employee injury benefit plan instructions · the purpose of the plan is to provide medical...

Employee Injury Benefit Plan Instructions

These instructions apply to all current employees and to all new-hires. Be sure that you

make this part of your new employee package.

This binder contains your Employee Injury Benefit Plan. You will need to follow the terms of this

ERISA plan in administering on-the-job injury claims. ERISA imposes fiduciary duties on the

administrator of the plan and therefore, your compliance with plan procedures is critical in being a

successful nonsubscriber. The following instructions will help you to successfully roll out and notify your

employees of the benefits and requirements of your new plan:

Tab 1: Schedule of Benefits; Employee Injury Benefit Plan; Notification of No Workers’

Compensation Insurance Coverage; Notice of Mandatory Arbitration Policy - this tab contains

a.) your schedule of benefits which lists the benefits available to employees should they

become injured on the job. It also provides information about your company and a contact person for

questions concerning the plan/benefits.

b.) your ERISA plan. This is your company plan and is to be kept for your records. Should an

employee have questions regarding the SPD, you may use this document for additional clarification if needed.

c.) your arbitration policy. Should an employee become injured and attempt to sue you, this

sheet will be used to prove to the court that the employee was provided notice of the arbitration

agreement and that he/she is bound by the terms.

It is important that you review these documents for accuracy

Tab 2: Schedule of Benefits; Summary Plan Description; Notification of No Workers’

Compensation Insurance Coverage; Notice of Mandatory Arbitration Policy - this tab contains

a.) the schedule of benefits.

b.) the SPD, a summary of your plan which is located in tab 1. 6 of this document must

be signed by each employee and returned to you to keep in your employee file. It is notification that you

do not carry Workers Compensation insurance coverage.

c.) the arbitration policy. This document must be signed by each employee and returned to you

to keep in your employee file.

• A copy of these documents must be given to every employee

• It is important that you obtain signatures of all employees for your files

Spanish Translations Please make sure that all employees requesting Spanish translations receive Spanish versions of the

documents. Failure to provide a translated Summary Plan Description to an employee who speaks

and reads only Spanish could jeopardize the Plan’s ability to enforce the provisions and

requirements set forth in the Employee Injury Benefit Plan, including mandatory arbitration.

Tab 3: Spanish translation of the Schedule of Benefits; Summary Plan Description; Notice of

No Workers’ Compensation Insurance Coverage; Mandatory Arbitration Policy

• A copy of these documents must be given to every employee

• It is important that you obtain signatures of all employees for your files

Insured Representative - Sign and Return

Tab 4: Confirmation of ERISA Plan Adoption and Rollout – this tab contains the form you

must complete, sign, and return to Midlands. Please keep a copy in this binder. It is confirmation that

you have followed the instructions above and have obtained the required signatures from your

employees. Should an employee become injured, Midlands may require a copy of that employee’s

signed forms.

03/15/12 Midlands Schedule

SCHEDULE OF BENEFITS TO [COMPANY NAME]

EMPLOYEE INJURY BENEFIT PLAN

Effective Date of this Schedule of Benefits: Effective Date of Plan:

Employer Name:

Employer Address:

Employer Phone: Fax: Email:

Contact Person for Participation Questions:

Contact Person for service of process on Plan:

Claims Administrator: Midlands Claim Administrators, Inc.

3503 NW 63rd

Street, Suite 305

Phone: 1-866-264-2805 Fax: 405-767-1212 Email: [email protected]

Plan #: Tax ID:

Maximum Benefit Limits:

If you are eligible for benefits under the Plan, the following are the maximum amount of Plan benefits that

will be paid:

Maximum payable per Participant for each Occurrence: $ 250,000 per Participant

Maximum payable, in the aggregate, to all Participants for a single Occurrence: $ 500,000 per Occurrence

Medical Benefits

Subject to the Maximum Benefit Limits and other terms of the Plan, if you suffer a Bodily Injury in the Scope

of Employment, the Plan will pay for 100% of Eligible Charges from approved health care Providers for a

period of time up to a Maximum Benefit Period (the maximum number of weeks benefits will be paid) of 104

weeks from the date of the Occurrence giving rise to your Bodily Injury. Your first Eligible Charge must have

been incurred within ninety (90) days of the date of the Occurrence causing your Bodily Injury.

Wage Replacement Benefits

If you are unable to return to work because of a Disability, the Plan will pay you wage replacement benefits,

subject to the Maximum Benefit Limits, other terms and conditions of the Plan, and the following limits:

Your Disability must begin within: 90 Days from date of Occurrence*

Percentage Average Weekly Earnings: 75% of Weekly Wage

Maximum Weekly Wage Replacement Benefit: $600.00

Elimination Period (period you must be off work before benefits start): 7 Days from date of Occurrence

Maximum Benefit Period: 104 weeks from date of Occurrence

Accidental Death, Dismemberment, and Loss of Use

If you die or lose bodily function that meets the definition of a “Loss” in the Plan within 365 days after an

Occurrence that caused your Bodily Injury, the Plan will pay (a) ten (10) times the your Base Annual Salary,

or (b) the applicable stipulated benefit detailed in the Schedule of Losses in the Plan (whichever is less),

subject to the Maximum Benefit Limits and other terms and conditions of the Plan. The total AD&D benefit

payable under the Plan will be reduced by all other Plan benefits otherwise paid or payable on your behalf.

IMPORTANT NOTICE: All Plan benefits are subject to the terms and conditions of the Plan. Please

see the Summary Plan Description and Plan Document for other benefits limitations and exclusions.

*This benefit is also payable if the Disability commences 180 days from the date of the Accident or Occurrence that caused the Disability, provided

you received medical treatment within 30 days from the date of the Accident or Occurrence, and you have remained under the Continuous Care and

treatment of a Provider since that time.

3/15/12 Midlands Plan (w OD/CT)

[ABC COMPANY]


3/15/12 Midlands Plan (w OD/CT) ii

TABLE OF CONTENTS

SECTION 1 DEFINITIONS

1.1 Accident or Accidental ................................................................................................................................... 1

1.2 Appropriate Care ........................................................................................................................................... 1

1.3 Base Annual Salary......................................................................................................................................... 1

1.4 Beneficiary ..................................................................................................................................................... 2

1.5 Benefit Period and Maximum Benefit Period ................................................................................................. 2

1.6 Bodily Injury................................................................................................................................................... 2

1.7 Chiropractic Care ........................................................................................................................................... 2

1.8 Code……........................................................................................................................................................ 2

1.9 Company ........................................................................................................................................................ 2

1.10 Concurrent Care Claim .................................................................................................................................. 3

1.11 Continuous Care ............................................................................................................................................. 3

1.12 Cumulative Trauma ........................................................................................................................................ 3

1.13 Disabled or Disability .................................................................................................................................... 3

1.14 Effective Date ................................................................................................................................................ 3

1.15 Eligibility Period ............................................................................................................................................ 3

1.16 Eligible Charges ............................................................................................................................................. 3

1.17 Elimination Period ......................................................................................................................................... 4

1.18 Employee ....................................................................................................................................................... 4

1.19 Employer ........................................................................................................................................................ 4

1.20 ERISA…......................................................................................................................................................... 4

1.21 Functional Capacity Examination .................................................................................................................. 4

1.22 Immediate Family .......................................................................................................................................... 4

1.23 Maximum Benefit Limit.................................................................................................................................. 4

1.24 Maximum Medical Improvement.................................................................................................................... 4

1.25 Medically Necessary ...................................................................................................................................... 4

1.26 Occupational Assessment................................................................................................................................ 4

1.27 Occupational Disease ..................................................................................................................................... 5

1.28 Occurrence ..................................................................................................................................................... 5

1.29 Participant ...................................................................................................................................................... 5

1.30 Physician ........................................................................................................................................................ 5

1.31 Plan……. ........................................................................................................................................................ 5

1.32 Plan Administrator ......................................................................................................................................... 5

1.33 Plan Year ....................................................................................................................................................... 6

1.34 Pre-Existing Condition ................................................................................................................................... 6

1.35 Pre-Service Claim .......................................................................................................................................... 6

1.36 Provider ......................................................................................................................................................... 6

1.37 Rehabilitation ................................................................................................................................................. 6

1.38 Rehabilitative Status ...................................................................................................................................... 6

1.39 Review Committee.......................................................................................................................................... 6

1.40 Schedule of Benefits ....................................................................................................................................... 6

1.41 Scope of Employment .................................................................................................................................... 6

1.42 Urgent Care Claim ......................................................................................................................................... 6

1.43 Usual and Customary Charge ......................................................................................................................... 7

1.44 Weekly Wage.................................................................................................................................................. 7

SECTION II REQUIREMENTS FOR ELIGIBILITY

2.1 Eligibility to Participate ................................................................................................................................. 7

2.2 Cessation of Participation .............................................................................................................................. 7

3/15/12 Midlands Plan (w OD/CT) iii

SECTION III BENEFITS

3.1 Eligibility for Benefits .................................................................................................................................... 7

3.2 Offset for Payment of Benefits........................................................................................................................ 7

3.3 Commencement and Duration of Payments ................................................................................................... 7

3.4 Medical Benefits ............................................................................................................................................. 8

3.5 Wage Replacement ......................................................................................................................................... 8

3.6 Death Benefits .............................................................................................................................................. 10

3.7 Accidental Dismemberment and Loss of Use Benefits ................................................................................. 10

Schedule of Losses ......................................................................................................................... 11

3.8 Physical Examination and Autopsy............................................................................................................... 12

SECTION IV REQUIREMENTS FOR RECEIPT OF BENEFITS

4.1 Occurrence Reporting and Drug Testing ...................................................................................................... 12

4.2 Designation of Providers............................................................................................................................... 13

4.3 Pre-Approval of Non-Emergency Services ................................................................................................... 13

4.4 Medical Treatment and Examination ............................................................................................................ 13

4.5 Exclusions ..................................................................................................................................................... 13

4.6 Subrogation .................................................................................................................................................. 15

4.7 Reimbursement ............................................................................................................................................. 16

4.8 Other Coverage and Coordination of Benefits ............................................................................................. 16

SECTION V ADMINISTRATION

5.1 Plan Administrator ........................................................................................................................................ 16

5.2 Duties of Third Party Administrator ............................................................................................................ 17

5.3 Duties of a Claims Administrator.................................................................................................................. 17

5.4 Notification of Adverse Benefit Determination ............................................................................................ 18

5.5 Content of Initial Notification of Adverse Benefit Determination ................................................................ 18

5.6 Timing of Initial Notification of Adverse Benefit Determination ................................................................. 18

5.7 Participant's Appeal of an Adverse Benefit Determination........................................................................... 19

5.8 Review of Adverse Benefit Determination ................................................................................................... 19

5.9 Notification of Benefit Determination on Review......................................................................................... 20

SECTION VI AMENDMENT AND TERMINATION

6.1 Amendment to the Plan................................................................................................................................. 21

6.2 Termination of Plan ..................................................................................................................................... 21

SECTION VII ADOPTION OF PLAN BY EMPLOYERS

7.1 Adoption Procedure ..................................................................................................................................... 22

7.2 Effect of Adoption by Employer .................................................................................................................. 22

7.3 Obligation of Employer ................................................................................................................................ 22

SECTION VIII MISCELLANEOUS

8.1 Non-alienation of Benefits ........................................................................................................................... 22

8.2 No Contract of Employment ........................................................................................................................ 22

8.3 Severability of Provisions ............................................................................................................................ 23

8.4 Heirs, Assigns and Personal Representatives ............................................................................................... 23

8.5 Headings and Captions ................................................................................................................................. 23

8.6 Gender and Number ..................................................................................................................................... 23

8.7 Controlling Law ........................................................................................................................................... 23

8.8 Title to Assets .............................................................................................................................................. 23

8.9 Expenses ...................................................................................................................................................... 23

3/15/12 Midlands Plan (w OD/CT) iv

8.10 Voluntary Payments: No Admission of Liability ......................................................................................... 23

8.11 Information to be Furnished ......................................................................................................................... 23

8.12 Limitation of Right ....................................................................................................................................... 23

8.13 Not a Policy of Workers' Compensation Insurance....................................................................................... 24

3/15/12 Midlands Plan (w OD/CT) - 1 -

[ABC COMPANY]


General Information

[ABC Company] (the “Company”) has adopted and established this Employee Injury Benefit Plan for the

exclusive benefit of Employees whose principal place of employment and residence is in the State of Texas.

The Company has elected to opt out of the Texas Workers’ Compensation Act for its Texas Employees, and

has adopted this Employee Injury Benefit Plan to provide benefits as set forth herein.

The effective date of this Plan is listed in the Schedule of Benefits, and it supersedes any and all prior

employee injury benefit plans pertaining to the subject matter hereof, and all prior programs or policies of

the Company concerning benefits for a Bodily Injury. Eligible Participants who sustain a Bodily Injury

after this date may be provided benefits in accordance with the terms and conditions of the Plan.

The purpose of the Plan is to provide medical benefits, limited Wage Replacement benefits,

dismemberment benefits, and/or accidental death benefits for a Participant who sustains a Bodily Injury as

defined by the terms of this Plan.

All benefits provided under this Plan will be paid from the general assets of the Employer. No Employee

contributions are used or allowed. The Employer has the right to obtain insurance contracts with one or

more insurers to provide funds to the Employer to pay certain benefits under the Plan.

SECTION I

DEFINITIONS

Capitalized terms not otherwise defined in the other sections of this Plan or the Schedule of Benefits

shall have the following meanings given to them in this section of the Plan:

1.1 Accident or Accidental means an event that occurs within the Participant’s Scope of

Employment and:

1. was unintended, unanticipated, unforeseen, unplanned and unexpected;

2. occurred at a specifically identifiable time and place;

3. occurred by chance or from unknown causes; and

4. directly (independent of sickness, disease, mental incapacity, bodily infirmity or any other cause)

resulted in Bodily Injury.

1.2 Appropriate Care means the determination of an accurate and medically supported diagnosis

and ongoing medical treatment and care of the Participant’s condition or Disability by a Provider that

conforms to generally-accepted medical standards, including frequency of treatment and care.

1.3 Base Annual Salary means the amount of compensation paid by the Employer to a Participant,

including overtime and commissions as reported to the Internal Revenue Service. For Participants

receiving compensation paid by commission, the Base Annual Salary shall be the average annual earnings

received from the Employer over the three year period immediately preceding the date of the Occurrence.

For Participants receiving compensation by commission that have less than three years employment history


with the Employer, average monthly earnings will be calculated and multiplied by 12 to calculate the Base

Annual Salary. The maximum Base Annual Salary that will be recognized for calculation of a Loss under

Section III(D) of this Plan (the Accidental Death, Dismemberment and Loss of Use Benefit) is $60,000,

regardless of whether a Participant has a Base Annual Salary in excess of this sum.

1.4 Beneficiary means the person or persons eligible for death benefits as determined in the

following priority:

1. if there is an Eligible Spouse, all death benefits shall be paid to the Eligible Spouse.

2. if there is no Eligible Spouse, death benefits shall be paid in equal shares to the Eligible Children. If

an Eligible Child has predeceased the Participant, death benefits that would have been paid to that

child if he or she had survived the Participant shall be paid in equal shares per stirpes to the children

of such deceased child.

For purposes of this definition of “Beneficiary”:

a. Eligible Spouse means the surviving spouse of the deceased Participant, recognized by a

marriage certificate issued under the laws of the State of Texas or similar government authority,

or by a Texas court decree of common law marriage (obtained at such person’s sole initiative

and expense); and

b. Eligible Child means a surviving child of the deceased Participant, whether by blood, marriage,

or legal adoption, if the child is:

i. under 18 years of age;

ii. less than 25 years of age and enrolled as a full-time student in an accredited educational

institution; or

iii. because of a physical or mental handicap, a dependent (as determined in accordance with the

support criteria set forth in Section 152 of the Internal Revenue Code and such other rules

as the Plan Administrator may prescribe) of the deceased Participant at the time of the

Participant’s death.

1.5 Benefit Period and Maximum Benefit Period mean the maximum number of weeks (as

specified in the Schedule of Benefits) for which benefits are payable, beginning the day of the Occurrence

giving rise to the Participant’s Bodily Injury.

1.6 Bodily Injury means an identifiable damage or harm to the physical structure of the body,

including death, sustained solely as the result of an Accident occurring within the Participant’s Scope of

Employment. Bodily Injury includes Cumulative Trauma and Occupational Disease, as defined in this

Plan.

1.7 Chiropractic Care means treatment or therapy provided by a person appropriately licensed to

provide chiropractic services, who is not a member of the Participant’s Immediate Family or household.

1.8 Code means the Internal Revenue Code of 1986, as amended from time to time. References to

any section of the Code shall include any successor provision thereto.

1.9 Company has the meaning given to it in the General Information section of this Plan.


1.10 Concurrent Care Decision means a decision by the Plan Administrator to terminate or reduce

(other than by Plan amendment or termination) a previously-approved course or number of treatments to be

provided to the Participant over a period of time, before the end of such period of time or number of

treatments.

