Retiree Accidental Death & Dismemberment Insurance

Transcription

1 Retiree Accidental Death & Dismemberment Insurance G Introduction G-2 Who Is Eligible G-3 Retiree Eligibility G-3 If You Are Rehired/Hired by the Company G-3 If Your Eligible Spouse Is Also a Company Employee or Retiree G-3 Dependent Eligibility G-4 Ineligible Dependents G-4 How to Change or Cancel Coverage G-5 When to Change or Cancel Coverage G-5 What the Plan Costs G-5 How the Plan Works G-5 Accidental Death and Dismemberment Benefits G-5 Other Benefits G-7 Travel Assistance Coverage G-9 Retiree Accidental Death & Dismemberment Insurance How Benefits Are Paid G-10 Exclusions and Limitations G-10 AD&D Exclusions and Limitations G-10 Travel Assistance Coverage Exclusions and Limitations G-10 Naming or Changing Your Beneficiary G-11 If You Don t Have a Beneficiary G-12 How to File a Claim G-12 Claim Review and Appeal Procedure G-13 When Coverage Ends G-13 Conversion of Coverage G-14 G-1

2 c Please refer to the Glossary beginning on page I-1 for the definitions of underlined terms used throughout this SPD. p Glossary, page I-1 In this chapter, the term Company refers to ConocoPhillips and the other companies that have adopted this Plan (as shown in Employers Participating in the Plan on this page). The term retiree is used to describe an eligible participant and does not imply any pension plan eligibility or benefit. References to a person s employment ending or an employment end date that impact an eligibility provision for the Plan also include 1) an employment status change from regular full-time to a status not eligible for employee coverage on or after Jan. 1, 2009 or 2) a leave of absence-labor Dispute on or after Jan. 1, Introduction Accidental death and dismemberment (AD&D) benefits under the ConocoPhillips Group Life Insurance Plan (the Plan) provide your family with valuable financial protection in the event of your death, dismemberment or other covered loss due to a covered accident. This coverage is in addition to any retiree life insurance available under other provisions of the Group Life Insurance Plan. p Retiree Life Insurance, page F-1 c Retiree AD&D coverage is available only to those who became eligible prior to Dec. 1, 2009 and who enrolled in coverage when initially eligible. EMPLOYERS PARTICIPATING IN THE PLAN As of Jan. 1, 2010, the most significant employers participating in the Plan are listed below. A complete current list of employers participating in the Plan may be obtained at any time, free of charge, from the Plan Administrator. > ConocoPhillips Company > ConocoPhillips Pipe Line Company > ConocoPhillips Expatriate Services Co. > Phillips Utility Gas Corp. p Plan Administration, page H-4 G-2

3 Who Is Eligible The following groups are not eligible for the Retiree AD&D Insurance Plan: > Heritage Burlington Resources Pre-1986 Louisiana Land & Exploration retirees > Heritage Burlington Resources Copper Range retirees > Heritage Tosco retirees under a Senior Executive Retirement Plan > Heritage Tosco El Dorado union-represented retirees > Store employees > Riverhead Pipeline Union retirees > Retirees with employment end date of Dec. 1, 2009 and after RETIREE ELIGIBILIT Y You are eligible to participate in the Plan if you are under age 65, you met the eligibility criteria prior to Dec. 1, 2009, you enrolled when initially eligible and: > You were a U.S. citizen or U.S. resident alien when your employment ended or employment status changed, and you meet all of the following conditions: You were a non-store employee paid on the direct U.S. dollar payroll 1 when your employment ended or employment status changed; You were an employee participating in AD&D Insurance under the ConocoPhillips Group Life Insurance Plan on your employment end date; You meet the 65-point rule for eligibility (age plus years of service); and Your Company employment ended on or after Jan. 1, 2003; > You were a ConocoPhillips employee whose employment status was regular full-time, you changed to an employment status or hours not eligible for the employee AD&D insurance on or after Jan. 1, 2009, and you met all of the eligibility provisions for retiree AD&D insurance on the date of your status change; > You were a ConocoPhillips employee on a leave of absence-labor Dispute, provided all the other eligibility provisions for retiree AD&D insurance were met on the day your leave began on or after Jan. 1, 2009; > You were a heritage Conoco employee who retired prior to Jan. 1, 2003 and elected AD&D coverage for yourself or yourself and your spouse. (Note: AD&D coverage for your children was not available, and the 65-point rule was not applicable for eligibility.) If You Are Rehired/Hired by the Company Your retiree coverage will end effective on the date your coverage as an active employee begins. Effective Dec. 1, 2009, when you subsequently end your employment, you cannot elect retiree AD&D insurance coverage. Note: Special rules apply if your spouse is also a Company employee or retiree. p If Your Eligible Spouse Is Also a Company Employee or Retiree, below If Your Eligible Spouse Is Also a Company Employee or Retiree c Review the rules used in determining spouse eligibility. p Dependent Eligibility, page G-4 If both you and your eligible dependent spouse work or have worked for the Company and are enrolled in AD&D, you can be enrolled for coverage both as a retiree and as a spouse of an employee. However, limits apply to the total amount of coverage you can elect for yourselves and for your covered dependent children. See How the Plan Works for details. p How the Plan Works, page G-5 Retiree Accidental Death & Dismemberment Insurance 1 Direct U.S. dollar payroll means that payroll check is written in U.S. dollars by a U.S. company participating in the Plan and is not converted to another currency before being paid to the employee. G-3

