STANDARD INSURANCE COMPANY A Stock Life Insurance Company 900 SW Fifth Avenue Portland, Oregon 97204-1282 (503) 321-7000 CERTIFICATE AND SUMMARY PLAN DESCRIPTION GROUP LIFE INSURANCE Policyholder: Flextronics International USA, Inc. Policy Number: 645862-A Effective Date: April 1, 2008 A Group Policy has been issued to the Policyholder. We certify that you will be insured as provided by the terms of the Group Policy. If your coverage is changed by an amendment to the Group Policy, we will provide the Policyholder with a revised Certificate or other notice to be given to you. This policy includes an Accelerated Benefit. Death benefits will be reduced if an Accelerated Benefit is paid. The receipt of this benefit may be taxable and may affect your eligibility for Medicaid or other government benefits or entitlements. However, if you meet the definition of "terminally ill individual" according to the Internal Revenue Code Section 101, your Accelerated Benefit may be non-taxable. You should consult your personal tax and/or legal advisor before you apply for an Accelerated Benefit. Possession of this Certificate does not necessarily mean you are insured. You are insured only if you meet the requirements set out in this Certificate. If the terms of the Certificate differ from the Group Policy, the terms stated in the Group Policy will govern. "We", "us" and "our" mean Standard Insurance Company. "You" and "your" mean the Member. All other defined terms appear with the initial letter capitalized. Section headings, and references to them, appear in boldface type. GC190-LIFE/S399 SI 14246-645862-A (2/18)
NOTICE OF PROTECTION PROVIDED BY CALIFORNIA LIFE AND HEALTH INSURANCE GUARANTEE ASSOCIATION This notice provides a brief summary regarding the protections provided to policyholders by the California Life and Health Insurance Guarantee Association ("the Association"). The purpose of the Association is to assure that policyholders will be protected, within certain limits, in the unlikely event that a member insurer of the Association becomes financially unable to meet its obligations. Insurance companies licensed in California to sell life insurance, health insurance, annuities and structured settlement annuities are members of the Association. The protection provided by the Association is not unlimited and is not a substitute for consumers care in selecting insurers. This protection was created under California law, which determines who and what is covered and the amounts of coverage. Below is a brief summary of the coverages, exclusions and limits provided by the Association. This summary does not cover all provisions of the law; nor does it in any way change anyone s rights or obligations or the rights or obligations of the Association. Persons Covered COVERAGE Generally, an individual is covered by the Association if the insurer was a member of the Association and the individual lives in California at the time the insurer is determined by a court to be insolvent. Coverage is also provided to policy beneficiaries, payees or assignees, whether or not they live in California. Amounts of Coverage The basic coverage protections provided by the Association are as follows. Life Insurance, Annuities and Structured Settlement Annuities For life insurance policies, annuities and structured settlement annuities, the Association will provide the following: Life Insurance 80% of death benefits but not to exceed $300,000 80% of cash surrender or withdrawal values but not to exceed $100,000 Annuities and Structured Settlement Annuities 80% of the present value of annuity benefits, including net cash withdrawal and net cash surrender values but not to exceed $250,000 The maximum amount of protection provided by the Association to an individual, for all life insurance, annuities and structured settlement annuities is $300,000, regardless of the number of policies or contracts covering the individual. Health Insurance The maximum amount of protection provided by the Association to an individual, as of April 1, 2011, is $470,125. This amount will increase or decrease based upon changes in the health care cost component of the consumer price index to the date on which an insurer becomes an insolvent insurer. SI 14246-645862-A (2/18)
COVERAGE LIMITATIONS AND EXCLUSIONS FROM COVERAGE The Association may not provide coverage for this policy. Coverage by the Association generally requires residency in California. You should not rely on coverage by the Association in selecting an insurance company or in selecting an insurance policy. The following policies and persons are among those that are excluded from Association coverage: A policy or contract issued by an insurer that was not authorized to do business in California when it issued the policy or contract A policy issued by a health care service plan (HMO), a hospital or medical service organization, a charitable organization, a fraternal benefit society, a mandatory state pooling plan, a mutual assessment company, an insurance exchange, or a grants and annuities society If the person is provided coverage by the guaranty association of another state Unallocated annuity contracts; that is, contracts which are not issued to and owned by an individual and which do not guaranty annuity benefits to an individual Employer and association plans, to the extent they are self-funded or uninsured A policy or contract providing any health care benefits under Medicare Part C or Part D An annuity issued by an organization that is only licensed to issue charitable gift annuities Any policy or portion of a policy which is not guaranteed by the insurer or for which the individual has assumed the risk, such as certain investment elements of a variable life insurance policy or a variable annuity contract Any policy of reinsurance unless an assumption certificate was issued Interest rate yields (including implied yields) that exceed limits that are specified in Insurance Code Section 1607.02(b)(2)(C). NOTICES Insurance companies or their agents are required by law to give or send you this notice. Policyholders with additional questions should first contact their insurer or agent. To learn more about coverages provided by the Association, please visit the Association s website at www.califega.org, or contact either of the following: The California Life and Health Insurance California Department of Insurance Guarantee Association Consumer Communications Bureau PO Box 16860 300 South Spring Street Beverly Hills, CA 90209-3319 Los Angeles CA 90013 (323) 782-0182 (800) 927-4357 Insurance companies and agents are not allowed by California law to use the existence of the Association or its coverage to solicit, induce or encourage you to purchase any form of insurance. When selecting an insurance company, you should not rely on Association coverage. If there is any inconsistency between this notice and California law, then California law will control. SI 14246-645862-A (2/18)
