Disability Plan Claim Kit. Introduction

Transcription

1 Disability Plan Claim Kit Nonunion Employees and Jeppesen Sanderson, Inc., Employees Introduction If an illness or injury prevents you from working, this claim kit provides the materials and information you need to file a claim. If your leave began before February 14, 2004, you will file your claim for short-term disability benefits with Aetna by telephone. You will not need to use the claim forms in this kit. However, the questions and answers in this kit still will apply to you. For example, if your claim is approved, Aetna will pay your short-term disability payments by check. You also can use the W-4 form in this kit if you would like to specify a certain level of tax withholding from your short-term disability benefits. Nonunion Employees If you are absent from work for more than seven consecutive calendar days as a result of illness or injury, you are eligible to apply for disability benefits. Please review this claim kit and refer to your Disability, Life, and Accident Plans summary plan description booklet for details. This kit and the booklet both are available from the nonunion health and welfare plans section of the Boeing Benefits & Compensation web site ( The leave of absence kit also contains this disability claim kit. To request a leave of absence or a leave of absence kit, please call Boeing TotalAccess. (See For More Information, on page 20.) Jeppesen Employees If you are absent from work for more than seven consecutive calendar days as a result of illness or injury, you are eligible to apply for disability benefits. Please review this claim kit and refer to your Disability, Life, and Accident Plans summary plan description booklet for details. This kit and the booklet both are available from the nonunion health and welfare plans section of the Boeing Benefits & Compensation web site ( The leave of absence kit also contains this disability claim kit. To request a leave of absence or a leave of absence kit, please call Jeppesen payroll. (See page 20.) Important Notice This information summarizes disability plan benefits and is general in nature. Every effort has been made to ensure accuracy. In the event of a conflict between this information and any of the Plans, the terms of the Plans will control. Copies of updated summary plan descriptions may be obtained by contacting the applicable Boeing service center through Boeing TotalAccess. Copies of the official Plan documents are available by written request to the Plan Administrator at the cost of reproduction. The Boeing Company reserves the right to change, modify, amend, or terminate any of the Plans or provisions described here at any time. February 17,

2 Table of Contents Instructions for Filing a Claim for Benefits... 3 Filing for Short Term Disability Benefits... 3 Filing for Long Term Disability Benefits... 3 Short Term Disability Payment Options Description... 5 Disability Benefits Request Form... 6 Attending Physician s Statement Form... 7 W-4 Form... 9 Questions and Answers Short Term Disability Benefits Benefits, Claims, and Payments Deductions From Short Term Disability Payments Return to Work Long Term Disability Benefits Benefits, Claims, and Payments Deductions From Long Term Disability Payments Return to Work For More Information February 17,

3 Instructions for Filing a Claim for Benefits To file for short term and/or long term disability benefits, you must complete and submit both of the following forms: Disability Benefits Request form Attending Physician s Statement form Filing for Short Term Disability Benefits If you are absent from work for more than seven consecutive calendar days, you may file a claim for short term disability benefits. Filing for Long Term Disability Benefits If you continue to be disabled after 26 weeks, you may be eligible for long term disability benefits. Aetna will send you the appropriate forms. Step 1: Required Complete and submit the Disability Benefits Request form. a. Complete section 1, Employee Information. Please type or print. b. Sign and date section 2, Employee Authorization. c. Section 3, Request for Short Term or Weekly Disability Income Payments, applies to short term disability benefits only. For more information on these options, see page 5. You must choose one of the following payment options: Option 1: Short Term Disability Plan benefits only. Option 2: Sick leave pay, vacation pay, floating holiday pay *, and/or Financial Security Plan ** (FSP) funds in addition to plan benefits. Option 3: Sick leave pay, vacation pay, floating holiday pay, and/or FSP funds instead of plan benefits initially, then plan benefits begin on the date you designate. If you choose option 3, the date you indicate to begin receiving plan benefits cannot be changed. If section 3 is left blank or the information required for the option selected is incomplete, your claim will be processed as a request for option 1. d. Sign and date section 4, Disability Income Authorization. e. Fax the Disability Benefits Request form to Aetna at or mail the original to Aetna, P.O. Box 1460, Portland, OR * Floating holiday pay may be available to Jeppesen employees. Certain Boeing employees are eligible to participate in the FSP. These employees may have FSP funds available to supplement short term disability benefits. ** February 17,

4 Step 2: Required Have your physician complete the Attending Physician s Statement form. a. Ask your physician to complete the entire form. b. Have your physician sign and date the form. c. Fax the form to Aetna at or mail the original to Aetna, P.O. Box 1460, Portland, OR Remember: Aetna must receive both the Disability Benefits Request form and Attending Physician s Statement form before your claim for benefits will be considered. Step 3: Optional Tax Deductions For information about taxation of disability benefits, please call Aetna. (See page 20.) You also should check with your tax adviser for additional information. Remember: When your disability ends, you should call Aetna and either Boeing TotalAccess (if you are a nonunion employee) or Jeppesen payroll (if you are a Jeppesen employee). (See page 20.) February 17,