4 DEPENDENT ELIGIBILITY If you enrolled in AD&D coverage, your eligible dependents can also be enrolled (but only if your AD&D insurance as an active employee was covering these dependents at the time your employment ended). c If you did not enroll to continue coverage on your eligible dependents during your retiree enrollment, you cannot add dependent coverage in the future. Eligible dependents include your spouse or commonlaw spouse and your dependent children, as defined in this section. (See also Ineligible Dependents at right.) p Ineligible Dependents, at right Definition of Your Spouse Definition of Your Child/ Stepchild Your legally married spouse per state law, including a common-law spouse 1. Note: For AD&D coverage, your spouse must be under age 65. If you are divorced, your ex-spouse is not an eligible dependent. Your unmarried biological or legally adopted child; or Your unmarried stepchild, provided the biological parent is your spouse (as defined above) and you and your spouse either remain married and reside in the same household or your spouse died while married to you. You can cover your unmarried child/ stepchild if: The child is under age 25 and meets all of the following requirements: The child is not employed full-time (average of 40+ hours/week; summer and part-time jobs excluded); and The child is dependent on you for financial support. OR Your disabled child is over age 25 and meets all of the following requirements: The child meets dependent child eligibility criteria other than age; The child was disabled before age 25; The Claims Administrator has approved the required proof of disability; and The child is and remains unable to work in self-sustaining employment. 1 The common-law marriage must be consummated in a state that recognizes common-law marriage, and all state requirements must have been met. Ineligible Dependents Regardless of the above, your dependent (child or spouse) is not eligible for coverage if any of the following apply: > The dependent is in the military or like forces of any country or any subdivision of a country; > He or she is a stillborn child or is not yet born; or > He or she is your domestic partner and/or the child of your domestic partner. G-4

5 How to Change or Cancel Coverage If you want to change or cancel AD&D coverage for yourself or for your eligible dependents, you submit your change request online or call the Benefits Center. If you have questions about changing or canceling your coverage, contact the Benefits Center. c If you did not enroll in retiree AD&D insurance when initially eligible, you cannot enroll in it in the future. WHEN TO CHANGE OR CANCEL COVER AGE You can decrease or cancel AD&D coverage at any time. Decreases in your coverage amount can be made only in $10,000 increments. Evidence of insurability (EOI) is not required. Changes in coverage will be effective the first of the month following your enrollment action. Cancellations of coverage will be effective the last day of the month of your enrollment action. What the Plan Costs You pay the entire cost of your AD&D coverage. The cost of AD&D coverage may change from year to year. The price for coverage for dependent children is the same, regardless of the number of children covered. When you change coverage, you ll receive information about how to access the current costs. How the Plan Works ACCIDENTAL DEATH AND DISMEMBER MENT BENEFITS The amount of coverage you elect your principal sum is paid if you or your spouse or dependent child dies as a result of a covered accidental injury. A percentage of your principal sum is paid for certain other covered losses. Coverage is subject to the limits and restrictions shown below. > Coverage for yourself must be in multiples of $10,000, starting at $20,000 up to a maximum of $1 million or 12 times your annual pay (rounded up to the next $10,000 increment), whichever is less. > Coverage for your spouse must be in multiples of $10,000 starting at $20,000 up to a maximum of $500,000 or the amount of your coverage, whichever is less. > Coverage for your dependent children must be in multiples of $10,000, starting at $10,000, up to a maximum of $50,000 or the amount of your coverage, whichever is less. Each of your dependent children will be covered for the amount elected. > If both you and your spouse work or have worked for the Company and are enrolled in AD&D, you can enroll for coverage both as a retiree and as a spouse. However: The combined maximum amounts of coverage cannot exceed $1 million per covered person; and The combined maximum for each of your child(ren) cannot exceed $50,000. (For example, if you have $30,000 coverage for each of your children, your spouse can have a maximum of $20,000 coverage for them.) Retiree Accidental Death & Dismemberment Insurance G-5

