LIFE AND ACCIDENTAL DEATH & DISMEMBERMENT BENEFITS SUMMARY PLAN DESCRIPTION August 1, 2009
TABLE OF CONTENTS DEFINITIONS...1 SCHEDULE OF BENEFITS...3 HOW TO FILE A CLAIM FOR BENEFITS...4 ELIGIBILITY...4 BENEFICIARY...4 DETERMINATION OF BENEFICIARY...5 LIFE BENEFIT...5 ACCELERATED LIFE BENEFIT...5 CONVERSION PRIVILEGE...6 WAIVER OF PREMIUM BENEFIT...6 AD&D BENEFIT...7 EUROP ASSISTANCE USA TRAVEL SERVICES...8 TIC/A/UAS 0809 i
The Company provides Life and Accidental Death and Dismemberment (AD&D) insurance to eligible Employees under Group Policy Number G00604834 issued by American United Life Insurance Company, One American Square, P.O. Box 6123, Indianapolis, IN 46206 (herein called the Insurance Company). The Plan Administrator for the policy is: TIC International Corporation 11590 North Meridian Street, Suite 600 Carmel, IN 46032-4529. 317 580 8686 The policy provides non-contributory Employee only Life and AD&D insurance (non-contributory insurance is fully paid for by the Company). Any information pertaining to benefits, including the information contained herein, is controlled and superseded by the policy. The policy may be amended or terminated by the Company at any time. Employees will be advised of significant changes. To examine the policy, please send a written request, in advance, to the Plan Administrator. Certificate of Insurance: An Employee who becomes insured under the policy will receive a Certificate of Insurance issued by the Insurance Company that summarizes the provisions, limitations and exclusions of the policy. The Certificate of Insurance is subject to the terms of the policy and is not itself a contract for insurance. DEFINITIONS The terms listed below apply to Life and AD&D insurance only. If a term's definition is different from its definition in the policy, the definition in the policy shall prevail. Accidental Bodily Injury means an injury occurring as a result of an accident, either directly or indirectly, along with all other related conditions, sustained by an Employee while insured under the policy. Accidental Death means death due to an accident, directly and independently of all other causes. Accidental Dismemberment means loss of sight, speech or hearing or severance of a body member due to an accident, directly and independently of all other causes. Losses are defined as follows: 1. Loss of sight means total, permanent blindness, and 2. Loss of speech means total, permanent and irrecoverable loss of vocal communication, and 3. Loss of hearing means total, permanent deafness in both ears that cannot be corrected, and 4. Loss of hand means complete severance of the arm through or above the wrist, and 5. Loss of thumb and index finder means complete severance of both the thumb and index finger at or above the metacarpophalangeal joints on the same hand, and 6. Loss of foot means complete severance through or above the ankle. Active Work and Actively at Work mean the use of time and energy in the services of the Company at the regular place of business by a person who is physically and mentally capable of performing each of the material and substantial duties of his or her regular job for a minimum of 30 hours per week. This includes time off for vacation, jury duty and funeral leave where the person could otherwise have been at Active Work. This does not include time off as a result of an injury, Accidental Bodily Injury, Sickness, strike or lockout. Beneficiary means the person(s) or other entity designated by the Employee on a form satisfactory to the Insurance Company to receive any benefits becoming payable under the policy. TIC/A/UAS 0809 1
DEFINITIONS (continued) UNITED ACTUARIAL SERVICES, INC. LIFE AND AD&D BENEFITS Date of Disability means the first day the Employee is not Actively at Work due to an Accidental Bodily Injury or Sickness that causes Total Disability. Company means United Actuarial Services, Inc. Elimination Period means a period of 180 consecutive days beginning on the Date of Disability. This period may include up to three (3) days of Active Work. Employee means a person whose employment with the Company constitutes his or her principal occupation and who regularly works at that occupation 30 or more hours per week. Employee does not include a person who is temporarily or seasonally employed by the Company. Evidence of Insurability means written proof, provided without expense to the Insurance Company, of a person s medical history upon which acceptance for insurance will be determined by the Insurance Company. Loss means loss of life, or, with regard to: a) hand or foot means complete severance through or above the wrist or ankle joint, b) sight means total, permanent blindness, c) speech means total, permanent and irrecoverable loss of vocal communication, d) hearing means total, permanent deafness in both ears which cannot be corrected by an means, and e) thumb and index finger means complete severance of both the thumb and index finger at or above the metacarpophalangeal joints on the same hand. Sickness means illness, bodily disorder or disease, pregnancy and any condition classified as a mental disorder in the International Classification of Diseases, Clinical Modification, published by Med-Index. Terminal Condition means an injury or Sickness that, despite appropriate medical care, is reasonably expected to result in the Employee s death within 12 months from the date of payment of the Accelerated Life Benefit, as determined by the Insurance Company. The Insurance Company may require the Employee to be examined by a physician of its choosing. Total Disability and Totally Disabled mean that because of Accidental Bodily Injury or Sickness the Employee cannot engage in any occupation for which he or she is reasonably fitted by training, education, or experience. If the Employee accepts any type of gainful employment, other than in a state-approved rehabilitation program or sheltered workshop, he or she will be considered fitted to that occupation. UAS 0809 2
