Voluntary AD&D. Welcome Package for:

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1 AXIS Insurance Company 1 University Square Drive, Suite 200 Princeton, NJ Voluntary AD&D Welcome Package for: Cedar Hill ISD Located at: 285 Uptown Blvd. #300 Cedar Hill, TX 75104

2 TABLE OF CONTENTS INTRODUCTION... 3 AXIS GLOBAL ACCIDENT & HEALTH... 3 PLAN ADMINISTRATOR/PRIMARY CONTACT ROLES AND RESPONSIBILITIES... 4 CONTACT DIRECTORY... 5 PREMIUM ADMINISTRATION... 6 CLAIM ADMINISTRATION... 7 PLAN ADMINISTRATION... 8 APPENDIX BENEFICIARY DESIGNATION FORM Travel Assistance brochure with ID card Claims Form This Welcome Package describes certain provisions of your Policy. It does not contain all terms and

3 INTRODUCTION Welcome to AXIS Global Accident & Health! This Welcome Package will help you better manage your self-administered insurance plan(s). For complete plan details, please refer to your Policy and all case-related documents. Your Policy and/or Certificate is the primary source of all plan details and provisions. Please visit our website for general information about AXIS Global Accident & Health. AXIS GLOBAL ACCIDENT & HEALTH AXIS Global Accident & Health s groundbreaking, committed approach to accident and health insurance enables our dedicated team of experienced specialists in underwriting, product development, claims and operations to more effectively deliver tailored solutions for our partners and customers. AXIS Global Accident & Health, a division of AXIS Capital Holdings Limited, is headquartered in Princeton, New Jersey. We have established a U.S. market presence and plan to expand in the U.K., Europe, Canada, Australia, and Asia. The corporate objective of AXIS Capital, a Bermuda-based global provider of specialty lines insurance and treaty reinsurance, is to create the leading diversified specialty insurance and reinsurance company in the world as measured by quality, sustainability, and profitability. For more information about AXIS Capital, visit our website at U.S. insurance coverage is underwritten by AXIS insurance Company. Coverage may not be available in all U.S. states and jurisdictions. Product availability and plan design features, including eligibility requirements, descriptions of benefits, exclusions or limitations may vary depending on state laws. Travel assistance services are provided through a service agreement with Europ Assistance, USA. 3 This Welcome Package describes certain provisions of your Policy. It does not contain all terms and

4 PLAN ADMINISTRATOR/PRIMARY CONTACT ROLES AND RESPONSIBILITIES As Plan Administrator/Primary Contact on a self-administered Policy, your role is critical to properly maintaining records related to eligibility, effective dates, premium remittance, beneficiary designations, enrollment changes, and related information. AXIS Global Accident & Health relies on you to report all enrollment and eligibility changes accurately and in a timely manner. Improper administration may result in incorrect application of premium, delay in claim approval and/or claim payment, and a loss in benefits for the Insured. Your AXIS Global Accident & Health Operations Team is available to assist you in any way we can during the implementation and ongoing life cycle of the Policy. Please contact us at any time. You can find key contact information on page 5 of this Manual. Your key responsibilities include, but are not limited to, the following: Remit premium with the completed Premium Remittance on time Support and facilitate benefit related questions Participate in premium audits Communicate and / or distribute Plan information to those covered by the Policy Maintain eligibility information Maintain beneficiary designations Maintain and report employee changes or terminations to ensure accurate premium charges and to avoid delays in claim payments Maintain and provide basic demographic data, when necessary Distribute and /or make available copies of the Summary Plan Description; Certificate Provide a copy of the Travel Assistance brochure ID card to those covered by the Policy 4 This Welcome Package describes certain provisions of your Policy. It does not contain all terms and

5 CONTACT DIRECTORY CEDAR HILL ISD 285 Uptown Blvd. #300, Cedar Hill, TX Policy Administrator/Primary Contact Kathy Shaw 285 Uptown Blvd. #300 Cedar Hill, TX Claims AXIS Global Accident & Health 1 University Square Drive, Ste. 200 Princeton, NJ Premium Remittance Address AXIS Insurance Company P.O. Box Atlanta, GA General Correspondence AXIS Global Accident & Health 1 University Square Drive, Suite 200 Princeton, NJ Telephone Address x4026 kathy.shaw@shisd.com Telephone Toll Free AXIS (2947) Address Brian.Smith@AXIScapital.com Overnight Delivery of Premium Wachovia Bank Attn: AXIS Wholesale Lockbox # Atlanta Avenue Hapeville, GA Telephone: (609) USInsurance.AccHealth@axiscapital.com AXIS Global Accident & Health Travel Assistance Services From the U.S. & Canada From other locations (call collect) AXIS.travel@europassistance-usa.com AXIS Service Representative (for Plan Administrator/Primary Contact) Sandra Midgley Sandra.Midgley@AXIScapital.com V.P. of North America Operations Michael J. Flanagan Michael.Flanagan@AXIScapital.com Company Website Broker Financial Benefit Services Kyle James 2121 N. Glenville Drive, Richardson, TX kylej@fbsbenefits.com Phone:

6 PREMIUM ADMINISTRATION Premium Remittance It is important to remit premium payment by the due date. Please note the Policy is self-administered, which means a Premium Remittance Statement must be completed and returned with the corresponding calculated premium. All your Remittance Statements are sent with the first bill. Please make sure the Remittance Statement is complete and sent in with the payment check. Premium is always due on or prior to the due date as stated in your Policy. Cancellation Grace Period If a premium is not paid when due, the Company may cancel this Policy at the end of the last period for which premium was paid, subject to the Grace Period provision. A grace period of 31 days will be provided for the payment of any premium due after the first. During the grace period, the Policy shall continue in force, unless the Policyholder has given written notice of discontinuance in advance of the premium due date and in accordance with the terms of this Policy. If the required premium is not paid during the grace period, coverage will terminate on the last day of the grace period. The Policyholder will be liable for the payment of a pro rata premium for the time the Policy was in force during the grace period. 6 This Welcome Package describes certain provisions of your Policy. It does not contain all terms and

7 CLAIM ADMINISTRATION Claim Forms Claims Process Our receipt of the Proof of Claim form begins the claims process. A Proof of Claim Form can be found in the Appendix section of this Administration Manual. Please remember claims must be submitted in a timely manner. A claimant can also receive a claim form by referring to the Contact Directory on page 5 of this Manual for telephone and information. The Proof of Claim form contains three parts: the Employer Section; the Employee Section and the Attending Physician Statement (not required for Accidental Death claims). After completing the Employee Section, the claimant should send the form to his or her employer to complete the Employer Section. After completing the form, the Employer should send the completed form to AXIS Global Accident & Health Claims Administrator. AXIS Global Accident & Health has contracted with Health Special Risks, Inc. ( HSRI ) to provide administrative services in conjunction with claims processing. HSRI or AXIS may contact the Employer, claimant, and/or the authorized claimant s representative to obtain any missing information. Please refer to the Contact Directory on page 5 of this Manual for and fax information. To process claims, AXIS Global Accident & Health requires certain documents. These documents vary based upon the type of claim and the terms and conditions of the Policy. The documents, which are listed in the Instructions to the Proof of Claim, may include police reports, death certificates (in the case of accidental death benefits), autopsy/toxicology reports (in certain situations) and relevant medical records. In addition, we also require information from the Employer that helps us verify coverage under the Policy, determine the benefit amount and determine the correct beneficiary. This information, which depends on the type of Policy and the terms and conditions of the Employer s benefit plan, may include: Proof of salary, employee class and/or work status Enrollment forms and/or proof of premium payments Beneficiary designation forms The employee s itinerary or any other information that demonstrates that the employee was on the business of the Employer at the time of the covered loss Payment of Claims This benefit program is administered under the Employee Retirement Income Security Act of 1974 as amended ( ERISA ). As Claims Administrator under this program, AXIS Global Accident & Health shall abide by the claims paying rules and regulations as set forth in ERISA. These rules and regulations provide certain timeframes in which to pay claims and establish an appeals process. 7 This Welcome Package describes certain provisions of your Policy. It does not contain all terms and

8 PLAN ADMINISTRATION Beneficiary Forms Benefits Certificates Changes in Broker of Record A Beneficiary Designation Form can be found in the Appendix section of this Administration Manual. It is the responsibility of the Plan Administrator/Primary Contact to retain and maintain the beneficiary forms. AXIS Global Accident & Health may require a copy of the Beneficiary Designation Form (if one was completed for the Insured) at the time of a claim. The Plan Administrator/Primary Contact is responsible for answering questions an Insured may have with regard to his/her benefit and coverage level. Please refer to the Contact Directory on page 5 of this Manual if you need assistance in answering questions. If applicable to your Policy, the Plan Administrator/Primary Contact is responsible for distributing and/or making available copies of the Certificates to all Insured covered under the Policy. Any request to change the Broker of Record must be communicated to AXIS Global Accident & Health in a timely manner. The Plan Administrator/Primary Contact is responsible for submitting a formal request. The letter must be on company letterhead and must specify the Policy number, Policyholder/group name, effective date of the Broker of Record change, specific coverage(s), name of the new broker, and be signed by an authorized representative of the Policyholder. The Broker of Record change letter should be sent to the General Correspondence Address listed under the Contact Directory on page 5 of this Manual. Eligibility Information The Plan Administrator/Primary Contact is responsible for maintaining eligibility Maintenance information to ensure accurate premium remittance. This may include capturing basic demographic information about the Insured and any eligible dependents, such as gender and date of birth. Eligibility requirements can be found in your Policy under the Schedule of Benefits. Policy Changes Premium Audit No change in this Policy will be valid until approved by one of the Company s executive officers and endorsed on or attached to this Policy. The Plan Administrator /Primary Contact is responsible for communicating any approved policy changes to all Insureds and if applicable, your broker. If necessary, the Plan Administrator/Primary Contact is responsible for participating in and answering questions relating to an audit performed on premium collected for the Policy. 8 This Welcome Package describes certain provisions of your Policy. It does not contain all terms and