1.11 Continuous Care means the weekly, monthly, bi-monthly or quarterly monitoring and/or

evaluation of the Participant’s Disability by a Provider.

1.12 Cumulative Trauma means an identifiable damage or harm to the physical structure of the

body, including death, that is caused by the combined effect of repetitive physical activities extending over

a period of time and which is: (1) is diagnosed by a Physician; (2) the Participant’s last day of last

performance of the activities causing the Cumulative Trauma occurred while the Plan was in effect; and (3)

the Cumulative Trauma was caused directly and independently of all other causes by the Participant’s

Scope of Employment. All Cumulative Traumas suffered by any one Participant are deemed to be a single

Cumulative Trauma.

1.13 Disabled or Disability means a Bodily Injury resulting from an Occurrence which prevents a

Participant from performing the duties for which the Participant is employed by the Employer, or prevents

the Participant from performing the duties of any occupation for which he or she is qualified to perform by

reason of education, training or experience. The Participant must be under Continuous Care during the

period of Disability.

1.14 Effective Date means the Effective Date of Plan specified in the Schedule of Benefits.

1.15 Eligibility Period means the period of time for which benefits are payable. The Eligibility

Period ends on the earlier of:

1. the day a Provider determines no further medical treatment or physical rehabilitation is necessary or

advisable; or

2. the day benefits payable under the Plan reach the applicable Maximum Benefit Limit defined in the

Schedule of Benefits; or

3. the day that marks the end of the Benefit Period defined in the Schedule of Benefits.

1.16 Eligible Charges means the actual charges for medical or dental services, procedures or

supplies, incurred by a Participant as a result of Bodily Injury, to the extent such charges have been

previously approved by the Plan Administrator, are Medically Necessary, and are Usual and Customary in

amount, including the following:

1. hospital facility charges;

2. charge for use of an operating room;

3. the fees for Providers;

4. Chiropractic Care, provided it is recommended by a Provider for the treatment of the Employee’s

Bodily Injury, and services are not rendered by the Provider recommending treatment;

5. the charge of a licensed graduate nurse who is not a member of the Participant’s Immediate Family;

6. charges for appliances, artificial limbs, and the Usual and Customary charge for medical emergency

ground ambulance services; and

7. charges for medical or surgical treatment, services, supplies, prescription drugs and any other

services deemed Medically Necessary.


1.17 Elimination Period means the number of days (as shown in the Schedule of Benefits) after the

Occurrence giving rise to the Participant’s Bodily Injury during which the Participant is Disabled, but for

which no Wage Replacement benefits are payable under the Plan.

1.18 Employee means a Participant who, at the time of an Occurrence, is employed in the regular

business of, and receives his or her pay on a regular basis by means of a salary or wage directly from the

Employer. Employee does not include an independent contractor or third-party agent. Employee includes

only those persons who, at the Employer’s direction, work in Texas, or temporarily (90 days or less) outside

of Texas, in the Employer’s regular business.

1.19 Employer means the Company and any affiliate, subsidiary, or entity owned and controlled by

the Company which has adopted the Plan pursuant to Section VII, below. However, each entity which

adopts this Plan will be deemed an Employer only with respect to its own Employees.

1.20 ERISA means the federal Employee Retirement Income Security Act of 1974 (ERISA), as

amended.

1.21 Functional Capacity Examination means an evaluation or testing performed by a Provider or

physical therapy professional to assess and evaluate a Participant’s physical limitations.

1.22 Immediate Family means a person who is related to the Participant in any of the following

ways: spouse, domestic partner or other person who lives with the Participant, brother-in-law, sister-in-law,

son-in-law, daughter-in-law, mother-in-law, father-in-law, parent (includes stepparent), brother or sister

(includes stepbrother or stepsister), or child (includes legally adopted or stepchild).

1.23 Maximum Benefit Limit means the maximum amount of all benefits payable under the Plan to,

or with respect to, any Participant for a single Bodily Injury, and/or with respect to all Participants related to

all Bodily Injuries arising from a single Occurrence. The Maximum Benefit Limit per Participant and per

Occurrence for this Plan are as shown in the Schedule of Benefits.

1.24 Maximum Medical Improvement means the point at which a Provider determines a Participant

who sustained a Bodily Injury will not significantly improve and there is no further surgery, medical

treatment, or therapeutic modalities recommended or advised.

1.25 Medically Necessary means service, supply or procedure that:

1. is essential for diagnosis, treatment or care of the Bodily Injury for which it is prescribed or

performed;

2. meets generally accepted standards of medical practice; and

3. is ordered by a Provider and performed under his or her care, supervision or order.

Even if the service, supply or procedure is Medically Necessary, the Participant will not be reimbursed for it

if the service, supply, or procedure is otherwise excluded by any condition, exclusion or definition in this

Plan.

1.26 Occupational Assessment means a test of vocational capabilities. The process includes a

review of the Participant’s medical records, injury and treatment history, background (education, military,


previous occupation(s)), evaluation of basic skills such as reading, understanding, spelling and/or math

capabilities, and vocational alternatives.

1.27 Occupational Disease means a sickness which results in Disability or death, is caused by the

Participant’s exposure to environmental or physical hazards, and which: (1) is diagnosed by a Physician,

and is generally accepted by the National Centers for Disease Control to be a disease caused by such

hazards; (2) exposure to such hazards is not an Accident but is caused or aggravated by the conditions

under which the Participant performs services during his or her Scope of Employment; (3) the Participant’s

last day of exposure to the environmental or physical hazards causing such condition occurs while this Plan

is in effect; and (4) such exposure results directly and independently of all other causes in an Occurrence.

Occupational Disease does not include ordinary diseases of life to which the general public is exposed. In

addition, the Occupational Disease must be caused by a disease producing agent or agents found present in

the Participant’s occupational environment. Further, the Participant must be under the Appropriate Care of

a Physician for the Occupational Disease. All Occupational Diseases suffered by any one Participant due to

exposure to the same or related disease producing agent or agents present in his or her occupational

environment are deemed to be a single Occupational Disease.

1.28 Occurrence means an Accident, or series of Accidents, arising out of one event or incident

occurring while the Plan is in effect, and in the Participant’s Scope of Employment with the Employer, that

result in his or her Bodily Injury. For purposes of administration of the Plan, the Occurrence date is

established as follows:

1. For Bodily Injury other than Occupational Disease or Cumulative Trauma, the Occurrence date is

the date of the Accident, or the date of the first in a series of Accidents.

2. For Occupational Disease, the Occurrence date is the date on which the Participant was last

exposed, in his or her Scope of Employment, to the disease producing agent or agents.

3. For Cumulative Trauma, the Occurrence date is the date on which the Participant last performed, in

the Scope of Employment, the activities causing such condition.

1.29 Participant means an eligible Employee who satisfies all requirements for participation in the

Plan and whose participation has not been terminated as provided herein.

1.30 Physician means a licensed practitioner of the healing arts acting within the scope of his or her

license who is not the Participant or a member of the Participant’s Immediate Family or a practitioner

retained by the Employer. Physician includes, but is not limited to, doctors, nurses and therapists.

Physician does not include a chiropractor unless recommended and referred by a Provider who is designated

as a licensed medical doctor (M.D.).

1.31 Plan means the Employee Injury Benefit Plan as set forth in this document, and the Schedule of

Benefits, and as hereafter amended.

1.32 Plan Administrator means the Company or person appointed by the Company who is

responsible for providing Participants with information about, and making determinations regarding rights

and benefits under, the Plan. The Company reserves the right to make any final determination regarding

rights and benefits under the Plan.


1.33 Plan Year means the twelve (12) month period ending on December 31. The first Plan year

shall be from the Effective Date of the Plan specified in the Schedule of Benefits until December 31 of that

calendar year.

1.34 Pre-existing Condition means any health condition for which, prior to the earlier of the date on

which the Employee became a Participant or the Effective Date of the Plan, the Participant was diagnosed,

examined, treated, or prescribed medications by a healthcare practitioner, or of which the Participant

manifested symptoms which were reasonably capable of diagnosis by a healthcare practitioner, or

symptoms which, in the opinion of a Physician, would have caused a reasonable person to be aware of such

condition.

1.35 Pre-Service Claim means any claim for medical benefits under the Plan which, by the terms of

the Plan, conditions the receipt of the benefit, in whole or in part, on obtaining approval or pre-certification

prior to obtaining the medical care.

1.36 Provider means a Physician or other health care provider designated or approved by the

Employer to administer medical treatment for which payment or reimbursement is authorized under this

Plan.

1.37 Rehabilitation means only those procedures that are performed for the purpose of restoring

bodily or body function lost as a result of Bodily Injury.

1.38 Rehabilitative Status means the employment status of an otherwise Disabled Participant who is

released by a Provider to return to work for an Employer working not less than 25% of the Participant’s

pre-injury, regular work week, provided the Participant remains under Continuous Care during the period of

Disability.

1.39 Review Committee means the group of individuals appointed by the Company to review and

make decisions regarding all requests for review of an adverse benefit decision.

1.40 Schedule of Benefits means the Schedule of Benefits associated with this Plan and in effect on

the date of the Occurrence giving rise to the Participant’s claim for benefits under this Plan.

1.41 Scope of Employment means an activity of any kind or character that involves the furtherance

of the Employer’s business, trade or profession at the Employer’s regular workplaces in Texas, or outside of

Texas for 90 days or less in a Plan Year. Scope of Employment does not include a Participant’s

transportation to and from the Employer’s regular workplace unless:

1. the transportation is furnished as a part of employment, or is paid for by the Employer; or

2. the means of such transportation is under the Employer’s control; or

3. the Participant is directed in his or her Scope of Employment to proceed from one place to another

place other than the regular workplace.

1.42 Urgent Care Claim means any claim for medical care or treatment with respect to which the

application of the time periods for making non-urgent care determinations:

1. could seriously jeopardize the life or health of the Participant or the ability of the Participant to

regain maximum function; or


2. in the opinion of a Physician with knowledge of the Participant’s condition, would subject the

Participant to severe pain that cannot be adequately managed without the care or treatment that is

the subject of the claim.

1.43 Usual and Customary Charge means the reasonable charge made by a Provider or other

providers of healthcare services, supplies, medication or equipment that does not exceed the amount of

charges made by other Physicians or health care providers rendering or furnishing such care or treatment

within the same area.

1.44 Weekly Wage means the Participant’s Base Annual Salary divided by fifty-two (52).

SECTION II

REQUIREMENTS FOR ELIGIBILITY

2.1 Eligibility to Participate

Each Employee who was an Employee on the Effective Date shall be eligible to participate in the

Plan on the Effective Date. Each other Employee shall be eligible to participate in the Plan as of the later

of:

1. the date he or she is employed by the Employer; or

2. the date on which he or she is classified as an Employee.

2.2 Cessation of Participation

A Participant will cease to be a Participant in the Plan with respect to Occurrences that arise on or

after the earlier of:

1. the date on which the Plan is terminated;

2. the date on which the Participant is no longer an Employee; or

3. the date on which the Employee provides written notice of withdrawal from the Plan to the

Plan Administrator.

SECTION III

PLAN BENEFITS

3.1 Eligibility for Benefits

A Participant shall only be eligible for payment of benefits if the Participant sustains a Bodily

Injury, and if the Participant follows the procedures and policies set forth below.

3.2 Offset for Payment of Benefits

All benefits paid under this Plan shall be considered made by the Company or other Employer and

shall not be considered payment from a “collateral source” as that term has been defined under any

applicable rule, statute, judicial decision, or directive. All benefits paid under this Plan shall be offset

against any alleged liability of the Employers, the Company, and their officers, directors, and agents to a

Participant and/or his or her Beneficiaries due to the Occurrence. No payment hereunder shall be deemed a

fringe benefit.

3.3 Commencement and Duration of Payments

Subject to the Elimination Period specified in the Schedule of Benefits, benefits payable under this

Plan shall commence on the day on which the Participant sustains a Bodily Injury, and shall continue for the


Eligibility Period as defined in the Schedule of Benefits. Notwithstanding any provision in this Plan to the

contrary, the total amount payable to any one Participant for all benefits shall not exceed the Maximum

Benefit Limit per Participant shown in the Schedule of Benefits, and the total amount payable to all

Participants related to all Bodily Injuries arising from a single Occurrence shall not exceed the Maximum

Benefit Limit per Occurrence shown in the Schedule of Benefits.

3.4 Medical Benefits

Medical benefits are payable only for expenses which are Eligible Charges for treatment of a Bodily

Injury. Medical benefits shall be paid by the Plan Administrator directly to a Provider, or to the Participant

as reimbursement for such expenses which have been paid directly by the Participant to a Provider.

However, the first Eligible Charge must have been incurred within ninety (90) days of the date of the

Occurrence causing the Bodily Injury, and only expenses which are Medically Necessary, Usual and

Customary in amount, and directly related to the Bodily Injury shall be payable under the Plan. Medical

Expenses, when combined with all other benefits paid under this Plan, shall not exceed the Maximum

Benefit Limit per Participant shown in the Schedule of Benefits.

The Employer may designate one or more Providers to administer medical treatment to Participants,

and the Employer may change designated Providers at any time. Benefits shall not be paid under this Plan

for treatment received from a health care provider that has not been designated as a Provider in accordance

with this Plan.

3.5 Wage Replacement

1. If a Participant has suffered a Disability as the result of a Bodily Injury, the Participant may be

eligible for Wage Replacement benefits under the Plan.

a. For any Wage Replacement benefit to be payable, the Disability must commence within

ninety (90) days of the date of the Occurrence causing the Bodily Injury, and must continue for the

duration of the Elimination Period specified in the Schedule of Benefits.

b. This benefit is also payable if the Disability commences within one-hundred eighty (180)

days from the date of the Occurrence that caused the Disability, provided the Participant received

medical treatment within thirty (30) days from the date of the Occurrence. The Participant must

remain under the Continuous Care and treatment of a Provider for the Bodily Injury during the

period of Disability.

c. Following the Elimination Period, the Participant is eligible for Wage Replacement benefits

for each workday of Disability as specified in the Plan. Wage Replacement benefits shall begin to

accrue on the first scheduled workday immediately following the Elimination Period and continue

for each succeeding week of Disability. Wage replacement benefits will be paid on the Participant’s

normal paydays during the period of the Participant’s Disability.

2. Wage Replacement benefits shall continue until the earlier of:

a. the day the total benefits paid under the Plan equals the applicable Maximum Benefit Limit

specified in the Schedule of Benefits;

b. the Participant’s date of death;

c. the day the Participant is released for full duty work by a Provider;

d. the expiration of the Maximum Benefit Period applicable to Wage Replacement benefits as

specified in the Schedule of Benefits;


e. the day the Participant fails to submit satisfactory proof of continuing Disability, fails to

submit to a Functional Capacity Examination or Occupational Assessment, and/or fails to return

to work on Rehabilitative Status;

f. the day the Participant is no longer suffering from a Disability; or

g. the day the Participant fails to comply with any provision of the Plan, or is otherwise

determined by the Plan Administrator not to be eligible for benefits under the Plan.

THE PARTICIPANT CANNOT PERFORM ANY OTHER JOB OR EMPLOYMENT WHILE

RECEIVING WAGE REPLACEMENT BENEFITS UNDER THE PLAN.

3. Wage Replacement benefits shall be calculated and paid to the Participant at the percentage of the

Participant’s Weekly Wage, up to the Maximum Weekly Disability Benefit Amount, as shown in the

Schedule of Benefits.

a. Wage Replacement benefits incurred as a direct result of a Bodily Injury are payable subject

to the applicable Maximum Benefit Limit as shown in the Schedule of Benefits, and other limits

under the Plan.

b. If the Disability does not exceed the Elimination Period shown in the Schedule of Benefits,

the Participant will not receive Wage Replacement benefits.

c. If the Participant is released to return to work during a pay period, the Participant’s actual

earnings will be supplemented by Wage Replacement benefits up to, but not exceeding, 100% of

the Participant’s Weekly Wage.

d. No benefits will be paid if the Participant refuses to participate in any medically

recommended Rehabilitation program, or if the Disability is treatable by medical care that is

reasonable and of a form that an ordinary person of the same or similar circumstances would

undergo, and the Participant has not availed himself or herself of the treatment.

4. Wage Replacement benefits payable under this Plan shall be reduced by any amounts for which the

Participant qualifies to receive under Social Security (including payments to eligible dependents), worker’s

compensation or any occupational disease act or law, state compulsory disability benefit law, or any

disability, retirement, or other income benefits provided through the Participant’s Employer and/or the

Company.

5. Termination of the Plan will not affect the payment of Wage Replacement benefits for a Disability

that began while the Plan was in effect.

