8
Plan Highlights Voluntary Accidental Death and Dismemberment Insurance Eligibility Each Active Full-Time Employee, working 30 hours or more per week , except any person working on a temporary or seasonal basis Benefit Amount Employee: You may select an amount of insurance in the amounl of $10,000 to a maximum of $500,000, in increments of $10,000. Contribution Requirements Coverage is 100% employee paid Rate per $1,000 of Benefit Insured Employee: $.052 Exclusions This Policy does not co ver any losses caused by: sickness, disease, or myocardial infarction, including medical or surgical tre atment thereof, is a contribu tin g facto c suicide, or int entionally self-inflicted injuries; wac an accident that occurs while in the armed forces of any country; riding in, getting into or out of any aircraft; sustained during Ihe Insured Per son's commiss ion or attem pted commi ssion of an assault or felony or to which the Insured's voluntary consumption of an illegal or controlled substance or a n on- prescribed narcotic or drug is a con tribu ting factor. For a comprehensive list of exclusions and limitations, please refer to the Certificate of Insurance . The Certi ficate also provides alt requ i rements necessary to receive a benefit. www.reliancestandard.com 1.800.351.7500 Benefit Reductions Due to Age Age Original Benefit Reduced by: 75 50% 80 75% Terminates at retirement. AD&D Schedule of Benefits For Accidimtal Loss of: Life Two or more Members Speech and hearing One Member Speech or Hearing Thumb and Index finge r of the same hand Provisions E xposure and Disappearance coverage Re servelNa ti on al Guard Education Benefit Day Care Benefit Seat BelVAir Bag Benefit Total L oss of U se Ben efit FMLA Extension Con version Privilege Amount Payable : 1 00% 100% 100% 50% 50% 25% World Net Tr avel Assistance is included with this policy. This P lan Highli ghts is a brief descri ption of Ihe important features of Ihe RSl insurance plan. It is nol a certificate of i nsurance or evidence of coverage. Ins u rance is provided u nder group AD&D policy form L RS-8604, e\ al ReLiRNce STANDRRD

Plan Highlights · Each Active Full-Time Employee, working 30 hours or more per week, except any person working on a temporary or seasonal basis Benefit Amount Employee: You may select

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Page 1: Plan Highlights · Each Active Full-Time Employee, working 30 hours or more per week, except any person working on a temporary or seasonal basis Benefit Amount Employee: You may select

Plan Highlights Voluntary Accidental Death and Dismemberment Insurance

Eligibility Each Active Full-Time Employee, working 30 hours or more per week, except any person working on a temporary or seasonal basis

Benefit Amount Employee: You may select an amount of insurance in the amounl of $10,000 to a maximum of $500,000, in increments of $10,000.

Contribution Requirements Coverage is 100% employee paid

Rate per $1,000 of Benefit Insured Employee: $.052

Exclusions This Policy does not cover any losses caused by: sickness, disease, or myocardial infarction, including medical or surgical treatment thereof, is a contributing factoc suicide, or intentionally self-inflicted injuries; wac an accident that occurs while in the armed forces of any country; riding in, getting into or out of any aircraft; sustained during Ihe Insured Person's commission or attempted commission of an assault or felony or to which the Insured's voluntary consumption of an illegal or controlled substance or a non­prescribed narcotic or drug is a contributing factor.

For a comprehensive list of exclusions and limitations, please refer to the Certificate of Insurance. The Certificate also provides alt requirements necessary to receive a benefit.

• www.reliancestandard.com • 1.800.351.7500

Benefit Reductions Due to Age Age Original Benefit Reduced by: 75 50% 80 75% Terminates at retirement.

AD&D Schedule of Benefits For Accidimtal Loss of: Life Two or more Members Speech and hearing One Member Speech or Hearing Thumb and Index finger of the same hand

Provisions • Exposure and Disappearance coverage • ReservelNational Guard • Education Benefit • Day Care Benefit • Seat BelVAir Bag Benefit • Total Loss of Use Benefit • FMLA Extension • Conversion Privilege

Amount Payable: 100% 100% 100% 50% 50% 25%

World Net Travel Assistance is included with this policy.

