Tenet Healthcare Corporation Your Group Life and Accidental Death and Dismemberment Plan Identification No. 546864 012 Underwritten by Unum Life Insurance Company of America 5/7/2014
CERTIFICATE OF COVERAGE Unum Life Insurance Company of America (referred to as Unum) welcomes you as a client. This is your certificate of coverage as long as you are eligible for coverage and you become insured. You will want to read it carefully and keep it in a safe place. Unum has written your certificate of coverage in plain English. However, a few terms and provisions are written as required by insurance law. If you have any questions about any of the terms and provisions, please consult Unum's claims paying office. Unum will assist you in any way to help you understand your benefits. If the terms and provisions of the certificate of coverage (issued to you) are different from the Summary of Benefits (issued to the Employer), the Summary of Benefits will govern. The Summary of Benefits may be changed in whole or in part. Only an officer or registrar of Unum can approve a change. The approval must be in writing and endorsed on or attached to the Summary of Benefits. Any other person, including an agent, may not change the Summary of Benefits or waive any part of it. The Summary of Benefits is delivered in and is governed by the laws of the governing jurisdiction and to the extent applicable by the Employee Retirement Income Security Act of 1974 (ERISA) and any amendments. For purposes of effective dates and ending dates under the group Summary of Benefits, all days begin at 12:01 a.m. and end at 12:00 midnight at the Employer's address. Unum Life Insurance Company of America 2211 Congress Street Portland, Maine 04122 CC.FP-2 CC.FP-1 (1/1/2014) REV 1
The insurance Summary of Benefits under which this certificate is issued is not a policy of Workers' Compensation Insurance. You should consult your Employer to determine whether your Employer is a subscriber to the Workers' Compensation system. CC.FP-2 (1/1/2014) REV 2
IMPORTANT NOTICE To obtain information or make a complaint: You may call Unum's toll-free telephone number for information or to make a complaint at: 1-800-321-3889 OPTION NUMBER 2 You may also write to Unum at: Deborah J. Jewett, Manager Customer Relations Unum Life Insurance Company of America 2211 Congress Street Portland, Maine 04122 You may contact the Texas Department of Insurance to obtain information on companies, coverages, rights or complaints at: 1-800-252-3439 You may also write the Texas Department of Insurance P.O. Box 149104 Austin, TX 78714-9104 FAX: (512) 475-1771 Web: http://www.tdi.state.tx.us E-mail: ConsumerProtection@tdi.state.tx.us PREMIUM OR CLAIM DISPUTES: Should you have a dispute concerning your premium or about a claim, you should contact the company first. If the dispute is not resolved, you may contact the Texas Department of Insurance (TDI). AVISO IMPORTANTE Para obtener informacion o para someter una queja: Usted puede llamar al numero de telefono gratis de Unum's para informacion o para someter una queja al: 1-800-321-3889 OPCION NUMERO 2 Usted tambien puede escribir a Unum: Deborah J. Jewett Gerente de Relaciones al Cliente Unum Life Insurance Company of America 2211 Congress Street Portland, Maine 04122 Puede comunicarse con el Departamento de Seguros de Texas para obtener informacion acerca de companias, coberturas, derechos o quejas al: 1-800-252-3439 Puede escribir al Departamento de Seguros de Texas P.O. Box 149104 Austin, TX 78714-9104 FAX: (512) 475-1771 Web: http://www.tdi.state.tx.us E-mail: ConsumerProtection@tdi.state.tx.us DISPUTAS SOBRE PRIMAS O RECLAMOS: Si tiene una disputa concerniente a su prima o a un reclamo, debe comunicarse con el la compania primero. Si no se resuelve la disputa, puede entonces comunicarse con el departamento (TDI). ATTACH THIS NOTICE TO YOUR CERTIFICATE OF COVERAGE: This notice is for information only and does not become a part or condition of the attached document. SUJETE ESTA NOTICIA A SU CERTIFICADO DE BENEFICIOS: Este aviso es solo para proposito de informacion y no se convierte en parte o condicion del documento adjunto. CC.FP-3 (1/1/2014) REV 3
TABLE OF CONTENTS LIFE INSURANCE PLAN BENEFITS AT A GLANCE...B@G-LIFE-1 ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE PLAN BENEFITS AT A GLANCE...B@G-AD&D-1 LIFE INSURANCE CLAIM INFORMATION...LIFE-CLM-1 ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE CLAIM INFORMATION...AD&D-CLM-1 GENERAL PROVISIONS...EMPLOYEE-1 LIFE INSURANCE BENEFIT INFORMATION...LIFE-BEN-1 OTHER BENEFIT FEATURES...LIFE-OTR-1 ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE BENEFIT INFORMATION...AD&D-BEN-1 OTHER BENEFIT FEATURES...AD&D-OTR-1 GLOSSARY...GLOSSARY-1 TOC-1 (1/1/2014) REV 4
BENEFITS AT A GLANCE LIFE INSURANCE PLAN This life insurance plan provides financial protection for your beneficiary(ies) by paying a benefit in the event of your death. The amount your beneficiary(ies) receive(s) is based on the amount of coverage in effect just prior to the date of your death according to the terms and provisions of the plan. You also have the opportunity to have coverage for your dependents. EMPLOYER'S ORIGINAL PLAN EFFECTIVE DATE: August 1, 2001 PLAN YEAR: August 1, 2001 through December 31, 2001 and each following January 1 through December 31 IDENTIFICATION NUMBER: 546864 012 ELIGIBLE GROUP(S): Group 1 All active Full-time Employees, who are benefit-eligible, in active employment in the United States with the Employer and who are not included in Group 2 or Group 5 Group 2 All active Full-time Employees, who are benefit-eligible, in active employment in the United States with the Employer, at one of the Employer locations or in one of the job/position categories that is permitted to fully opt out of this Plan Group 3 All active Part-time 1 Employees, who are benefit-eligible, in active employment in the United States with the Employer and who are not included in Group 4 or Group 6 Group 4 All active Part-time 1 Employees in active employment in the United States with the Employer at one of the Employer locations or in one of the job/position categories that is permitted to fully opt out of this Plan Group 5 All active Full-time Employees, who are benefit-eligible, in active employment in the United States with the Employer, at one of the Employer locations or in one of the job/position categories that is permitted to select an alternative to this Plan Group 6 All active Part-time Employees in active employment in the United States with the Employer at one of the Employer locations or in one of the job/position categories that is permitted to select an alternative to this Plan Group 7 Emergency Medical Personnel in active employment in the United States with the Employer who are defined as "personnel who provide pre-hospital care and transportation of the sick and/or injured within established protocol and work 24 hour shifts" Group 8 All Union Employees of Atlanta Medical Center (Facility 800), Cypress Fairbanks Medical Center (Facility 125), St. Francis Hospital, Memphis (Facility 516), and South Fulton Medical Center (Facility 800) Note: You are only eligible for plan benefits provided by one Tenet facility, even though you may be employed by more than one Tenet affiliated facility. B@G-LIFE-1 (1/1/2014) REV 5