5 Short Term Disability Payment Options Description If you are absent from work for more than seven consecutive calendar days as a result of an illness or injury, you may be eligible to receive Short Term Disability Plan benefits. Your benefits begin on the eighth day of your absence and end after 26 weeks. During the first seven calendar days of your absence, you may receive income by using sick leave pay, vacation pay, floating holiday pay *, and/or FSP funds. Starting with your eighth consecutive day of absence, you have three options for receiving disability payments: Option 1 You receive Short Term Disability Plan benefits, which provide 80 percent of your weekly salary for weeks 2 through 13 and 60 percent of your weekly salary for weeks 14 through 26. You cannot use sick leave pay, vacation pay, floating holiday pay, and/or FSP funds to supplement your income under this option. Option 2 You receive Short Term Disability Plan benefits as indicated in option 1 as well as sick leave pay, vacation pay, floating holiday pay, and/or FSP funds. These payments supplement your disability income to equal 100 percent of your salary. You must indicate the type of payments (i.e., sick leave pay, vacation pay, floating holiday pay, and/or FSP funds) and the order in which you want to receive the payments on the Disability Benefits Request form. Option 3 Initially, you receive sick leave pay, vacation pay, floating holiday pay, and/or FSP funds equal to 100 percent of your salary instead of Short Term Disability Plan benefit payments. This means that you do not receive Short Term Disability Plan benefits under this option until the date you indicate you want the plan benefits to begin. You must indicate the type of payments (i.e., sick leave pay, vacation pay, floating holiday pay, and/or FSP funds) and the order in which you want to receive the payments on the form. Payments under this option continue until a date that you want to begin receiving Short Term Disability Plan benefits. You indicate this date on the Disability Benefits Request form. When this date passes, you automatically begin to receive disability payments in the same manner as option 2. Short Term Disability Plan benefits end 26 weeks after the initial date of disability. Under no circumstances will benefits continue after the 26-week time period. Note: If you choose option 3, the date you indicate to begin receiving plan benefits cannot be changed. * Floating holiday pay may be available to Jeppesen employees. FSP funds may be available to employees who previously participated in the Plan and have remaining balances. February 17,

6 Disability Benefits Request Form Instructions: Complete sections 1 and 3; sign and date sections 2 and EMPLOYEE INFORMATION NAME First Middle Last SOCIAL SECURITY NUMBER HOME ADDRESS DATE OF BIRTH / / SHIFT 1st Other STATUS Full time Part time EMPLOYEE TYPE Nonunion Union Local # and location GENDER Male Female JOB TITLE/OCCUPATION HOME PHONE LAST DAY WORKED WORK PHONE RETURN TO WORK DATE (if known) MANAGER S NAME: PHONE: WAS MORE THAN 1/2 SHIFT WORKED ON THE LAST DAY? Yes No LIST ANY OTHER INCOME BENEFITS YOU HAVE APPLIED FOR OR ARE RECEIVING (SUCH AS WORKERS COMPENSATION, SOCIAL SECURITY, OTHER RETIREMENT INCOME, OR MILITARY PAY) BENEFIT AMOUNT $ Per Day Week Month 2. EMPLOYEE AUTHORIZATION WAS CONDITION RELATED TO EMPLOYMENT? Yes No ACCIDENT? Yes No CAUSE OF DISABILITY IF AN ACCIDENT: DATE OF ACCIDENT: PLACE IT HAPPENED: HOW IT HAPPENED: To all providers of health care: You are authorized to provide Aetna Life Insurance Company or one of its affiliated companies ( Aetna ), and any independent claim administrators and consulting health professionals and utilization review organizations with whom Aetna has contracted, information concerning health care advice, treatment or supplies provided the patient (including that related to mental illness and/or AIDS/ARC/HIV). This information will be used to evaluate claims for benefits. Aetna may provide the employer named above with any benefit calculation used in payment of this claim for the purpose of reviewing the experience and operation of the policy or contract. In the event of an employee s long term disability, Aetna may provide employee s life insurance carrier with the minimum diagnostic information necessary to implement the premium disability waiver provision of such life insurance coverage. This authorization is valid for the term of the policy or contract under which a claim has been submitted. I know that I have a right to receive a copy of the authorization upon request and agree that a photographic copy of this authorization is as valid as the original. Employee s or Authorized Person s Signature: Date: 3. REQUEST FOR SHORT TERM OR WEEKLY DISABILITY INCOME PAYMENTS FOR DISABILITY BENEFITS STARTING AFTER YOUR WAITING PERIOD Option 1: Short Term Disability Plan or Weekly Disability Plan benefits ONLY Option 2: Sick leave pay, vacation pay, floating holiday pay, and FSP funds in addition to Short Term Disability Plan or Weekly Disability Plan benefits as follows: Option 3: Sick leave pay, vacation pay, floating holiday pay, and FSP funds instead of Short Term Disability Plan or Weekly Disability Plan benefits as follows: ORDER OF PAYMENT Sick Leave 1st 2nd 3rd 4th Vacation 1st 2nd 3rd 4th Floating Holiday Pay 1st 2nd 3rd 4th FSP 1st 2nd 3rd 4th ORDER OF PAYMENT Sick Leave 1st 2nd 3rd 4th Vacation 1st 2nd 3rd 4th Floating Holiday Pay 1st 2nd 3rd 4th FSP 1st 2nd 3rd 4th YOU MUST COMPLETE: Date short term or weekly disability benefits should start: (MM/DD/YY) The date you indicate cannot be changed. 4. DISABILITY INCOME AUTHORIZATION I request disability plan benefits. I also request The Boeing Company to pay me the additional benefits checked on this form. If I receive any payment(s) as a result of this disability (other than Boeing benefits), I will report it (them) to Aetna (please refer to your benefit booklet for a complete list of payments that are considered other income benefits). I authorize The Boeing Company or Aetna, as the administrative agent for Boeing, to recover overpayments by deducting them from future disability benefits, paychecks, or through other methods. I authorize the exchange of information between The Boeing Company and Aetna and/or their agents for the purposes of administering these benefits. I understand that prior to the payment of any benefit under this plan, I must authorize release of such medical records as Aetna in its sole discretion determines are necessary. Employee s or Authorized Person s Signature: Date: REV (01APR2003) Send the completed, signed form and Attending Physician s Statement form to: Aetna, P.O. Box 1460, Portland, OR 97207, Fax: , Phone:

7 The patient is responsible for completion of this form without expense to the company. You may use the Remarks section on the reverse side if you need more room to respond. Complete this form in full and send to: Aetna P.O. Box 1460 Portland, OR Employer Information Patient Information Name BOEING Disability Attending Physician's Statement Please fax your completed form to our Portland, Oregon office at (877) (NOTE: The top portion of Page 2 MUST be completed before faxing.) If you have any questions, please call our Portland, Oregon office at (800) Type of Claim Disability Life Waiver of Premium PTD Name Social Security Number Birthdate (MM/DD/YYYY) Address (include No. Street, Town, State, Zip Code) Address is new 1. History (a) Height Weight (b) Date symptoms first appeared or accident happened... Mo. Day Yr. (c) Date patient ceased work because of illness or injury... Mo. Day Yr. (d) Has patient ever had same or similar condition? No Yes, state when and describe. (e) Is condition due to injury or sickness arising out of patient's employment? No Yes Unknown (f) Names and addresses of other treating physicians Name Address Name Address Name Address (g) For medical reasons, the above named person will need to be absent from work due to a disability beginning on And ending on. 2. Diagnosis (a) Date of last examination... Mo. Day Yr. (b) ICD diagnostic code (mandatory) (c) Diagnosis (including any complications) (d) Subjective symptoms (e) Objective findings (including current X-rays, EKG's, laboratory data and any clinical findings): (1.) Clinical Findings: (2.) Diagnostic Studies and Results: 3. Dates of Treatment 4. Nature of Treatment (f) If disability is due to pregnancy, the expected delivery date is... Mo. Day Yr. (g) Other disease or infirmity affecting present condition (a) Date of first visit... Mo. Day Yr. (b) Date of last visit... Mo. Day Yr. (c) Frequency... Weekly Monthly Other (specify) (d) Is patient still under your care for this condition? Yes No, indicate date service terminated. (a) Type and dates of treatment: (b) Prescribed medications: (c) Surgical procedures and dates: 5. Progress (a) Patient has... Recovered Improved Stabilized Retrogressed (b) Patient is... Ambulatory House confined Bed confined Hospital confined (c) Has patient been hospital confined? No Yes, give name and address of hospital Confined from through GC (12-02)

8 Employer Information (REQUIRED) BOEING 6. Cardiac (if applicable) 7. Limitations Patient Information (REQUIRED) Page 2 Social Security Number (REQUIRED) (a) Functional capacity limitation (American Heart Ass'n): Class 1 (none) Class 3 (marked) Class 2 (slight) Class 4 (complete) (b) Blood Pressure (last visit): / Systolic / Diastolic (a) What are patient's present capabilities? (b) What are present limitations (physical and/or mental)? (c) What restrictions are placed on patient? 8. Physical Impairment As defined in Federal Dictionary of Occupational Titles. Class 1 - No limitation of functional capacity; capable of heavy work*. No restrictions. (0-10%) Class 2 - Medium manual activity.* (15-30%) Class 3 - Slight limitation of functional capacity; capable of light work.* (35-55%) Class 4 - Moderate limitation of functional capacity; capable of clerical/administrative (sedentary*) activity. (60-70%) Class 5 - Severe limitation of functional capacity; incapable of minimal (sedentary*) activity. (75-100%) Remarks: 9. Mental/ Nervous Impairment (if applicable) Please define "stress" as it applies to this claimant. Do you believe the patient is competent to endorse checks and direct the use of proceeds thereof? No Yes 10. Prognosis (a) What is the patient's prognosis? Guarded Good Fair Poor Other (b) When do you feel patient's maximum medical improvement will be reached? 1 Mo. 1-3 Mos. 3-6 Mos. 6-9 Mos. 1 yr. or longer (c) What is the estimated date of the patient's return to work? own job/occ other occ no return expected (d) Do you consider the patient to be a viable candidate for Vocational Rehabilitation (job retraining)? Yes No, please explain Remarks Attending Physician's Name (print) Specialty Degree Address (No. Street, City, State, Zip Code) Telephone Warning: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to claim was provided by the applicant. California Residents: For your protection, California law requires notice of the following: Any person who knowingly and with intent to defraud or deceive any insurance company files a statement of claim containing any materially false, incomplete or misleading information is guilty of a crime and may be subject to fines, confinement in a state prison and substantial civil penalties. Colorado Residents: An insurer or agent who knowingly provides false or misleading information to defraud a claimant regarding insurance proceeds must be reported to the Insurance Division. Pennsylvania Residents: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. Signature Date