6. Subsequent Disability

a. This Plan will provide Wage Replacement benefits for successive periods of Disability

resulting from entirely different and unrelated causes, only if such periods of Disability are

separated by at least one (1) full day during which the Participant is not Disabled, and performs

the Participant’s regular job duties. In such event, the Participant shall be required to satisfy a

new Elimination Period, and will begin a new Maximum Benefit Period, with respect to Wage

Replacement benefits.

b. This Plan will provide Wage Replacement benefits for successive periods of Disability

resulting from the same or related causes, only if such periods of Disability are separated by at

least six (6) months during which the Participant is not Disabled. In such event, the Participant

shall be required to satisfy a new Elimination Period, and will begin a new Maximum Benefit

Period, with respect to Wage Replacement benefits.


c. In the event that a Participant: (A) returns to full-time work for the Employer for a period of

not more than two (2) consecutive weeks; and (B) is subsequently Disabled from the same or

related causes, he or she will be considered continually Disabled, and this Plan will provide

Wage Replacement benefits for successive periods of Disability resulting from the same or

related causes which are separated by less than six (6) months without the Participant satisfying a

new Elimination Period, but the Participant will not begin a new Maximum Benefit Period.

7. Rehabilitation Disability Benefit

After initial medical treatment for a Bodily Injury, a Provider may release the injured Participant to return to

work under one of the following options.

a. Full Duty. The Participant may resume full range of duties routinely associated with the

performance of his or her job and Wage Replacement benefits will be discontinued; or

b. Rehabilitative Status.

When a Participant returns to work under Rehabilitative Status, the Participant will be eligible to continue

Wage Replacement benefits for the balance of the hours that they are unable to work up to 100% of their

normal work week. The Wage Replacement benefits will be paid subject to the Wage Replacement limits

shown in the Schedule of Benefits. This benefit will be payable for an initial three-month period while

Rehabilitative Status continues, and may be extended by the Plan Administrator for additional three-month

periods, up to a maximum of twelve (12) months, in any one period of Disability.

THE PLAN ADMINISTRATOR MAY REQUIRE THE PARTICIPANT TO SUBMIT PROOF OF

CONTINUED DISABILITY AND OF CONTINUOUS CARE. THIS MAY BE DONE AS OFTEN

AS THE PLAN ADMINISTRATOR CONSIDERS NECESSARY AND REASONABLE. FAILURE

TO SUBMIT THE REQUESTED PROOF WILL CAUSE THE PLAN ADMINISTRATOR TO

SUSPEND WAGE REPLACEMENT OR REHABILITATION DISABILITY BENEFITS UNTIL

SUCH PROOF IS RECEIVED.

3.6 Death Benefit

In the event a Participant dies as a direct result of a Bodily Injury within three hundred and sixty-

five (365) days from the date of the Occurrence, the Beneficiary of the Participant shall be entitled to

receive a Death Benefit equal to the lesser of:

a. ten (10) times the Participant’s Base Annual Salary; or

b. the stipulated benefit detailed in the Schedule of Losses below.

The total Death Benefit paid will not exceed the Maximum Benefit Limit per Participant shown in the

Schedule of Benefits, and will be reduced by all benefits otherwise paid or payable to, or on behalf of, the

Participant under this Plan.

3.7 Accidental Dismemberment and Loss of Use Benefit

In the event a Participant suffers a loss described in the Schedule of Losses below as the direct result

of a Bodily Injury, and the loss is within three hundred and sixty-five (365) days of the Occurrence, the

Participant will be entitled to receive the amount set forth in such Schedule, less any other benefits payable

under the Plan for the same loss. Dismemberment and Loss of Use benefits shall not be paid if a Death

Benefit is payable under this Plan.


If a Participant suffers more than one scheduled loss as the result of one Occurrence, a benefit will

only be paid for the scheduled loss which provides the larger benefit, and will be less any other benefits

payable under the Plan for the same loss. The total benefits paid will not exceed the Maximum Benefit

Limit per Participant shown in the Schedule of Benefits.

SCHEDULE OF LOSSES

LOSS: BENEFIT:

(Stated as a percentage of the

Maximum Benefit Limit Per Participant for each

Occurrence as shown in the Schedule of Benefits)

Death 100%

Both Hands 100%

Both Feet 100%

Sight of Both Eyes 100%

One Hand and One Foot 100%

One Hand and Sight of One Eye 100%

One Foot and Sight of One Eye 100%

Speech and Hearing in Both Ears 100%

Use of Both Arms and Both Legs 100%

Use of Both Arms or Both Legs 75%

Use of One Arm and One Leg 75%

Speech 50%

Hearing in Both Ears 50%

One Hand 50%

One Foot 50%

Sight of One Eye 50%

Use of One Arm or One Leg 50%

One Thumb 25%

In addition to the Definitions in Section I of this Plan, the following Definitions apply to benefits for

Accidental Dismemberment and Loss of Use:

1. Loss with regard to:

a. a hand or foot means the complete severance through or above the wrist joint or the

ankle joint;

b. sight of an eye means the total and irrevocable loss of the entire sight in that eye;

c. hearing in an ear means the total and irrevocable loss of the entire ability to hear in

that ear;

d. speech means the total and irrecoverable loss of the entire ability to speak;

e. an arm or leg means the complete severance through or above the shoulder or hip

joint.

f. one thumb means the complete severance through or above the metacarpophalangeal

joint of the digit;


g. use of an arm, hand, leg or foot means the total loss of the ability to perform each and

every act and service that the arm, hand, leg or foot was able to perform before the

Occurrence.

2. The total loss of the ability to perform must continue without interruption, for a period of not

less than 365 consecutive days and be irrevocable and beyond remedy by surgical or other

means.

3. Severance means the complete and permanent separation and dismemberment of the part

from the body.

The amount payable for Accidental Dismemberment or Loss of Use shall be limited to the lesser of:

1. ten (10) times the Participant’s Base Annual Salary as defined by this Plan; or

2. the stipulated benefit detailed in the Schedule of Losses, above.

The total Accidental Dismemberment and Loss of Use benefits paid will not exceed the Maximum Benefit

Limit per Participant shown in the Schedule of Benefits, and will be reduced by all benefits otherwise paid

or payable to, or on behalf of, the Participant under this Plan.

3.8 Physical Examination and Autopsy.

The Plan Administrator, at the Company’s expense, has the right to have a Participant examined by

a Provider when and as often as reasonably necessary during the Eligibility Period. In the case of a

Disability claim, the Plan Administrator also has the right to require the Participant, at the Company’s

expense, to submit to an Occupational Assessment and/or a Functional Capacity Examination. Failure of

the Participant to submit to such examination will result in the termination of benefits under this Plan to

such Participant. The Plan Administrator may also have an autopsy performed, at the Company’s expense,

on a Participant whose death gives rise to a claim for death benefits under this Plan, unless prohibited by

law.

SECTION IV

REQUIREMENTS FOR RECEIPT OF BENEFITS

In order to receive payment of any benefits under this Plan, a Participant must comply with all

requirements of this Section.

4.1 Occurrence Reporting and Drug Testing

The Participant must report every incident which the Participant believes resulted in Bodily

Injury. The report must be made immediately (by the end of the scheduled workday and/or the end of the

scheduled shift on the day of the Occurrence) to the Participant’s Manager, Supervisor or other person in

charge at the time. That person will then assist the Participant in obtaining necessary medical treatment

and in completing required report forms. The Participant shall be required to submit to drug and/or alcohol

testing, and to provide a recorded statement, affidavit or deposition regarding an Occurrence, as requested

by the Employer. The Participant must notify the Employer of his or her expected recovery time

immediately after primary medical treatment and after each succeeding appointment with the treating

Provider.


4.2 Designation of Providers

The Company will designate one or more Providers to administer medical treatment and the

Company may change designated providers at any time. Other than benefits paid for emergency medical

expenses, no benefits will be paid under the Plan for treatment received from a health care provider that has

not been designated as a Provider in accordance with this Plan. A Company-designated Provider is not

agent of the Employer. A Participant may elect to use a provider or hospital or other medical care provider

who is not designated by the Company, but the Plan will not pay benefits for any medical expenses charged

for such medical provider’s services.

4.3 Pre-Approval of Non-Emergency Services

Other than those required on an emergency basis, all medical procedures, including surgeries

and rehabilitation procedures must be pre-approved as Pre-Service claims by the Plan Administrator, or

Claims Administrator (if any) in order for the charges for such services to be eligible for payment under the

Plan. Contact information for the Claims Administrator (if any) is contained in the Schedule of Benefits.

4.4 Medical Treatment and Examination

The Participant must follow fully and completely the advice and course of medical treatment

prescribed by the treating Provider. The Participant must keep and attend all scheduled appointments to

fulfill the prescribed medical treatment plan. The Participant may be required to submit to examination by

a Provider as often as is reasonably necessary.

4.5 Exclusions

In addition to the other conditions and limitations on the payment of Plan benefits, no benefits shall

be provided under this Plan, or benefits shall immediately terminate, with respect to an Occurrence for any

Loss which the Plan Administrator determines resulted in whole or in part from, or contributed to by, or as

a natural and probable consequence of any of the following:

1. suicide or any attempt at suicide, self-inflicted or attempt at self-inflicted Bodily Injury, or auto-

eroticism, or any Bodily Injury that is intentionally aggravated by the Participant;

2. participation in:

a. a riot or act of civil disturbance;

b. an assault or a felony, except an assault committed in defense of the Employer’s business or

property;

c. war or act of war, whether declared or undeclared;

d. service in the military of any country or any civilian non-combatant unit serving with such forces;

3. voluntary payment made to a Participant that is not required by this Plan;

4. travel to and from work, except when:

a. the transportation is furnished as a part of employment, or is paid for by the Employer, or the

means of such transportation is under the Employer’s control; or

b. the Participant is directed in his or her Scope of Employment to proceed from one place to

another place other than the regular workplace;

5. an act of a third person intending to injure the Participant because of personal reasons and not

directed at the Participant as an Employee or because of his or her employment with the Employer;


6. voluntary participation in an off-duty recreational, social, or athletic activity not constituting part of

the Participant’s Scope of Employment;

7. claims arising from employment relationships including, without limitation, claims for any type of

employment discrimination, wrongful discharge, retaliatory discharge, coercion, sexual harassment,

Americans with Disabilities Act claims, and claims arising under the Labor Code of any state, and

all other claims affecting or arising from the employment relationship whether arising under state or

federal statutes or regulations or the common law (except for plan benefits awarded under actions

brought pursuant to §502(a)(1)(B) of ERISA; 29 U.S.C. §1132 (a)(1)(B));

8. liability under the Federal Employer’s Liability Act, United States Longshore and Harbor Workers’

Compensation Act, the Jones Act, or the Migrant Seasonal Agricultural Worker Protection Act;

9. charges incurred by a Participant for which he or she is entitled to receive benefits under any state

workers’ compensation law, occupational disease law, unemployment compensation disability

benefits law, or other similar law;

10. any diagnostic procedure, treatment, service or supply that is not Medically Necessary;

11. that part of any charge which is in excess of the Usual and Customary charge;

12. any Bodily Injury occurring while the Participant was under the influence of alcohol;

13. any Bodily Injury occurring while the Participant was under the influence of drugs, unless such

drugs were taken under the direction of and as prescribed by a Physician;

14. the use of or exposure to:

a. asbestos, asbestos fibers or asbestos products; or

b silicon or silica;

c. mold, microbes or fungus;

d. the hazardous properties of nuclear material except nuclear or radiological medicine which is

used for patient care and diagnosis, approved by OSHA, JCAHO, or the American Hospital

Accreditation Association, and not used for research purposes or clinical tests;

15. all statutory causes of action including, without limitation, Title VII of Civil Rights Act of 1964,

Civil Rights Act of 1991, Civil Rights Act of 1866, Age Discrimination in Employment Act,

Employee Retirement Income Security Act (except for plan benefits awarded under actions brought

pursuant to §502(a)(1)(B) of ERISA; 29 U.S.C. §1132 (a)(1)(B)), Fair Labor Standards Act,

Bankruptcy Code, Texas Commission on Human Rights, Texas Workers’ Compensation Act,

Railway Labor Act, and National Labor Relations Act;

16. infections of any kind, regardless of how contracted, except viral and bacterial infections that are

directly caused by an Occurrence;

17. travel or flight in or on (including getting in or out of, or on or off of) any vehicle used for aerial

navigation, if the Participant is:

a. flying in any aircraft that is rocket propelled;

b. flying in any aircraft being used for aerobatics; racing or an endurance test, crop dusting,

seeding, fertilizing or spraying; fighting a fire; any exploration, pipe or power line patrol;

the pursuit of animals or birds; aerial photography, banner towing or skywriting; or any

test or experimental usage;

c. flying when a special permit or waiver from the proper authority has to be issued;


d. riding as a passenger in any aircraft not intended or licensed for the transportation of

passengers;

e. performing, learning to perform or instructing others to perform as a pilot or crew

member of any aircraft;

f. riding as a passenger in an aircraft owned, leased or operated by the Employer;

18. any Pre-Existing Condition;

19. osteoarthritis, arthritis, and/or any other degenerative process of the joints, bones, tendons or

ligaments not a direct result of an Occurrence;

20. mental, nervous, emotional and/or psychological condition or disorder not a direct result of an

Occurrence;

21. the medical or surgical treatment of sickness, disease, mental incapacity or bodily infirmity, whether

the loss results directly or indirectly from the treatment;

22. stroke or cerebrovascular accident or event, cardiovascular accident or event, myocardial infarction

or heart attack, coronary thrombosis, or aneurysm that are not the direct result of an Occurrence;

23. any Bodily Injury that is feigned or fraudulent;

24. any Bodily Injury resulting from a Participant engaging in scuffling, horseplay, fighting or other

altercation;

25. the Participant’s failure or refusal to comply with any of the terms, conditions and requirements of

the Plan (regardless of whether such failure or refusal gave rise to the Occurrence or Bodily Injury).

4.6 Subrogation

If the Plan pays or provides benefits for a Bodily Injury that was caused by an act or omission of any

third person or organization, the Plan will be subrogated to all of the Participant’s and his or her

Beneficiaries’ rights of recovery to the extent of such benefits provided, or the reasonable value of services

or benefits provided by the Plan, including those rights of recovery against underinsured/uninsured

automobile insurance coverage or no fault insurance coverage, such as personal injury or medical payments

protection.

Upon receiving any benefits from the Plan, the Participant and his or her Beneficiaries are

considered to have assigned their rights of recovery to the Plan to the extent of such benefits. If the

Participant has retained an attorney to pursue the Participant’s rights of recovery, the Plan is not responsible

for paying any portion of the Participant’s attorney’s fees or costs. The Plan’s rights will not be affected by

any release that is entered into without the written consent of the Plan Administrator.

If the Participant or his or her Beneficiaries receive benefits under the Plan, the Participant or his or

her Beneficiaries must immediately notify the Plan Administrator of the name of any individual or

organization against whom the Participant or his or her Beneficiaries might have a claim as a result of the

Participant’s Bodily Injury (including any insurance company that provides coverage for the Participant).

For example, if the Participant is injured in an automobile accident, and the person who hit the Participant

was at fault, the person who hit the Participant (and his insurance company) is a person whose act or

omission has caused the Participant’s Bodily Injury. The Participant and his or her Beneficiaries must

cooperate with the Plan to provide information about the Participant’s Bodily Injury, and the Participant and

his or her Beneficiaries must agree to sign any necessary document for the Plan, and provide all requested


information sought by the Plan in furtherance of the Plan’s right to subrogate the Participant’s claim and/or

those of the Participant’s Beneficiaries. The Plan may:

• place a lien against a third party or insurance company to the extent benefits have been paid under

this Plan;

• bring an action on its own behalf, or on behalf of the Participant or his or her Beneficiaries, against

the person, organization or insurance company; and

• cease paying the Participant or his or her Beneficiaries benefits until they provide the Plan with the

documents necessary for the Plan to exercise its rights and privileges of subrogation.

4.7 Reimbursement

If the Plan pays or provides the Participant or his or her Beneficiaries benefits for a Bodily Injury

that was caused by an act or omission of a third person or organization, and/or if the Participant has sought

recovery from insurance or a third party, the Plan has the right to be repaid first for any benefits paid under

this Plan from any settlement, judgment, or insurance proceeds the Participant or his or her Beneficiaries

receive. The Plan has a right to reimbursement whether or not a portion of the settlement, judgment, or

insurance proceeds was identified as a reimbursement of medical expenses, lost wages or other types of

benefits provided by the Plan. The Participant and his or her Beneficiaries agree, by accepting benefits

under the Plan, to provide the Plan with a lien, to the extent the Plan has paid benefits, to be filed with the

responsible party or insurance company.

If the Participant or his or her Beneficiaries do not reimburse the Plan from any settlement,

judgment, or insurance proceeds, the Plan is entitled to reduce current or future medical or expense benefits

payable to the Participant or payable on the Participant’s behalf until the Plan has been fully reimbursed.

Anyone receiving benefits under the Plan agrees that their spouse, children, estate, legal

representatives, heirs, dependents and wrongful death beneficiaries will be bound to the subrogation and

reimbursement provisions set forth above. By accepting benefits under this Plan, the Participant and his or

her Beneficiaries expressly disclaim the made whole and common fund doctrines.