This Plan Highlights is a brief description of Ihe important features of Ihe RSl insurance plan. It is nol a certificate of insurance or evidence of coverage. Insurance is provided under group AD&D policy form LRS-8604, e\ al

ReLiRNce STANDRRD

Page 2: Plan Highlights · Each Active Full-Time Employee, working 30 hours or more per week, except any person working on a temporary or seasonal basis Benefit Amount Employee: You may select

Reliance Standard Voluntary Plans Accidental Death and Dismemberment Insurance

Premium Table Plan Holder: Partners Excavating Company

Scheduled Benefit: Each eligible employee and spouse may elect an amount of insurance, in increments of $10,000 from a minimum of $10,000 to a maximum of $500,000.

Weekly Premiums

I Benefil Ami I Individual I Benefil Ami [iildMdual IBenefil Ami I Individual

I $10,000 I $0.12 I $210,000 I $2.52 I $410,000 I $4.92

I $20,000 I $0.24 I $220,000 I $2.64 f $420,000 I $5.04

I $30,000 I $0.36 I $230,000 I $2.76 I $430,000 I $5.16

I $40,000 I $0.48 I $240,000 I $2.88 I $440,000 I $5.28 I I $50,000 1$D.6O- 1 $250,000 I $3.00 I $450,000 I $5.40 I

, r- ---I I $60,000 I $0.72 I $260,000 I $3.12 I $460,000 , $5.52 ,

I $70,000 r $0.84 1 $270,000 r$314-Two:ooo··r $5.64"--1 I $80,000 I $0.96 I $280,000 I $3.36 : $480,000 55.76 -: i 590,000 r $108- r- $290,00o - '- $i 48"-i$490:Ooii '" SS":Ba '-' 1----- - -,--- --- - -- ,- ._._-_.- .. _.- - -- .-- ... I $100,000 i $120 : $300,000 $3.60 5500,000 $6.00

1"-$11 0,iioo T s13T - :- $310,"0'00 ~ -$"372 fw o'"oooT s1M- i- $32:0,0001 $fS4-I $130,000 I $1.56 r 5330,000 i$3.96"­I $140,000 I $1 .68 I $340,000 I $4.08

I $150,000 I $1.80 $350,000 I $4.20

I $160,000 I $192 $360,000 I $4.32

I $170,000 I $2.04 $370,000 I $4.44

I $180,000 I $2.16 $380,000 I $4.56

I $190,000 I $2.28 $390,000 I $4.68

I $200,000 I $2.40 $400,000 54.80

Rates are subject to change.

Page 3: Plan Highlights · Each Active Full-Time Employee, working 30 hours or more per week, except any person working on a temporary or seasonal basis Benefit Amount Employee: You may select

10 Reasons You Should Consider Voluntary Accidental Death and Dismemberment Protection

I. Accidental death is more common than you think In 2004, I I I ,()()() people died fium accidents. In fact. accidents are the leading cause of death in adults under 40 and the fifth leading cause of death for people of all ages.'

2. If you die suddenly due to an accident, your family will face unexpected expenses and have to make financial decisions quickly. This insurance is in addition to your regular life insurance and can cover major expenses like funeral costs and lost income for family members.

3. If you are severely injured in an accident, you may have expenses that are not covered by other insurance, like special equipment and the cost of renovating your' home to make it accessible.

4. You can purchase the insurance your family needs with the convenience you require.

5. Your employer makes it possible for you to purchase this coverage at grDUp rates.

6. You pay for your coverage thrDugh easy parmll deduction.

7. You cannot be turned down for this insurance, as long as you are eligible.

8. You can convert this coverage to an individual policy and take it with you if you change jobs.

9. You are buying Accidental Death and Dismembemnent insur-ance from Reliance Standand Ufe Insurance Company, a national insurer in business for over 100 years.

And the best reason of all:

10. You'll know your family is taken care of. And that's no accident

This Information is not an insul"ilI'lce policy and docs not desoilx! the whole plan. FOf" mOrl! detailed Infoonatton,)oOU must ask)Ol..I'" employcr or Human

Resources bef'M!fits manager. Thero is a detailed d€!SCJlplJOO of !he plan's provisions. hmltatroos and exclusions in the Ccrttficate of InstDWlcc or Policy. which

is issued to )OU after your appflGltlOn IS processed

Reliance Standard Ufc In>urancc Company provides insurance products in all states (C!.><.cept New York). the District or Columbia, Puerto Rico and the

US.Vifl:;n IsI.1nds.