SCHEDULE OF BENEFITS Classification Life AD&D Amount Principle Sum All eligible Employees... *... * * Two (2) times salary up to the next $1,000, if not an even $1,000, not to exceed $200,000. Accelerated Life Benefit: An Employee with a Terminal Condition may request payment of an Accelerated Life Benefit equal to either 25% or 50% of the Life Amount not to exceed a maximum payment of $100,000. Reduction of Insurance at Age 70: Life and AD&D insurance will be reduced beginning at age 70 as follows: Age When Reduction Occurs... Percentage Remaining From Amount in Effect at Age 69 70 74... 45% 75 79... 30% 80 84... 20% 85 89... 15% 90 and older... 10% TIC/A/UAS 0809 3
HOW TO FILE A CLAIM FOR BENEFITS A claim should be sent to the Insurance Company as soon after a loss as possible. Death claims must be submitted within three (3) years of loss. Waiver of Premium Benefit claims must be furnished within 12 months of loss. Claims filed after these time limits may still be considered if it is shown that timely submission was not possible. Death claims should include a completed claim form and certified death certificate or other appropriate proof of loss. The Insurance Company may also require the Insurance Certificate, medical records, police reports, proofs of employment and other pertinent records. Notice of an injury claims under the AD&D portion of the policy must be submitted within 31 days of the date of the accident. The Insurance Company must receive acceptable proof of loss within 90 days after the date of loss. Late claims may be considered if it is proven that timely submission of the claim was not possible. The Insurance Company may have the injured person examined by a physician of it choice. Claim forms may be obtained from the Insurance Company or the Plan Administrator. The Insurance Company, at its expense, may have the insured examined by a physician of its choice as often as reasonably necessary or, in the event of death, an autopsy performed. ELIGIBILITY Employees will become eligible for Life and AD&D insurance on the date next following completion of 30 days of Active Work. Enrollment: To become insured, an eligible Employee must give the Plan Administrator a request for coverage on a form satisfactory to the Insurance Company within 31 days from the Employee s eligibility date. A form may be obtained by contacting the Plan Administrator. Effective Date of Insurance: Insurance will be effective for Employees who are Actively at Work on the eligibility date. If an Employee is not Actively at Work on the date insurance would otherwise be effective, the effective date will be the date of return to Active Work. Termination of Insurance: Life and AD&D insurance terminates on the earliest of the following: 1. The date the policy terminates, or 2. The date the insured is no longer eligible for insurance, or 3. The date for which a required contribution is not made, or 4. The date the insured retires, or 5. The date the insured enters active military service for any country except for temporary duty of 30 days or less, or 6. The date the insured ceases Active Work. In addition to the above, AD&D insurance terminates when Life insurance reduces to zero or, for Total Disability, the end of the Waiver of Premium Benefit Elimination Period. AD&D insurance is not included in the Conversion Privilege. BENEFICIARY An Employee may designate a Beneficiary on the Life and AD&D application form. The designation may name one (1) or more Beneficiaries, establish an order of payment and specify the distribution of proceeds. The application form must be completed and sent to the Plan Administrator within 31 days of the Employee's eligibility date. TIC/A/UAS 0809 4
BENEFICIARY (continued) UNITED ACTUARIAL SERVICES, INC. LIFE AND AD&D BENEFITS A Beneficiary designation may be changed at any time by submitting a completed Beneficiary change form to the Plan Administrator. The change will be effective on the date the change form is signed by the Employee, except that, the Insurance Company is not liable if benefits are paid to the previous Beneficiary before the change form is received. DETERMINATION OF BENEFICIARY The Insurance Company will determine how benefits will be distributed in the following order: 1. If more than one (1) Beneficiary is designated and no order of preference is given, than all Beneficiaries who outlive the Employee will share equally. If more than one (1) Beneficiary is listed within the same order of payment and no distribution is specified, then all Beneficiaries will share equally. 