9 Form W-4 (2004) Purpose. Complete Form W-4 so that your employer can withhold the correct Federal income tax from your pay. Because your tax situation may change, you may want to refigure your withholding each year. Exemption from withholding. If you are exempt, complete only lines 1, 2, 3, 4, and 7 and sign the form to validate it. Your exemption for 2004 expires February 16, See Pub. 505, Tax Withholding and Estimated Tax. Note: You cannot claim exemption from withholding if: (a) your income exceeds $800 and includes more than $250 of unearned income (e.g., interest and dividends) and (b) another person can claim you as a dependent on their tax return. Basic instructions. If you are not exempt, complete the Personal Allowances Worksheet below. The worksheets on page 2 adjust your withholding allowances based on itemized deductions, certain credits, adjustments to income, or two-earner/two-job situations. Complete all worksheets that apply. However, you may claim fewer (or zero) allowances. Head of household. Generally, you may claim head of household filing status on your tax return only if you are unmarried and pay more than 50% of the costs of keeping up a home for yourself and your dependent(s) or other qualifying individuals. See line E below. Tax credits. You can take projected tax credits into account in figuring your allowable number of withholding allowances. Credits for child or dependent care expenses and the child tax credit may be claimed using the Personal Allowances Worksheet below. See Pub. 919, How Do I Adjust My Tax Withholding? for information on converting your other credits into withholding allowances. Nonwage income. If you have a large amount of nonwage income, such as interest or dividends, consider making estimated tax payments using Form 1040-ES, Estimated Tax for Individuals. Otherwise, you may owe additional tax. Two earners/two jobs. If you have a working spouse or more than one job, figure the total number of allowances you are entitled to claim on all jobs using worksheets from only one Form W-4. Your withholding usually will be most accurate when all allowances are claimed on the Form W-4 for the highest paying job and zero allowances are claimed on the others. Nonresident alien. If you are a nonresident alien, see the Instructions for Form 8233 before completing this Form W-4. Check your withholding. After your Form W-4 takes effect, use Pub. 919 to see how the dollar amount you are having withheld compares to your projected total tax for See Pub. 919, especially if your earnings exceed $125,000 (Single) or $175,000 (Married). Recent name change? If your name on line 1 differs from that shown on your social security card, call to initiate a name change and obtain a social security card showing your correct name. A Personal Allowances Worksheet (Keep for your records.) Enter 1 for yourself if no one else can claim you as a dependent You are single and have only one job; or B Enter 1 if: You are married, have only one job, and your spouse does not work; or B Your wages from a second job or your spouse s wages (or the total of both) are $1,000 or less. C D E F G Enter 1 for your spouse. But, you may choose to enter -0- if you are married and have either a working spouse or more than one job. (Entering -0- may help you avoid having too little tax withheld.) Enter number of dependents (other than your spouse or yourself) you will claim on your tax return Enter 1 if you will file as head of household on your tax return (see conditions under Head of household above) Enter 1 if you have at least $1,500 of child or dependent care expenses for which you plan to claim a credit (Note: Do not include child support payments. See Pub. 503, Child and Dependent Care Expenses, for details.) Child Tax Credit (including additional child tax credit): If your total income will be less than $52,000 ($77,000 if married), enter 2 for each eligible child. If your total income will be between $52,000 and $84,000 ($77,000 and $119,000 if married), enter 1 for each eligible child plus 1 additional if you have four or more eligible children. H Add lines A through G and enter total here. Note: This may be different from the number of exemptions you claim on your tax return. H For accuracy, If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions complete all and Adjustments Worksheet on page 2. worksheets If you have more than one job or are married and you and your spouse both work and the combined earnings from all jobs that apply. exceed $35,000 ($25,000 if married) see the Two-Earner/Two-Job Worksheet on page 2 to avoid having too little tax withheld. If neither of the above situations applies, stop here and enter the number from line H on line 5 of Form W-4 below. Form W-4 Cut here and give Form W-4 to your employer. Keep the top part for your records. Employee s Withholding Allowance Certificate A C D E F OMB No Department of the Treasury Internal Revenue Service Your employer must send a copy of this form to the IRS if: (a) you claim more than 10 allowances or (b) you claim "Exempt" and your wages are normally more than $200 per week. 1 Type or print your first name and middle initial Last name 2 Your social security number G 2004 Home address (number and street or rural route) City or town, state, and ZIP code 3 Single Married Married, but withhold at higher Single rate. Note: If married, but legally separated, or spouse is a nonresident alien, check the Single box. 4 If your last name differs from that shown on your social security card, check here. You must call for a new card. 5 Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2) 5 6 Additional amount, if any, you want withheld from each paycheck 6 $ 7 I claim exemption from withholding for 2004, and I certify that I meet both of the following conditions for exemption: Last year I had a right to a refund of all Federal income tax withheld because I had no tax liability and This year I expect a refund of all Federal income tax withheld because I expect to have no tax liability. If you meet both conditions, write Exempt here 7 Under penalties of perjury, I certify that I am entitled to the number of withholding allowances claimed on this certificate, or I am entitled to claim exempt status. Employee s signature (Form is not valid unless you sign it.) Date 8 Employer s name and address (Employer: Complete lines 8 and 10 only if sending to the IRS.) 9 Office code (optional) 10 Employer identification number (EIN) For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat. No Q Form W-4 (2004)