4.8 Other Coverage and Coordination of Benefits

If any Participant is covered under one or more other plans, including, but not limited to, insurance,

indemnity or reimbursement, the benefits payable for expenses under this Plan shall apply only in excess of

the other contract of insurance, indemnity or reimbursement.

SECTION V

PLAN ADMINISTRATION

5.1 Plan Administrator

The Plan Administrator is responsible for administration of the Plan. The Plan Administrator shall

be the person or persons, individual, corporate or otherwise, designated in writing by the Company. In the

event that the Company does not designate a Plan Administrator, the Company will act as the Plan

Administrator. An individual Plan Administrator will be indemnified by the Participant’s Employer against

any and all liabilities arising by reason of an act or failure to act made in good faith and pursuant to the

provisions of the Plan. The Company may remove a designated Plan Administrator at any time and either

act as the Plan Administrator or name a successor. During any period in which the selection of an

Administrator is pending, the Company will act as the Plan Administrator.


ERISA requires that certain persons who are deemed “fiduciaries,” as defined in Section 3(21) (A)

of ERISA, be designated as “Named Fiduciaries” in the Plan. The Plan Administrator is herby designated

the Named Fiduciary and shall have only the powers, duties, and responsibilities specified by the Plan or

delegated by the Company. The Named Fiduciary may designate another person or persons to carry out

some of the Named Fiduciary’s duties. The Plan Administrator and each person designated by the Named

Fiduciary will be furnished a copy of the Plan, and their agreement to carry out their responsibilities will be

made in writing. No Named Fiduciary shall be liable for any act or omission of any person who is

designated to carry out fiduciary responsibilities except to the extent that the Named Fiduciary did not act in

accordance with the standard contained in Section 404(a) of ERISA with respect to allocation or

designation, continuation thereof, or implementation or establishment of, the allocation or designation

procedures.

5.2 Duties of the Plan Administrator

The Plan Administrator shall have all the powers necessary or appropriate to accomplish his or her

duties under the Plan. The Plan Administrator shall have the discretionary power and authority to interpret

the Plan to determine, among other matters, eligibility for participation, whether a Bodily Injury qualifies

for benefits under the Plan, whether charges are Eligible Charges, and whether a Participant has complied

with Plan requirements. Except as required by ERISA, all determinations made by the Plan Administrator

shall be final and not subject to review by anyone. The Plan Administrator shall interpret the Plan to

ascertain the purpose of the provision or provisions in question and attempt to reasonably make application

of the Plan with respect to the individual rights of the Participant. During administration of the Plan, the

Plan Administrator will exercise his or her authority in a non-discriminatory manner whenever he or she is

required to make a discretionary decision so that all similarly situated Participants will receive substantially

the same treatment. The duties of the Plan Administrator shall include, but are not limited to:

1. Interpreting and construing the provisions of the Plan, deciding any disputes which may arise

relative to the rights of a Participant or his or her Beneficiary under the Plan, and directing the

administration of the Plan;

2. Maintenance of complete and accurate records of all Plan transactions in a manner necessary for

proper administration of the Plan and to meet any applicable disclosure and reporting requirements

of ERISA;

3. Adoption of rules and procedures necessary for efficient administration of the Plan provided that the

rules and procedures are consistent with the terms of the Plan;

4. Reviewing claims and rendering decisions on claims for benefits under the Plan;

5. Determining the eligibility of a claim for benefits under the Plan;

6. Enforcing the terms of the Plan and the rules or procedures that are adopted;

7. Ascertaining that the Participant or their Beneficiary received the benefits to which they were

entitled under the Plan; and

8. Employing or appointing agents to manage or assist in the management of claims.

5.3 Duties of a Claims Administrator

The Plan Administrator may appoint a third party as a Claims Administrator. The services and

assistance of the third party Claims Administrator are provided pursuant to an agreement between the

Employer and/or Company and the third party.


5.4 Notification of Adverse Benefit Determination

In general, if any claim for Disability Benefits or Medical Benefits (including Urgent Care,

Concurrent Care, Pre-Service Claim and Post-Service Claim) brought by a Participant or a Participant’s

authorized representative under the Plan (individually and collectively a “Participant”) is:

1. wholly or partially denied; or

2. the Plan Administrator otherwise makes an adverse benefit determination as defined in the

Department of Labor regulations regarding claims procedures (in either case, referred to

herein as an “adverse benefit determination”);

The Plan Administrator will notify the Participant of the adverse benefit determination within a reasonable

period of time.

5.5 Content of Initial Notification of Adverse Benefit Determination

The initial notification of any adverse benefit determination must be in writing and may be delivered

electronically. The initial notification of an Urgent Care claim may be provided orally, provided that a

written notification is furnished to the participant not later than 3 days after the oral notification. The

notification shall be written in a manner to be understood by the Participant and should include:

1. the specific reason or reasons for the adverse determination;

2. reference to the specific Plan provisions on which the determination was based;

3. a description of any additional material or information necessary for the Participant to perfect the

claim and an explanation of why such material or information is necessary;

4. a description of the Plan’s review procedures, including a statement of the Participant’s right to

bring civil action under section 502(a) of ERISA following an adverse determination on review;

5. a description of any internal rule, guideline, protocol, or other criterion relied upon to make the

adverse determination, and that a copy of such will be provided free of charge to the Participant

upon request;

6. an explanation of the scientific or clinical judgment for determining an adverse benefit

determination based on the Plan’s limitations or exclusions for Medically Necessary or experimental

treatment; and

7. in the case of an adverse benefit determination concerning a claim involving Urgent Care, a

description of the expedited review process applicable to such claims.

5.6 Timing of Initial Notification of Adverse Benefit Determination

The initial notification of an adverse benefit determination should be provided as soon as possible

after receipt of the claim, but not later than the time frames specified as follows:

1. For Urgent Care claims, the initial notification must be made within 72 hours. If an Urgent Care

claim requires additional information in order for the Plan Administrator to render a decision, the

Plan Administrator must notify the Participant of the specific information necessary to complete the

claim within twenty-four (24) hours of receipt of the Urgent Care claim. The Plan Administrator

will permit the Participant at least forty-eight (48) hours to provide the specific information. The

Plan Administrator must render a decision on an Urgent Care claim that required additional

information no later than forty-eight (48) hours after the earlier of the receipt of the additional

information or the end of the time period the Plan Administrator gave the Participant to provide the

additional information.

2. For Pre-Service claims, the initial notification must be made within 15 days. In the event

circumstances outside of the Plan Administrator’s control require an extension of the period for

rendering a decision and provided the Plan Administrator notifies the Participant of the need for the


extension prior to the expiration of the initial 15-day period, the period for determining the

eligibility of the requested care may be extended one time for up to fifteen (15) days. If such an

extension is necessary due to a failure of the Participant to submit the information necessary to

decide the claim, the notice of extension shall specifically describe the required information, and the

Participant shall be afforded at least 45 days from receipt of the notice within which to provide the

specified information. In the event a Participant is notified of the need for additional information,

the time period for processing the claim will not begin to run again until the additional information

is received from the Participant or the Participant’s authorized representative.

3. For Post-Service claims the initial notification must be made within 30 days.

4. For Disability claims, the initial notification must be made within 45 days. In the case of a claim

regarding Disability benefits, if the Plan Administrator determines that an extension of time for

processing the claim is necessary due to matters beyond its control, the Plan Administrator may

extend the initial 45-day period for up to 30 days provided it gives the Participant written notice of

such extension within the initial 45-day period. If, prior to the end of the first 30-day extension

period, the Plan Administrator determines that, due to matters beyond its control, a decision cannot

be rendered within that extension period, such determination period may be extended for a second

period of up to an additional 30 days provided it gives the Participant written notice of such

extension within the first 30-day extension period. The extension notice shall indicate the special

circumstances requiring an extension of time and the date by which the Plan Administrator expects

to render the determination. The extension notices for processing a claim for Disability benefits will

contain:

a) the special circumstances requiring an extension of time,

b) the date by which the Plan Administrator expects to render a decision,

c) a specific explanation of the standards on which entitlement of a benefit is based,

d) the unresolved issues that prevent a decision on the claim, and

e) the additional information needed to resolve those issues.

The Participant will be afforded at least 45 days within which to provide the additional specified

information. In the event a Participant is notified of the need for additional information, the time

period for processing the claim will not begin until the additional information is received from the

Participant or his or her authorized representative.

5.7 Participant’s Appeal of an adverse benefit determination

A Participant may appeal an adverse benefit determination within 180 days after the date on which a

Participant receives a written notice of the determination. The appeal must be in writing and should include

comments, documents, records, and other information relating to the claim for benefits that the Participant

desires the Review Committee to consider for a review of the adverse benefit determination.

The Participant, upon request and free of charge, may have reasonable access to, and copies of all

documents, records, and other information relevant to the Participant’s claim for benefits.

5.8 Review of adverse benefit determination

The appeal for an adverse benefit determination will be reviewed and a decision rendered no later

than 60 days after the request for review is received by the Review Committee, unless the Review

Committee determines that special circumstances require an extension of time for processing the claim. If

the Review Committee determines that an extension of time for processing is required, written notice of the

extension shall be furnished to the Participant prior to the termination of the initial 60-day period. In no

event shall such extension exceed a period of 60 days from the end of the initial period. The extension


notice shall indicate the special circumstances requiring an extension of time and the date by which the

Review Committee expects to render the determination on review.

The Review Committee will review the appeal of a denied Urgent Care Claim as soon as possible,

taking into account the medical exigencies, but not later than seventy-two (72) hours of receipt of the

appeal, and render a decision on the appeal within such time period.

The Review Committee will provide a full and fair review of the claim, taking into account all

comments, documents, records, and other information submitted by the Participant relating to the claim,

without regard as to whether such information was submitted or considered in the initial benefit

determination.

In conducting its review of an adverse benefit determination, the Review Committee will not afford

deference to the initial adverse benefit determination, and the review will not be conducted by the

individual who made the initial adverse benefit determination or by the subordinate of such individual.

In reviewing an adverse benefit determination that is based in whole or in part on a medical

judgment, including determinations, if applicable, with regard to whether a particular treatment, drug, or

other item is experimental, investigational or not Medically Necessary or appropriate, the Review

Committee will consult with a health care professional who has appropriate training and experience. Any

such health care professional will not be the individual who was consulted in connection with the initial

adverse benefit determination or the subordinate of such individual.

In reviewing an adverse benefit determination on a claim for benefits, the Review Committee will

provide the Participant with the identification of medical or vocational experts whose advice was obtained

on behalf of the Review Committee in connection with the appeal of the Participant’s adverse benefit

determination, regardless of whether the advice was relied upon in making the benefit determination.

In reviewing an adverse benefit determination on an Urgent Care claim, the Review Committee will

provide the Participant with an expedited review process pursuant to which a request for an expedited

appeal of an adverse benefit determination may be submitted orally or in writing by the Participant, and all

necessary information, including the Review Committee’s benefit determination on review shall be

transmitted between the Plan and the Participant by telephone, facsimile, or other available similarly

expeditious method.

Subject to the foregoing, the Review Committee may, in its discretion, hold a hearing to make a

benefit determination.

5.9 Notification of benefit determination on review

The Review Committee will notify the Participant of its decision on the appeal in writing. The

Review Committee will notify the Participant of its decision within a reasonable period, but not later than 5

days after the decision is made.

The decision of the Review Committee on an appeal claim for Disability Benefits or Medical

Benefits (including Urgent Care, Concurrent Care, Pre-Service and Post-Service claims) will be in writing,

and will be written in a manner to be understood by the Participant, and will include:

1. the specific reason or reasons for the adverse determination;


2. reference to the specific Plan provisions on which the determination was based;

3. statement that the Participant is entitled to receive upon request and free of charge, reasonable

access to, and copies of all documents, records, and other information relevant to the Participant’s

claim for benefits;

4. if an internal rule, guideline, protocol, or other criterion was relied upon to make the adverse

determination, a statement that the Participant is entitled to a copy of such rule and it will be

provided free of charge upon request;

5. if the determination was based upon the Plan’s limitations or exclusions for Medically Necessary or

experimental treatment, it has been so stated, and a detailed scientific or clinical explanation of this

judgment will be provided free of charge upon request;

6. a statement that the Participant may have other voluntary alternative dispute resolution options, such

as mediation and one way to find out what may be available is to contact the local U.S. Department

of labor or the Plan Administrator;

7. a statement that the Participant has the right to bring civil action under section 502(a) of ERISA

following an adverse determination on review.

The procedures set forth in this Section are intended to comply with the provisions of ERISA and

the regulations adopted thereunder applicable to “employee welfare benefit plans,” as that term is defined in

ERISA, which are solely funded by employers. To the extent they do not comply with ERISA, any

amendment thereto, or regulation subsequently adopted under ERISA, the Plan Administrator has the

authority to deviate from the terms of this Plan to comply with ERISA and its applicable regulations.

5.10 Limitation on Time to Bring Civil Action under ERISA.

No legal action arising from an adverse benefit determination can be brought under ERISA after the

latter of one year from the filing of the claim, or 45 days from the final decision of the Review Committee.

SECTION VI

AMENDMENT AND TERMINATION

6.1 Amendment to the Plan

The provisions of this Plan may be amended at any time and from time to time by the Company;

provided, however, that no amendment shall deprive any Participant or Beneficiary of any of the benefits to

which he or she is entitled under this Plan and which have become payable under the terms of this Plan.

Each amendment shall be approved by resolution of the governing authority of the Company, and unless

expressly provided otherwise, all Employers shall be bound by any amendment adopted. Each Participant

shall be sent a copy of any amendment to, or modification of, the Plan and shall be presumed to have

consented thereto unless the Participant withdraws as a Participant in the Plan, in writing, within 30 days

after receiving written notice of the modification or amendment.

6.2 Termination of Plan

Any Employer (including the Company) may elect, at any time and without advance notice or delay,

to terminate its adoption of this Plan and re-enter the statutory workers’ compensation system of the State

of Texas. Furthermore, this Plan shall automatically terminate if state law is changed such that it becomes

unlawful to do business without subscribing to statutory workers’ compensation and/or for such other

reasons that may make the Plan null and void. In the event the Plan is terminated, the benefits payable at

the time of termination shall continue to be paid pursuant to the provisions of the Plan at the time of

termination.


SECTION VII

ADOPTION OF PLAN BY EMPLOYERS

7.1 Adoption Procedure

Any affiliate, subsidiary, or entity owned and controlled by the Company may become an Employer

under the Plan provided that:

1. the governing authority of the Company approves the adoption of the Plan by the subsidiary or

affiliate and designates such subsidiary or affiliate as an Employer for purposes of the Plan;

2. the subsidiary or affiliate adopts the Plan together with all amendments in effect;

3. the subsidiary or affiliate agrees to be bound by any other terms and conditions which may be

required by the Company, provided that such terms and conditions are not inconsistent with the

purposes of the Plan; and

4. the subsidiary or affiliate is an insured under the policy of insurance (if any) that funds benefits

payable under the Plan

7.2 Effect of Adoption by Employer

Any subsidiary or affiliate of the Company which adopts the Plan pursuant to this Section shall be

deemed to be an Employer for all purposes hereunder unless otherwise specified by resolutions of the

governing authority of the Company that designated the subsidiary or affiliate as an Employer.

7.3 Obligation of Employer

Each Employer shall pay any amounts necessary to fund any benefits hereunder for its Participants,

but not for any Participants who are employees of another Employer. Each Employer shall keep records

and furnish the information with respect to its Employees as the Plan Administrator shall require. Each

Employer may be required to pay its pro rata share of the costs of administering this Plan and benefits

hereunder.

SECTION VIII

MISCELLANEOUS 8.1 Non-alienation of Benefits

None of the payments, benefits, or rights of any Participant shall be subject to any claim of any

creditor, and, in particular, to the fullest extent permitted by law, all such payments, benefits, and rights

shall be free from attachment, garnishment, trustee's process, or any other legal or equitable process

available to any creditor of such Participant. No Participant shall have the right to alienate, anticipate,

pledge, encumber, or assign any of the benefits or payments which he or she may expect to receive,

contingently or otherwise, under this Plan.

8.2 No Contract of Employment

Neither the establishment of this Plan nor any modification thereof, nor the creation of any fund,

trust or account, nor the payment of any benefits shall be construed as giving any Employee, or any person

whomsoever, the right to be retained in the service of the Employer, and all Employees shall remain subject

to discharge to the same extent as if the Plan had never been adopted. In short, this Plan in no way changes

the at will employment status of any Participant or Employee.


8.3 Severability of Provisions

If any provision of the Plan shall be held invalid or unenforceable, such invalidity or

unenforceability shall not affect any other provision hereof, and this Plan shall be construed and enforced as

if such provision had not been included.

8.4 Heirs, Assigns and Personal Representatives

This Plan shall be binding upon the heirs, executors, administrators, successors, and assigns of the

parties, including each Participant and Beneficiary, present and future.