Benefit eligible employees are employees who meet the eligibility criteria set forth in the Tenet Employee Benefit Plan. MINIMUM HOURS REQUIREMENT: Employees must be working at least the minimum number of hours per week as defined by the Tenet affiliated facility. WAITING PERIOD: REHIRE: For employees in an eligible group on or before August 1, 2001: 30 days of continuous active employment in a benefits eligible position. For employees entering an eligible group after August 1, 2001: 30 days of continuous active employment in a benefits eligible position. If your employment ends and you are rehired within 12 months, the date you are eligible for coverage will be your rehire date as long as you have previously satisfied the waiting period. All other Summary of Benefits' provisions will apply. CREDIT PRIOR SERVICE: Unum will apply any prior period of work with your Employer toward the waiting period to determine your eligibility date. WHO PAYS FOR THE COVERAGE: For You: Basic Benefit: Your Employer pays the cost of your coverage. Supplemental Benefit: You pay the cost of your coverage. For Your Dependents: You pay the cost of your dependent coverage. LIFE INSURANCE BENEFIT: AMOUNT OF LIFE INSURANCE FOR YOU BASIC BENEFIT Group 1, Group 7, Group 8 1 x annual pay to a maximum of $50,000 Group 2, Group 5 Option 1 1 x annual pay to a maximum of $50,000 Option 2 Waived Coverage B@G-LIFE-2 (1/1/2014) REV 6
Group 8 No Coverage All amounts are rounded to the next higher multiple of $1,000, if not already an exact multiple thereof. SUPPLEMENTAL BENEFIT OPTIONS: Group 1, Group 2, Group 3, Group 4, Group 5, Group 6, Group 7 Option 1 1 x annual pay Option 2 2 x annual pay Option 3 3 x annual pay Option 4 4 x annual pay Option 5 5 x annual pay Option 6 6 x annual pay Option 7 Waived Coverage Group 8 Option 1 1 x annual pay Option 2 2 x annual pay Option 3 3 x annual pay Option 4 4 x annual pay Option 5 Waived Coverage All amounts are rounded to the next higher multiple of $1,000, if not already an exact multiple thereof. B@G-LIFE-3 (1/1/2014) REV 7
AMOUNT OF SUPPLEMENTAL LIFE INSURANCE AVAILABLE IF YOU BECOME INSURED AT CERTAIN AGES OR HAVE REACHED CERTAIN AGES WHILE INSURED If you have reached age 65, but not age 70 on January 1 of the current plan year, your amount of life insurance will be: - 65% of the amount of life insurance you had prior to age 65; or - 65% of the amount of life insurance shown above if you become insured on or after age 65 but before age 70. If you receive an increase in the amount of your life insurance due to a change in your annual pay, this amount will also be reduced to 65%. In no event will the amount of supplemental life insurance be less than $10,000. If you have reached age 70 or more on January 1 of the current plan year, your amount of life insurance will be: - 50% of the amount of life insurance you had prior to your first reduction; or - 50% of the amount of life insurance shown above if you become insured on or after age 70. If you receive an increase in the amount of your life insurance due to a change in your annual pay, this amount will also be reduced to 50%. In no event will the amount of supplemental life insurance be less than $10,000. EVIDENCE OF INSURABILITY: Evidence of insurability is required if: - the amount of your supplemental life insurance is over $750,000; or - you have not been approved by Unum for an amount of supplemental life insurance over $750,000. MINIMUM BENEFIT OF LIFE INSURANCE FOR YOU: Basic Benefit $10,000 Supplemental Benefit $10,000 MAXIMUM BENEFIT OF SUPPLEMENTAL LIFE INSURANCE FOR YOU: $2,500,000 SEATBELT(S) BENEFIT FOR YOU Seatbelt(s): The lesser of: - 10% of your amount of life insurance; or - $10,000 AMOUNT OF LIFE INSURANCE FOR YOUR DEPENDENTS You must have applied for and been approved for Supplemental Life in order to cover your spouse and children for life insurance. Spouse: Group 1, Group 2, Group 3, Group 4, Group 5, Group 6, Group 7 Option 1 $5,000 B@G-LIFE-4 (1/1/2014) REV 8
Option 2 $10,000 Option 3 $25,000 Option 4 $50,000 Option 5 $100,000 Option 6 Waived Coverage Group 8 Option 1 $5,000 Option 2 $10,000 Option 3 $25,000 Option 4 $50,000 Option 5 Waived Coverage The amount of your spouse's life insurance will reduce by the same percentage and at the same time your life insurance reduces. However, if your spouse's current level is less than 50% of your reduced amount of supplemental life insurance, your spouse's amount will not reduce at that time. In no event will your spouse's amount of life insurance be more than 50% of your amount of supplemental life insurance. Group 1, Group 2, Group 3, Group 4, Group 5, Group 6, Group 7 Children: Option 1 Live birth to age 26: $5,000 Option 2 Live birth to age 26: $10,000 Option 3 Live birth to age 26: $25,000 B@G-LIFE-5 (1/1/2014) REV 9
Option 4 Waived Coverage Group 8 Option 1 Live birth to age 26: $5,000 Option 2 Live birth to age 26: $10,000 Option 3 Waived Coverage THE AMOUNT OF LIFE INSURANCE FOR A DEPENDENT WILL NOT BE MORE THAN 100% OF YOUR AMOUNT OF SUPPLEMENTAL LIFE INSURANCE. SOME LOSSES MAY NOT BE COVERED UNDER THIS PLAN. OTHER FEATURES: Accelerated Benefit Continuity of Coverage Conversion Portability NOTE: Portability under this plan is available to an insured spouse in the event of divorce from an insured employee, subject to all terms and conditions otherwise applicable to ported spouse coverage. The above items are only highlights of this plan. For a full description of your coverage, continue reading your certificate of coverage section. B@G-LIFE-6 (1/1/2014) REV 10