9 Premium Remittance Summary Plan Description (SPD) Travel Assistance It is important to remit premium payment by the due date. Premium is always due on or prior to the due date as stated in your Policy. If applicable, a Premium Calculation Worksheet must be completed and returned with the corresponding calculated premium. The Plan Administrator/Primary Contact is responsible for distributing and/or making available copies of the Summary Plan Description to all Insureds covered under the Policy. A Travel Assistance brochure ID card can be found in the Appendix section of this Administration Manual. To access travel assistance benefits, an Insured can call or the Travel Assistance Company using the information on the ID card. The contact information is also available under the Contact Directory on page 5 of this Manual. To ensure accuracy and prompt assistance, please refer to the Policyholder Name and Policy Number as noted on the ID card. It is the responsibility of the Plan Administrator/Primary Contact to provide a copy of the ID card to every Insured Person. 9 This Welcome Package describes certain provisions of your Policy. It does not contain all terms and

10 APPENDIX Beneficiary Designation Form Travel Assistance Brochure with ID card Claims Form 10 This Welcome Package describes certain provisions of your Policy. It does not contain all terms and

11 BENEFICIARY DESIGNATION FORM ACCIDENTAL DEATH & DISMEMBERMENT INSURANCE Instructions: Please complete, sign and date this form to designate your beneficiary(ies) or to change your existing beneficiary(ies). This form cancels all prior designations. If more than one beneficiary is named and no percentages are indicated, payment will be made to them in equal shares. If there are more than three (3) primary and/or contingent beneficiaries, please attach a separate sheet of paper. Return the completed form to your employer. SECTION 1: Employee Information Name (Last Name, Suffix, First Name, MI) Social Security Number Employer Name Check the coverages listed below to which this beneficiary designation applies: All Basic AD&D AD&D Travel Accident SECTION 2: Primary Beneficiary(ies) I choose the person(s) named below to be the primary beneficiary(ies) of the AXIS Insurance Company Accidental Death Insurance benefits listed above that may be payable at the time of my death. If any primary beneficiary(ies) is disqualified or dies before me, his/her percentage of this benefit will be paid to the remaining primary beneficiary(ies). Name & Address Relationship Social Security Number Date of Birth Percentage SECTION 3: Contingent Beneficiary(ies) Total Must Equal 100% If all primary beneficiaries are disqualified or die before me, I choose the person(s) named below to be my contingent beneficiary(ies). Name & Address Relationship Social Security Number Date of Birth Percentage Total Must Equal 100% SECTION 4: Signature X Employee Signature Date

12 Important Information About Designation of Beneficiaries Beneficiary Information Primary Beneficiary(ies) means the person(s) you choose to receive your accidental death insurance benefits. Please specify the percentage of the benefit you want paid to each beneficiary; these percentages should total 100%. If any primary beneficiary is disqualified or dies before you, his/her percentage of the benefit will be paid to the remaining primary beneficiary(ies). Contingent Beneficiary(ies) means the person(s) you choose to receive your accidental death insurance benefits only if all primary beneficiaries are disqualified or die before you. Please specify the percentage of the benefit you want paid to each beneficiary; these percentages should total 100%. If any contingent beneficiary is disqualified or dies before you, his/her percentage of the benefit will be paid to the remaining contingent beneficiary(ies). Minor Beneficiary(ies) When you designate minors as beneficiaries, it is important to understand that insurance benefits may not be released to a minor child. They may, however, be paid to court appointed guardian of the child s estate. The regulations governing minor beneficiaries vary by state. Trust You may designate a valid trust as a beneficiary. The insurance company reserves the right to request a copy of the trust document, or any part thereof, at the time of claim. General Information Updates to Your Beneficiary Designation You can change your beneficiary designation at any time. You may wish to review your designation periodically. Consult an Attorney This information is not intended to be relied on as legal advice. You may wish to get the assistance of an attorney to help ensure your beneficiary designation correctly reflects your intentions. 12 This Welcome Package describes certain provisions of your Policy. It does not contain all terms and

13 Travel Assistance brochure with ID card 13 This Welcome Package describes certain provisions of your Policy. It does not contain all terms and

14 Claims Form (This is ONLY a Sample form) 14 This Welcome Package describes certain provisions of your Policy. It does not contain all terms and