2012 Summary Annual Reports
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1 2012 Summary Annual Reports To the Participants in any of the following Employee Benefits Plans: Payless ShoeSource, Inc. Optional Life Insurance Plan Payless ShoeSource, Inc. Company Paid Life Insurance Plan Payless ShoeSource, Inc. Medical Plan Payless ShoeSource, Inc. Dental Care Plan Payless ShoeSource, Inc. Long-Term Disability Plan Payless ShoeSource, Inc. Short-Term Disability Plan Payless ShoeSource, Inc. Business Travel and Accident Plan Payless ShoeSource, Inc. Severance Plan The following material, along with this cover letter, comprises what is known as the Summary Annual Report for the above listed Employee Benefit Plans of Payless ShoeSource, Inc. and its subsidiaries. Each year an Annual Report is filed with the Employee Benefits Security Administration for each of these plans. This booklet is intended to summarize the contents of these reports. We encourage all Associates to take the time to read this material. Sincerely, Betty Click Senior Vice President, Human Resources-Collective Brands, Inc.
2 For Payless ShoeSource, Inc. Optional Life Insurance Plan This is a summary of the annual report of the Payless ShoeSource, Inc. Optional Life Insurance Plan, EIN , Plan No. 507, for period January 01, 2012 through December 31, The annual report has been filed with the Employee Benefits Security Administration, U.S. Department of Labor, as required under the Employee Retirement Income Security Act of 1974 (ERISA). The plan has a contract with Hartford Life And Accident to pay life insurance claims incurred under the terms of the plan. The total premiums paid for the plan year ending December 31, 2012 were $795,563. The charge to cover copying costs will be $0.00 for the full annual report, or $0.00 per page for any part thereof.
3 For Payless ShoeSource, Inc. Company Paid Life Insurance Plan This is a summary of the annual report of the Payless ShoeSource, Inc. Company Paid Life Insurance Plan, EIN , Plan No. 506, for period January 01, 2012 through December 31, The annual report has been filed with the Employee Benefits Security Administration, U.S. Department of Labor, as required under the Employee Retirement Income Security Act of 1974 (ERISA). The plan has a contract with Hartford Life And Accident to pay life insurance claims incurred under the terms of the plan. The total premiums paid for the plan year ending December 31, 2012 were $223,947.
4 For Payless ShoeSource, Inc. Medical Plan This is a summary of the annual report of the Payless ShoeSource, Inc. Medical Plan, EIN , Plan No. 551, for period January 01, 2012 through December 31, The annual report has been filed with the Employee Benefits Security Administration, U.S. Department of Labor, as required under the Employee Retirement Income Security Act of 1974 (ERISA). Payless ShoeSource, Inc. has committed itself to pay certain medical claims incurred under the terms of the plan. The plan has contracts with Combined Insurance Company Of America, Hmsa - Bluecross Blueshield Of Hawaii, Kaiser Permanente - Northern, Kaiser Permanente - Southern, Cigna Healthcare, Voluntary Limited - Benefits Plans, Triple S, Inc., Takecare and Hartford Life And Accident to pay health, dental, vision, prescription drug, HMO and PPO claims incurred under the terms of the plan. The total premiums paid for the plan year ending December 31, 2012 were $5,879,430. Because some contract are so called "experience-rated" contracts, the premium costs are affected by, among other things, the number and size of the claims. Of the total insurance premiums paid for the plan year ending December 31, 2012 the premiums paid under such "experience rated" contracts were $543,416 and the total of all benefit claims paid under these "experience-rated" contracts during the plan year was $487,555. financial information and information on payments to service providers.
5 For Payless ShoeSource, Inc. Dental Plan This is a summary of the annual report of the Payless ShoeSource, Inc. Dental Plan, EIN , Plan No. 524, for period January 01, 2012 through December 31, The annual report has been filed with the Employee Benefits Security Administration, U.S. Department of Labor, as required under the Employee Retirement Income Security Act of 1974 (ERISA). Payless ShoeSource, Inc. has committed itself to pay all dental claims incured under the terms of the plan. financial information and information on payments to service providers.
6 For Payless ShoeSource, Inc. Long-Term Disability Plan This is a summary of the annual report of the Payless ShoeSource, Inc. Long-Term Disability Plan, EIN , Plan No. 508, for period January 01, 2012 through December 31, The annual report has been filed with the Employee Benefits Security Administration, U.S. Department of Labor, as required under the Employee Retirement Income Security Act of 1974 (ERISA). The plan has a contract with Hartford Life And Accident to pay long-term disability claims incurred under the terms of the plan. The total premiums paid for the plan year ending December 31, 2012 were $887,547.
7 For Payless ShoeSource Inc, Group Short Term Disability Plan This is a summary of the annual report of the Payless ShoeSource Inc, Group Short Term Disability Plan, EIN , Plan No. 509, for period January 01, 2012 through December 31, The annual report has been filed with the Employee Benefits Security Administration, U.S. Department of Labor, as required under the Employee Retirement Income Security Act of 1974 (ERISA). The plan has a contract with Hartford Life & Accident to pay temporary disability and indemnity claims incurred under the terms of the plan. The total premiums paid for the plan year ending December 31, 2012 were $329,112. financial information and information on payments to service providers; and ShoeSource Inc. at 3231 SE Sixth Avenue, Topeka, KS 66607, or by telephone at (785) plan (Payless ShoeSource Inc., 3231 SE Sixth Avenue, Topeka, KS 66607) and at the U.S.
8 For Payless ShoeSource, Inc. Business Travel Accident Plan This is a summary of the annual report of the Payless ShoeSource, Inc. Business Travel Accident Plan, EIN , Plan No. 505, for period February 01, 2012 through January 31, The Business Travel Accident Plan applies to associates of Payless ShoeSource, Inc. and its affiliates authorized to partiicpate in the Plan including Collective Lecenising Interantional, LLC. The annual report has been filed with the Employee Benefits Security Administration, U.S. Department of Labor, as required under the Employee Retirement Income Security Act of 1974 (ERISA). The plan has a contract with Ace American Insurance Company to pay Accidental Death & Dismemberment claims incurred under the terms of the plan. The total premiums paid for the plan year ending January 31, 2013 were $28,652.
9 For Payless ShoeSource, Inc. Severance Plan This is a summary of the annual report of the Payless ShoeSource, Inc. Severance Plan, EIN , Plan No. 552, for period January 01, 2012 through December 31, The annual report has been filed with the Employee Benefits Security Administration, U.S. Department of Labor, as required under the Employee Retirement Income Security Act of 1974 (ERISA). Payless ShoeSource, Inc. has committted itself to pay all claims incurred under the terms of the plan. ShoeSource, Inc. at 3231 SE 6th Avenue, Topeka, KS 66607, or by telephone at (785) plan (Payless ShoeSource, Inc., 3231 SE 6th Avenue, Topeka, KS 66607) and at the U.S.
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