CALIFORNIA NOTICE OF COMPLAINT PROCEDURE Should any dispute arise about your premium or about a claim that you have filed, write to the company that issued the group policy at: Standard Insurance Company PO Box 2177 Portland, OR 97208-2177 (888) 937-4783 If the problem is not resolved, you may also write to the State of California at: Department of Insurance Consumer Services Division 300 S. Spring Street, 11th FL Los Angeles, CA 90013 1-800-927-HELP (4357) This notice of complaint procedure is for information only and does not become a part or condition of this group policy/certificate. SI 14246-645862-A (2/18)
Table of Contents COVERAGE FEATURES... 1 GENERAL POLICY INFORMATION... 1 BECOMING INSURED... 1 PREMIUM CONTRIBUTIONS... 3 SCHEDULE OF INSURANCE... 4 REDUCTIONS IN INSURANCE... 7 OTHER BENEFITS... 8 OTHER PROVISIONS... 8 ERISA SUMMARY PLAN DESCRIPTION INFORMATION... 9 LIFE INSURANCE... 10 A. Insuring Clause... 10 B. Amount Of Life Insurance... 10 C. Changes In Life Insurance... 10 D. Repatriation Benefit... 11 E. Suicide Exclusion: Life Insurance... 11 F. When Life Insurance Becomes Effective... 11 G. When Life Insurance Ends... 12 H. Reinstatement Of Life Insurance... 12 I. Minnesota Extension Of Life Insurance Benefit... 13 DEPENDENTS LIFE INSURANCE... 15 A. Insuring Clause... 15 B. Amount Of Dependents Life Insurance... 15 C. Changes In Dependents Life Insurance... 15 D. Suicide Exclusion: Dependents Life Insurance... 16 E. Definitions For Dependents Life Insurance... 16 F. Becoming Insured For Dependents Life Insurance... 17 G. When Dependents Life Insurance Ends... 17 ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE... 18 A. Insuring Clause... 18 B. Definition Of Loss For AD&D Insurance... 18 C. Amount Payable... 19 D. Changes In AD&D Insurance... 19 E. AD&D Insurance Exclusions... 19 F. Other AD&D Benefits... 20 G. Becoming Insured For AD&D Insurance... 22 H. When AD&D Insurance Ends... 22 DEPENDENTS ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE... 22 A. Insuring Clause... 22 B. Definition Of Loss For Dependents AD&D Insurance... 23 C. Definitions For Dependents AD&D Insurance... 23 D. Amount Payable... 23 E. Changes In Dependents AD&D Insurance... 23 F. Other Dependents AD&D Benefits... 23 G. Dependents AD&D Exclusions... 24 H. When Dependents AD&D Insurance Becomes Effective... 25 I. When Dependents AD&D Insurance Ends... 25 ACTIVE WORK PROVISIONS... 26 CONTINUITY OF COVERAGE... 26 STRIKE CONTINUATION... 26 PORTABILITY OF INSURANCE... 27 SI 14246-645862-A (2/18)
WAIVER OF PREMIUM... 28 ACCELERATED BENEFIT... 29 RIGHT TO CONVERT... 30 CLAIMS... 32 ASSIGNMENT... 34 BENEFIT PAYMENT AND BENEFICIARY PROVISIONS... 35 ALLOCATION OF AUTHORITY... 37 TIME LIMITS ON LEGAL ACTIONS... 37 INCONTESTABILITY PROVISIONS... 38 CLERICAL ERROR, AGENCY, AND MISSTATEMENT... 38 TERMINATION OR AMENDMENT OF THE GROUP POLICY... 39 DEFINITIONS... 39 ERISA INFORMATION AND NOTICE OF RIGHTS... 41 SI 14246-645862-A (2/18)
Index of Defined Terms Accelerated Benefit, 29 Active Work, Actively At Work, 26 AD&D Insurance, 39 Air Bag Benefit, 24 Air Bag System, 20, 24 Annual Earnings, 39 Automobile, 20, 24 Beneficiary, 35 Child, 40 Class Definition, 2 Contributory, 40 Conversion Period, 30 Dependent, 16, 23 Dependents AD&D Insurance, 40 Dependents Life Insurance, 40 Disabled, 40 Domestic Partner, 41 Eligibility Waiting Period, 40 Employer(s), 1 Evidence Of Insurability, 40 Family Status Change, 40 Group Policy, 41 Group Policy Effective Date, 1 Group Policy Number, 1 Guarantee Issue Amount (Dependents Life), 2 Guarantee Issue Amount (Plan 1), 2 Guarantee Issue Amount (Plan 2), 2 Injury, 41 Insurance (for Accelerated Benefit), 30 Insurance (for Right to Convert), 31 Insurance (for Waiver Of Premium), 28 Life Insurance, 41 Loss, 18, 23 Maximum Conversion Amount, 8 Member, 1 Minimum Time Insured, 8 Noncontributory, 41 Physician, 41 Policyholder, 1 Pregnancy, 41 Prior Plan, 41 Proof Of Loss, 32 Qualifying Event, 31 Qualifying Medical Condition, 29 Recipient, 36 Right To Convert, 30 Seat Belt Benefit, 23 Seat Belt System, 20, 24 Sickness, 41 Spouse, 41 Totally Disabled, 28, 31 Waiting Period (for Waiver Of Premium), 28 Waiver Of Premium, 28 War, 19 You, Your (for Right To Convert), 31 SI 14246-645862-A (2/18)
COVERAGE FEATURES This section contains many of the features of your group life insurance. Other provisions, including exclusions and limitations, appear in other sections. Please refer to the text of each section for full details. The Table of Contents and the Index of Defined Terms help locate sections and definitions. GENERAL POLICY INFORMATION Group Policy Number: 645862-A Type of Insurance Provided: Life Insurance: Dependents Life Insurance: Accidental Death And Dismemberment (AD&D) Insurance: Yes Yes Yes Dependents Accidental Death And Dismemberment (AD&D) Insurance: Yes Policyholder: Employer(s): Group Policy Effective Date: April 1, 2008 Flextronics International USA, Inc. Flextronics International USA, Inc. Flextronics America, LLC Policy Issued in: California BECOMING INSURED To become insured for Life Insurance you must: (a) Be a Member; (b) Complete your Eligibility Waiting Period; and (c) Meet the requirements in Life Insurance and Active Work Provisions. The Active Work requirement will not apply to Members who are retired on the Group Policy Effective Date. The requirements for becoming insured for coverages other than Life Insurance are set out in the text. Definition Of Member: You are a Member if you are: 1. A regular status employee of the Employer who is on the Employer's U.S. payroll and regularly working at least 30 hours each week, other than a former employee of AGM hired between April 3, 2017, and October 31, 2017; or 2. A retiree of Dii, New York who was insured under the Prior Plan on March 31, 2008. You are not a Member if you are: 1. A temporary or seasonal employee. 2. A leased employee. 3. An independent contractor. 4. A full-time member of the armed forces of any country. Revised 2/10/2018-1 - 645862-A