8.5 Headings and Captions

The headings and captions herein are provided for reference and convenience only, and shall not be

considered part of the Plan, and shall not be used in the construction of the Plan.

8.6 Gender and Number

Except where otherwise clearly indicated by context, the masculine and the neuter shall include the

feminine and the neuter, and the singular shall include the plural, and vice-versa.

8.7 Controlling Law

This Plan shall be construed and enforceable according to the laws of the State of Texas to the

extent not preempted by Federal law, which shall otherwise control. This Plan is an unfunded “employee

welfare benefit plan” as defined in Section 3 (1) of' ERISA, as a plan maintained for the purpose of

providing medical, surgical, or hospital care and other benefits in the event of Bodily Injury.

8.8 Title to Assets

No Participant shall have any right to, or interest in, any assets of the Company or any Employer

upon termination of his or her employment or otherwise, except as provided from time to time under this

Plan.

8.9 Expenses

All expenses for the management and administration of the Plan shall be paid by the Employer.

8.10 Voluntary Payments; No Admission of Liability

Establishment of this Plan by the Employer is voluntary and the Plan may be prospectively

terminated or amended at any time and for any reason. Payments under this Plan shall not in any way

constitute an admission of liability or responsibility by the Employer for Bodily Injury.

8.11 Information to Be Furnished

Participants shall provide the Company, Employer, and Plan Administrator with such information

and evidence, and shall sign such documents, as may reasonably be requested from time to time for the

purpose of administration of the Plan. Failure to do so will result in forfeiture of all benefits under this

Plan.

8.12 Limitation of Right

Neither the establishments of the Plan, nor any amendment thereof, nor the payment of any benefits,

will be construed, as giving to any Participant or other person any legal or equitable right against the

Company, the Employer, nor the Plan Administrator, except as provided herein.


8.13 Not a Policy of Workers’ Compensation Insurance

THIS IS NOT A POLICY OF WORKERS’ COMPENSATION INSURANCE. THE EMPLOYER

DOES NOT BECOME A SUBSCRIBER TO THE WORKERS’ COMPENSTATION SYSTEM BY

ADOPTING THS PLAN, AND IF THE EMPLOYER IS A NON-SUBSCRIBER, THE EMPLOYER

LOSES THOSE BENEFITS WHICH WOULD OTHERWISE ACCRUE UNDER THE WORKERS’

COMPENSATION LAWS. THE EMPLOYER MUST COMPLY WITH THE WORKERS’

COMPENSATION LAWS AS IT PERTAINS TO NON-SUBSCRIBERS AND THE REQUIRED

NOTIFICATIONS THAT MUST BE FILED AND POSTED.

IN WITNESS WHEREOF, this Plan has been executed by the Company this ______ day of __________,

201_, to be effective as of ________________________.

Company Name

By:_____________________________________

Signature and Title

1

03/15/12 Midlands SPD (w OD/CT)

SUMMARY PLAN DESCRIPTIONSUMMARY PLAN DESCRIPTIONSUMMARY PLAN DESCRIPTIONSUMMARY PLAN DESCRIPTION [ABC COMPANY][ABC COMPANY][ABC COMPANY][ABC COMPANY] WORKPLACEWORKPLACEWORKPLACEWORKPLACE INJURY BENEFIT PLANINJURY BENEFIT PLANINJURY BENEFIT PLANINJURY BENEFIT PLAN

IntroductionIntroductionIntroductionIntroduction

[ABC COMPANY][ABC COMPANY][ABC COMPANY][ABC COMPANY] (the “Company”), is pleased to sponsor an occupational injury benefit plan, known as the “[[[[ABC COMPANY]ABC COMPANY]ABC COMPANY]ABC COMPANY] Workplace Injury Benefit Plan” (the “PlanPlanPlanPlan”), for participating e e e employeesmployeesmployeesmployees whose principal place of employment and residence, is in the State of Texas. (If youyouyouyou meet the definition of an employee employee employee employee and meet the requirements for participation in the PlanPlanPlanPlan set forth in Part I(B), below, youyouyouyou are a participantparticipantparticipantparticipant in the PlanPlanPlanPlan). Capitalized terms, and those in bold font, have the meaning given to them in Part II of this Summary Plan Description (this “SPD”). This SPD only highlights the more important provisions of the PlanPlanPlanPlan, and does not review all PlanPlanPlanPlan provisions. If there is a conflict between a statement in this SPD and the PlanPlanPlanPlan, the terms of the PlanPlanPlanPlan control. You may request a

full copy of the PlanPlanPlanPlan from the Plan AdministratorPlan AdministratorPlan AdministratorPlan Administrator at any time.

The PlanPlanPlanPlan will replace in its entirety any previous benefit plans covering emploemploemploemployee yee yee yee occupational injuries or illnesses with respect to occurrencesoccurrencesoccurrencesoccurrences arising on or after the PlanPlanPlanPlan Effective DateEffective DateEffective DateEffective Date set forth in the Schedule of Benefits Schedule of Benefits Schedule of Benefits Schedule of Benefits that forms a part of the Plan Plan Plan Plan and this SPD. The PlanPlanPlanPlan YYYYearearearear is the 12-month period January 1 through December 31, although the first PlanPlanPlanPlan YYYYear ear ear ear begins on the PlanPlanPlanPlan Effective DateEffective DateEffective DateEffective Date in the Schedule of BenefitsSchedule of BenefitsSchedule of BenefitsSchedule of Benefits.

The Company is the Plan AdministratorPlan AdministratorPlan AdministratorPlan Administrator. The interpretation of the PlanPlanPlanPlan by the Plan AdministratorPlan AdministratorPlan AdministratorPlan Administrator will be

conclusive as to all matters. The Plan Plan Plan Plan AdministratorAdministratorAdministratorAdministrator is responsible for providing youyouyouyou with information about the PlanPlanPlanPlan, and has sole authority and discretion to make determinations regarding rights and benefits under the PlanPlanPlanPlan. The Plan Plan Plan Plan AdministratorAdministratorAdministratorAdministrator also has the primary authority for filing the various reports, forms, and returns with the U.S. Department of Labor. If an insurance company reimburses benefits to CompanyCompanyCompanyCompany or pays benefits under the terms of an insurance policy on behalf of an eeeemployermployermployermployer under this PlanPlanPlanPlan, the insurance company will administer those claims and payments. The name of the person designated as agent for service of legal process and the address where legal process may be served upon the PlanPlanPlanPlan is set forth in the Schedule of Benefits.Schedule of Benefits.Schedule of Benefits.Schedule of Benefits.

PART IPART IPART IPART I GeneralGeneralGeneralGeneral

A.A.A.A. What is the purpose of the Plan? What is the purpose of the Plan? What is the purpose of the Plan? What is the purpose of the Plan? The purpose of the PlanPlanPlanPlan is to provide payment for medical expenses, wage replacement benefits during a

period of disabilitydisabilitydisabilitydisability, as well as benefits in the event of Accidental Death, Dismemberment and Loss of Use, for participants participants participants participants who sustain bodily injurybodily injurybodily injurybodily injury in their scope of employmentscope of employmentscope of employmentscope of employment. Establishment and maintenance of the PlanPlanPlanPlan is voluntary, and payments under the PlanPlanPlanPlan do not in any way constitute an admission of liability or responsibility by the

employeremployeremployeremployer for any workplace injury youyouyouyou may suffer. Nothing in the PlanPlanPlanPlan gives youyouyouyou the right to be retained in the service of an employeremployeremployeremployer for any period of time, and youryouryouryour employment remains subject to termination to the same extent as if the PlanPlanPlanPlan had never been adopted.

B.B.B.B. Am I eligible to participate in the PlanAm I eligible to participate in the PlanAm I eligible to participate in the PlanAm I eligible to participate in the Plan???? YouYouYouYou are eligible to participate in the Plan if youyouyouyou were an employeeemployeeemployeeemployee on the effective dateeffective dateeffective dateeffective date. If not, youyouyouyou will be eligible to participate in the PlanPlanPlanPlan if youyouyouyou otherwise meet the definition of an employee employee employee employee as of the later of: (1) the date

youyouyouyou were employed by an ememememployerployerployerployer; or (2) the date on which youyouyouyou are classified as an employee employee employee employee by an employeremployeremployeremployer. The PlanPlanPlanPlan, including its subrogation and recoupment provisions, are binding on youyouyouyou and youryouryouryour heirs, executors, administrators, successors, and assigns, including each of youryouryouryour beneficiarbeneficiarbeneficiarbeneficiariesiesiesies, present and future. CCCC.... How are the benefits funded?How are the benefits funded?How are the benefits funded?How are the benefits funded? PlanPlanPlanPlan benefits are funded solely by the employeremployeremployeremployers s s s which have adopted the PlanPlanPlanPlan. The Plan Plan Plan Plan does not accumulate assets to fund PlanPlanPlanPlan benefits. There is no PlanPlanPlanPlan trust fund. The CompanyCompanyCompanyCompany may, at its sole election, obtain

and pay for one or more insurance policies to indemnify it or pay benefits on its behalf. YouYouYouYou have no rights to be a party to such insurance policies. YouYouYouYou have no right or obligation to make any premium payment, contribution to the PlanPlanPlanPlan, or payment of PPPPlan lan lan lan benefits. YouYouYouYou have no right to or interest in any assets of the CompanyCompanyCompanyCompany or any employeremployeremployeremployer, except as provided from time to time under this PlanPlanPlanPlan. Neither establishment nor amendment of the PlanPlanPlanPlan, nor the payment of any benefits, will be construed as giving youyouyouyou or other person any legal or equitable right against the CompanyCompanyCompanyCompany, the employeremployeremployeremployer, or the Plan AdministratorPlan AdministratorPlan AdministratorPlan Administrator, except as provided in the PlanPlanPlanPlan. All benefits paid under the PlanPlanPlanPlan will be considered made by the CompanyCompanyCompanyCompany or other eeeemployermployermployermployer and will not be considered payment from a “collateral

source”. All benefits paid under this PlanPlanPlanPlan will be offset against any alleged liability of the eeeemployermployermployermployerssss the CompanyCompanyCompanyCompany, and their officers, directors, and agents to youyouyouyou and/or your beneficiariyour beneficiariyour beneficiariyour beneficiarieseseses arising out of an ooooccurrenceccurrenceccurrenceccurrence. No payment hereunder will be deemed a fringe benefit.

2


DDDD.... How long How long How long How long will the Plan remain in effect? the Plan remain in effect? the Plan remain in effect? the Plan remain in effect?

The CompanyCompanyCompanyCompany reserves the right to terminate or amend the PlanPlanPlanPlan at any time or as often as the Company Company Company Company deems appropriate. An employer employer employer employer which adopts the PlanPlanPlanPlan may terminate its participation in the PlanPlanPlanPlan at any time it

sees fit. This Plan Plan Plan Plan is automatically terminated as to the CompanyCompanyCompanyCompany or an employer employer employer employer on the date which the CompanyCompanyCompanyCompany and/or employer employer employer employer become subscribers under the Texas Workers Compensation Act. Termination or amendment of the PlanPlanPlanPlan will not affect the payment of benefits to which youyouyouyou became entitled due to an occurrenceoccurrenceoccurrenceoccurrence before the effective date of the termination or amendment of the PlanPlanPlanPlan. However, even if youyouyouyou are eligible to participate in the PlanPlanPlanPlan, no benefits will be paid with respect to an occurrence occurrence occurrence occurrence which occurs after the earlier of: (1) the date on which the PlanPlanPlanPlan is terminated; (2) the date on which youyouyouyou are no longer an employeeemployeeemployeeemployee; or (3) the date on which youyouyouyou provide written notice of withdrawal from the Plan Plan Plan Plan to the Plan AdministratorPlan AdministratorPlan AdministratorPlan Administrator.

EEEE.... When are benefits offered through the Plan?When are benefits offered through the Plan?When are benefits offered through the Plan?When are benefits offered through the Plan? YouYouYouYou are eligible for payment of benefits if and when youyouyouyou sustain a bodily injurybodily injurybodily injurybodily injury as the result of an occurrenceoccurrenceoccurrenceoccurrence

while the PlanPlanPlanPlan is in effect. The date of an occurrenceoccurrenceoccurrenceoccurrence is important because, to be eligible for benefits under the PlanPlanPlanPlan, youyouyouyou must promptly report each occurrenceoccurrenceoccurrenceoccurrence to youryouryouryour supervisor (see Part IV(A), below).

None of youryouryouryour benefits will be subject to any claim of any creditor, and, in particular, the benefits and rights youyouyouyou are entitled to under the PlanPlanPlanPlan will be free from attachment, garnishment, trustee's process, or any other legal or

equitable process available to any of youryouryouryour creditors. YouYouYouYou also do not have the right to alienate, anticipate, pledge, encumber, or assign any of the benefits or payments to which youyouyouyou may expect to receive, contingently or otherwise, under the PlanPlanPlanPlan.

PART IPART IPART IPART IIIII DefinitionsDefinitionsDefinitionsDefinitions

The terms in bold below will have the following meanings when they appear in bold or are capitalized in this

SPD and in the accompanying Schedule of BenefitsSchedule of BenefitsSchedule of BenefitsSchedule of Benefits: AccidentAccidentAccidentAccident or or or or AccidentAccidentAccidentAccidentalalalal means an event that occurs within youryouryouryour Scope of EmploymentScope of EmploymentScope of EmploymentScope of Employment and:

1. was unintended, unanticipated, unforeseen, unplanned and unexpected; 2. occurred at a specifically identifiable time and place; 3. occurred by chance or from unknown causes; and 4. directly (independent of sickness, disease, mental incapacity, bodily infirmity or any other cause) resulted in

Bodily InjuryBodily InjuryBodily InjuryBodily Injury.

Appropriate CareAppropriate CareAppropriate CareAppropriate Care means the determination of an accurate and medically supported diagnosis and ongoing medical treatment and care of youryouryouryour condition or ddddisabilityisabilityisabilityisability by a ProviderProviderProviderProvider that conforms to generally-accepted medical standards, including frequency of treatment and care.

Base Annual SalaryBase Annual SalaryBase Annual SalaryBase Annual Salary means the amount of compensation paid to you you you you by the EmployerEmployerEmployerEmployer, including overtime and commissions as reported to the Internal Revenue Service. If you you you you receive compensation paid by commission, youryouryouryour Base Annual SalaryBase Annual SalaryBase Annual SalaryBase Annual Salary will be the average annual earnings youyouyouyou received from the EmployerEmployerEmployerEmployer over the three year period immediately preceding the date of the OccurOccurOccurOccurrrrrenceenceenceence. If you you you you receive compensation by commission and have less than three years employment history with the EmployerEmployerEmployerEmployer, your your your your average monthly earnings will be calculated and multiplied by 12 to calculate the Base Annual SalaryBase Annual SalaryBase Annual SalaryBase Annual Salary. The maximum Base Annual SalaryBase Annual SalaryBase Annual SalaryBase Annual Salary that will be recognized for calculation of a Loss for purposes of the Accidental Death, Dismemberment and Loss of Use Benefit is $60,000, regardless of

whether youyouyouyou have a Base Annual SalaryBase Annual SalaryBase Annual SalaryBase Annual Salary in excess of this sum. Beneficiary Beneficiary Beneficiary Beneficiary means the person or persons eligible for death benefits as determined in the following priority:

1. if youyouyouyou have an Eligible Spouse, all death benefits will be paid to your your your your Eligible Spouse. 2. if yyyyou ou ou ou do not have an Eligible Spouse, death benefits will be paid in equal shares to your your your your Eligible Children. If

an Eligible Child has predeceased youyouyouyou, death benefits that would have been paid to that child if he or she had lived longer than you you you you will be paid in equal shares per stirpes to the children of such deceased child. For purposes of this definition of “Beneficiary”: a. Eligible Spouse Eligible Spouse Eligible Spouse Eligible Spouse means youryouryouryour surviving spouse, recognized by a marriage certificate issued under the laws

of the State of Texas or similar government authority, or by a Texas court decree of common law marriage (obtained at such person’s sole initiative and expense; and.

b. Eligible ChildEligible ChildEligible ChildEligible Child means youryouryouryour surviving child, whether by blood, marriage, or legal adoption, if the child is: i. under 18 years of age;

3


ii. less than 25 years of age and enrolled as a full-time student in an accredited educational institution; or

iii. because of a physical or mental handicap, your your your your dependent (as determined in accordance with the support criteria set forth in Section 152 of the Internal Revenue Code and such other rules as the

Plan AdministratorPlan AdministratorPlan AdministratorPlan Administrator may prescribe)

at the time of the youryouryouryour death from a Bodily InjuryBodily InjuryBodily InjuryBodily Injury suffered in your Scope of Employmentyour Scope of Employmentyour Scope of Employmentyour Scope of Employment. Benefit PeriodBenefit PeriodBenefit PeriodBenefit Period and Maximum Benefit Period Maximum Benefit Period Maximum Benefit Period Maximum Benefit Period mean the maximum number of weeks (as specified in the Schedule of Schedule of Schedule of Schedule of BenefitsBenefitsBenefitsBenefits) for which benefits are payable, beginning the day the OccurrenceOccurrenceOccurrenceOccurrence giving rise to youryouryouryour Bodily InjuryBodily InjuryBodily InjuryBodily Injury is sustained.