Benefits an! provided under group poiicy form series lRS-861}1, el aI.

I NaIJ:JruI Safl1ry Councirs'1rvY Faru'" 1005 - 1006 edillon

RellRNce STRNDRRD

RS-2081 (09,07 )

Page 4: Plan Highlights · Each Active Full-Time Employee, working 30 hours or more per week, except any person working on a temporary or seasonal basis Benefit Amount Employee: You may select

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Page 5: Plan Highlights · Each Active Full-Time Employee, working 30 hours or more per week, except any person working on a temporary or seasonal basis Benefit Amount Employee: You may select

What You Should Know About

Voluntary Accidental Death and Dismemberment Insurance

What would happen if you weren't here? How would your family's life change if something happened to you?

If you're married, could your spouse pay all the bills with just one paycheck? What would happen to yourfamily's future plans?

If you are a single pall,n, how would YOUI- children be pnovided for?

Even if you're single and have no children, how will your credit cand, car payment and mortgage obligations be settied?

Should I be concerned?

Accidents do happen. In the United States, on average, 267 persons die fnom unintentional injury (accidents) a day.That's one person every 5- 1/2 minutes: I 15 by motor vehicle accidents, 40 by falls, 24 by assaults and 88 by other accidents including work related accidents. I

I National Vital Statistics Report March 14,2003

How can I protect my family?

The answer is Accidental Death and Dismembell11ent insurance. Your employer is offering you the opportunity to participate in a Voluntary Accidental Death and Dismemberment insurance pnogram as part of a comprehensive employee benefrts package.

What is Voluntary Accidental Death and

Dismemberment insurance?

It's 24-hour insurance pnotection that pnovides a benefrt for the death of the insured as a result of an accident It can also pnovide a benefrt for an accident which does not result in death, but results in a loss due to dismembetment

Your employer has made it possible for you to obtain this insurance with:

• Lower cost group rates

• No medical examinations required

• The convenience of payroll deduction

"Voluntary" means that M:'s your choice.

You choose the amount of coverage you and your family need and can afford. Your accident insurance will pay you or your beneficiary an amount based on your choice.

Reliance Standand Life Insurance Company provides this insurance. Reliance Standand has been in business for over 95 years, and it specializes in employee gnoup benefrts.

Who is eligible? You are eligible to participate in this plan if you are:

• Actively at work

• A full-time employee working 30 or more hours a week

Your spouse is eligible to participate in this plan.

Your children are eligible if they are:

• Unmanied and financially dependent on you l

• Undel- age 20' or under age 26 if a full-time student'

• Foster children, adopted children, or stepchildren as long as

they are in your custody'

Your employer also may require that you work for the company for a minimum period of t ime before you can buy insurance.

I Financial dependency not required in Maine

1 Under age 21 in Louisiana; Under age 22 in North Dakota

J In Florida, a dependent up to age 25 can be either: (a) financially dependent on you and residing with you; or (b) a full-time student In Texas, a dependent is eligible until age 25. No ful l-time student requirement

• In Louisiana and Minnesota your grandchildren are eligible if they are in your custody

How much coverage can I buy?

You can choose coverage for yourself in any amount fnom $10,000 to $500,000 in $ 10,000 units, not to exceed ten times your basic annual eamings.

You may choose coverage for your spouse and children. Your employer selects the dependent schedule fnom two available options. Please see your enrollment materials for infol1llation on the dependent plan being offered to you.

Page 6: Plan Highlights · Each Active Full-Time Employee, working 30 hours or more per week, except any person working on a temporary or seasonal basis Benefit Amount Employee: You may select

Will coverage reduce over time?

Yes, the following age reduction formula is applicable to your benefrt

Ages:

75 - 79

Amounts Reduce to:

50.0% of the amount available or in force at age 74

80 or more 25.0% of the amount available or in force at age 74

How is an Accidental Death and Dismemberment benefit paid?