Class Definitions: Class 1: Class 2: Class 3: Class 4: Class 5: Chief Executive Officer Active nonunion employees working at the Minnesota location formerly known as Multek Flexible Circuits Active union employees working at the Minnesota location formerly known as Multek Flexible Circuits All other active Members Dii, New York retirees Eligibility Waiting Period: For Class 3 Members: For all other Members: You are eligible on the following applicable date, but not before the Group Policy Effective Date: The first day of the calendar month following six consecutive months as a Member. The first day of the calendar month following the date you become a Member. However, if you become a Member because your former employer was purchased by the Employer or because you were transferred to work for the Employer as part of an asset purchase, you are eligible on the later of (a) April 1, 2008, and (b) the date you become a Member. Evidence Of Insurability: Required in all of the following instances: a. For late application for Plan 2 Life Insurance and Dependents Life Insurance for Spouse (if you apply more than 31 days after becoming eligible). b. For reinstatements if required. c. For Members and Spouses eligible but not insured for Contributory life insurance under the Prior Plan. d. For any Plan 1 Life Insurance Benefit in excess of the Guarantee Issue Amount of $2,000,000, or for an amount of Plan 1 Life Insurance in excess of $50,000 if you change from Option 2 to Option 1 more than 31 days after becoming eligible. e. For any Plan 2 Life Insurance Benefit in excess of the Guarantee Issue Amount of the lesser of (a) an amount equal to 2 times your Annual Earnings, or (b) $500,000. f. For any Dependents Life Insurance Benefit in excess of the Guarantee Issue Amount of $50,000. g. For elective increases in Plan 2 Life Insurance. h. For elective increases in Dependents Life Insurance for your Spouse. Note: The Evidence Of Insurability requirements will be waived as shown below. On April 1, 2008: Evidence Of Insurability will not be required to become insured on April 1, 2008 for amounts of Plan 1 Life Insurance, Plan 2 Life Insurance and Dependents Life Insurance equal to or less Revised 2/10/2018-2 - 645862-A
than the amounts of coverage for which you were insured on March 31, 2008 under the Prior Plan. With respect to Members working for Flextronics America, LLC If you were not insured for additional life insurance on March 31, 2008 under the Prior Plan, Evidence Of Insurability will not be required to become insured on April 1, 2008 for an amount of Plan 2 Life Insurance equal to one times your Annual Earnings. If you were insured for additional life insurance on March 31, 2008 under the Prior Plan, Evidence Of Insurability will not be required to increase the amount of your Plan 2 Life Insurance on April 1, 2008 by an amount equal to one times your Annual Earnings. With respect to all other Members If you were insured on March 31, 2008 under the Prior Plan for an amount of additional life insurance equal to one times your Annual Earnings, Evidence Of Insurability will not be required to become insured on April 1, 2008 for a Plan 2 Life Insurance Benefit equal to the lesser of (a) two times your Annual Earnings, or (b) $500,000. On January 1, 2009: A Member employed by Flextronics America, LLC who is insured on December 31, 2008 for a Plan 2 Life Insurance Benefit equal to one times the Member s Annual Earnings and not exceeding $500,000, will not be required to submit Evidence Of Insurability to become insured on January 1, 2009 for a Plan 2 Life Insurance Benefit equal to two times the Member s Annual Earnings, not to exceed $500,000. However, Evidence Of Insurability will not be waived if the Member previously submitted Evidence Of Insurability that was not approved. On September 1, 2010: If you are a Class 2 Member and were insured for Contributory life insurance under the Prior Plan on August 31, 2010, Evidence Of Insurability will not be required for you to become insured on September 1, 2010 for an equal or lesser amount of Plan 2 Life Insurance (or for an amount equal to the next higher multiple of Annual Earnings, if the amount of your Contributory life insurance in effect on August 31, 2010 is not equal to a multiple of your Annual Earnings). If you are a Class 2 Member and your Spouse was insured for Contributory dependents life insurance under the Prior Plan on August 31, 2010, Evidence Of Insurability will not be required for your Spouse to become insured on September 1, 2010 for an equal or lesser amount of Dependents Life Insurance. PREMIUM CONTRIBUTIONS Plan 1 Life Insurance: Plan 2 Life Insurance: Dependents Life Insurance: Plan 1 AD&D Insurance: Plan 2 AD&D Insurance: Dependents AD&D Insurance: Noncontributory Contributory Contributory Noncontributory Contributory Contributory Revised 2/10/2018-3 - 645862-A
SCHEDULE OF LIFE INSURANCE SCHEDULE OF INSURANCE You will become insured under Plan 1 if you meet the requirements to become insured under the Group Policy. The Employer pays the cost of Plan 1 Life Insurance. If you are insured under Plan 1 and the schedule provides a Plan 2 Life Insurance Benefit for your class, you may also become insured under Plan 2, provided you meet the requirements to become insured for Plan 2 Life Insurance. Plan 2 is a Contributory plan requiring premium contributions from Members. Plan 1 Life Insurance Benefit (basic): Class 1 Members: Class 2 and 4 Members: Class 3 Members: $23,000 Class 5 Members: You may elect Option 1 or Option 2. You will be insured under Option 1 unless you elect Option 2: Option 1: 2 times your Annual Earnings, plus $100,000, subject to a maximum of $3,000,000 Option 2: $50,000 You may elect Option 1 or Option 2. You will be insured under Option 1 unless you elect Option 2: Option 1: 2 times your Annual Earnings, subject to a maximum of $3,000,000 Option 2: $50,000 Equals the amount of your Noncontributory life insurance in effect on March 31, 2008, under the Prior Plan. Note: If you wish to limit the amounts of your Plan 1 Life Insurance and Plan 1 AD&D Insurance to $50,000 each (to avoid imputed income), contact your human resources representative to obtain a waiver form. For