Bodily InjuryBodily InjuryBodily InjuryBodily Injury means an identifiable damage or harm to the physical structure of the body, including death, sustained solely as the result of an AccidentAccidentAccidentAccident occurring within your Scope of EmploymentScope of EmploymentScope of EmploymentScope of Employment. Bodily InjuryBodily InjuryBodily InjuryBodily Injury includes Cumulative Cumulative Cumulative Cumulative TraumaTraumaTraumaTrauma and Occupational DiseaseOccupational DiseaseOccupational DiseaseOccupational Disease. Chiropractic CareChiropractic CareChiropractic CareChiropractic Care means treatment or therapy provided by a person appropriately licensed to provide chiropractic

services, who is not a member of youryouryouryour Immediate FamilyImmediate FamilyImmediate FamilyImmediate Family or household. Code Code Code Code means the Internal Revenue Code of 1986, as amended from time to time. References to any section of the Code will include any successor provision thereto. CompanyCompanyCompanyCompany has the meaning given to it in the first paragraph of this SPD.

Concurrent Care DecisionConcurrent Care DecisionConcurrent Care DecisionConcurrent Care Decision means a decision by the Plan AdministratorPlan AdministratorPlan AdministratorPlan Administrator to terminate or reduce (other than by PlanPlanPlanPlan amendment or termination) a previously-approved course or number of treatments to be provided to you you you you over a period of time, before the end of such period of time or number of treatments. Continuous CareContinuous CareContinuous CareContinuous Care means the weekly, monthly, bi-monthly or quarterly monitoring and/or evaluation of youryouryouryour ddddisabilityisabilityisabilityisability by a ProviderProviderProviderProvider.

CCCCumulative Traumaumulative Traumaumulative Traumaumulative Trauma means an identifiable damage or harm to the physical structure of the body, including death, that is caused by the combined effect of repetitive physical activities extending over a period of time and which is: (1) is diagnosed by a PhysiPhysiPhysiPhysiciancianciancian; (2) youryouryouryour last day of last performance of the activities causing the Cumulative Cumulative Cumulative Cumulative TraumaTraumaTraumaTrauma occurred while the PlanPlanPlanPlan was in effect; and (3) the Cumulative TraumaCumulative TraumaCumulative TraumaCumulative Trauma was caused directly and independently of all other causes by youryouryouryour Scope of EmploymentScope of EmploymentScope of EmploymentScope of Employment. All CumCumCumCumulative Traumaulative Traumaulative Traumaulative Traumassss suffered by youyouyouyou are deemed to be a single Cumulative TraumaCumulative TraumaCumulative TraumaCumulative Trauma.

DisabledDisabledDisabledDisabled or DisabilityDisabilityDisabilityDisability means a Bodily InjuryBodily InjuryBodily InjuryBodily Injury resulting from an OccurOccurOccurOccurrrrrenceenceenceence which prevents youyouyouyou from performing the duties for which youyouyouyou are employed by the EmployerEmployerEmployerEmployer, or prevents yoyoyoyouuuu from performing the duties of any occupation for which youyouyouyou are qualified to perform by reason of education, training or experience. The ParticipantParticipantParticipantParticipant must be under Continuous CareContinuous CareContinuous CareContinuous Care during the period of DisabilityDisabilityDisabilityDisability. Effective DateEffective DateEffective DateEffective Date means the Effective DateEffective DateEffective DateEffective Date of PlanPlanPlanPlan specified in the Schedule of BenefitsSchedule of BenefitsSchedule of BenefitsSchedule of Benefits.

Eligibility Period Eligibility Period Eligibility Period Eligibility Period means the period of time for which benefits are payable. The Eligibility PeriodEligibility PeriodEligibility PeriodEligibility Period ends on the earlier of:

1. the day a ProviderProviderProviderProvider determines no further medical treatment or physical rehabilitation is necessary or advisable; or

2. the day benefits payable under the PlanPlanPlanPlan reach the applicable Maximum Benefit LimitMaximum Benefit LimitMaximum Benefit LimitMaximum Benefit Limit defined in the Schedule Schedule Schedule Schedule of Benefitsof Benefitsof Benefitsof Benefits; or

3. the day that marks the end of the MaximumMaximumMaximumMaximum Benefit PeriodBenefit PeriodBenefit PeriodBenefit Period defined in the Schedule of BenefitsSchedule of BenefitsSchedule of BenefitsSchedule of Benefits.

ElElElEligible Chargesigible Chargesigible Chargesigible Charges means the actual charges for medical or dental services, procedures or supplies, incurred by youyouyouyou as a result of Bodily InjuryBodily InjuryBodily InjuryBodily Injury, to the extent such charges have been previously approved by the Plan AdministratorPlan AdministratorPlan AdministratorPlan Administrator, are Medically NecessaryMedically NecessaryMedically NecessaryMedically Necessary, and are Usual and CustomaryUsual and CustomaryUsual and CustomaryUsual and Customary in amount, including the following:

1. hospital facility charges;

2. charge for use of an operating room; 3. the fees for ProvidersProvidersProvidersProviders; 4. Chiropractic CareChiropractic CareChiropractic CareChiropractic Care, provided it is recommended by a ProviderProviderProviderProvider for the treatment of youryouryouryour Bodily InjuryBodily InjuryBodily InjuryBodily Injury, and

services are not rendered by the ProviderProviderProviderProvider recommending treatment; 5. the charge of a licensed graduate nurse who is not a member of the youryouryouryour Immediate FamilyImmediate FamilyImmediate FamilyImmediate Family;

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6. charges for appliances, artificial limbs, and the Usual and CustomaryUsual and CustomaryUsual and CustomaryUsual and Customary charge for medical emergency ground ambulance services; and

7. charges for medical or surgical treatment, services, supplies, prescription drugs and any other services deemed Medically NecessaryMedically NecessaryMedically NecessaryMedically Necessary.

Elimination PeriodElimination PeriodElimination PeriodElimination Period means the number of days (as shown in the Schedule of BenefitsSchedule of BenefitsSchedule of BenefitsSchedule of Benefits) after the OccOccOccOccurrenceurrenceurrenceurrence giving rise to your Bodily InjuryBodily InjuryBodily InjuryBodily Injury during which youyouyouyou are DisabledDisabledDisabledDisabled, but for which no Wage Replacement benefits are payable under the PlanPlanPlanPlan. EmployeeEmployeeEmployeeEmployee means a ParticipantParticipantParticipantParticipant who, at the time of an OccurrenceOccurrenceOccurrenceOccurrence, is employed in the regular business of, and receives his or her pay on a regular basis by means of a salary or wage directly from the EmployerEmployerEmployerEmployer. EmployeeEmployeeEmployeeEmployee does

not include an independent contractor or third-party agent. EmployeeEmployeeEmployeeEmployee includes only those persons who, at the Employer’sEmployer’sEmployer’sEmployer’s direction, work in Texas, or temporarily (90 days or less) outside of Texas, in the Employer’sEmployer’sEmployer’sEmployer’s regular business. EmployerEmployerEmployerEmployer means the CompanyCompanyCompanyCompany and any affiliate, subsidiary, or entity owned and controlled by the CompanyCompanyCompanyCompany which has adopted the PlanPlanPlanPlan pursuant to Section VII of the PPPPlanlanlanlan. However, each entity which adopts the Plan Plan Plan Plan will be

considered an EmployerEmployerEmployerEmployer only with respect to its own EmployeesEmployeesEmployeesEmployees. ERISA ERISA ERISA ERISA means the federal Employee Retirement Income Security Act of 1974 (ERISA), as amended. Functional Capacity ExaminationFunctional Capacity ExaminationFunctional Capacity ExaminationFunctional Capacity Examination means an evaluation or testing performed by a ProviderProviderProviderProvider or physical therapy professional to assess and evaluate youryouryouryour physical limitations.

Immediate FamilyImmediate FamilyImmediate FamilyImmediate Family means a person who is related to you you you you in any of the following ways: spouse, domestic partner or other person who lives with youyouyouyou, brother-in-law, sister-in-law, son-in-law, daughter-in-law, mother-in-law, father-in-law, parent (includes stepparent), brother or sister (includes stepbrother or stepsister), or child (includes legally adopted or stepchild). Maximum BMaximum BMaximum BMaximum Benefit Limit enefit Limit enefit Limit enefit Limit means the maximum amount of all benefits payable under the PlanPlanPlanPlan to, or with respect to, any ParticipantParticipantParticipantParticipant for a single Bodily InjuryBodily InjuryBodily InjuryBodily Injury, and/or with respect to all ParticipantsParticipantsParticipantsParticipants related to all Bodily InjuriesBodily InjuriesBodily InjuriesBodily Injuries arising

from a single OccurrenceOccurrenceOccurrenceOccurrence. The MMMMaximum Benefit Limitaximum Benefit Limitaximum Benefit Limitaximum Benefit Limit per ParticipantParticipantParticipantParticipant and per OccurrenceOccurrenceOccurrenceOccurrence for the Plan Plan Plan Plan are as shown in the Schedule of BenefitsSchedule of BenefitsSchedule of BenefitsSchedule of Benefits. Maximum Medical ImprovementMaximum Medical ImprovementMaximum Medical ImprovementMaximum Medical Improvement means the point at which a ProviderProviderProviderProvider determines youryouryouryour medical condition resulting from a Bodily InjuryBodily InjuryBodily InjuryBodily Injury will not significantly improve and there is no further surgery, medical treatment, or therapeutic modalities recommended or advised.

Medically NecessaryMedically NecessaryMedically NecessaryMedically Necessary means service, supply or procedure that:

1. is essential for diagnosis, treatment or care of the Bodily InjuryBodily InjuryBodily InjuryBodily Injury for which it is prescribed or performed; 2. meets generally accepted standards of medical practice; and 3. is ordered by a ProviderProviderProviderProvider and performed under his or her care, supervision or order.

Even if the service, supply or procedure is Medically NecessaryMedically NecessaryMedically NecessaryMedically Necessary, you you you you will not be reimbursed for it if the service,

supply, or procedure is otherwise excluded by any condition, exclusion or definition in the Plan Plan Plan Plan. Occupational AssessmentOccupational AssessmentOccupational AssessmentOccupational Assessment means a test of vocational capabilities. The process includes a review of your your your your medical records, injury and treatment history, background (education, military, previous occupation(s)), evaluation of basic skills such as reading, understanding, spelling and/or math capabilities, and vocational alternatives. Occupational DiseaseOccupational DiseaseOccupational DiseaseOccupational Disease means a sickness which results in DisabilityDisabilityDisabilityDisability or death, is caused by your your your your exposure to

environmental or physical hazards, and which: (1) is diagnosed by a PhysicianPhysicianPhysicianPhysician, and is generally accepted by the National Centers for Disease Control to be a disease caused by such hazards; (2) exposure to such hazards is not an AccidentAccidentAccidentAccident but is caused or aggravated by the conditions under which you you you you perform services during your your your your Scope of Scope of Scope of Scope of EmploymentEmploymentEmploymentEmployment; (3) your your your your last day of exposure to the environmental or physical hazards causing such condition occurs while the PlanPlanPlanPlan is in effect; and (4) such exposure results directly and independently of all other causes in an OccurrenceOccurrenceOccurrenceOccurrence. Occupational DiseaseOccupational DiseaseOccupational DiseaseOccupational Disease does not include ordinary diseases of life to which the general public is exposed.

In addition, the OccupatOccupatOccupatOccupational Diseaseional Diseaseional Diseaseional Disease must be caused by a disease producing agent or agents found present in youryouryouryour occupational environment. Further, the ParticipantParticipantParticipantParticipant must be under the Appropriate CareAppropriate CareAppropriate CareAppropriate Care of a Physician for the Occupational DiseaseOccupational DiseaseOccupational DiseaseOccupational Disease. All Occupational DiseaseOccupational DiseaseOccupational DiseaseOccupational Diseases suffered by you you you you due to exposure to the same or related disease producing agent or agents present in your your your your occupational environment are deemed to be a single Occupational Occupational Occupational Occupational DiseaseDiseaseDiseaseDisease.

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OccurrenceOccurrenceOccurrenceOccurrence means an AccidentAccidentAccidentAccident, or series of AccidentsAccidentsAccidentsAccidents, arising out of one event or incident occurring while the PlanPlanPlanPlan is in effect, and in your your your your Scope of EmploymentScope of EmploymentScope of EmploymentScope of Employment with an EmployerEmployerEmployerEmployer, that result in your your your your Bodily InjuryBodily InjuryBodily InjuryBodily Injury. For purposes of administration of the PlanPlanPlanPlan, the OccurrenceOccurrenceOccurrenceOccurrence date is established as follows:

1. For Bodily InjuryBodily InjuryBodily InjuryBodily Injury other than OcOcOcOccupational Diseasecupational Diseasecupational Diseasecupational Disease or Cumulative TraumaCumulative TraumaCumulative TraumaCumulative Trauma, the OccurrenceOccurrenceOccurrenceOccurrence date is the date of the AccidentAccidentAccidentAccident, or the date of the first in a series of AccidentsAccidentsAccidentsAccidents.

2. For Occupational DiseaseOccupational DiseaseOccupational DiseaseOccupational Disease, the OccurrenceOccurrenceOccurrenceOccurrence date is the date on which you you you you were last exposed, in your Scope of your Scope of your Scope of your Scope of EmploymEmploymEmploymEmploymentententent to the disease producing agent or agents.

3. For Cumulative TraumaCumulative TraumaCumulative TraumaCumulative Trauma, the OccurrenceOccurrenceOccurrenceOccurrence date is the date on which you you you you last performed, in the Scope of Scope of Scope of Scope of EmploymentEmploymentEmploymentEmployment, the activities causing such condition.

ParticipantParticipantParticipantParticipant means an eligible EmployeeEmployeeEmployeeEmployee who satisfies all requirements for participation in the PlanPlanPlanPlan and whose participation has not been terminated in the manner specified in the PlanPlanPlanPlan. If you meet these criteria, the term “youyouyouyou” as used in this SPD means the same thing as participantparticipantparticipantparticipant. PhysicianPhysicianPhysicianPhysician means someone other than youyouyouyou, a member of the youryouryouryour Immediate FamilyImmediate FamilyImmediate FamilyImmediate Family,,,, or a practitioner retained by the EmployerEmployerEmployerEmployer, and, and, and, and who is a licensed practitioner of the healing arts acting within the scope of his or her license.

Physician includes, but is not limited to, doctors, nurses and therapists. Physician does not include a chiropractor unless recommended and referred by a ProviderProviderProviderProvider who is designated as a licensed medical doctor (M.D.).