6 The following table shows the percentage of the total benefit amount that you and/or your covered dependents would receive in the event of death or severe injury resulting from a covered accident. For the following covered loss 1... The Plan pays this portion of your total principal sum 2... Life 100% Hand or foot 50% Sight in one eye 50% Both hands or both feet or sight in both eyes 100% Either hand or foot and sight in one eye 100% One hand and one foot 100% Thumb and index finger of either hand 25% Speech and hearing in both ears 100% Speech or hearing in both ears 50% Movement 3 of both upper and lower limbs (quadriplegia) 200% Movement 3 of both lower limbs (paraplegia) 75% Movement 3 of three limbs (triplegia) 75% Movement 3 of the upper and lower limbs of one side of the body (hemiplegia) 66% Movement 3 of one limb (uniplegia) 50% Traumatic brain injury 4 100% Coma 5 1% monthly beginning on the 31st day of the coma for the duration of the coma up to 100% of your principal sum. 1 Loss means: Loss of sight means permanent and uncorrectable loss of sight in the eye. Loss of thumb and index finger of same hand means that the thumb and index finger are permanently severed through or above the metacarpophalangeal joints. Loss of speech means the entire and irrecoverable loss. Loss of hearing means the entire and irrecoverable loss of hearing in both ears. 2 In the event of a covered accident, no more than the principal sum will be paid as a result of a single accident with multiple losses. 3 Movement means the complete and irreversible paralysis of a limb. 4 Traumatic brain injury means physical damage to the brain within 90 days after the covered accident and after at least five days in the hospital and that is certified by a physician at the end of 12 consecutive months to be permanent, complete, irreversible and which prevents the injured person from performing all the substantial and material functions and activities of a person of like age and gender in good heath. 5 Coma means at least 30 continuous days of complete and continuous unconsciousness that begins within 30 days after the covered accident and inability to respond to external or internal stimuli as verified by a physician. The loss must be the direct result of the covered accident and must be incurred within 365 days after the accident, unless designated otherwise. G-6

7 c If the conveyance in which the covered person is riding disappears, is wrecked or sinks, and the covered person is not found within one year of the event, it will be presumed that the person lost their life as a result of a covered accident. If travel in the conveyance is covered, the principal sum will be paid. If a covered person is exposed to weather because of a covered accident and this incident results in a loss of life, the principal sum will be paid. c Acts of war, whether declared or undeclared, will be covered with the exception of certain countries (contact the Benefits Center for current countries because the list is subject to change). OTHER BENEFITS If AD&D benefits are paid as the result of a covered accident, the following benefits may also apply: AD&D Benefit Common Disaster Available if you and your covered spouse die as the result of the same covered accident Description Your spouse s AD&D benefit amount will be increased to equal the lesser of the full amount payable for your loss of life or an amount which, when added to your principal sum, equals $1,000,000. Retiree Accidental Death & Dismemberment Insurance Child Education Available if you or your covered spouse die as a result of injuries suffered in a covered accident > The child education AD&D benefit for each covered child is the lesser of actual costs or an annual amount equal to 20% of your or your spouse s principal sum, up to a maximum AD&D benefit of $25,000 per year. The minimum benefit is $2,500. > The AD&D benefit may be paid annually for four consecutive years, provided your covered child continues his or her education. > The AD&D benefit is payable to each covered child who, on the date of the death, was either: Enrolled as a full-time (at least 12 course credit hours per semester) post-high school student in an accredited institution of learning; or Enrolls as a full-time (at least 12 course credit hours per semester) post-high school student in an accredited institution of learning within 365 days after the date of the death. > Before the AD&D benefit is paid each year, the covered child may be required to present written proof to the Claims Administrator that he or she is attending an institution of higher learning on a full-time basis. > If you and your covered spouse die simultaneously, AD&D benefits under this provision will not exceed the overall maximum applied to the combined total of your and your spouse s principal sums. > If there are no dependent children who qualify for this AD&D benefit, an additional AD&D benefit of $2,500 will be paid to your designated beneficiary. p Naming or Changing Your Beneficiary, page G-11 (continued) G-7