the waiver of coverage to be valid, this form must be signed by you and notarized, signed by a representative of the Policyholder, and returned to us. Plan 2 Life Insurance Benefit (additional): Class 1, 2, and 4 Members: Class 3 and 5 Members: The Repatriation Benefit: You may apply for 1, 2, 3, 4, or 5 times your Annual Earnings, subject to a maximum of $3,000,000 when combined with your Plan 1 Life Insurance Benefit. None The expenses incurred to transport your body to a mortuary near your primary place of residence, but not to exceed $5,000 or 10% of the Life Insurance Benefit, whichever is less. SCHEDULE OF DEPENDENTS LIFE INSURANCE You may become insured for Dependents Life Insurance if you are insured for Plan 1 Life Insurance, the schedule provides a Dependents Life Insurance Benefit for your class, and you and your Dependents meet the requirements to become insured. Dependents Life Insurance is a Contributory plan requiring premium contributions from Members. Revised 2/10/2018-4 - 645862-A
Dependents Life Insurance Benefit for your Spouse: Class 1, 2 and 4 Members: You may apply for any multiple of $5,000, from $10,000 up to $100,000. Class 3 and 5 Members: None The amount of Dependents Life Insurance for your Spouse may not exceed 100% of the amount of your Life Insurance. Dependents Life Insurance Benefit for your Child: Class 1, 2 and 4 Members: You may apply for any multiple of $5,000, up to $25,000. Class 3 and 5 Members: None The amount of Dependents Life Insurance for your Child may not exceed 100% of the amount of your Life Insurance. SCHEDULE OF AD&D INSURANCE You will become insured under Plan 1 if the schedule provides a Plan 1 AD&D Insurance Benefit for your class and you meet the requirements to become insured under the Group Policy. The Employer pays the cost of Plan 1 AD&D Insurance. If you are insured under Plan 1 and the schedule provides a Plan 2 AD&D Insurance Benefit for your class, you may also become insured under Plan 2, provided you meet the requirements to become insured for Plan 2 AD&D Insurance. Plan 2 is a Contributory plan requiring premium contributions from Members. Plan 1 AD&D Insurance Benefit (basic): Class 1 Members: Class 2 and 4 Members: Class 3 Members: Class 5 Members: 2 times your Annual Earnings, plus $100,000, subject to a maximum of $3,000,000 2 times your Annual Earnings, subject to a maximum of $3,000,000 Equals the amount of your Plan 1 Life Insurance None Plan 2 AD&D Insurance Benefit (additional): Class 1, 2 and 4 Members: Class 3 and 5 Members: You may apply for 1, 2, 3, 4, or 5 times your Annual Earnings, subject to a maximum of $3,000,000 when combined with your Plan 1 AD&D Insurance Benefit. None The amount payable for certain Losses is less than 100% of the AD&D Insurance Benefit. See AD&D Table Of Losses. Revised 2/10/2018-5 - 645862-A
SCHEDULE OF DEPENDENTS AD&D INSURANCE You may become insured for Dependents AD&D Insurance if you are insured for Plan 2 AD&D Insurance and your Dependents meet the requirements to become insured. Dependents AD&D Insurance is a Contributory plan requiring premium contributions from Members. Dependents AD&D Insurance Benefit: Class 1, 2, and 4 Members: Spouse: Children: Class 3 and 5 Members: 50% of your Plan 2 AD&D Insurance Benefit 20% of your Plan 2 AD&D Insurance Benefit for each Child, not to exceed $10,000 per Child None The amount payable for certain Losses is less than 100% of the Dependents AD&D Insurance Benefit. See AD&D Table Of Losses. OTHER AD&D BENEFITS Seat Belt Benefit: For you: For your Dependents: Air Bag Benefit: The amount of the Seat Belt Benefit is the lesser of (1) $25,000; or (2) the Plan 1 and Plan 2 AD&D Insurance Benefit payable for Loss of your life. The amount of the Seat Belt Benefit is the lesser of (1) $25,000; or (2) the Dependents AD&D Insurance Benefit payable for Loss of your Dependent s life. For you: The lesser of (1) $5,000; or (2) the Plan 1 and Plan 2 AD&D Insurance Benefit payable for Loss of your life. For your Dependents: Career Adjustment Benefit: Child Care Benefit: Higher Education Benefit: The lesser of (1) $5,000; or (2) the Dependents AD&D Insurance Benefit payable for Loss of your Dependent s life. The tuition expenses for training incurred by your Spouse within 36 months after the date of your death, exclusive of room and board, but not to exceed $5,000 per year, or the cumulative total of $10,000 or 25% of the Plan 1 and Plan 2 AD&D Insurance Benefit, whichever is less. The total child care expense incurred by a Guardian within 36 months after the date of your death for all Children under age 13, but not to exceed $5,000 per year, or the cumulative total of $10,000 or 25% of the Plan 1 and Plan 2 AD&D Insurance Benefit, whichever is less. The tuition expenses incurred per Child at an accredited institution of higher education within 4 years after the date of your death, exclusive of room and board, but not to exceed $5,000 per year, or the cumulative total of $20,000 or 25% of the Plan 1 and Plan 2 AD&D Insurance Benefit, whichever is less. Revised 2/10/2018-6 - 645862-A
Occupational Assault Benefit: Public Transportation Benefit: AD&D TABLE OF LOSSES The lesser of (1) $25,000; or (2) 50% of the Plan 1 and Plan 2 AD&D Insurance Benefit otherwise payable for your Loss. The lesser of (1) $200,000; or (2) 100% of the Plan 1 and Plan 2 AD&D Insurance Benefit otherwise payable for the Loss of your life. The amount payable is a percentage of the AD&D Insurance Benefit or Dependents AD&D Insurance Benefit in effect on the date of the accident and is determined by the Loss suffered as shown in the following table: Loss: a. Life 100% b. One hand or one foot 50% Percentage Payable: c. Sight in one eye, speech, or hearing in both ears d. Two or more of the Losses listed in b. and c. above e. Thumb and index finger of the same hand 50% 100% 25%* f. Quadriplegia 100% g. Hemiplegia 50% h. Paraplegia 50% No more than 100% of your AD&D Insurance or Dependents AD&D Insurance will be paid for all Losses resulting from one accident. * No AD&D Insurance Benefit or Dependents AD&D Insurance will be paid for Loss of thumb and index finger of the same hand if an AD&D Insurance Benefit or Dependents AD&D Insurance is payable for the Loss of that entire hand. REDUCTIONS IN INSURANCE If you reach an age shown below, the amount of insurance will be the amount determined from the Schedule Of Insurance, multiplied by the appropriate percentage below: For Class 1, 2, and 4 Members: Plan 1 Life Insurance (Option 1 only), Plan 2 Life Insurance, and Plan 1 AD&D Insurance: Member s Age On January 1: Percentage: 65 through 69 65% 70 through 74 45% 75 through 79 30% 80 or over 20% Revised 2/10/2018-7 - 645862-A