10 Form W-4 (2004) Page 2 Deductions and Adjustments Worksheet Note: Use this worksheet only if you plan to itemize deductions, claim certain credits, or claim adjustments to income on your 2004 tax return. 1 Enter an estimate of your 2004 itemized deductions. These include qualifying home mortgage interest, charitable contributions, state and local taxes, medical expenses in excess of 7.5% of your income, and miscellaneous deductions. (For 2004, you may have to reduce your itemized deductions if your income is over $142,700 ($71,350 if married filing separately). See Worksheet 3 in Pub. 919 for details.) 1 $ 2 Enter: $9,700 if married filing jointly or qualifying widow(er) $7,150 if head of household 2 $ $4,850 if single $4,850 if married filing separately 3 Subtract line 2 from line 1. If line 2 is greater than line 1, enter -0-3 $ 4 Enter an estimate of your 2004 adjustments to income, including alimony, deductible IRA contributions, and student loan interest 4 $ 5 Add lines 3 and 4 and enter the total. (Include any amount for credits from Worksheet 7 in Pub. 919) 5 $ 6 Enter an estimate of your 2004 nonwage income (such as dividends or interest) 6 $ 7 Subtract line 6 from line 5. Enter the result, but not less than -0-7 $ 8 Divide the amount on line 7 by $3,000 and enter the result here. Drop any fraction 8 9 Enter the number from the Personal Allowances Worksheet, line H, page Add lines 8 and 9 and enter the total here. If you plan to use the Two-Earner/Two-Job Worksheet, also enter this total on line 1 below. Otherwise, stop here and enter this total on Form W-4, line 5, page 1 10 Two-Earner/Two-Job Worksheet (See Two earners/two jobs on page 1.) Note: Use this worksheet only if the instructions under line H on page 1 direct you here. 1 Enter the number from line H, page 1 (or from line 10 above if you used the Deductions and Adjustments Worksheet) 1 2 Find the number in Table 1 below that applies to the LOWEST paying job and enter it here 2 3 If line 1 is more than or equal to line 2, subtract line 2 from line 1. Enter the result here (if zero, enter -0- ) and on Form W-4, line 5, page 1. Do not use the rest of this worksheet 3 Note: If line 1 is less than line 2, enter -0- on Form W-4, line 5, page 1. Complete lines 4 9 below to calculate the additional withholding amount necessary to avoid a year-end tax bill. 4 Enter the number from line 2 of this worksheet 4 5 Enter the number from line 1 of this worksheet 5 6 Subtract line 5 from line Find the amount in Table 2 below that applies to the HIGHEST paying job and enter it here 7 8 Multiply line 7 by line 6 and enter the result here. This is the additional annual withholding needed 8 9 Divide line 8 by the number of pay periods remaining in For example, divide by 26 if you are paid every two weeks and you complete this form in December Enter the result here and on Form W-4, line 6, page 1. This is the additional amount to be withheld from each paycheck 9 Table 1: Two-Earner/Two-Job Worksheet Married Filing Jointly Married Filing Jointly If wages from HIGHEST paying job are $0 - $40,000 $40,001 and over AND, wages from LOWEST paying job are $0 - $4,000 4,001-8,000 8,001-17,000 17,001 and over If wages from HIGHEST paying job are $0 - $60,000 60, , , , , , ,001 and over $0 - $4,000 4,001-8,000 8,001-15,000 15,001-22,000 22,001-25,000 25,001-31,000 Enter on line 2 above Table 2: Two-Earner/Two-Job Worksheet Married Filing Jointly Enter on line 7 above Privacy Act and Paperwork Reduction Act Notice. We ask for the information on this form to carry out the Internal Revenue laws of the United States. The Internal Revenue Code requires this information under sections 3402(f)(2)(A) and 6109 and their regulations. Failure to provide a properly completed form will result in your being treated as a single person who claims no withholding allowances; providing fraudulent information may also subject you to penalties. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation, to cities, states, and the District of Columbia for use in administering their tax laws, and using it in the National Directory of New Hires. We may also disclose this information to Federal and state agencies to enforce Federal nontax criminal laws and to combat terrorism. You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB If wages from HIGHEST paying job are $40,001 and over $ ,020 1,090 AND, wages from LOWEST paying job are 31,001-38,000 38,001-44,000 44,001-50,000 50,001-55,000 55,001-65,000 65,001-75,000 75,001-85,000 85, , , , ,001 and over Enter on line 2 above If wages from HIGHEST paying job are $0 - $30,000 30,001-70,000 70, , , , ,001 and over All Others control number. Books or records relating to a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential, as required by Code section The time needed to complete this form will vary depending on individual circumstances. The estimated average time is: Recordkeeping, 46 min.; Learning about the law or the form, 13 min.; Preparing the form, 59 min. If you have comments concerning the accuracy of these time estimates or suggestions for making this form simpler, we would be happy to hear from you. You can write to the Tax Products Coordinating Committee, Western Area Distribution Center, Rancho Cordova, CA Do not send Form W-4 to this address. Instead, give it to your employer. $ $ $ If wages from LOWEST paying job are $0 - $6,000 6,001-11,000 11,001-18,000 18,001-25,000 25,001-31,000 31,001-44,000 44,001-55,000 55,001-70,000 70,001-80,000 80, , ,001 and over All Others Enter on line 2 above Enter on line 7 above $ ,020 1,090

11 Questions and Answers Short Term Disability Benefits Benefits, Claims, and Payments 1. Who may apply for Short Term Disability Plan benefits? Nonunion employees and Jeppesen employees are eligible for benefits under the Short Term Disability Plan. You may qualify for plan benefits if an illness or injury prevents you from working for more than seven consecutive calendar days. 2. What are the definitions of disabled and salary in relation to Short Term Disability Plan benefits? Disabled means that you are unable to perform the material duties of your own occupation or other appropriate work the Company makes available as a result of illness (including a pregnancy-related condition) or accidental injury and you are earning 80 percent or less of your predisability earnings. Salary means your base salary, plus shift, lead, and foreign and domestic pay differentials, but excluding bonuses, overtime, cost-of-living allowances, incentive compensation, or other compensation that you receive from Boeing or a participating subsidiary. 3. When should I file a claim for Short Term Disability Plan benefits? You should file a Short Term Disability Plan claim as soon as you know that your medical absence will last more than seven consecutive calendar days. Plan benefits are not available until you satisfy this seven-day waiting period and Aetna approves your claim. The claim process may take up to three weeks after your date of disability. You may submit a claim before your absence occurs if the absence is scheduled (e.g., for surgery or because of pregnancy). You must submit your claim for short term disability benefits within 31 days of the date your disability benefits are first payable. 4. How may I get a disability claim kit? You may print the disability claim kit from the nonunion health and welfare plans section of the Benefits & Compensation web site ( The disability claim kit also is included in the leave of absence kit, which nonunion employees can request by calling Boeing TotalAccess; Jeppesen employees should call Jeppesen payroll. (See page 20.) February 17,