8 AD&D Benefit Seat Belt Use (Includes Child Restraint Device) Available if you or your covered dependent are injured or die as a result of an automobile accident and the conditions in the next column were met Description > The seat belt use AD&D benefit is equal to 10% of the covered person s principal sum, up to a maximum AD&D benefit of $25,000. The minimum AD&D benefit is $1,000. This AD&D benefit is payable to the covered person s beneficiary. > It s payable if you or your covered dependent are injured or die as a result of an automobile accident, and that person was: In an accident while driving or riding as a passenger in a passenger car; and Wearing a seat belt which was properly fastened at the time of the accident; and Injured or died as a result of the injuries sustained in the accident. > A police officer investigating the accident must certify that the seat belt was properly fastened. A copy of such certification must be submitted with the claim for benefits. The minimum AD&D benefit will be paid if it cannot be determined that the covered person was wearing a seat belt at the time of the accident. Spouse Education Available if you die as a result of a covered accident Day Care Benefit Available if you or your covered spouse die as a result of a covered accident > The spouse education AD&D benefit is equal to the tuition charges incurred for a period of up to two consecutive academic years, not to exceed $12,500 per academic year as a full-time student in an accredited school, with an overall maximum of $25,000. The minimum benefit is $2,500. > This benefit is payable to your surviving spouse, provided he or she was enrolled as a full-time student in an accredited school on the date of your death or enrolls as a full-time student in an accredited school within one year after your death. > If there is no surviving spouse who qualifies for this AD&D benefit, an AD&D benefit of $2,500 will be paid to your designated beneficiary. > For each child, the annual child care AD&D benefit is the lesser of actual charges or 10% of the covered person s principal sum, up to a maximum AD&D benefit of $10,000 per year. The minimum benefit is $1,000. > For each child, the AD&D benefit may be paid annually for four consecutive years, provided your covered child remains in day care. > Proof that child care charges have been paid is required before payment of AD&D benefit. AD&D benefit will be made to the person who has primary responsibility for the child s day care expense. Child care charges incurred after the date a child attains age 12 will not be paid. > This benefit pays for child care center charges incurred due to the accidental death of you or your covered spouse, provided: The child was enrolled in child care prior to or is enrolled in child care within 12 months after the covered person s death; and The child care center is operated in a private home, school or other facility on a daily basis for 12 months a year, provides and makes a charge for the care of children and is licensed as a day care center or is operated by a licensed day care provider if such licensing is required by the state or jurisdiction in which it is located. > In the event you and your covered spouse die simultaneously, or you die while a child care benefit is being paid on account of your covered spouse s death, the total amount of AD&D benefit will not exceed the above maximum applied to the combined total of your and your spouse s principal sums. > If there is no child who qualifies for this AD&D benefit, an AD&D benefit of $1,000 will be paid to your designated beneficiary. G-8