Plan 1 Life Insurance (Option 2 only): Plan 1, Option 2 Life Insurance will not be reduced due to a change in your age. For Class 3 and 5 Members: Your Insurance will not be reduced due to a change in your age. Note: Amounts of insurance after reduction due to a change in your age are rounded to the next higher multiple of $1,000, if not already a multiple of $1,000. OTHER BENEFITS Waiver Of Premium: Accelerated Benefit: Yes, for Plan 1 and Plan 2 Life Insurance for active Members only Yes, for Plan 1 and Plan 2 Life Insurance and Dependents Life Insurance for active Members only OTHER PROVISIONS Limits on Right To Convert if Group Policy terminates or is amended: Minimum Time Insured: 5 years Maximum Conversion Amount: $10,000 Suicide Exclusion: Applies to: a. Plan 2 Life Insurance b. Dependents Life Insurance c. AD&D Insurance d. Dependents AD&D Insurance Strike Continuation: Yes. The Strike Continuation premium percentage is 120% of the Premium Rate. Continuity of Coverage: Minnesota Extension Of Life Insurance Benefit: Annual Earnings based on: Insurance Eligible For Portability: For you: Life Insurance: Yes Yes, for Minnesota residents. The Minnesota Extension Of Life Insurance Benefit premium is 102% of the Premium Rate for the Group Policy. Earnings in effect on your last full day of Active Work. (Note: Portability is not available to Members working in Puerto Rico) Yes Minimum combined amount: $10,000 Maximum combined amount: $1,000,000 Revised 2/10/2018-8 - 645862-A
For your Spouse: Dependents Life Insurance: Yes Minimum amount: $5,000 Maximum amount: $100,000 For your Child: Dependents Life Insurance: For you: Yes Minimum amount: $1,000 Maximum amount: $5,000 AD&D Insurance: Yes Minimum combined amount: $10,000 Maximum combined amount: $1,000,000 ERISA SUMMARY PLAN DESCRIPTION INFORMATION Name of Plan: Name, Address of Plan Sponsor: Life Insurance, AD&D Insurance and Dependents Life and AD&D Insurance Flextronics International USA, Inc. 6201 America Center Dr. San Jose CA 95002 Plan Sponsor Tax ID Number: 94-3061570 Plan Number: 501 Type of Plan: Type of Administration: Name, Address, Phone Number of Plan Administrator: Name, Address of Registered Agent for Service of Legal Process: If Legal Process Involves Claims For Benefits Under The Group Policy, Additional Notification of Legal Process Must Be Sent To: Sources of Contributions: Funding Medium: Group Insurance Plan Contract Administration Plan Sponsor (408) 576-1961 Plan Administrator Standard Insurance Company 1100 SW 6th Ave Portland OR 97204-1093 Employer/Member Standard Insurance Company - Fully Insured Plan Fiscal Year End: December 31 Revised 2/10/2018-9 - 645862-A
LIFE INSURANCE A. Insuring Clause If you die while insured for Life Insurance, we will pay benefits according to the terms of the Group Policy after we receive Proof Of Loss satisfactory to us. B. Amount Of Life Insurance See the Coverage Features for the Life Insurance schedule. C. Changes In Life Insurance You must apply for any elective changes in your Plan 2 Life Insurance. You may apply for increases only during the annual enrollment period or within 31 days following a Family Status Change. See the Coverage Features for Evidence Of Insurability requirements. 1. Increases Subject to the Active Work Provisions, an increase in your Life Insurance becomes effective as follows: a. Increases Subject To Evidence Of Insurability An elective increase in Plan 2 Life Insurance which is subject to Evidence Of Insurability and for which you apply during an annual enrollment period becomes effective on the later of (a) the following January 1, and (b) the date we approve your Evidence Of Insurability. An elective increase in Plan 2 Life Insurance which is subject to Evidence Of Insurability and for which you apply prior to or within 31 days following a Family Status Change becomes effective on the later of (a) the date of the Family Status Change, and (b) the date we approve your Evidence Of Insurability. An increase in your Life Insurance due to a change in your classification or Annual Earnings and which is subject to Evidence Of Insurability becomes effective on the later of (a) the first day of the calendar month coinciding with or next following the date of the change, and (b) the date we approve your Evidence Of Insurability. b. Increases Not Subject To Evidence Of Insurability 2. Decreases An elective increase in Plan 2 Life Insurance which is not subject to Evidence Of Insurability and for which you apply during an annual enrollment period becomes effective on the following January 1. An elective increase in Plan 2 Life Insurance which is not subject to Evidence Of Insurability and for which you apply prior to or within 31 days following a Family Status Change becomes effective on the later of (a) the date of the Family Status Change, and (b) the date you apply. An increase in your Life Insurance due to a change in your classification or Annual Earnings and which is not subject to Evidence Of Insurability becomes effective on the first day of the calendar month coinciding with or next following the date of the change. An elective decrease in your Plan 2 Life Insurance for which you apply during an annual enrollment period becomes effective on the following January 1. An elective decrease in your Plan 2 Life Insurance for which you apply at any other time is effective on the date you apply for the decrease. Revised 2/10/2018-10 - 645862-A