PlanPlanPlanPlan means the Employee Injury Benefit Plan and the Schedule of BenefitsSchedule of BenefitsSchedule of BenefitsSchedule of Benefits to which this SPD relates, as periodically amended. Plan AdministratorPlan AdministratorPlan AdministratorPlan Administrator means the CompanyCompanyCompanyCompany or person appointed by the CompanyCompanyCompanyCompany who is responsible for providing

ParticipantsParticipantsParticipantsParticipants with information about, and making determinations regarding rights and benefits under, the PlanPlanPlanPlan. The ComComComCompanypanypanypany reserves the right to make any final determination regarding rights and benefits under the PlanPlanPlanPlan. Plan YearPlan YearPlan YearPlan Year means the twelve (12) month period ending on December 31. The first Plan YearPlan YearPlan YearPlan Year will be from the Effective Effective Effective Effective DateDateDateDate of the PlanPlanPlanPlan specified in the ScScScSchedule of Benefitshedule of Benefitshedule of Benefitshedule of Benefits until December 31 of that calendar year. PrePrePrePre----existing Conditionexisting Conditionexisting Conditionexisting Condition means any health condition for which, prior to the earlier of the date on which you you you you became a

ParticipantParticipantParticipantParticipant or the Effective DateEffective DateEffective DateEffective Date of the PlanPlanPlanPlan, you you you you were diagnosed, examined, treated, or prescribed medications by a healthcare practitioner, or of which youyouyouyou manifested symptoms which were reasonably capable of diagnosis by a healthcare practitioner, or symptoms which, in the opinion of a PhysicianPhysicianPhysicianPhysician, would have caused a reasonable person to be aware of such condition. PrePrePrePre----Service Claim Service Claim Service Claim Service Claim means any claim for medical benefits under the PlanPlanPlanPlan which, by the terms of the PlanPlanPlanPlan, conditions

the receipt of the benefit, in whole or in part, on obtaining approval or pre-certification prior to obtaining the medical care. ProviderProviderProviderProvider means a PhysicianPhysicianPhysicianPhysician or other health care provider designated or approved by the EmployerEmployerEmployerEmployer to administer medical treatment for which payment or reimbursement is authorized under the PlanPlanPlanPlan. Rehabilitation Rehabilitation Rehabilitation Rehabilitation means only those procedures that are performed for the purpose of restoring bodily or body function

lost as a result of Bodily InjuryBodily InjuryBodily InjuryBodily Injury. Rehabilitative StatusRehabilitative StatusRehabilitative StatusRehabilitative Status means youryouryouryour employment status if youyouyouyou are otherwise ddddisabledisabledisabledisabled, but released by a ProviderProviderProviderProvider to return to work for an EmplEmplEmplEmployeroyeroyeroyer working less than full-time, but not less than 25% of youryouryouryour pre-injury, regular work week, provided youyouyouyou remain under Continuous CareContinuous CareContinuous CareContinuous Care during the period of ddddisabilityisabilityisabilityisability. Review Committee Review Committee Review Committee Review Committee means the group of individuals appointed by the CompanyCompanyCompanyCompany to review and make decisions

regarding all requests for review of an adverse benefit decision. Schedule of BenefitsSchedule of BenefitsSchedule of BenefitsSchedule of Benefits means the Schedule of BenefitsSchedule of BenefitsSchedule of BenefitsSchedule of Benefits associated with the Plan Plan Plan Plan and in effect on the date of the OccurOccurOccurOccurrrrrenceenceenceence giving rise to youryouryouryour claim for benefits under the Plan Plan Plan Plan. Scope of EmploymentScope of EmploymentScope of EmploymentScope of Employment means an activity of any kind or character that involves the furtherance of your your your your Employer’sEmployer’sEmployer’sEmployer’s

business, trade or profession atatatat youryouryouryour Employer’sEmployer’sEmployer’sEmployer’s regular workplaces in Texas, or outside of Texas for 90 days or less in a Plan YearPlan YearPlan YearPlan Year. SSSScope of Employmentcope of Employmentcope of Employmentcope of Employment does not include youryouryouryour transportation to and from your your your your Employer’sEmployer’sEmployer’sEmployer’s regular workplace unless:

1. the transportation is furnished as a part of employment, or is paid for by your your your your EmployerEmployerEmployerEmployer; or 2. the means of such transportation is under your your your your EmplEmplEmplEmployer’soyer’soyer’soyer’s control; or

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3. you you you you are directed in your your your your Scope of EmploymentScope of EmploymentScope of EmploymentScope of Employment to proceed from one place to another place other than your your your your regular workplace.

Urgent Care ClaimUrgent Care ClaimUrgent Care ClaimUrgent Care Claim means any claim for medical care or treatment with respect to which the application of the time

periods for making non-urgent care determinations: 1. could seriously jeopardize youryouryouryour life or health or youryouryouryour ability to regain maximum function; or 2. in the opinion of a PhysicianPhysicianPhysicianPhysician with knowledge of youryouryouryour condition, would subject youyouyouyou to severe pain that

cannot be adequately managed without the care or treatment that is the subject of the claim. Usual and CustomaryUsual and CustomaryUsual and CustomaryUsual and Customary Charge Charge Charge Charge means the reasonable charge made by a ProviderProviderProviderProvider or other ProvidersProvidersProvidersProviders of healthcare services, supplies, medication or equipment that does not exceed the amount of charges made by other PhysiciansPhysiciansPhysiciansPhysicians

or health care providers rendering or furnishing such care or treatment within the same area. Weekly WageWeekly WageWeekly WageWeekly Wage means youryouryouryour Base Annual SalaryBase Annual SalaryBase Annual SalaryBase Annual Salary divided by fifty-two (52).

PART IIIPART IIIPART IIIPART III Plan BenefitsPlan BenefitsPlan BenefitsPlan Benefits

AAAA.... WhatWhatWhatWhat are are are are the limits to the the limits to the the limits to the the limits to the benefits offered through the Plan? benefits offered through the Plan? benefits offered through the Plan? benefits offered through the Plan? There are limits on what the PlanPlanPlanPlan will pay and on how long after an occurrence occurrence occurrence occurrence such payments will be made. The specific dollar limits, and time periods applicable to Plan Plan Plan Plan benefits are set forth in the Schedule of BenefitsSchedule of BenefitsSchedule of BenefitsSchedule of Benefits in effect on the date of occurrenceoccurrenceoccurrenceoccurrence B.B.B.B. What are the benefits offered through the Plan?What are the benefits offered through the Plan?What are the benefits offered through the Plan?What are the benefits offered through the Plan?

1.1.1.1. MEDICAL EXPENSE BENEFITSMEDICAL EXPENSE BENEFITSMEDICAL EXPENSE BENEFITSMEDICAL EXPENSE BENEFITS Medical expense benefits are payable only for expenses which are eligible chargeseligible chargeseligible chargeseligible charges for treatment of a bodily bodily bodily bodily injuryinjuryinjuryinjury. . . . Medical expenses will be paid by the Plan AdministratorPlan AdministratorPlan AdministratorPlan Administrator directly to a providerproviderproviderprovider, or to youyouyouyou as reimbursement for such expenses which youyouyouyou have paid directly to a providerproviderproviderprovider. YourYourYourYour first eligible chargeeligible chargeeligible chargeeligible charge must have been incurred within ninety (90) days of the date of the occurrenceoccurrenceoccurrenceoccurrence

causing youryouryouryour bodily injurybodily injurybodily injurybodily injury, and only expenses which are medically necessarymedically necessarymedically necessarymedically necessary and usual and customaryusual and customaryusual and customaryusual and customary in amount and directly related to the bodily injurybodily injurybodily injurybodily injury will be payable under the PlanPlanPlanPlan. Payments for medical expenses, when combined with all other benefits paid under the PlanPlanPlanPlan,,,, will not exceed the Maximum Benefit LimitMaximum Benefit LimitMaximum Benefit LimitMaximum Benefit Limit payable to any one participantparticipantparticipantparticipant for any one occurrence occurrence occurrence occurrence as listed on the Schedule of Schedule of Schedule of Schedule of BenefitsBenefitsBenefitsBenefits in effect on the date of occurrenceoccurrenceoccurrenceoccurrence.

2.2.2.2. WAGE REPLACEMENT BENEFITSWAGE REPLACEMENT BENEFITSWAGE REPLACEMENT BENEFITSWAGE REPLACEMENT BENEFITS

If youyouyouyou suffer a disability disability disability disability as the result of a bodily injurybodily injurybodily injurybodily injury, youyouyouyou may be eligible for Wage Replacement Benefits,

subject to the elimination periodelimination periodelimination periodelimination period, Maximum Benefit Period, and Maximum Weekly Disability Benefit Amount shown on the Schedule of BenefitsSchedule of BenefitsSchedule of BenefitsSchedule of Benefits in effect on the date of the occurrenceoccurrenceoccurrenceoccurrence.

a.a.a.a. Reporting and Waiting PeriodsReporting and Waiting PeriodsReporting and Waiting PeriodsReporting and Waiting Periods

To receive Wage Replacement Benefits, youryouryouryour disabilitydisabilitydisabilitydisability must last longer than the elimination period elimination period elimination period elimination period and have

begun within:

1. 90 days after the date of the occurrencoccurrencoccurrencoccurrenceeee that caused the disabilitydisabilitydisabilitydisability; or 2. 180 days after the date of the occurrenceoccurrenceoccurrenceoccurrence that caused the disabilitydisabilitydisabilitydisability, provided:

a. youyouyouyou received medical treatment within 30 days from the date of the occurrenceoccurrenceoccurrenceoccurrence that caused the disabilitydisabilitydisabilitydisability; and

b. youyouyouyou have remained under the continuous carecontinuous carecontinuous carecontinuous care of a pppproviderroviderroviderrovider.

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Following the elimination periodelimination periodelimination periodelimination period, youyouyouyou will be eligible for Wage Replacement Benefits for each workday of your your your your ddddisabilityisabilityisabilityisability as specified in the PlanPlanPlanPlan. Wage Replacement benefits will begin to accrue on youryouryouryour first scheduled workday immediately following the elimelimelimelimination pination pination pination perioderioderioderiod and continue for each succeeding week of ddddisabilityisabilityisabilityisability. Wage Replacement Benefits will be paid on youryouryouryour normal paydays during the period of your ddddisabilityisabilityisabilityisability. If youyouyouyou are released

to return to work during a pay period, youryouryouryour actual earnings will be supplemented by Wage Replacement Benefits up to, but not exceeding, 100% of youryouryouryour Weekly WageWeekly WageWeekly WageWeekly Wage.

b.b.b.b. Rehabilitation Disability Benefit Rehabilitation Disability Benefit Rehabilitation Disability Benefit Rehabilitation Disability Benefit

After initial medical treatment for a Bodily InjuryBodily InjuryBodily InjuryBodily Injury, a ProviderProviderProviderProvider may release you you you you to return to work under one of the following options.

1. Full Duty: YouYouYouYou resume full range of duties routinely associated with the performance of youryouryouryour job and Wage

Replacement Benefits will end; or 2. Rehabilitative StatusRehabilitative StatusRehabilitative StatusRehabilitative Status: YouYouYouYou are released by a ProviderProviderProviderProvider to return to work for an EmployEmployEmployEmployerererer working less than full-time, but not less than 25% of youryouryouryour pre-injury, regular work week, provided youyouyouyou remain under Continuous CareContinuous CareContinuous CareContinuous Care during the period of ddddisabilityisabilityisabilityisability.

If you you you you return to work under Rehabilitative StatusRehabilitative StatusRehabilitative StatusRehabilitative Status, you you you you will be eligible to continue Wage Replacement Benefits for the balance of the hours that youyouyouyou are unable to work, up to 100% of youryouryouryour normal work week. The Wage Replacement

Benefits will be paid subject to the Wage Replacement limits shown in the Schedule of BenefitsSchedule of BenefitsSchedule of BenefitsSchedule of Benefits. This benefit will be payable for an initial three-month period while Rehabilitative StatusRehabilitative StatusRehabilitative StatusRehabilitative Status continues, and may be extended by the Plan Plan Plan Plan AdministratorAdministratorAdministratorAdministrator for additional three-month periods, up to a maximum of twelve (12) months, in any one period of disabilitydisabilitydisabilitydisability.

cccc.... SubsequenSubsequenSubsequenSubsequent Disabilityt Disabilityt Disabilityt Disability

If you return to work for an employer employer employer employer after a period of disabilitydisabilitydisabilitydisability,,,, or on rehabilitative statusrehabilitative statusrehabilitative statusrehabilitative status, and become

disabled disabled disabled disabled due to a bodily injurybodily injurybodily injurybodily injury you must satisfy a new elimination periodelimination periodelimination periodelimination period, and will begin a new Maximum Benefit Maximum Benefit Maximum Benefit Maximum Benefit PeriodPeriodPeriodPeriod with respect to Wage Replacement Benefits, if the two disabilitiesdisabilitiesdisabilitiesdisabilities:

1. arise from entirely different and unrelated causes and the two periods of disabilitydisabilitydisabilitydisability are separated by at least one (1) full day during which youyouyouyou are not ddddisabledisabledisabledisabled, and during which youyouyouyou perform yoyoyoyourururur regular job duties; or 2. result from the same or related causes, and such periods of ddddisabilityisabilityisabilityisability are separated by at least six (6) months during which youyouyouyou are not ddddisabledisabledisabledisabled.

You You You You will not have to satisfy a new elimination periodelimination periodelimination periodelimination period, and will not start a new Maximum Benefit PeriodMaximum Benefit PeriodMaximum Benefit PeriodMaximum Benefit Period if youyouyouyou: (A) return to full-time work for an EmployerEmployerEmployerEmployer for a period of not more than two (2) consecutive weeks; and (B) after that period of time are ddddisabledisabledisabledisabled from the same or related causes. In that circumstance, youyouyouyou will be considered continually ddddisabledisabledisabledisabled.

d.d.d.d. Deductions from Your Wage Replacement BenefitsDeductions from Your Wage Replacement BenefitsDeductions from Your Wage Replacement BenefitsDeductions from Your Wage Replacement Benefits

Taxes will be withheld from youryouryouryour Wage Replacement Benefits, just as they are from your normal paycheck. Wage Replacement Benefits will also be reduced by any amounts youyouyouyou qualify to receive under Social Security (including payments to eligible dependents), worker’s compensation or any occupational disease act or law, state compulsory disability benefit law, or any disability, retirement, or other income benefits provided through youryouryouryour eeeemployermployermployermployer and/or the CompanyCompanyCompanyCompany. YOUYOUYOUYOU MAY NOT PERFORM ANY OTHER JOB OR EMPLOYMENT WHILE RECEIVING WAGE REPLACEMENT BENEFITS.

e.e.e.e. Termination of Wage Replacement BenefitsTermination of Wage Replacement BenefitsTermination of Wage Replacement BenefitsTermination of Wage Replacement Benefits

Wage Replacement Benefits will continue until the earlier of:

1. the day the total benefits paid under the PlanPlanPlanPlan equal the applicable Maximum Benefit LimitMaximum Benefit LimitMaximum Benefit LimitMaximum Benefit Limit specified in the Schedule of BenefitsSchedule of BenefitsSchedule of BenefitsSchedule of Benefits; 2. your your your your death; 3. the day youyouyouyou are released for full duty work by a ProviderProviderProviderProvider;

4. the end of the Maximum Benefit PeriodMaximum Benefit PeriodMaximum Benefit PeriodMaximum Benefit Period applicable to Wage Replacement Benefits as shown in the Schedule of BenefitsSchedule of BenefitsSchedule of BenefitsSchedule of Benefits; 5. the day youyouyouyou fail or refuse to submit satisfactory proof of continuing disabilitydisabilitydisabilitydisability, fail or refuse to submit to a Functional Capacity ExaminationFunctional Capacity ExaminationFunctional Capacity ExaminationFunctional Capacity Examination or Occupational AssessmentOccupational AssessmentOccupational AssessmentOccupational Assessment, and/or fail or refuse to return to work on Rehabilitative StatusRehabilitative StatusRehabilitative StatusRehabilitative Status; 6. the day youyouyouyou are no longer suffering from a disabilitydisabilitydisabilitydisability;

7. the day you you you you fail or refuse to participate in any medically recommended rrrrehabilitationehabilitationehabilitationehabilitation program; or

8


8. the day you you you you fail or refuse to comply with any provision of the PlanPlanPlanPlan, or are otherwise determined by the Plan Plan Plan Plan AdministratorAdministratorAdministratorAdministrator not to be eligible for benefits under the PlanPlanPlanPlan.

THE PLAN ADMINISTRATORPLAN ADMINISTRATORPLAN ADMINISTRATORPLAN ADMINISTRATOR MAY REQUIRE YOUYOUYOUYOU TO SUBMIT PROOF OF CONTINUED DISABILITYDISABILITYDISABILITYDISABILITY AND OF

CONTINUOUS CARECONTINUOUS CARECONTINUOUS CARECONTINUOUS CARE. THIS MAY BE DONE AS OFTEN AS THE PLAN ADMINISTRATORPLAN ADMINISTRATORPLAN ADMINISTRATORPLAN ADMINISTRATOR CONSIDERS NECESSARY AND REASONABLE. FAILURE TO SUBMIT THE REQUESTED PROOF WILL CAUSE THE PLAN ADMINISTRATORPLAN ADMINISTRATORPLAN ADMINISTRATORPLAN ADMINISTRATOR TO SUSPEND WAGE REPLACEMENT BENEFITS UNTIL SUCH PROOF IS RECEIVED.

3.3.3.3. ACCIDENTAL DEATH, DISMEMBERMENT AND LOSS OF USE BEACCIDENTAL DEATH, DISMEMBERMENT AND LOSS OF USE BEACCIDENTAL DEATH, DISMEMBERMENT AND LOSS OF USE BEACCIDENTAL DEATH, DISMEMBERMENT AND LOSS OF USE BENEFITSNEFITSNEFITSNEFITS In the event you you you you die or suffer a loss loss loss loss (as defined below) as a direct result of a Bodily InjuryBodily InjuryBodily InjuryBodily Injury within three hundred and sixty-five (365) days from the date of the occurrenceoccurrenceoccurrenceoccurrence, youyouyouyou (or in the case of youryouryouryour death, youryouryouryour

beneficiarybeneficiarybeneficiarybeneficiary) will be entitled to receive a payment equal to the smaller of: a. ten (10) times the your Base Annual Salaryyour Base Annual Salaryyour Base Annual Salaryyour Base Annual Salary; or b. the applicable benefit shown in the Schedule of Losses below. In no event will the total Accidental Death, Dismemberment and Loss of Use Benefit exceed the Maximum Benefit Maximum Benefit Maximum Benefit Maximum Benefit LimitLimitLimitLimit per participantparticipantparticipantparticipant shown in the Schedule of BenefitsSchedule of BenefitsSchedule of BenefitsSchedule of Benefits, and all such payments will be reduced by all benefits related

to the same occurrence occurrence occurrence occurrence which were otherwise paid to youyouyouyou or on youryouryouryour behalf under the PlanPlanPlanPlan, such as Medical or Wage Replacement Benefits. Dismemberment and Loss of Use benefits will not be paid if a death benefit is payable under the PlanPlanPlanPlan. Also, if you you you you suffer more than one scheduled losslosslossloss as the result of a single ooooccurrenceccurrenceccurrenceccurrence, a benefit will only be paid for the scheduled losslosslossloss which provides the larger benefit, and will be less any other benefits payable under the PlanPlanPlanPlan as the result of the same occurrenceoccurrenceoccurrenceoccurrence. The total benefits paid to youyouyouyou or on your behalf will not exceed the Maximum Benefit Maximum Benefit Maximum Benefit Maximum Benefit

LimitLimitLimitLimit per pppparticipantarticipantarticipantarticipant shown in the Schedule of BenefitsSchedule of BenefitsSchedule of BenefitsSchedule of Benefits.