9 TR AVEL ASSISTANCE COVER AGE Travel assistance coverage provides pre-trip information, emergency medical assistance and emergency personal services, 24 hours a day, 365 days a year worldwide for you, your spouse and dependent children (under the age of 19 or under the age of 25 if a full-time student in actual attendance at an accredited school or college and primarily dependent on you for support and maintenance) when you have an emergency on a covered trip. Travel assistance services which are available only when specific Plan criteria are met are shown below. You or your health insurance is responsible for incurred medical expenses, just as if you were home. Contact the travel assistance Claims Administrator for more information. For all of the services listed here, the travel assistance Claims Administrator must be contacted and the service or expense approved in advance in order for coverage to apply. Travel assistance services arranged and provided by the Claims Administrator are subject to a limit of $1 million (combined single limit) to the insured. Pre-Trip Information > Visa passport, inoculation and immunization requirements > International hot spots > Travel advisories > Foreign exchange rates > Embassy and consular referrals Retiree Accidental Death & Dismemberment Insurance Emergency Medical Assistance Emergency Personal Services > Medical referrals Referrals to physicians, dentists and medical facilities worldwide > Medical monitoring Professional monitoring of your care to determine if further intervention, medical transportation or possibly repatriation is needed > Medical evacuation Arrangement for transportation to the closest medical facility that can provide an appropriate level of care > Repatriation Arrangement for transportation home for further medical treatment > Traveling companion assistance If your traveling companion s previously made travel arrangements are lost due to your hospitalization, new travel arrangements and funding for their return home > Dependent children assistance When dependent children are left unattended due to your hospitalization, travel arrangements and funding for their return home with a qualified escort, if necessary > Visit by a family member or friend If you are traveling alone and are hospitalized for at least seven consecutive days or are in critical condition, travel arrangements and funding for a family member or friend to visit, if that service is deemed medically necessary > Emergency medical payments Advancement of funds to cover on-site medical expenses, upon satisfactory guarantee of your personal-expense reimbursement > Return of mortal remains Arrangement and funding for proper return of remains for burial in the event of death while traveling > Medication and eyeglass assistance Whenever possible, prescriptions or eyeglasses will be replaced if lost, stolen or used up, subject to local law. Payment for the items is your responsibility > Sending and receiving emergency messages Relay of emergency messages to and from friends, relatives and business associates toll-free 24 hours a day/7 days a week > Emergency travel arrangements Airline, hotel and car rental reservations or changes. Note: You pay the cost of airfare (unless it was approved as medically necessary by the attending physician), food, hotel and car expenses > Emergency cash Advancement of funds > Locating lost items Assistance in locating lost luggage and personal possessions > Legal assistance Assistance in locating an attorney > Bail advancement Advancement of funds for bail, where permitted by law (you pay attorney fees) > Translation Telephone translation G-9

10 How Benefits Are Paid If you die, AD&D benefits will be paid to your designated beneficiary(ies). All other AD&D benefit payments will be paid to person(s) designated by Plan provisions. Most AD&D benefits are paid in a single lump-sum payment. AD&D benefits are paid as soon as the insurance company receives proof supporting the claim. p Naming or Changing Your Beneficiary, page G-11 Exclusions and Limitations c Note: This list of exclusions and limitations is not exhaustive. The terms of the insurance contract will control concerning events that do not qualify as a covered accident and, therefore, do not qualify for AD&D benefits. AD&D EXCLUSIONS AND LIMITATIONS AD&D benefits are not payable for injuries or death caused by, contributed to or resulting from any of the following conditions: > Suicide or attempted suicide, whether sane or insane; > Intentionally self-inflicted injury; > War or act of war, whether declared or not, in certain countries (contact the Benefits Center for current countries because the list is subject to change); > Service as a full-time member of the armed forces (land, water, air) of any country or international authority except Reserve National Guard Service; > Travel on any aircraft: As a student pilot, crew member, passenger or pilot, unless it is owned or leased on behalf of the Company; As a flight instructor or examiner; or Being used for tests, experimental purposes, stunt flying, racing or endurance tests; > Intake of drugs, including but not limited to sedatives, narcotics, barbiturates, amphetamines or hallucinogens, unless as prescribed by or administered by a physician; > Committing or attempting to commit a felony; or > Driving while intoxicated: Blood alcohol content or results of other means of testing blood alcohol level or results of other means of testing other substances that meet or exceed the legal presumption of intoxication, or under the influence, under the law of the state where the incident occurred. TRAVEL ASSISTANCE COVERAGE EXCLUSIONS AND LIMITATIONS The Plan will not provide services or pay for expenses caused by or resulting from: > Suicide or attempted suicide; > Mental or emotional disorders, unless hospitalized; > War or participation in any military maneuver or training exercise; > Piloting an aircraft; > Commission of or the attempt to commit a criminal act; > Traveling to obtain medical services or treatment; > Being under the influence of drugs or intoxicants, unless prescribed by a physician; > Pregnancy or childbirth (except for complications of pregnancy); > Injury or illness that can be treated locally and does not prevent continuation of the trip; > Participation as a professional in athletics; and > Assistance not shown as being covered. p Travel Assistance Coverage, page G-9 G-10