Reliance Standand will pay the benefrt amount listed below if injury results in anyone of the following losses within 365 days from the date of the accident Howeve, we will only pay one (the larger) benefrt if more than one loss results from anyone accident

Loss of Life

Benefrt The Principal Sum

Loss ofTwo or More Members

Benefrt The Principal Sum

Loss of Speech and Hearing

Benefrt The Principal Sum

Loss of One Member

Benefrt 112 the Principal Sum

Loss of Speech or Hearing

Benefrt 112 the Principal Sum

Loss oIThumb and Index Finger of the Same Hand

Benefrt 114 the Principal Sum

What is a umember"?

Member means hand, foot or eye.

Are there any exclusions?

Reliance Standand will not pay a benefrt for losses:

• Caused by or resu~ing fium war or any act of wac declared

or undeclared

• Caused by an accident that occurs while in the armed forces

of any country. except as shown under Reserve National

Guard coverage

• Caused by or resu~ing fnom riding in, gettng into or out of any

aircraft unless you are a passenger (not a pilot or crew member)

in tested and appnoved civilian aircraft as outined in the policy

and the aircraft is not owned, leased, or operated by or on

behalf of the policyholder or any other of your employers

• To which sickness, disease, or myocardial infarction, including

medical or surgical treatment thereof. where IT. is a

contributing factor

• Caused by suicide or intentionally self-inflicted injuries

Your plan may also contain an alcohol/drug exclusion and an assault/felony exclusion. If so, it will be stated in the Certificate of Insurance or Policy.

How much does this accident insurance cost?

Voluntary Accidental Death and Dismemberment insurance is offered at group rates' through convenient payroll deduction. The cost is based on the benefrt amount you select The cost may change annually on the anniversary of the group policy (see your plan highlights).Your employer will tell you the date your first paynoll deduction will be taken. You must be actively at work on the effective date of your coverage. If you are not, your coverage becomes effective the day you retum to work full-time.

*Rates are subject to change.

What if my employment terminates? If you or your insured dependent become ineligible for any reason other than termination of this group plan, you may convert to an individual policy without proof of good health. You must apply within 31 days of termination.You may not convert an amount greater than your benefrt amount under this plan or $250,000 whichever is less.

How do I enroll? Fill out the enrollment request form. Be sure to answer all the questions about your benefrt choices.

Your coverage begins on the entry date that is specified in your gnoup poli~ as long as you are actively at work on that date. If you are not, your coverage will begin on the date you retum to full-time work

Page 7: Plan Highlights · Each Active Full-Time Employee, working 30 hours or more per week, except any person working on a temporary or seasonal basis Benefit Amount Employee: You may select

Do I have to have a physical or answer medical que~tions?

No.

Can I get more coverage later?

Yes. During your annual enrollment period, you can increase your coverage up to the plan's maximum.

When will coverage end?

Reliance Standard may not terminate insurance coverage unless:

• Premium is not paid when due

• You are no longer in a class eligible for this insurance

• The master policy terminates

Are there other benefits I should "now about?

Yes. Your plan includes these additional beneffls:

Reserve-National Guard Coverage

Coverage continues while, as a member of the Reserve Corps or National Guard, you or a covered dependent are traveling to or from or attending a service school, or are traveling to or from or attending regularly scheduled or routine training for up to 60 days. Participation in authorized inactive duty training, a parade or exhibition is also covered. No benefrt is payable for any loss that occurs during active duty.

Exposure

If a loss results from exposure to the elements due to a covered accident it will be treated as if it were an injury.

Disappearance

Reliance Standand will presume that a loss of life has occurred if:

• You or a covered dependent are riding on a conveyance that is

involved in an accident

• The conveyance is wrecked, sinks or disappears as a result and

• You or a covered dependent's body is not found within

one year

Extension of Family Coverage

Coverage will continue on covered family members without premium payment for up to 24 months following your covered accidental death.

Newlywed Provision

You have automatic coverage for your spouse for up to 31 days if you are covered under the insurance plan, manry and do not immediately change coverage to a family plan. This provision is only applicable if spousal coverage is available.

Newborn Provision

You have automatic coverage for a newbom child for up to 3 I days if you are covered under the insurance plan, have a child and do not immediately change coverage to a family plan. This provision is only applicable if dependent child coverage is available.