12 5. How may I get a Short Term Disability Plan claim form? The disability claim form is part of this disability claim kit, which you can print from the nonunion health and welfare plans section of the Benefits & Compensation web site ( This form also is included in the leave of absence kit. Nonunion employees can request one by calling Boeing TotalAccess; Jeppesen employees should call Jeppesen payroll. (See page 20.) 6. What funds may I receive during the first seven consecutive calendar days of absence? Nonunion employees may use sick leave pay, vacation pay, and any remaining FSP funds. Jeppesen employees may use sick leave pay, vacation pay, and floating holiday pay. 7. What payments may I receive after the first seven consecutive calendar days of absence? You may receive payments from a variety of sources for up to 26 weeks, depending on which Short Term Disability Plan payment option you choose: Option 1: You receive Short Term Disability Plan benefits, which provide 80 percent of your weekly salary for weeks 2 through 13, then 60 percent of your weekly salary for weeks 14 through 26. Option 2: You receive Short Term Disability Plan benefits as indicated for option 1 as well as sick leave pay, vacation pay, floating holiday pay, and/or FSP funds. These payments supplement your income to equal 100 percent of your salary. Option 3: You receive sick leave pay, vacation pay, floating holiday pay, and/or FSP funds to equal 100 percent of your salary instead of Short Term Disability Plan benefit payments. Then, short term disability benefits begin on the date you specify. 8. If I am disabled for more than seven consecutive calendar days, should my supervisor enter sick leave pay, vacation pay, and/or floating holiday pay into ETS or other electronic timekeeping system or complete my time sheets for me? If you are a nonunion employee, no. Sick leave pay and vacation pay should not be entered into the Employee Timekeeping System (ETS) after the seventh consecutive calendar day of your disability leave. If you are a Jeppesen employee, yes. Your supervisor must enter your time in the applicable electronic timekeeping system or complete your time sheets after the seventh consecutive calendar day of your disability leave. 9. Under what circumstances could I receive less than the full Short Term Disability Plan benefit payment? Income benefits from other sources, such as Social Security benefits, retirement income, state disability income, or workers compensation, will reduce benefit payments under the Short Term Disability Plan. Please consult your Disability, Life, and Accident Plans summary plan description booklet for a complete list of other income that may February 17,

13 be deducted from your disability benefit payments ( You cannot receive more than 100 percent of your predisability earnings. 10. If I choose option 1 or option 2, when will I receive my first Short Term Disability Plan payment? You will receive your first payment approximately three weeks after the date your disability began. This length of time is determined by how much time you need to complete and submit the Disability Benefits Request form and how much time your physician needs to complete and submit the Attending Physician s Statement form. You may want to check with your physician to make sure that the completed Attending Physician s Statement form is submitted to Aetna as quickly as possible. Generally, Aetna will process disability claims within seven consecutive calendar days after receiving all necessary information, including the completed Disability Benefits Request form and Attending Physician s Statement form. The first payment from Aetna will include any retroactive amounts due. After the first payment, checks are sent weekly. 11. What are some of the reasons I might choose option 3 under the Short Term Disability Plan? One reason you might choose option 3 is that Voluntary Investment Plan (VIP) contributions continue, based on your full salary, for the period that you receive full pay from sick leave pay, vacation pay, or floating holiday pay. Normal contributions continue as long as you continue to draw full pay from the Company. When you choose option 1, VIP contributions stop. If you choose option 2, your VIP contributions will equal only the percentage of sick leave pay, vacation pay, or floating holiday pay that you are receiving (e.g., 20 percent or 40 percent). You also may choose option 3 to use excess sick leave that has accumulated in your unused sick leave account or if you anticipate a short leave and prefer not to file a claim for Short Term Disability Plan benefits. 12. If I choose option 3, how long will Short Term Disability Plan benefits be paid? Aetna will pay Short Term Disability Plan benefits for the balance of the 26-week period that began on the first day of your disability. For example, assume you choose option 3 and specify that you want to receive sick leave pay for 14 weeks. After 14 weeks of sick leave pay, Aetna will begin paying Short Term Disability Plan payments at 60 percent of your salary for 12 weeks, the remainder of the 26-week period. 13. If I want to use sick leave pay, vacation pay, and/or floating holiday pay only, do I need to file a claim for Short Term Disability Plan benefits? No. For example, if you expect to be off work for three weeks because of surgery and you want to use sick leave pay for the full three weeks, you will not need to file a claim for disability benefits. However, if you later learn that your absence will last longer than three weeks and you want to begin receiving Short Term Disability Plan benefits, you must then file a claim. February 17,

14 14. If I choose option 3, may I change the start date I select for Short Term Disability Plan benefits to start? No. Once you select a date for Short Term Disability Plan benefits to start, you cannot change that date. Please carefully evaluate how much sick leave pay, vacation pay, floating holiday pay, or FSP funds you want to use before selecting a date. 15. If I choose option 2 or 3, which includes sick leave pay, vacation pay, and/or floating holiday pay, where will that pay be sent? If you have direct deposit, that method of payment will continue. Otherwise, your check will be mailed to your home address. Aetna mails Short Term Disability Plan benefit payments to your home address. Direct deposit is not available for this benefit payment. 16. How much will I pay for health and welfare coverages while I am receiving Short Term Disability Plan benefits? Your regular contributions will continue for health and welfare coverages, except for the dependent care reimbursement account, during the first six months of medical leave. Dependent care reimbursement account contributions will continue until the end of the calendar month in which your leave begins. Your contributions will be taken from any payments made by the payroll department (i.e., sick leave pay, vacation pay, and/or floating holiday pay) as long as there is sufficient pay to take a deduction. After that, the Boeing Service Center for Health and Welfare Plans will bill you for coverage. During the first six months of your leave, all Company-paid coverages except Business Travel Accident Plan coverage will continue to be paid by the Company. Business Travel Accident Plan coverage ends on the date that your leave begins. If you are on leave for more than six months, the Boeing Service Center for Health and Welfare Plans will send you information about continuing your health and welfare coverages. 17. If my pay changes, when will my Short Term Disability Plan payments change? If you are actively at work and your weekly salary either increases or decreases, your coverage amount (the weekly benefit for which you may be eligible) will change automatically on the first of the month following or coinciding with the date the Boeing Service Center for Health and Welfare Plans is notified of your change in salary. For example, for merit increases effective in March but paid in April, short term disability coverage increases are effective May 1. However, if you are not actively at work on the day the coverage change is to become effective, the effective date for your new coverage amount will be delayed until the first day of the month following or coinciding with the day you return to work for one full day. February 17,