2. If there are no named or living Beneficiaries, the Employee s estate is not substantial and there are no statutory requirements to the contrary, payment will be made, at the Insurance Company s option, to a surviving relative. Relatives will be considered, in descending order of preference, as follows: a) spouse, b) child(ren), c) parent(s), d) brother(s) and sister(s). 3. The Employee s estate. The Insurance Company, at its option, may pay proceeds up to $2,000 to any person it believes is equitably entitled to payment by reason of having incurred funeral or other expenses incident to the Employee s death. Assignments: Employees may assign their insurance ownership rights to any other person or entity except the Company. The assignment must be in a form satisfactory to the Insurance Company. The Insurance Company does not guarantee the validity of any assignment. Collateral assignments are not permitted. LIFE BENEFIT On receipt of satisfactory proof of an insured Employee s death, the Insurance Company will pay the amount of insurance due the Beneficiary. The proceeds will be paid in a lump sum unless another payment option is selected by the Employee prior to death or by the Beneficiary. The Insurance Company may be contacted for payment options. ACCELERATED LIFE BENEFIT An insured Employee, who is Totally Disabled under the Waiver of Premium Benefit and is diagnosed with a Terminal Condition may request to receive a one (1) time, lump sum Accelerated Life Benefit while living. At the Employee s request, the benefit may be either 25% or 50% of the Life Amount shown in the Schedule of Benefits. In a community property state, the Insurance Company must receive prior written consent from the Employee s spouse, if any, authorizing payment of the benefit. To request an Accelerated Life Benefit, the Employee must provide a completed claim form and any other information that the Insurance Company needs to review the claim. The Insurance Company may require the Employee to be examined by a physician of its choice. The Life Amount (including the amount which may be converted under the Conversion Privilege) will be reduced by the amount of the Accelerated Life Benefit and an interest charge. The remaining life insurance will be continued in accordance with the terms and conditions of the policy. NOTE: AD&D insurance will terminate upon approval of the Waiver of Premium Benefit. An Accelerated Life Benefit will not be paid if: 1. The Employee has designated an irrevocable Beneficiary or made an assignment of Life insurance benefits, or TIC/A/UAS 0809 5
ACCELERATED BENEFIT (continued) 2. All or a portion of the Employee s Life insurance benefits are to be paid to a former spouse or trustee as part of a divorce decree or property settlement, or child support order, or 3. The Employee s Life insurance terminates, or 4. The policy terminates. Payment of an Accelerated Life Benefit may be taxable and/or affect the family s eligibility for public assistance. An Employee should consult with a qualified tax advisor and with social service agencies before requesting an Accelerated Life Benefit. CONVERSION PRIVILEGE Life Insurance may be converted, without Evidence of Insurability, to an individual policy issued by the Insurance Company if it terminates due to: 1. Termination of employment or membership in a class eligible for insurance, or 2. A reduction in the benefit amount, or 3. Disapproval of a Waiver of Premium Benefit request, or 4. After five (5) or more years of continuous coverage, termination of the policy or the class under which the Employee is eligible. The conversion policy can be up to the amount of Life insurance terminated or, with respect to number 4, above, the smaller of: a) the amount of Life insurance terminated minus any new group life insurance for which the Employee becomes eligible for within 31 days of the date insurance under this policy terminated or b) $10,000. Acceptable written application for conversion and the first premium must be submitted to the Insurance Company within 31 days after the later of the date: 1. Insurance under this policy terminates, or 2. Conversion notification by the Plan Administrator (NOTE: If conversion notification is not received within 15 days of termination of insurance, an additional application period will begin that will end on the earlier of: a) 15 days after notice is received, or b) 60 days from the end of the original 31 day conversion period), or 3. Denial of a Waiver of Premium Benefit request. The conversion policy may be any type of insurance offered by the Insurance Company except term insurance. The premium will be at the Insurance Company's customary rate based on age and class of risk. If death occurs during the conversion application period, the insurance that could have been converted to an individual policy will be paid even if no application for conversion was made. In no event will a death benefit be payable under both the Conversion Privilege and the Waiver of Premium Benefit. AD&D insurance and the Waiver of Premium Benefit are not available for conversion. WAIVER OF PREMIUM BENEFIT Upon satisfaction of a six (6) month Elimination Period the Insurance Company will waive further premium payments for Life insurance if an Employee becomes Totally Disabled before age 60 and while insured under the policy. The Employee must submit proof of Total Disability, acceptable to the Insurance Company, during the three (3) month period prior to the end of the Elimination Period, and, thereafter, one (1) month prior to the end of each following year of disability. TIC/A/UAS 0809 6