BENEFITS AT A GLANCE ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE PLAN This accidental death and dismemberment insurance plan provides financial protection for your beneficiary(ies) by paying a benefit in the event of your death or for you in the event of any other covered loss. The amount you or your beneficiary(ies) receive(s) is based on the amount of coverage in effect just prior to the date of your death or any other covered loss according to the terms and provisions of the plan. You also have the opportunity to have coverage for your dependents. EMPLOYER'S ORIGINAL PLAN EFFECTIVE DATE: August 1, 2001 PLAN YEAR: August 1, 2001 through December 31, 2001 and each following January 1 through December 31 IDENTIFICATION NUMBER: 546864 012 ELIGIBLE GROUP(S): Group 1 All active Full-time Employees, who are benefit-eligible, in active employment in the United States with the Employer and who are not included in Group 2 or Group 5 Group 2 All active Full-time Employees, who are benefit-eligible, in active employment in the United States with the Employer, at one of the Employer locations or in one of the job/position categories that is permitted to fully opt out of this Plan Group 3 All active Part-time 1 Employees, who are benefit-eligible, in active employment in the United States with the Employer and who are not included in Group 4 or Group 6 Group 4 All active Part-time 1 Employees in active employment in the United States with the Employer at one of the Employer locations or in one of the job/position categories that is permitted to fully opt out of this Plan Group 5 All active Full-time Employees, who are benefit-eligible, in active employment in the United States with the Employer, at one of the Employer locations or in one of the job/position categories that is permitted to select an alternative to this Plan Group 6 All active Part-time Employees in active employment in the United States with the Employer at one of the Employer locations or in one of the job/position categories that is permitted to select an alternative to this Plan Group 7 Emergency Medical Personnel in active employment in the United States with the Employer who are defined as "personnel who provide pre-hospital care and transportation of the sick and/or injured within established protocol and work 24 hour shifts" Group 8 All Union Employees of Atlanta Medical Center (Facility 800), Cypress Fairbanks Medical Center (Facility 125), St. Francis Hospital, Memphis (Facility 516), South Fulton Medical Center (Facility 800), Des Peres Hospital (Facility 746), Desert Regional Medical Center (Facility 694), Doctors Hospital of Manteca (Facility 405), Doctor's Medical Center - Modesto (Facility 930), Fountain Valley Regional Hospital (Facility 024), John F. Kennedy Memorial Hospital (Facility 266), Lakewood Regional Medical Center (Facility 012), Los Alamitos Medical Center (Facility 169), B@G-AD&D-1 (1/1/2014) REV 11
Modesto Radiology Imaging (Facility 725), North Fulton Medical Center (Facility 342), Providence Memorial Hospital (Facility 069), San Ramon Regional Medical Center (Facility 075), Sierra Medical Center (Facility 168), Sierra Providence East (Facility 826), Sierra Vista Regional Medical Center (Facility 206), St. Christopher Hospital (Facility 868), St. Louis University (Facility 102), and Twin Cities Community Hospital (Facility 166) in active employment in the United States with the Employer Note: You are only eligible for plan benefits provided by one Tenet facility, even though you may be employed by more than one Tenet affiliated facility. Benefit eligible employees are employees who meet the eligibility criteria set forth in the Tenet Employee Benefit Plan. MINIMUM HOURS REQUIREMENT: Employees must be working at least the minimum number of hours per week as defined by the Tenet affiliated facility. WAITING PERIOD: REHIRE: For employees in an eligible group on or before August 1, 2001: 30 days of continuous active employment in a benefits eligible position. For employees entering an eligible group after August 1, 2001: 30 days of continuous active employment in a benefits eligible position. If your employment ends and you are rehired within 12 months, the date you are eligible for coverage will be your rehire date as long as you have previously satisfied the waiting period. All other Summary of Benefits' provisions will apply. CREDIT PRIOR SERVICE: Unum will apply any prior period of work with your Employer toward the waiting period to determine your eligibility date. WHO PAYS FOR THE COVERAGE: For You: Basic Benefit: Your Employer pays the cost of your coverage. Supplemental Benefit: You pay the cost of your coverage. For Your Dependents: You pay the cost of your dependent coverage. B@G-AD&D-2 (1/1/2014) REV 12
ACCIDENTAL DEATH AND DISMEMBERMENT BENEFIT: AMOUNT OF ACCIDENTAL DEATH AND DISMEMBERMENT (AD&D) INSURANCE FOR YOU (FULL AMOUNT) BASIC BENEFIT Group 1, Group 7, Group 8 1 x annual pay to a maximum of $50,000 Group 2, Group 5 Option 1 1 x annual pay to a maximum of $50,000 Option 2 Waived Coverage Group 3, Group 4, Group 6 No Coverage All full-time Senior Management in active employment in the United States with the Employer or while receiving severance or salary continuation (while domiciled in the United States) 2 x annual earnings to a maximum of $550,000 All amounts are rounded to the next higher multiple of $1,000, if not already an exact multiple thereof. SUPPLEMENTAL BENEFIT OPTIONS: Group 1, Group 2, Group 3, Group 4, Group 5, Group 6, Group 7 Option 1 1 x annual pay Option 2 2 x annual pay Option 3 3 x annual pay Option 4 4 x annual pay Option 5 5 x annual pay Option 6 6 x annual pay Option 7 Waived Coverage B@G-AD&D-3 (1/1/2014) REV 13
Group 8 Option 1 1 x annual pay Option 2 2 x annual pay Option 3 3 x annual pay Option 4 4 x annual pay Option 5 Waived Coverage All amounts are rounded to the next higher multiple of $1,000, if not already an exact multiple thereof. MINIMUM BENEFIT OF ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE FOR YOU: Basic Benefit $10,000 Supplemental Benefit $10,000 MAXIMUM BENEFIT OF SUPPLEMENTAL ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE FOR YOU: $500,000 AMOUNT OF ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE FOR YOUR DEPENDENTS (FULL AMOUNT) You may elect accidental death and dismemberment insurance for your spouse and children even if you do not elect supplemental accidental death and dismemberment insurance for yourself. Spouse: Group 1, Group 2, Group 3, Group 4, Group 5, Group 6, Group 7 Option 1 $25,000 Option 2 $50,000 Option 3 $100,000 Option 4 Waived Coverage B@G-AD&D-4 (1/1/2014) REV 14