A decrease in your Life Insurance because of a change in your classification or Annual Earnings becomes effective on the first day of the calendar month coinciding with or next following the date of the change. A decrease in your Life Insurance because of a change in your age becomes effective on the January 1 coinciding with or next following the date of the change in your age. D. Repatriation Benefit The amount of the Repatriation Benefit is shown in the Coverage Features. We will pay a Repatriation Benefit if all of the following requirements are met. 1. A Life Insurance Benefit is payable because of your death. 2. You die more than 200 miles from your primary place of residence. 3. Expenses are incurred to transport your body to a mortuary near your primary place of residence. E. Suicide Exclusion: Life Insurance The Coverage Features states which Life Insurance plan is subject to this suicide exclusion. If your death results from suicide or other intentionally self-inflicted Injury, while sane or insane, 1 and 2 below apply. 1. The amount payable will exclude the amount of your Life Insurance which is subject to this suicide exclusion and which has not been continuously in effect for at least 2 years on the date of your death. In computing the 2-year period, we will include time you were insured under the Prior Plan. 2. We will refund all premiums paid for that portion of your Life Insurance which is excluded from payment under this suicide exclusion. F. When Life Insurance Becomes Effective Subject to the Active Work Provisions, your Life Insurance becomes effective as follows: 1. Plan 1 Life Insurance Plan 1 Life Insurance subject to Evidence Of Insurability becomes effective on the date we approve your Evidence Of Insurability. See the Coverage Features for Evidence Of Insurability requirements. Plan 1 Life Insurance not subject to Evidence Of Insurability becomes effective on the date you become eligible. 2. Plan 2 Life Insurance You must apply in writing for Plan 2 Life Insurance and agree to pay premiums. If you do not apply within 31 days after becoming eligible, you may only apply during an annual enrollment period or within 31 days following a Family Status Change. See the Coverage Features for Evidence Of Insurability requirements. a. Plan 2 Life Insurance subject to Evidence Of Insurability Plan 2 Life Insurance which is subject to Evidence Of Insurability and for which you apply prior to or within 31 days following the date you become eligible is effective on the latest of (a) the date you become eligible, (b) the date you apply, and (c) the date we approve your Evidence Of Insurability. Plan 2 Life Insurance which is subject to Evidence Of Insurability and for which you apply during an annual enrollment period is effective on the later of (a) the following January 1, Revised 2/10/2018-11 - 645862-A
and (b) the date we approve your Evidence Of Insurability. Plan 2 Life Insurance which is subject to Evidence Of Insurability and for which you apply prior to or within 31 days following a Family Status Change is effective on the later of (a) the date of the Family Status Change, and (b) the date we approve your Evidence Of Insurability. b. Plan 2 Life Insurance not subject to Evidence Of Insurability Plan 2 Life Insurance which is not subject to Evidence Of Insurability and for which you apply prior to or within 31 days following the date you become eligible is effective on the later of (a) the date you become eligible, and (b) the date you apply. Plan 2 Life Insurance which is not subject to Evidence Of Insurability and for which you apply during an annual enrollment period is effective on the following January 1. Plan 2 Life Insurance which is not subject to Evidence Of Insurability and for which you apply prior to or within 31 days following a Family Status Change is effective on the later of (a) the date of the Family Status Change, and (b) the date you apply. G. When Life Insurance Ends Life Insurance ends automatically on the earliest of: 1. The date the last period ends for which you made a premium contribution, if your insurance is Contributory; 2. The date the Group Policy terminates. However, if you are a Minnesota resident and we fail to make a good faith effort to provide you with at least 30 days prior notice of termination, insurance may be continued for up to 120 days beyond the date your coverage would otherwise end, unless the Group Policy is replaced, or we have reasonable evidence to indicate that it will be replaced, by a substantially similar policy or plan; 3. The date your employment terminates, unless you qualify for coverage as a Class 5 Member. However, if you are a Minnesota resident you may have the right to extend your Life Insurance Benefit and your Dependents Life Insurance Benefit under the Minnesota Extension Of Life Insurance Benefit provision; and 4. The date you cease to be a Member. However, if you cease to be a Member because you are working less than the required minimum number of hours, your Life Insurance will be continued with premium payment during the following periods, unless it ends under 1. through 3. above. a. While your ability to work is limited because of Sickness, Injury, or Pregnancy. b. During the first 90 days of a temporary layoff. c. During a leave of absence if continuation of your insurance under the Group Policy is required by a federal or state-mandated family or medical leave act or law. d. During any other paid temporary leave of absence approved by your Employer in advance and in writing and lasting not more 90 days. e. During any other unpaid temporary leave of absence approved by your Employer in advance and in writing and lasting not more 60 days. If you are a Minnesota resident and you do not qualify under a. through e. above, you may have the right to extend your Life Insurance Benefit and your Dependents Life Insurance Benefit under the Minnesota Extension Of Life Insurance Benefit provision. H. Reinstatement Of Life Insurance If your Life Insurance ends, you may become insured again as a new Member. However, 1 through Revised 2/10/2018-12 - 645862-A