11 Naming or Changing Your Beneficiary You must name a beneficiary (the person or persons designated to receive AD&D benefits in the event of your death). You may name as many beneficiaries as you wish including individual persons, your estate, a trust, church or charitable organization. > For spouse and dependent AD&D benefits, you re the designated beneficiary, and no one else can be named (including a contingent beneficiary). If you and your dependent(s) die within the same 24-hour period, the AD&D benefits will be paid as described under If You Don t Have a Beneficiary. p If You Don t Have a Beneficiary, page G-12 > If you designate more than one beneficiary without identifying their respective shares, the beneficiaries will share equally. > When designating your beneficiary, provide the Social Security number and as much information as possible (e.g., full name, date of birth, current address). > By law, benefits cannot be paid directly to a minor (anyone under 18 years old) they must either be paid to the guardian of the minor s estate or held by the insurance company until the child reaches legal age. If any beneficiary is a minor, the Claims Administrator may pay his or her share, until a legal guardian of the minor s estate is appointed, to a person who at the Claims Administrator s option and opinion is providing financial support and maintenance for the minor. This payment will release the Claims Administrator from all further liability for the amount paid. > If your marriage status changes (divorce, re-marriage, etc) you may wish to make a new valid beneficiary designation. Advising the Company of your status change does not change your beneficiary designation. You must make a new beneficiary designation if you want to make changes to your existing designation. If you named your spouse as your beneficiary prior to your divorce, your divorce does not automatically revoke your election and your ex-spouse will remain your beneficiary until you change your beneficiary designation. > Unless you specify otherwise, AD&D benefits for any beneficiary who dies before you, at the same time as you, or within 24 hours of your death will be paid as described under If You Don t Have a Beneficiary. p If You Don t Have a Beneficiary, page G-12 > From time to time, you may be required to make a new valid beneficiary designation for the purpose of administration of the Plan. You can name or change your beneficiary designation at any time. Your beneficiary designation must be submitted online at conocophillips or by calling the Benefits Center. A beneficiary designation by any other means will not be accepted. Your valid beneficiary designation is effective on the date you (or the owner of your coverage, if you had assigned your coverage prior to Jan. 1, 2006) make the designation. Retiree Accidental Death & Dismemberment Insurance G-11

12 c For participants who were enrolled in AD&D coverage as an employee or former employee prior to Jan. 1, 2007, if you did not fill out a new beneficiary form during the 2007 annual enrollment or thereafter, all life insurance beneficiary forms completed before then became invalid as of March 31, If you have not made a new valid beneficiary designation, claims will be paid as described in this section. p Naming or Changing Your Beneficiary, page G-11 IF YOU DON T HAVE A BENEFICIARY AD&D benefits will be paid according to the claims to be paid provisions shown below if: > You didn t designate a beneficiary; > Your designated primary and contingent beneficiaries die before you, at the same time as you, or within 24 hours of your death; or > For dependent AD&D benefits, your dependent dies before you, at the same time as you, or within 24 hours of your death. The claims to be paid provisions state that the Claims Administrator may pay all or part of the AD&D benefits due in the following order: > The executors or administrators of your estate; or > Your surviving legally married spouse, if applicable; then > Your surviving children, in equal shares; then > If no child survives you, your surviving parents, in equal shares. Any payments made will relieve the Claims Administrator of any liability for the Plan benefits. c The Benefits Center is the initial point of contact for all notice of claim submissions under the AD&D Plan. Send your completed claims and supporting documentation to the address shown in the claim packet. How to File a Claim To initially file a claim for AD&D benefits, you, a family member or your beneficiary should contact the Benefits Center and provide the covered person s and retiree s name and Social Security number, date of the accident or death and contact information for next of kin. Claims must be received by the Benefits Center within 30 days of a loss due to a covered accidental injury or death. Delayed claims will be accepted if the accident was reported as soon as reasonably possible. Proof of loss should be submitted within 90 days of when it is due. To file a claim for Travel Assistance Services, contact the Claims Administrator when services are needed. For death claims, a certified death certificate must be provided before any AD&D benefits can be paid. Other documents (for example, a copy of trust or estate documents) may also be required, depending on your beneficiary designations. The claimant will be advised if additional documents are needed to support a claim. When you file a claim with the Plan, you re consenting to the release of information to the Claims Administrator and granting certain rights to the Claims Administrator. p Information and Consents Required From You, page H-28 G-12