Group 8 Option 1 $25,000 Option 2 $50,000 Option 3 Waived Coverage Children: Group 1, Group 2, Group 3, Group 4, Group 5, Group 6, Group 7 Option 1 Live birth to age 26: $10,000 Option 2 Live birth to age 26: $25,000 Option 3 Waived Coverage Group 8 Option 1 Live birth to age 26: $10,000 Option 2 Waived Coverage SEATBELT(S) BENEFIT FOR YOU Basic Coverage Seatbelt(s): The lesser of: - 10% of the Full Amount of your basic accidental death and dismemberment insurance; or - $10,000 The Seatbelt(s) and Air Bag Benefit is separate from any accidental death and dismemberment benefit which may be payable. To receive the Seatbelt(s) Benefit, your accidental death benefit must be paid first. SEATBELT(S) AND AIR BAG BENEFIT FOR YOU AND YOUR DEPENDENTS: (Supplemental Restraint Benefit) Seatbelt(s): - 10% of the Full Amount of your supplemental accidental death and dismemberment insurance to a maximum of $25,000. - 10% of the Full Amount of your dependent's accidental death and dismemberment insurance to a maximum of $25,000. Air bag: - 5% of the Full Amount of your supplemental accidental death and dismemberment insurance to a maximum of $12,500. - 5% of the Full Amount of your dependent's accidental death and dismemberment insurance to a maximum of $12,500. B@G-AD&D-5 (1/1/2014) REV 15
The Seatbelt(s) and Air Bag Benefit is separate from any accidental death and dismemberment benefit which may be payable. The Air Bag Benefit is payable only if the Seatbelt Benefit is payable. To receive the Seatbelt(s) and Air Bag Benefit, your or your dependent's accidental death benefit must be paid first. COMA BENEFIT Monthly Benefit Amount: 1% of the Full Amount of your or your dependent's accidental death and dismemberment insurance. The Coma Benefit will reduce your or your dependent's total accidental death and dismemberment insurance. COMMON ACCIDENT BENEFIT Combined Maximum Benefit (you and your spouse): $1,000,000 COBRA BENEFIT Maximum Benefit Amount Per Year: Up to 3% of the Full Amount of your supplemental accidental death and dismemberment insurance to a maximum of $4,500. Maximum Benefit Period: 3 years This benefit is payable only while the Survivor continues to pay the premium for the continued coverage. The COBRA Benefit is separate from any accidental death and dismemberment benefit which may be payable. To receive the COBRA Benefit, your accidental death benefit must be paid first. REHABILITATION BENEFIT Maximum Benefit Amount: $5,000 The Rehabilitation Benefit is separate from any accidental death and dismemberment benefit which may be payable. FELONIOUS ASSAULT BENEFIT Maximum Benefit Amount: 25% of the Full Amount of your supplemental accidental death and dismemberment insurance. The Felonious Assault Benefit is separate from any accidental death and dismemberment benefit which may be payable. SOME LOSSES MAY NOT BE COVERED UNDER THIS PLAN. OTHER FEATURES: Portability NOTE: Portability under this plan is available to an insured spouse in the event of divorce from an insured employee, subject to all terms and conditions otherwise applicable to ported spouse coverage. The above items are only highlights of this plan. For a full description of your coverage, continue reading your certificate of coverage section. B@G-AD&D-6 (1/1/2014) REV 16
CLAIM INFORMATION LIFE INSURANCE WHEN DO YOU OR YOUR AUTHORIZED REPRESENTATIVE NOTIFY UNUM OF A CLAIM? We encourage you or your authorized representative to notify us as soon as possible, so that a claim decision can be made in a timely manner. If a claim is based on death, written notice and proof of claim must be sent no later than 90 days after the date of death. If it is not possible to give proof within this time limit, it must be given no later than 1 year after the proof is required as specified above. These time limits will not apply during any period you or your authorized representative lacks the legal capacity to give us proof of claim. The claim form is available from your Human Resources Representative or you or your authorized representative can request a claim form from Unum. If you or your authorized representative does not receive the form from Unum within 15 days of the request, send Unum written proof of claim without waiting for the form. WHAT INFORMATION IS NEEDED AS PROOF OF YOUR CLAIM? Proof of claim, provided at your or your authorized representative's expense, must show the cause of death. Also a certified copy of the death certificate must be given to us. In some cases, you will be required to give Unum authorization to obtain additional medical and non-medical information as part of your proof of claim. Unum will deny your claim if the appropriate information is not submitted. WHEN CAN UNUM REQUEST AN AUTOPSY? In the case of death, Unum will have the right and opportunity to request an autopsy where not forbidden by law. HOW DO YOU DESIGNATE OR CHANGE A BENEFICIARY? (Beneficiary Designation) At the time you become insured, you should name a beneficiary on your enrollment form for your death benefits under your life insurance. You may change your beneficiary at any time by filing a form approved by Unum with your Employer. The new beneficiary designation will be effective as of the date you sign that form. However, if we have taken any action or made any payment before Unum receives that form, that change will not go into effect. It is important that you name a beneficiary and keep your designation current. If more than one beneficiary is named and you do not designate their order or share of payments, the beneficiaries will share equally. The share of a beneficiary who dies before you, or the share of a beneficiary who is disqualified, will pass to any surviving beneficiaries in the order you designated. LIFE-CLM-1 (1/1/2014) REV 17