4 below will apply. 1. If your Life Insurance ends because you cease to be a Member, and if you become a Member again within 12 months, the Eligibility Waiting Period will be waived. 2. If your Life Insurance ends because you fail to make a required premium contribution, you must provide Evidence Of Insurability to become insured again. 3. If you exercised your Right To Convert, you must provide Evidence Of Insurability to become insured again. 4. If your Life Insurance ends because you are on a federal or state-mandated family or medical leave of absence, and you become a Member again immediately following the period allowed, your insurance will be reinstated pursuant to the federal or state-mandated family or medical leave act or law. I. Minnesota Extension Of Life Insurance Benefit 1. Members Who Become Eligible For Extension While Insured Under The Group Policy In accordance with Minnesota Statute 61A.092, as amended, you may extend your Life Insurance Benefit and your Dependents Life Insurance Benefit for up to 18 months after you cease to be a Member because of a voluntary or involuntary layoff, whether partial or total, or termination of employment. a. Electing Extension You must elect in writing to extend your Life Insurance Benefit and your Dependents Life Insurance Benefit within 60 days of the later of: (1) The date on which your Life Insurance Benefit under the Group Policy would otherwise end; and (2) The date you receive written notice from your Employer of your right to extend your Life Insurance Benefit and your Dependents Life Insurance Benefit. If you do not extend your Life Insurance Benefit, you may not extend your Dependents Life Insurance Benefit. Your extended Life Insurance Benefit and your Dependents Life Insurance Benefit will be retroactive to the date your Life Insurance Benefit would have ended because you ceased to be a Member due to a layoff or termination of employment. b. Premium Requirements You must pay the entire premium for your extended Life Insurance Benefit and Dependents Life Insurance Benefit, including the Employer's share, if any, on or before each Premium Due Date. The premiums for your extended Life Insurance Benefit and your Dependents Life Insurance Benefit will equal a percentage of the Premium rate for the Group Policy (see Coverage Features). We may change Premium Rates according to the terms of the Group Policy, or as otherwise allowed by law. c. Amount Subject To Extension The amount of Life Insurance Benefit and Dependents Life Insurance Benefit you may extend is the amount in effect on the day before your layoff or termination of employment. You may not change the amount of Life Insurance Benefit or Dependents Life Insurance Benefit you extend. d. When Extension Ends Revised 2/10/2018-13 - 645862-A
Your extended Life Insurance Benefit and your Dependents Life Insurance Benefit will end automatically on the earliest of: (1) The date you become insured under any other group life insurance plan. (2) The last day of the 18-month extension period. (3) The day the last period ends for which you made a premium contribution. (4) The date the Group Policy terminates. (5) For your Spouse, the date of your divorce or termination of your Domestic Partner relationship. (6) For any Dependent: (i) The date your Life Insurance Benefit extended under this provision ends. (ii) The date the Dependent ceases to be a Dependent. (iii) The date the Dependent becomes insured under any other group life insurance plan. When your extended Life Insurance Benefit and Dependents Life Insurance Benefit end, you and your Dependents may have the Right To Convert to an individual life insurance policy (see Right To Convert). e. Death During The Election Period If you or your insured Dependent die during the 60-day election period and before you make an election to accept or decline extension, we will pay a death benefit equal to the maximum Life Insurance Benefit or Dependents Life Insurance Benefit you had a right to extend. The benefit will be paid according to the Benefit Payment And Beneficiary Provisions. If a benefit is paid under the Minnesota Extension Of Life Insurance Benefit provision, it will not be paid under Right To Convert. f. Group Policy Provisions Except as provided above, a Life Insurance Benefit or Dependents Life Insurance Benefit extended under this provision is subject to all other terms of the Group Policy. With respect to any notice you are required to provide to the Policyholder or your Employer under other provisions of the Group Policy, such notice must be provided to us while your Life Insurance Benefit or Dependents Life Insurance Benefit is extended. 2. Persons Who Elected Extension Under The Employer's Group Life Insurance Program With A Prior Carrier If, in accordance with section 61A.092, as amended, you and your Dependents were insured under the Prior Plan on the day before the effective date of your Employer's coverage under the Group Policy, your Life Insurance Benefit and Dependents Life Insurance Benefit will be extended under the Group Policy subject to the following: a. Payment Of Benefits Payment of benefits will be under the terms of the Prior Plan or the Group Policy, whichever pays less. No benefits will be paid if benefits are payable under the Prior Plan. b. Premium Requirements You must pay the entire premium for your extended Life Insurance Benefit and your Dependents Life Insurance Benefit, including the Employer's share, if any, on or before each Premium Due Date. Revised 2/10/2018-14 - 645862-A
The premiums for your extended Life Insurance Benefit and your Dependents Life Insurance Benefit will equal a percentage of the Premium Rate for the Group Policy (see Coverage Features). We may change Premium Rates according to the terms of the Group Policy, or as otherwise allowed by law. c. When Extension Ends Your extended Life Insurance Benefit and Dependents Life Insurance Benefit will end automatically on the earliest of: (1) The date you become insured under any other group life insurance plan. (2) Eighteen months after the date you became eligible for extension under your Employer's group life insurance program with a prior carrier due to a layoff or termination of employment. (3) The date the last period ends for which you made a premium contribution. (4) The date the Group Policy terminates. (5) For your Spouse, the date of your divorce or termination of your Domestic Partner relationship. (6) For any Dependent (i) The date your Life Insurance Benefit extended under this provision ends. (ii) The date the Dependent ceases to be a Dependent. (iii) The date the Dependent becomes insured under any other group life insurance plan. When your extended Life Insurance Benefit and Dependents Life Insurance Benefit ends, you and your Dependents may have the Right To Convert to an individual life insurance policy (see Right To Convert). d. Group Policy Provisions Except as provided above, a Life Insurance Benefit or Dependents Life Insurance Benefit extended under this provision is subject to all other terms of the Group Policy. With respect to any notice you are required to provide to the Policyholder or your Employer under other provisions of the Group Policy, such notice must be provided to us while your Life Insurance Benefit or Dependents Life Insurance Benefit is extended. (REPAT_SUIC PART) LI.LF.CA.2X DEPENDENTS LIFE INSURANCE A. Insuring Clause If your Dependent dies while insured for Dependents Life Insurance, we will pay benefits according to the terms of the Group Policy after we receive Proof Of Loss satisfactory to us. B. Amount Of Dependents Life Insurance See the Coverage Features for the amount of your Dependents Life Insurance. C. Changes In Dependents Life Insurance You must apply for any elective changes in your Dependents Life Insurance. You may apply for increases only during the annual enrollment period or within 31 days following a Family Status Change. See the Coverage Features for Evidence Of Insurability requirements. 1. Increases Revised 2/10/2018-15 - 645862-A
