat this new Total Disability as part of your prior Total Disability if you returned to work and were Actively at Work for less than: - six months, if due to the same or related causes; - one day, if due to an entirely unrelated cause. You will not have to complete a new Elimination Period. Your monthly LTD benefit will be subject to the same terms and conditions as were applicable to the original Total Disability. Your monthly LTD benefit will not continue if: - you become eligible for coverage under any other group LTD policy; or - the Group Policy terminates. If your new Total Disability begins later than the time periods specified, you will need to complete a new Elimination Period. What happens if I participate in a Rehabilitation Program? If you participate in a Rehabilitation Program, you will receive the greater of: - your Benefit Percentage (as shown in the Benefit Highlights) multiplied by 1.10; or - your current Net Monthly Benefit payable multiplied by To calculate the increased benefit: Long-Term Disability Plan Part Two 23