If you do not name a beneficiary, or if all named beneficiaries do not survive you, or if your named beneficiary is disqualified, your death benefit will be paid to the first surviving family members of the family members in the order listed below: - spouse; - child or children; - mother or father; - sisters or brothers; or - your estate. If we are to make payments to a beneficiary who lacks the legal capacity to give us a release, Unum may pay up to $2,000 to the person or institution that appears to have assumed the custody and main support of the beneficiary. This payment made in good faith satisfies Unum's legal duty to the extent of that payment and Unum will not have to make payment again. Also, at Unum's option, we may pay up to $1,000 to the person or persons who, in our opinion, have incurred expenses for your last sickness and death. In addition, if you do not survive your spouse, and dependent life coverage is continued, then your surviving spouse should name a beneficiary according to the requirements specified above for you. HOW WILL UNUM MAKE PAYMENTS? If your or your dependent's life claim is at least $10,000, Unum will make available to the beneficiary a retained asset account (the Unum Security Account). Payment for the life claim may be accessed by writing a draft in a single sum or drafts in smaller sums. The funds for the draft or drafts are fully guaranteed by Unum. If the life claim is less than $10,000, Unum will pay it in one lump sum to you or your beneficiary. Also, you or your beneficiary may request the life claim to be paid according to one of Unum's other settlement options. This request must be in writing in order to be paid under Unum's other settlement options. If you do not survive your spouse, and dependent life coverage is continued, then your surviving spouse's death claim will be paid to your surviving spouse's beneficiary. All other benefits will be paid to you. WHAT HAPPENS IF UNUM OVERPAYS YOUR CLAIM? Unum has the right to recover any overpayments due to: - fraud; and - any error Unum makes in processing a claim identified within 60 days. You must reimburse us in full. We will determine the method by which the repayment is to be made. LIFE-CLM-2 (1/1/2014) REV 18
Unum will not recover more money than the amount we paid you. WHAT ARE YOUR ASSIGNABILITY RIGHTS FOR THE DEATH BENEFITS UNDER YOUR LIFE INSURANCE? (Assignability Rights) The rights provided to you by the plan for life insurance are owned by you, unless: - you have previously assigned these rights to someone else (known as an "assignee"); or - you assign your rights under the plan(s) to an assignee. We will recognize an assignee as the owner of the rights assigned only if: - the assignment is in writing, signed by you, and acceptable to us in form; and - a signed or certified copy of the written assignment has been received and registered by us at our home office. We will not be responsible for the legal, tax or other effects of any assignment, or for any action taken under the plan(s') provisions before receiving and registering an assignment. LIFE-CLM-3 (1/1/2014) REV 19
CLAIM INFORMATION ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE WHEN DO YOU OR YOUR AUTHORIZED REPRESENTATIVE NOTIFY UNUM OF A CLAIM? We encourage you or your authorized representative to notify us as soon as possible, so that a claim decision can be made in a timely manner. Written notice and proof of claim must be sent no later than 90 days after the date of death or the date of any other covered loss. If it is not possible to give proof within these time limits, it must be given no later than 1 year after the time proof is required as specified above. These time limits will not apply during any period you or your authorized representative lacks the legal capacity to give us proof of claim. The claim form is available from your Human Resources Representative or you or your authorized representative can request a claim form from Unum. If you or your authorized representative does not receive the form from Unum within 15 days of your request, send Unum written proof of claim without waiting for the form. HOW DO YOU FILE A CLAIM FOR A COVERED LOSS? You or your authorized representative and your Employer must fill out your own sections of the claim form and then give it to your attending physician. Your physician should fill out his or her section of the form and send it directly to Unum. WHAT INFORMATION IS NEEDED AS PROOF OF CLAIM? If claim is based on death or other covered loss, proof of claim for death or covered loss, provided at your or your authorized representative's expense, must show: - the cause of death or covered loss; - the extent of the covered loss; - the date of covered loss; and - the name and address of any hospital or institution where treatment was received, including all attending physicians. Also, in case of death, a certified copy of the death certificate must be given to us. In some cases, you will be required to give Unum authorization to obtain additional medical and non-medical information as part of your proof of claim. Unum will deny your claim if the appropriate information is not submitted. WHEN CAN UNUM REQUEST AN AUTOPSY? In the case of death, Unum will have the right and opportunity to request an autopsy where not forbidden by law. AD&D-CLM-1 (1/1/2014) REV 20
HOW DO YOU DESIGNATE OR CHANGE A BENEFICIARY? (Beneficiary Designation) At the time you become insured, you should name a beneficiary on your enrollment form for your death benefits under your accidental death and dismemberment insurance. You may change your beneficiary at any time by filing a form approved by Unum with your Employer. The new beneficiary designation will be effective as of the date you sign that form. However, if we have taken any action or made any payment before Unum receives that form, that change will not go into effect. It is important that you name a beneficiary and keep your designation current. If more than one beneficiary is named and you do not designate their order or share of payments, the beneficiaries will share equally. The share of a beneficiary who dies before you, or the share of a beneficiary who is disqualified, will pass to any surviving beneficiaries in the order you designated. If you do not name a beneficiary, or if all named beneficiaries do not survive you, or if your named beneficiary is disqualified, your death benefit will be paid to the first surviving family members of the family members in the order listed below: - spouse; - child or children; - mother or father; - sisters