Subject to the Active Work Provisions, an increase in Dependents Life Insurance becomes effective as follows: a. Increases Subject To Evidence Of Insurability (applies to Spouses only) An elective increase in Dependents Life Insurance which is subject to Evidence Of Insurability and for which you apply during an annual enrollment period becomes effective on the later of (a) the following January 1, and (b) the date we approve your Spouse s Evidence Of Insurability. An elective increase in Dependents Life Insurance which is subject to Evidence Of Insurability and for which you apply prior to or within 31 days following a Family Status Change becomes effective on the later of (a) the date of the Family Status Change, and (b) the date we approve your Spouse s Evidence Of Insurability. b. Increases Not Subject To Evidence Of Insurability 2. Decreases An elective increase in Dependents Life Insurance which is not subject to Evidence Of Insurability and for which you apply during an annual enrollment period becomes effective on the following January 1. An elective increase in Dependents Life Insurance which is not subject to Evidence Of Insurability and for which you apply prior to or within 31 days following a Family Status Change becomes effective on the later of (a) the date of the Family Status Change, and (b) the date you apply. An elective decrease in Dependents Life Insurance for which you apply during an annual enrollment period becomes effective on the following January 1. An elective decrease in Dependents Life Insurance for which you apply at any other time becomes effective on the date you apply for the decrease. A decrease in Dependents Life Insurance because of a change in your Spouse s age becomes effective on the January 1 coinciding with or next following the date of the change in your Spouse s age. A decrease in Dependents Life Insurance because of a decrease in your Life Insurance becomes effective on the date your Life Insurance decreases. D. Suicide Exclusion: Dependents Life Insurance If a Dependent's death results from suicide or other intentionally self-inflicted Injury, while sane or insane, 1 and 2 below will apply. 1. The amount payable will exclude the amount of Dependents Life Insurance which has not been continuously in effect for at least 2 years on the date of death. In computing the 2-year period, we will include time insured under the Prior Plan. 2. We will refund all premiums paid for Dependents Life Insurance which is excluded from payment under this suicide exclusion which we determine are attributable to that Dependent. E. Definitions For Dependents Life Insurance Dependent means your Spouse or Child. Dependent does not include a person who is a full-time member of the armed forces of any country. Revised 2/10/2018-16 - 645862-A
F. Becoming Insured For Dependents Life Insurance 1. Eligibility You become eligible to insure your Dependents on the later of: a. The date your Life Insurance becomes effective; and b. The date you first acquire a Dependent. A Member may not be insured as both a Member and a Dependent. A Child may not be insured by more than one Member. 2. Effective Date You must apply in writing for Dependents Life Insurance and agree to pay premiums. If you do not apply within 31 days after becoming eligible, you may only apply during an annual enrollment period or within 31 days following a Family Status Change. See the Coverage Features for Evidence Of Insurability requirements. Subject to the Active Work Provisions, Dependents Life Insurance becomes effective as follows: a. Dependents Life Insurance subject to Evidence Of Insurability (applies to Spouses only) Dependents Life Insurance which is subject to Evidence Of Insurability and for which you apply prior to or within 31 days following the date you become eligible is effective on the latest of (a) the date you become eligible, (b) the date you apply, and (c) the date we approve your Spouse s Evidence Of Insurability. Dependents Life Insurance which is subject to Evidence Of Insurability and for which you apply during an annual enrollment period is effective on the later of (a) the following January 1, and (b) the date we approve your Spouse s Evidence Of Insurability. Dependents Life Insurance which is subject to Evidence Of Insurability and for which you apply prior to or within 31 days following a Family Status Change is effective on the later of (a) the date of the Family Status Change, and (b) the date we approve your Spouse s Evidence Of Insurability. b. Dependents Life Insurance not subject to Evidence Of Insurability Dependents Life Insurance which is not subject to Evidence Of Insurability and for which you apply prior to or within 31 days following the date you become eligible is effective on the later of (a) the date you become eligible, and (b) the date you apply. Dependents Life Insurance which is not subject to Evidence Of Insurability and for which you apply during an annual enrollment period is effective on the following January 1. Dependents Life Insurance which is not subject to Evidence Of Insurability and for which you apply prior to or within 31 days following a Family Status Change is effective on the later of (a) the date of the Family Status Change, and (b) the date you apply. c. While Dependents Life Insurance for your Children is in effect, each new Child becomes insured immediately. G. When Dependents Life Insurance Ends Dependents Life Insurance ends automatically on the earliest of: 1. Five months after you die (no premiums will be charged for your Dependents Life Insurance during this time). 2. The date your Life Insurance ends. Revised 2/10/2018-17 - 645862-A