WAIVER OF PREMIUM BENEFIT (continued) The Waiver of Premium Benefit applies to Life insurance only. AD&D insurance, if any, will terminate on the date the Waiver of Premium Benefit is approved by the Insurance Company. A physician other than the Employee or a member of the Employee s family must certify Total Disability. After two (2) years, the Insurance Company, at its expense, may have the Employee examined by a physician of its choice annually. Life insurance continued under the Waiver of Premium Benefit will reduce in accordance with the age reduction provision in the Schedule of Benefits and upon any reduction of coverage for the Employee s class. The Conversion Privilege may be elected within 31 days of the date coverage under the Waiver of Premium Benefit is denied or otherwise ceases. Under no circumstances will a death benefit be payable under both the Conversion Privilege and the Waiver of Premium Benefit. Termination of Waiver of Premium Benefit: The Waiver of Premium Benefit will end on the earliest date the following occurs: 1. Unsatisfactory proof of Totally Disabled is submitted, or 2. The Employee accepts employment or is found able to accept employment for which he or she is reasonably fitted by training, education or experience, or 3. The Employee refuses to submit to medical examination, or 4. Proof of continuous Total Disability is not submitted annually unless it is not possible to do so, or 5. Attainment of age 70, or 6. Retirement. AD&D BENEFIT If an Employee has an accident that results in Accidental Death or Accidental Dismemberment within 90 days from the occurrence of such accident, subject to satisfactory proof of Loss, the Insurance Company will pay: 1, The AD&D Principal Sum shown in the Schedule of Benefits for Loss of: a) life, or b) Loss of both hands or feet, or c) speech and hearing, or d) sight of both eyes, or e) one hand and one foot or f) one hand or one foot and sight in one eye, or 2. One-half the AD&D Principal Sum shown in the Schedule of Benefits for Loss of: a) sight of one eye, or b) one hand or one foot, or c) speech or hearing, or 3. One-quarter the AD&D Principal Sum shown in the Schedule of Benefits for Loss of a thumb and index finger. The total amount for all Losses resulting from an accident will never exceed the Principal Sum. Benefits are payable in one (1) lump sum to the Employee, if living, otherwise, to the Beneficiary. Exclusions and Limitations: Benefits are not payable for loss due directly or indirectly to: 1. Suicide or attempted suicide whether sane or insane; or 2. Air travel as a crew member, or 3. Participation in a riot or from war or an act of war, whether declared or undeclared, or 4. Commission of an assault or felony, or TIC/A/UAS 0809 7
AD&D BENEFIT (continued) UNITED ACTUARIAL SERVICES, INC. LIFE AND AD&D BENEFITS 5. The voluntary inhaling of gas (unless due to occupational accident), or 6. Sickness other than infection occurring as a result of accidental injury, or 7. The voluntary taking of: a) a prescription drug in a manner other than as prescribed by a physician, b) any other federally or state-controlled substance in an unlawful manner, c) non-prescription medicine, in a manner other than as indicated in the printed instructions, or d) poison. EUROP ASSISTANCE USA TRAVEL SERVICES Employees who are covered in an AUL group life insurance policy have access to certain global emergency services through the Europ Assistance USA (EA) program. Spouses, domestic partners and children of eligible Employees, regardless of whether or not they meet the Plan s definition of Dependent, may also use the service. EA provides the insured with immediate access to physicians, dentists, medical facilities and pharmacies while traveling 100 or more miles away from place of permanent residence. The key services provided by EA include: 1. Medical search and referral of physicians, dentists and medical facilities; 2. Medical emergency monitoring; 3. Emergency medical evacuation to the nearest treatment facility; 4. Medically supervised repatriation; 5. Care for minor children left unattended as a result of a medical emergency; 6. Transportation of a designated family member or friend to join an insured patient who is traveling alone; 7. Repatriation of remains; 8. Traveling companion assistance; 9. Replacement of medication and eyeglasses; 10. Vehicle return; 11. Emergency travel arrangements; 12. Emergency cash; 13. Lost luggage, document, or personal possession assistance; 14. Legal and bail assistance; 15. Interpreter/translation assistance and; 16. Pre-trip information on country profiles. To receive a brochure detailing EA services call the Corporate Human Resources Department. You may also contact EA direct at: For calls in the US/Canada: 1 866 294 2469 For calls from other locations call collect: +1 240 330 1509 Email: OPS@europassistance-usa.com TIC/A/UAS 0809 8