15 Deductions From Short Term Disability Payments 18. What tax deductions will be taken from my Short Term Disability Plan benefits? Aetna deducts Federal income tax, Social Security tax, and if required or requested, state income tax. The federal withholding rate automatically is 27 percent. Aetna does not take any other deductions that would normally be taken from your payroll check. Please call Aetna for details. (See page 20.) 19. If I select option 2 or option 3, what deductions will be taken from my sick leave pay, vacation pay, or floating holiday pay? Taxes. Federal, state, and/or Social Security taxes will continue to be withheld based on the amount of pay you receive. See the answer to question 18 for more information about deductions. Health and welfare plan contributions. Contributions for medical and dental coverage, the health care reimbursement account, and supplemental life, accident, or disability coverages (if applicable) generally will continue as long as there is sufficient pay to take deductions. VIP contributions. If enough pay is available, VIP contributions will continue at the same investment percentage in effect before your disability. For example, if you normally earn $1,000 per pay period and invest 8 percent of your pay, your normal VIP deduction is $80. If you become disabled and choose to receive 20 percent of your pay ($200) to supplement the 80 percent of pay that you receive as a Short Term Disability Plan payment, your VIP contribution will be $16 (8 percent of $200). VIP loan deductions. Loan repayments will be deducted if there is enough pay to take the entire loan deduction. If there is not enough pay, you will be notified by the plan administrator about continuing to make payments. Other deductions. Deductions, including credit union deposits and U.S. savings bond purchases, will continue to be made if there is enough pay to take the deductions. 20. If I elect option 2 or option 3 and choose to receive FSP funds, what deductions will come out of my FSP check? Payments from the FSP will have 20 percent tax withholding. In addition, because the FSP is a qualified retirement plan, distributions may be subject to a 10 percent early withdrawal penalty. However, FICA taxes will not be withheld from FSP payments. No other deductions will be taken from FSP payments. Return to Work 21. What will I have to do to return to work on my regular schedule? When you are ready to return from a leave of absence, call Boeing TotalAccess (if you are a nonunion employee) or Jeppesen payroll (if you are a Jeppesen employee). You also need to call Aetna to avoid any overpayment of disability benefits. (See page 20.) February 17,

16 22. What will happen if I return to work for a brief time and then go back on leave? If you return to work for fewer than 60 days and go back on leave because of the same illness or injury, your second period of disability will be treated as an extension of the first period of disability under the Short Term Disability Plan. For example, if you go on leave for 16 weeks, return to work for 45 days, and then go on leave again because of the same illness or injury, there will be no waiting period for the second period of leave. If you had chosen option 1 or option 2, payments would resume at 60 percent and would be paid for the balance of the 26-week period (10 weeks). If you return to work for fewer than 60 days and go back on leave for a different illness or injury, the second period of disability will be considered a new, separate 26-week period of disability. A new waiting period of seven consecutive calendar days will apply. This also will be true if you return to work for more than 60 days and go back on leave for any reason. In any of these circumstances, call Aetna and Boeing TotalAccess (if you are a nonunion employee) or Jeppesen payroll (if you are a Jeppesen employee). (See page 20.) 23. What will happen if I return to work on a reduced schedule? If your disability prevents you from working your regular schedule and you plan to return to work on a reduced schedule, please call Aetna. (See page 20.) If your reduced work schedule is approved as rehabilitative employment, you may be eligible to continue receiving Short Term Disability Plan benefits from Aetna. However, the combination of your earnings and your payments from Aetna cannot exceed 100 percent of your predisability earnings. You also should call Boeing TotalAccess (if you are a nonunion employee) or Jeppesen payroll (if you are a Jeppesen employee). (See page 20.) Long Term Disability Benefits Benefits, Claims, and Payments 1. Who may apply for Long Term Disability Plan benefits? You may qualify for plan benefits if an illness or injury prevents you from working for more than 26 weeks. 2. What are the definitions of disabled and indexed predisability earnings in relation to Long Term Disability Plan benefits? During the first 24 months of long term disability benefit payments, disabled means that you are unable to perform the material duties of your own occupation, or other appropriate work the Company makes available, as a result of illness (including a pregnancy-related condition) or accidental injury and you are earning 80 percent or less of your indexed predisability earnings. February 17,