13 CL AIM REVIEW AND APPEAL PROCEDURE For information about when to expect a response to your claim from the Claims Administrator and/or Appeals Administrator or how to file an appeal if your claim is denied, refer to the Claims and Appeals Procedures section. p Claims and Appeals Procedures, page H-24 When Coverage Ends Your coverage will end on the earliest of the following events: > The date on which you no longer meet the Plan s eligibility requirements; p Retiree Eligibility, page G-3 > The last day of the month in which you terminate your AD&D insurance coverage; > The last day of the month in which your coverage is terminated for any other reason not stated in this section; > The last day of the month in which you don t pay the required costs; > The last day of the month in which you reach age 65; > The date on which you are eligible for AD&D coverage as an employee, if you are rehired by the Company or if your employment status changes; > The date of your death; > The date on which the Company terminates AD&D coverage; or > The date on which the Group Life Insurance Plan is terminated. c Questions about benefit claims should be directed first to the representative handling your claim, who may direct you to the Claims Administrator. The Claims Administrator approves or denies claims based on the applicable terms of the Plan documents, including the insurance contract. c If your AD&D coverage ends, you may be eligible to continue coverage through an individual policy. p Conversion of Coverage, page G-14 Retiree Accidental Death & Dismemberment Insurance Coverage for your covered dependent(s) ends on the earliest of the following events: > The last day of the month in which your coverage ends for any reason; > The date on which you no longer meet the Plan s eligibility requirements; p Retiree Eligibility, page G-3 > The last day of the month in which you terminate the AD&D insurance coverage; > The last day of the month in which your dependent no longer qualifies as an eligible dependent as defined by the Plan; > The last day of the month in which coverage for your dependent(s) is terminated for any other reason not stated in this section; > The last day of the month in which you don t pay the required costs for dependent AD&D coverage; > The last day of the month in which your spouse reaches age 65 or your dependent child reaches age 25, as applicable; > The date on which you are eligible for AD&D coverage as an employee, if you are rehired by the Company; > The last day of the month in which your dependent becomes eligible for coverage as a Company employee; > The date of your dependent s death; or > The date on which the Group Life Insurance Plan is terminated. G-13

14 CONVERSION OF COVER AGE AD&D insurance may be continued through a group conversion policy offered by the insurance company. This provision applies if: > Your AD&D coverage ended because you are no longer eligible, your spouse s coverage ended due to divorce or annulment, or your spouse and/or child(ren) s coverage ended due to your death; and > You were enrolled in AD&D coverage and were current with payment of your costs at the time coverage ended. Some rules apply to continued AD&D coverage: > The participant must apply for continuation of coverage within the allowed days specified on the application that he or she will receive. > The maximum coverage for you or your dependents is the amount in effect immediately prior to the date it ended, unless your state has a lower maximum amount. > The policy will be a direct relationship between the participant and the insurance company, and the AD&D provisions described in this chapter will no longer apply. Rates will be based on the participant s current age and may differ from the rates paid prior to coverage continuation. The participant will be billed monthly by the insurance company. > If the participant dies from an accident within the 31-day continuation period, the coverage amount in force on the date of termination will be paid to the beneficiary(ies). For information about AD&D continuation options, contact the Benefits Center. G-14