or brothers; or - your estate. If we are to make payments to a beneficiary who lacks the legal capacity to give us a release, Unum may pay up to $2,000 to the person or institution that appears to have assumed the custody and main support of the beneficiary. This payment made in good faith satisfies Unum's legal duty to the extent of that payment and Unum will not have to make payment again. Also, at Unum's option, we may pay up to $1,000 to the person or persons who, in our opinion, have incurred expenses for your last sickness and death. In addition, if you do not survive your spouse, and dependent accidental death and dismemberment coverage is continued, then your surviving spouse should name a beneficiary according to the requirements specified above for you. HOW WILL UNUM MAKE PAYMENTS? If your or your dependent's accidental death or dismemberment claim is at least $10,000 Unum will make available to you or your beneficiary a retained asset account (the Unum Security Account). Payment for the accidental death or dismemberment claim may be accessed by writing a draft in a single sum or drafts in smaller sums. The funds for the draft or drafts are fully guaranteed by Unum. If the accidental death or dismemberment claim is less than $10,000, Unum will pay it in one lump sum to you or your beneficiary. AD&D-CLM-2 (1/1/2014) REV 21
Also, you or your beneficiary may request the accidental death claim to be paid according to one of Unum's other settlement options. This request must be in writing in order to be paid under Unum's other settlement options. If you do not survive your spouse, and dependent accidental death and dismemberment coverage is continued, then your surviving spouse's death claim will be paid to your surviving spouse's beneficiary. All other benefits will be paid to you. WHAT HAPPENS IF UNUM OVERPAYS YOUR CLAIM? Unum has the right to recover any overpayments due to: - fraud; and - any error Unum makes in processing a claim identified within 60 days. You must reimburse us in full. We will determine the method by which the repayment is to be made. Unum will not recover more money than the amount we paid you. WHAT ARE YOUR ASSIGNABILITY RIGHTS FOR THE DEATH BENEFITS UNDER YOUR ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE BENEFITS? (Assignability Rights) The rights provided to you by the plan(s) for accidental death insurance benefits are owned by you, unless: - you have previously assigned these rights to someone else (known as an "assignee"); or - you assign your rights under the plan(s) to an assignee. We will recognize an assignee as the owner of the rights assigned only if: - the assignment is in writing, signed by you, and acceptable to us in form; and - a signed or certified copy of the written assignment has been received and registered by us at our home office. We will not be responsible for the legal, tax or other effects of any assignment, or for any action taken under the plan(s') provisions before receiving and registering an assignment. AD&D-CLM-3 (1/1/2014) REV 22
GENERAL PROVISIONS WHAT IS THE CERTIFICATE OF COVERAGE? This certificate of coverage is a written statement prepared by Unum and may include attachments. It tells you: - the coverage for which you may be entitled; - to whom Unum will make a payment; and - the limitations, exclusions and requirements that apply within a plan. WHEN ARE YOU ELIGIBLE FOR COVERAGE? If you are working for your Employer in an eligible group, the date you are eligible for coverage is the later of: - the plan effective date; or - the day after you complete your waiting period. WHEN DOES YOUR COVERAGE BEGIN? This plan provides different benefit options in addition to the basic benefit if applicable. When you first become eligible for coverage, you may apply for any supplemental option, however, you cannot be covered under more than one option at a time. Evidence of insurability is required for any amount of supplemental life insurance over the amount shown in the LIFE INSURANCE "BENEFITS AT A GLANCE" page. Your Employer pays 100% of the cost of your coverage under the basic benefit. You will automatically be covered under the basic benefit at 12:01 a.m. on the date you are eligible for coverage. When you and your Employer share the cost of your coverage for any supplemental benefit option under a plan or when you pay 100% of the cost yourself for any supplemental benefit option, you will be covered at 12:01 a.m. on the later of: - the date you are eligible for coverage, if you apply for insurance on or before that date; or - the date Unum approves your evidence of insurability form, if evidence of insurability is required. All full-time Senior Management in active employment in the United States with the Employer or while receiving severance or salary continuation (while domiciled in the United States) This plan provides different benefit options in addition to two basic benefits if applicable. When you first become eligible for coverage, you may apply for any supplemental option, however, you cannot be covered under more than one option at a time. Evidence of insurability is required for any amount of supplemental life insurance over the amount shown in the LIFE INSURANCE "BENEFITS AT A GLANCE" page. EMPLOYEE-1 (1/1/2014) REV 23
Your Employer pays 100% of the cost of your coverage under both the basic benefits. You will automatically be covered under the basic benefits at 12:01 a.m. on the date you are eligible for coverage. When you and your Employer share the cost of your coverage for any supplemental benefit option under a plan or when you pay 100% of the cost yourself for any supplemental benefit option, you will be covered at 12:01 a.m. on the later of: - the date you are eligible for coverage, if you apply for insurance on or before that date; or - the date Unum approves your evidence of insurability form, if evidence of insurability is required. WHEN CAN YOU APPLY FOR COVERAGE IF YOU APPLY MORE THAN 31 DAYS AFTER YOUR ELIGIBILITY DATE? (LATE ENTRANTS) If you waived coverage or opted out of coverage when you were first eligible, you can only apply during an annual enrollment period or within 31 days of a change in status. Evidence of insurability is required: Group 1, Group 2, Group 3, Group 4, Group 7, Group 8 - for any amount of supplemental life insurance. Group 5, Group 6 - for any amount of supplemental