17 After the first 24 months of long term disability benefit payments, disabled means that you are unable to perform the material duties of any reasonable occupation for which you may be fitted by training, education, or experience as a result of illness (including a pregnancy-related condition) or accidental injury and you are earning 80 percent or less of your predisability earnings. Indexed predisability earnings means your base monthly salary immediately before a total disability began, adjusted by the Consumer Price Index on each anniversary of the date on which your long term disability benefits began, but never reduced below your initial base monthly salary. 3. When should I file a claim for Long Term Disability Plan benefits? You must submit your claim for long term disability benefits within 90 days of the date your 26-week waiting period ends. Aetna will forward the appropriate forms to you. You do not need to complete another Disability Benefits Request form. 4. Under what circumstances could I receive less than the full Long Term Disability Plan benefit payments? Income benefits from other sources, such as Social Security benefits, retirement benefits, state disability income, or workers compensation, will reduce benefit payments under the Long Term Disability Plan. Please consult your Disability, Life, and Accident Plans summary plan description booklet for a complete list of other income that may be deducted from your disability benefit payments. The booklet is available from the nonunion health and welfare plans section of the Benefits & Compensation web site ( 5. How much will I pay for health and welfare coverages while I am receiving Long Term Disability Plan benefits? You will be eligible to continue your current medical coverage and health care reimbursement account through COBRA. You will pay the active employee contribution rate. You will be eligible to continue your current dental coverage through COBRA by paying the full cost of the premium. The Boeing Service Center for Health and Welfare Plans will forward information to you and your dependents, if applicable, regarding COBRA rights. You will not be required to pay the premiums for supplemental long term disability coverage (if applicable) while you are receiving benefits under the Long Term Disability Plan. If you have been approved for long term disability benefits before age 65, your basic life insurance and supplemental life insurance (if applicable) will continue at no cost to you while you are receiving long term disability benefits until you reach age 65. Please review your Disability, Life, and Accident Plans summary plan description booklet for complete information ( February 17,

18 Your basic accidental death and dismemberment coverage will end when you become eligible for long term disability benefits. You may continue your coverage under the Supplemental Accidental Death and Dismemberment Plan for up to 24 months by paying the full cost of the premiums. Please consult your Disability, Life, and Accident Plans summary plan description booklet ( or call the Boeing Service Center for Health and Welfare Plans through Boeing TotalAccess. (See page 20.) 6. If my pay changes, when will my Long Term Disability Plan payments change? If you are actively at work and your base monthly salary either increases or decreases, your coverage amount (the monthly benefit for which you may be eligible) will change automatically on the first of the month following or coinciding with the date the Boeing Service Center for Health and Welfare Plans is notified of the change in your salary. For example, for merit increases effective in March but paid in April, long term disability coverage increases are effective May 1. However, if you are not actively at work on the day the coverage change is to become effective, the effective date for your new coverage amount will be delayed until the first day of the month following or coinciding with the day you return to work for one full day. 7. May I use sick leave pay, vacation pay, floating holiday pay, and/or FSP funds to supplement Long Term Disability Plan benefits (if eligible)? No. Sick leave pay, vacation pay, floating holiday pay, and/or FSP funds may only be used to supplement Short Term Disability Plan benefits. Deductions From Long Term Disability Payments 8. What tax deductions are taken from my long term disability benefits? Aetna deducts Federal income tax, and if required or requested, state income tax. Social Security tax may be applicable; call Aetna for details. (See page 20.) The Federal withholding rate automatically is 27 percent. If you want a different rate, you may submit a current-year W-4 form to Aetna. Aetna does not take any other deductions that would normally be taken from your payroll check. Return to Work 9. What will I have to do to return to work on my regular schedule? When you are ready to return from a leave of absence, call Boeing TotalAccess (if you are a nonunion employee) or Jeppesen payroll (if you are a Jeppesen employee). You also need to notify Aetna to eliminate any overpayment of disability benefits. (See page 20.) February 17,

19 10. If I submit a W-4 form to Aetna while I am on disability leave, what will happen to the W-4 on file with Boeing or my payroll department? And what will happen when I return to work? The W-4 form that you submit to Aetna while on disability leave supersedes the W-4 form on file with Boeing or your payroll department only while you are receiving Long Term Disability Plan benefits. When you return to work, the W-4 on file with Boeing or your payroll department automatically takes effect again. (Please be sure to submit the correct year W-4 form; otherwise, you may experience a delay in receiving your adjusted benefits.) 11. What will happen if I return to work for a brief time and then go back on leave? For specific details on separate periods of disability, please call Aetna. (See page 20.) 12. What will happen if I return to work on a reduced schedule? If your disability prevents you from working your regular schedule and you plan to return to work on a reduced schedule, please call Aetna. If your reduced work schedule is approved as rehabilitative employment, you may be eligible to continue receiving Long Term Disability Plan benefits from Aetna. Please call Aetna for details. You also should call Boeing TotalAccess (if you are a nonunion employee) or Jeppesen payroll (if you are a Jeppesen employee). (See page 20.) February 17,

20 For More Information For information about... Please call... Eligibility under the Short Term Disability Plan or Long Term Disability Plan Filing a claim for disability benefits For nonunion employees: Requesting a leave of absence or a leave of absence kit Sick leave or vacation payments For Jeppesen employees: Requesting a leave of absence or a leave of absence kit Sick leave, vacation, and floating holiday payments for Jeppesen employees VIP and FSP account payments Boeing Service Center for Health and Welfare Plans, through Boeing TotalAccess Representatives are available Monday through Friday from 9 a.m. to 8 p.m. ET (8 a.m. to 7 p.m. CT; 7 a.m. to 6 p.m. MT; 6 a.m. to 5 p.m. PT). Aetna (hearing impaired: ) Representatives are available Monday through Friday from 9 a.m. to 8 p.m. ET (8 a.m. to 7 p.m. CT; 7 a.m. to 6 p.m. MT; 6 a.m. to 5 p.m. PT). Boeing TotalAccess Representatives are available Monday through Friday from 8 a.m. to 9 p.m. ET (7 a.m. to 8 p.m. CT; 6 a.m. to 7 p.m. MT; 5 a.m. to 6 p.m. PT). Jeppesen payroll department Boeing Savings Service Center, through Boeing TotalAccess Representatives are available Monday through Friday from 9 a.m. to 8 p.m. ET (8 a.m. to 7 p.m. CT; 7 a.m. to 6 p.m. MT; 6 a.m. to 5 p.m. PT). Boeing TotalAccess BEMS ID (or Social Security number) and Boeing TotalAccess PIN/password required Boeing Web: World Wide Web: Telephone: (hearing impaired: ) February 17,