Family and Medical Leave Act (FMLA)/Military

Service Leave of Absence

Your Accidental Death and Dismemberment insurance and that of your insured dependents can continue for up to 12 weeks in a 12 month period:

• If you are on a leave of absence approved by your employer

under FMLA

• If you are on an approved leave of absence due to entering

military se",ice of the United States

You must continue to pay your premiums while on either of these leaves. All coverage provisions apply during the leave period, except that for military services leave there is no coverage for any loss which occurs while you are on active duty if such loss is caused by or arises out of such military service, including but not limited to war or act of war (declared or undeclared).

World Net 24-HourTravel Assistance

WorldNet is a comprehensive range of information, referral, coordination and arrangement services designed to respond to most medical care sITuations and many other emergencies you may have when you travel. It also olrers pre-trip assistance before you travel and infomnation on things like passport/visa requirements, foreign currency and weather:

Complete details of these beneffls are contained in the Certificate of Insurance or Policy

Page 8: Plan Highlights · Each Active Full-Time Employee, working 30 hours or more per week, except any person working on a temporary or seasonal basis Benefit Amount Employee: You may select

How much does voluntary accidental death and dismemberment insurance cost?

How do I enroll? Why should I buy this coverage now?

Are there any additional benefits available?

Yes.Your employer may have chosen to include one or more of the following optional benefrts in your Voluntary Accidental Death and Dismembemnent plan (see your plan highlights).

Common Carrier

Pnovides an additional benefrt equal to a pencentage of the Accidental Death and Dismembemnent benerrt if an accident occurs on a plane, bus, train, ship, taxi or public conveyance licensed to can-y passengers for hire.This provision is not available to operators of common eamers or crew. This benefrt is available to you and your insured dependents.

Education Benefit

Pnovides a benefrt to assist with the higher education costs of a covered child (in 12th grade or ennolled in an institute of higher leaming) in the event of you or your insured spouse's covered accidental death.The pnovision also pnovides a benefrt for your spouse to secure professional or trade training wIThin 30 months of your accidental death (the Education Benefrt is not available in Pennsylvania).

Total Loss of Use

Pnovides a benefrt if a covered accidental injury does not cause death or dismemberment, but leaves you or your insured dependent with "total loss of use of amns or legs" (incurable paralysis or stiffening, which affects the entire limb).The benefrt is payable if the loss occurs within a year fium an injury and after 12 months, is medically judged to be pemnanent

Payment is based on the following schedule:

Loss of Use of Both Amns and Both Legs

Benefrt The Principal Sum

Loss of Use of Both Amns and One Leg or Both Legs and One Amn

Benefrt 3/4 the Principal Sum

Loss of Use of Both Amns or Both Legs

Benefrt 213 the Principal Sum

Loss of Use of One Amn and One Leg Benefrt 213 the Principal Sum

Loss of Use of One Arm or" One Leg

Benefrt 1/2 the Principal Sum

Reliance Standand will only pay one (the larger) benefrt if more than one loss results from anyone accident The benefrt is not payable in addition to a PemnanentTotal Disability benefrt (if offered) or the Accidental Death and Dismembemnent benefrt

Permanent Total Disability

Pnovides a benefrt if you are totally disabled as defined as a resu~ of a covered accident The benefrt is paid as a lump sum equal to the principal sum or a pencent of the principal sum for a specified period of time.

This benefrt is reduced by any benefrts that are paid or payable to you under the Total Loss of Use benefrt (if applicable) and the Accidental Death and Dismembemnent benefrt for the same accident

Seat Belt I Air Bag

Provides an addITional benerrt if death occurs in an auto accident while you or your covered dependent are wearing a seat belt The benefrt also pnovides an additional benefit, if while wearing a seat be~ and where your seat was pnotected by an air bag that innates, you still suffer an accidental death (the Air Bag benefrt is not available in Florida or Oregon).

Survivor Benefit

If dependent coverage is in effect on the date of a covered accident that resu~ in your death, Reliance Standand will pay an additional monthly benefrt for a specified period of time.The benefrt will be payable to your spouse, if living, or to your living eligible child(ren),