life insurance over the amount shown in the LIFE INSURANCE "BENEFITS AT A GLANCE" page. Unum and your Employer determine when the annual enrollment period begins and ends. Coverage applied for at an annual enrollment period will begin at 12:01 a.m. on the later of: - the first day of the next plan year; or - the date Unum approves your evidence of insurability, if evidence of insurability is required. Coverage applied for at a change in status will begin at 12:01 a.m. on the later of: - the date of the change in status, if you apply within 31 days after the date of the change in status; or - the date Unum approves your evidence of insurability, if evidence of insurability is required. All full-time Senior Management in active employment in the United States with the Employer or while receiving severance or salary continuation (while domiciled in the United States) If you waived coverage under one or both basic benefits or opted out of supplemental coverage when you were first eligible, you can only apply during an annual enrollment period or within 31 days of a change in status. EMPLOYEE-2 (1/1/2014) REV 24
Evidence of insurability is required: Group 1, Group 2 - for any amount of supplemental life insurance. Group 5 - for any amount of supplemental life insurance over the amount shown in the LIFE INSURANCE "BENEFITS AT A GLANCE" page. Unum and your Employer determine when the annual enrollment period begins and ends. Coverage applied for at an annual enrollment period will begin at 12:01 a.m. on the later of: - the first day of the next plan year; or - the date Unum approves your evidence of insurability, if evidence of insurability is required. Coverage applied for at a change in status will begin at 12:01 a.m. on the later of: - the date of the change in status, if you apply within 31 days after the date of the change in status; or - the date Unum approves your evidence of insurability, if evidence of insurability is required. WHEN CAN YOU CHANGE YOUR COVERAGE BY CHOOSING ANOTHER SUPPLEMENTAL BENEFIT OPTION? (This does not apply to Late Entrants) You can change your coverage by applying for a different supplemental benefit option only during an annual enrollment period or within 31 days of a change in status. You can decrease your coverage any number of levels. Evidence of insurability is required if you increase your coverage by any level or if you apply for any amount of supplemental life insurance over the amount shown in the LIFE INSURANCE "BENEFITS AT A GLANCE" page. If you are not approved for the increase in your coverage, you will automatically remain at the same level you had prior to applying for the increase. Unum and your Employer determine when the annual enrollment period begins and ends. A change in coverage that is made during an annual enrollment period will begin at 12:01 a.m. on the later of: - the first day of the next plan year; or - the date Unum approves your evidence of insurability form, if evidence of insurability is required. A change in coverage due to a change in status will begin at 12:01 a.m. on the later of: - the date of the change in status; or EMPLOYEE-3 (1/1/2014) REV 25
- the date Unum approves your evidence of insurability form, if evidence of insurability is required. Changes in coverage must be consistent with the change in status. If you end employment and are rehired within 12 months, you will be insured on the date you return to active employment. You may also apply for any one supplemental benefit option without evidence of insurability. WHAT IF YOU ARE ABSENT FROM WORK ON THE DATE YOUR COVERAGE WOULD NORMALLY BEGIN? If you are absent from work due to injury, sickness or personal leave of absence, your coverage will begin on the date you return to active employment. ONCE YOUR COVERAGE BEGINS, WHAT HAPPENS IF YOU ARE NOT WORKING DUE TO INJURY OR SICKNESS? If you are not working due to injury or sickness, and if premium is paid, you may continue to be covered up to 12 months. ONCE YOUR COVERAGE BEGINS, WHAT HAPPENS IF YOU ARE TEMPORARILY NOT WORKING? If you are on a personal leave of absence, and if premium is paid, you will be covered for up to 12 months following the date your personal leave of absence begins. If you return to active employment from a personal leave of absence, you may elect the same coverage that you had under the plan just prior to the date your personal leave of absence began. Evidence of insurability will be required. ONCE YOUR COVERAGE BEGINS, WHAT HAPPENS IF THERE IS A SEVERANCE AGREEMENT WITH THE EMPLOYER? Your Employer may continue your Group Life Insurance coverage, subject to the payment of premium, for up to the earliest of the following: - the end of the severance agreement; - three years from the date your severance agreement begins; or - the date you are covered under another employer's group plan. The extension is not available if you are being severed due to illness or injury. ONCE YOUR COVERAGE BEGINS, WHAT HAPPENS IF YOU ARE NOT WORKING DUE TO A LABOR DISPUTE INVOLVING YOUR EMPLOYER? If you are not working due to a labor dispute involving your Employer, and if premium is paid, coverage will be continued until: - the expiration of 6 months from the date you ceased active employment; - the date you accept active employment with another Employer; or - the date less than seventy-five percent (75%) of the employees affected by the labor dispute are continuing insurance; EMPLOYEE-4 (1/1/2014) REV 26
whichever occurs first. To keep your insurance in force, you must pay, on time, to your Employer or Union, an amount equal to 120% of the required premium during the continuation. Your Employer or Union will forward your premium to us. WHEN WILL CHANGES TO YOUR COVERAGE TAKE EFFECT? Once your coverage begins, any increased or additional coverage due to a change in your annual pay will take effect on the first day of the next plan year. Evidence of insurability is not required for any increased or additional coverage due to a change in your annual pay. However, if you receive an increase of 25% or more in your annual pay, you may request the change in your amount of insurance due to the increase in annual pay to be effective prior to the next plan year. You must be in active employment or on a covered leave of absence. - a plan change requested by your Employer will take effect: - immediately; or - the date Unum approves your evidence of insurability form, if evidence of insurability is required. You must be in active employment or on a covered leave of absence. If you are not in active employment due to injury or sickness, any increased or additional coverage due to a change in your annual pay or due to a plan change will begin on the date you return to active employment. Any decrease in coverage will take effect on the plan anniversary but will not affect a payable claim that occurs prior to the decrease. WHEN DOES YOUR COVERAGE END? Your coverage under the Summary of Benefits or a plan ends on the earliest of: - the date the Summary of Benefits or a plan is cancelled; - the date you no longer are in an eligible group; - the date your eligible group is no longer covered; - the last day of the period for which you made any required contributions; or - the last day you are in active employment unless continued due to a labor dispute or due to a personal leave of absence or due to an injury or sickness, as described in this certificate of coverage. Unum will provide coverage for a payable claim which occurs while you are covered under the Summary of Benefits or plan. EMPLOYEE-5 (1/1/2014) REV 27
WHEN ARE YOU ELIGIBLE TO ELECT DEPENDENT COVERAGE? If you elect supplemental coverage for yourself or are insured under the plan, you are eligible to elect dependent coverage for your spouse only, your dependent children only or both. WHEN ARE YOUR DEPENDENTS ELIGIBLE FOR COVERAGE? The date your dependents are eligible for coverage is the later of: - the date your insurance begins; or - the date you first acquire a dependent. WHAT DEPENDENTS ARE ELIGIBLE FOR COVERAGE? The following dependents are eligible for coverage under the plan: - Your lawful spouse. If both you and your spouse are in active employment with your Employer, you may choose to be covered as an employee and as a spouse. You may cover your spouse as a dependent if your spouse is enrolled for coverage as an employee. "Spouse" wherever used includes domestic partner. - Your domestic partner. Your domestic partner is the person named in your declaration of domestic partnership. You must execute and provide the plan administrator with such a declaration which states and gives proof that the domestic partner has had the same permanent residence as you for a minimum of 12 consecutive months prior to the date insurance would become effective for that domestic partner. You must not have signed a declaration of domestic partnership with anyone else within the last 6 months of signing the latest declaration of domestic partnership. Also, the domestic partner must be at least 18 years of age, competent to contract, not related by blood closer than would bar marriage, the sole named domestic partner, not married to anyone else and the declaration of domestic partnership must be approved and recorded by the plan administrator. You may cover your domestic partner as a dependent if your domestic partner is enrolled for coverage as an employee. - Your children from live birth to age 26, regardless of any handicap. Stillborn children are not eligible for coverage. - Your dependent children age 26 and over are eligible, provided they are unable to earn a living because of a physical or mental disability and you are the main source of support and maintenance. Unum must receive proof within 31 days of the date as the child attains age 26 and as required during the first two years. After the first two years Unum will ask for proof when needed but not more than once a year.* Children include your own natural offspring and legally adopted children. They also include stepchildren and foster children. A child will be considered adopted on the date of placement in your home. These children are considered eligible dependents regardless of any handicap. EMPLOYEE-6 (1/1/2014) REV 28
No child may be covered by more than one employee in the plan. No child can be covered as both an employee and a dependent. *Note: The 31 day proof requirement is waived beginning on April 1, 2012 and ending on January 1, 2013. WHEN DOES YOUR DEPENDENT COVERAGE BEGIN? This plan provides different benefit options for your dependents. When your dependents become eligible for coverage, you may apply for any dependent option. However, your dependents cannot be covered under more than one option at a time. When you and your Employer share the cost of your dependent coverage for any option under a plan or when you pay 100% of the cost yourself for any choice, your dependents will be covered at 12:01 a.m. on the later of: - the date your dependents are eligible for coverage, if you apply for insurance on or before that date or within 31 days after your dependent's eligibility date; or - the date Unum approves your dependent's evidence of insurability form, if evidence of insurability is required. WHEN CAN YOU APPLY FOR DEPENDENT COVERAGE IF YOU APPLY MORE THAN 31 DAYS AFTER YOUR DEPENDENTS' ELIGIBILITY DATE? (Late Entrants) You can apply for dependent coverage only during an annual enrollment period or within 31 days of a change in status. Evidence of insurability is required for any amount of dependent spouse life insurance. Unum and your Employer determine when the annual enrollment period begins and ends. Dependent coverage will begin at 12:01 a.m. on the date Unum approves your dependent's evidence of insurability form. WHEN CAN YOU CHANGE YOUR DEPENDENT COVERAGE BY CHOOSING ANOTHER OPTION? (This does not apply to Late Entrants) You can change your dependent coverage by applying for a different option only during an annual enrollment period or within 31 days of a change in status. You can increase or decrease your dependent coverage any number of levels. Evidence of insurability is required if you increase your dependent spouse coverage by any level. If your dependent spouse is not approved for the increase in coverage, your dependent spouse will remain at the same level your dependent spouse had prior to applying for the increase. Unum and your Employer determine when the annual enrollment period begins and ends. A change in coverage that is made during an annual enrollment period will begin at 12:01 a.m. on the later of: - the first day of the next plan year; or - the date Unum approves your dependent's evidence of insurability form, if evidence of insurability is required. EMPLOYEE-7 (1/1/2014) REV 29