SCHEDULE OF LOSSESSCHEDULE OF LOSSESSCHEDULE OF LOSSESSCHEDULE OF LOSSES

LOSS:LOSS:LOSS:LOSS: BENEFITBENEFITBENEFITBENEFIT: : : : (Stated as a percentage of the Maximum Benefit Limit Maximum Benefit Limit Maximum Benefit Limit Maximum Benefit Limit per ParticipantParticipantParticipantParticipant for each Occurrence Occurrence Occurrence Occurrence as shown in the Schedule of BenefitsSchedule of BenefitsSchedule of BenefitsSchedule of Benefits)

Death 100%

Both Hands 100% Both Feet 100% Sight of Both Eyes 100% One Hand and One Foot 100% One Hand and Sight of One Eye 100%

One Foot and Sight of One Eye 100% Speech and Hearing in Both Ears 100% Use of Both Arms and Both Legs 100% Use of Both Arms or Both Legs 75% Use of One Arm and One Leg 75% Speech 50% Hearing in Both Ears 50%

One Hand 50% One Foot 50% Sight of One Eye 50% Use of One Arm or One Leg 50% One Thumb 25% In addition to the Definitions in Part II of this SPD, the following Definitions apply to benefits for Accidental

Dismemberment and Loss of Use:

1. LossLossLossLoss with regard to: a. a hand or foot means the complete severance through or above the wrist joint or the ankle joint; b. sight of an eye means the total and irrevocable loss of the entire sight in that eye;

c. hearing in an ear means the total and irrevocable loss of the entire ability to hear in that ear;

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d. speech means the total and irrecoverable loss of the entire ability to speak; e. an arm or leg means the complete severance through or above the shoulder or hip joint. f. one thumb means the complete severance through or above the metacarpophalangeal joint of the digit;

g. use of an arm, hand, leg or foot means the total loss of the ability to perform each and every act and service that the arm, hand, leg or foot was able to perform before the ooooccurrenceccurrenceccurrenceccurrence.

2. The total loss of the ability to perform must continue without interruption, for a period of not less than 365 consecutive days and be irrevocable and beyond remedy by surgical or other means.

3. Severance means the complete and permanent separation and dismemberment of the part from the body.

Unless prohibited by law, the Plan AdministratoPlan AdministratoPlan AdministratoPlan Administratorrrr, at the Company’sCompany’sCompany’sCompany’s expense, may have an autopsy performed if youyouyouyou die and youryouryouryour death gives rise to a claim for death benefits under the PlanPlanPlanPlan. CCCC.... What What What What is not covered by the Planis not covered by the Planis not covered by the Planis not covered by the Plan? ? ? ? In addition to the other conditions and limitations on the payment of PlanPlanPlanPlan benefits, no benefits will be provided, or benefits will immediately terminate, with respect to an occurrenceoccurrenceoccurrenceoccurrence under the PlanPlanPlanPlan for any losslosslossloss or claim

which the Plan AdministratorPlan AdministratorPlan AdministratorPlan Administrator determines arises out of: 1. suicide or any attempt at suicide, self-inflicted or attempt at self-inflicted Bodily InjuryBodily InjuryBodily InjuryBodily Injury, or auto- eroticism, or any Bodily InjuryBodily InjuryBodily InjuryBodily Injury that is intentionally aggravated by youyouyouyou; 2. participation in:

a. a riot or act of civil disturbance; b. an assault or a felony, except an assault committed in defense of the EmployerEmployerEmployerEmployer’s business or

property; c. war or act of war, whether declared or undeclared; d. service in the military of any country or any civilian non-combatant unit serving with such forces;

3. voluntary payment made to youyouyouyou that is not required by the Plan Plan Plan Plan; 4. travel to and from work, except when:

a. the transportation is furnished as a part of employment, or is paid for by your your your your eeeemployermployermployermployer, or the

means of such transportation is under youryouryouryour eeeemployermployermployermployer’s control; or b. youyouyouyou are directed your your your your Scope of EmploymentScope of EmploymentScope of EmploymentScope of Employment to proceed from one place to another place other than youryouryouryour regular workplace;

5. an act of a third person intending to injure youyouyouyou because of personal reasons and not directed at youyouyouyou as an EmployeeEmployeeEmployeeEmployee or because of youryouryouryour employment with the eeeemployermployermployermployer; 6. voluntary participation in an off-duty recreational, social, or athletic activity not constituting part of

youryouryouryour Scope of EmploymentScope of EmploymentScope of EmploymentScope of Employment; 7. claims arising from employment relationships including, without limitation, claims for any type of employment discrimination, wrongful discharge, retaliatory discharge, coercion, sexual harassment, Americans with Disabilities Act claims, and claims arising under the Labor Code of any state, and all other claims affecting or arising from the employment relationship whether arising under state or federal statutes or regulations or the common law (except for plan benefits awarded under actions brought pursuant to §502(a)(1)(B) of ERISA; 29 U.S.C. §1132 (a)(1)(B));

8. liability under the Federal Employer’s Liability Act, United States Longshore and Harbor Workers’ Compensation Act, the Jones Act, or the Migrant Seasonal Agricultural Worker Protection Act;

9. charges incurred by youyouyouyou for which you you you you are entitled to receive benefits under any state workers’ compensation law, occupational disease law, unemployment compensation disability benefits law, or other similar law; 10. any diagnostic procedure, treatment, service or supply that is not Medically NecessaryMedically NecessaryMedically NecessaryMedically Necessary; 11. that part of any charge which is in excess of the Usual and CustomaryUsual and CustomaryUsual and CustomaryUsual and Customary charge; 12. any Bodily InjuryBodily InjuryBodily InjuryBodily Injury occurring while youyouyouyou were under the influence of alcohol;

13. any Bodily InjuryBodily InjuryBodily InjuryBodily Injury occurring while youyouyouyou were under the influence of drugs, unless such drugs were taken under the direction of and as prescribed by a pppphysicianhysicianhysicianhysician; 14. the use of or exposure to: a. asbestos, asbestos fibers or asbestos products; or b. silicon or silica; c. mold, microbes or fungus;

d. the hazardous properties of nuclear material except nuclear or radiological medicine which is

used for patient care and diagnosis, approved by OSHA, JCAHO, or the American Hospital Accreditation Association, and not used for research purposes or clinical tests;

10


15. all statutory causes of action including, without limitation, Title VII of Civil Rights Act of 1964, Civil Rights Act of 1991, Civil Rights Act of 1866, Age Discrimination in Employment Act, Employee Retirement Income Security Act (except for plan benefits awarded under actions brought pursuant to §502(a)(1)(B) of ERISA; 29 U.S.C. §1132 (a)(1)(B)), Fair Labor Standards Act, Bankruptcy Code,

Texas Commission on Human Rights, Texas Workers’ Compensation Act, Railway Labor Act, and National Labor Relations Act;

16. infections of any kind, regardless of how contracted, except viral and bacterial infections that are directly caused by an OccurrenceOccurrenceOccurrenceOccurrence; 17. travel or flight in or on (including getting in or out of, or on or off of) any vehicle used for aerial navigation, if youyouyouyou are:

a. flying in any aircraft that is rocket propelled; b. flying in any aircraft being used for aerobatics; racing or an endurance test, crop dusting, seeding,

fertilizing or spraying; fighting a fire; any exploration, pipe or power line patrol; the pursuit of animals or birds; aerial photography, banner towing or skywriting; or any test or experimental usage; c. flying when a special permit or waiver from the proper authority has to be issued; d. riding as a passenger in any aircraft not intended or licensed for the transportation of passengers; e. performing, learning to perform or instructing others to perform as a pilot or crew member of any aircraft;

f. riding as a passenger in an aircraft owned, leased or operated by the ememememployerployerployerployer; 18. any PrePrePrePre----Existing ConditionExisting ConditionExisting ConditionExisting Condition; 19. osteoarthritis, arthritis, and/or any other degenerative process of the joints, bones, tendons or ligaments not a direct result of an ooooccurccurccurccurrencerencerencerence; 20. mental, nervous, emotional and/or psychological condition or disorder not a direct result of an ooooccurrenceccurrenceccurrenceccurrence; 21. the medical or surgical treatment of sickness, disease, mental incapacity or bodily infirmity, whether

the loss results directly or indirectly from the treatment; 22. stroke or cerebrovascular accident or event, cardiovascular accident or event, myocardial infarction or heart attack, coronary thrombosis, or aneurysm that are not the direct result of an ooooccurrenceccurrenceccurrenceccurrence 23. any Bodily InjuryBodily InjuryBodily InjuryBodily Injury that is feigned or fraudulent; 24. any Bodily InjuryBodily InjuryBodily InjuryBodily Injury resulting from you you you you engaging in scuffling, horseplay, fighting or other altercation; 25. youryouryouryour failure or refusal to comply with any of the terms, conditions and requirements of the PlanPlanPlanPlan

(regardless of whether such failure or refusal gave rise to the occurrenceoccurrenceoccurrenceoccurrence or Bodily InjuryBodily InjuryBodily InjuryBodily Injury). DDDD.... What if my iWhat if my iWhat if my iWhat if my injuries were caused by a third party? njuries were caused by a third party? njuries were caused by a third party? njuries were caused by a third party? If the PlanPlanPlanPlan pays or provides benefits for a Bodily InjuryBodily InjuryBodily InjuryBodily Injury that was caused by an act or omission of any third person or organization, the PlanPlanPlanPlan will be subrogated to all of youryouryouryour and your your your your bbbbeneficiaries’eneficiaries’eneficiaries’eneficiaries’ rights of recovery to the extent of such benefits provided, or the reasonable value of services or benefits provided by the PlanPlanPlanPlan, including those rights of recovery against underinsured/uninsured automobile insurance coverage or no fault insurance

coverage, such as personal injury or medical payments protection. Upon receiving any benefits from the PlanPlanPlanPlan, youyouyouyou and your byour byour byour beneficiarieseneficiarieseneficiarieseneficiaries are considered to have assigned their rights of recovery to the PlaPlaPlaPlannnn to the extent of such benefits. If youyouyouyou have retained an attorney to pursue youryouryouryour rights of recovery, the PlanPlanPlanPlan is not responsible for paying any portion of youryouryouryour attorney’s fees or costs. The Plan’sPlan’sPlan’sPlan’s rights will not be affected by any release entered into without the written consent of the Plan AdministratorPlan AdministratorPlan AdministratorPlan Administrator.

If youyouyouyou or your your your your bbbbeneficiarieseneficiarieseneficiarieseneficiaries receive benefits under the PlanPlanPlanPlan, yyyyouououou and your your your your bbbbeneficiarieseneficiarieseneficiarieseneficiaries must immediately notify the Plan Administrator Plan Administrator Plan Administrator Plan Administrator of the name of any individual or organization against whom youyouyouyou or your your your your bbbbeneficiarieseneficiarieseneficiarieseneficiaries might have a claim as a result of your your your your Bodily InjuryBodily InjuryBodily InjuryBodily Injury (including any insurance company that provides coverage for youyouyouyou). For example, if you are injured in an automobile accident while in the Scope of EmploymentScope of EmploymentScope of EmploymentScope of Employment, and the person who hit you was at fault, the person who hit youyouyouyou (and his insurance company) is a person whose act or omission has caused the youryouryouryour Bodily Injury Bodily Injury Bodily Injury Bodily Injury. YouYouYouYou and your beneficiariesyour beneficiariesyour beneficiariesyour beneficiaries must cooperate with the PlanPlanPlanPlan to provide information about

your Bodily Injuryyour Bodily Injuryyour Bodily Injuryyour Bodily Injury, and youyouyouyou and your byour byour byour beneficiarieseneficiarieseneficiarieseneficiaries must agree to sign any necessary document for the PlanPlanPlanPlan, and provide all requested information sought by the PlanPlanPlanPlan in furtherance of the Plan’sPlan’sPlan’sPlan’s right to subrogate youryouryouryour claim and/or those of the your your your your bbbbeneficiarieseneficiarieseneficiarieseneficiaries. The PlanPlanPlanPlan may: 1. place a lien against a third party or insurance company to the extent benefits have been paid under the PlanPlanPlanPlan; 2. bring an action on its own behalf, or on behalf of youyouyouyou or your byour byour byour beneficiarieseneficiarieseneficiarieseneficiaries, against the person,

organization or insurance company; and 3. cease paying yyyyou ou ou ou and your beneficiaries your beneficiaries your beneficiaries your beneficiaries benefits until they provide the PlanPlanPlanPlan with the documents necessary for the PlanPlanPlanPlan to exercise its rights and privileges of subrogation.

11


If the PlanPlanPlanPlan pays or provides yyyyou ou ou ou or your beneficiaries your beneficiaries your beneficiaries your beneficiaries benefits for a Bodily InjuryBodily InjuryBodily InjuryBodily Injury that was caused by an act or omission of a third person or organization, and/or if youyouyouyou have sought recovery from insurance third party, the PlanPlanPlanPlan has the right to be repaid first to the extent of any benefits paid under the PlanPlanPlanPlan from any settlement, judgment,

or insurance proceeds yyyyou ou ou ou or your beneficiaries your beneficiaries your beneficiaries your beneficiaries receive. The PlanPlanPlanPlan has a right to reimbursement whether or not a portion of the settlement, judgment, or insurance proceeds was identified as a reimbursement of medical expenses, lost wages, or other types of benefits provided by the PlanPlanPlanPlan. You You You You and your beneficiariesyour beneficiariesyour beneficiariesyour beneficiaries agree, by accepting benefits under the PlanPlanPlanPlan, to provide the PlanPlanPlanPlan with a lien, to the extent the PlanPlanPlanPlan has paid benefits, to be filed with the responsible party or insurance company. If yyyyou ou ou ou or your beneficiaries your beneficiaries your beneficiaries your beneficiaries do not reimburse the PlanPlanPlanPlan from any settlement, judgment, or insurance

proceeds, the PlanPlanPlanPlan is entitled to reduce current or future PlanPlanPlanPlan benefits payable to youyouyouyou or on youryouryouryour behalf until the PlanPlanPlanPlan has been fully reimbursed. Anyone receiving benefits under the PlanPlanPlanPlan agrees that their spouse, children, estate, legal representatives, heirs, dependents and wrongful death beneficiaries will be bound to the subrogation and reimbursement provisions set forth above. By accepting benefits under this PlanPlanPlanPlan, yyyyou ou ou ou and your beneficiaries your beneficiaries your beneficiaries your beneficiaries expressly disclaim the made

whole and common fund doctrines.

EEEE.... What What What What if I am entitled to payment if I am entitled to payment if I am entitled to payment if I am entitled to payment under another benefit plan or insurance policy?under another benefit plan or insurance policy?under another benefit plan or insurance policy?under another benefit plan or insurance policy? If any youyouyouyou are covered under one or more other plans, including, but not limited to, insurance, indemnity or reimbursement, the benefits payable for expenses under the PlanPlanPlanPlan will apply only in excess of the other contract of insurance, indemnity or reimbursement.

PART IVPART IVPART IVPART IV Claims ProcessingClaims ProcessingClaims ProcessingClaims Processing

AAAA.... How do I make a cHow do I make a cHow do I make a cHow do I make a claim for Plan laim for Plan laim for Plan laim for Plan bbbbenefits?enefits?enefits?enefits? If youyouyouyou are eligible to participate in the PlanPlanPlanPlan, in addition to actually sustaining a bodily injurybodily injurybodily injurybodily injury in the scope of scope of scope of scope of employmentemploymentemploymentemployment, youyouyouyou must report every occurrenceoccurrenceoccurrenceoccurrence which youyouyouyou believe resulted in bodily injurybodily injurybodily injurybodily injury. . . . You You You You must make the report immediately (by the end of the scheduled workday and/or the end of the scheduled shift on the day of the

occurrenceoccurrenceoccurrenceoccurrence) to youryouryouryour manager, supervisor or other person in charge at the time. That person will then assist youyouyouyou in obtaining necessary medical treatment and in completing required report forms. YouYouYouYou must provide the CompanyCompanyCompanyCompany, employeremployeremployeremployer, and Plan AdministratorPlan AdministratorPlan AdministratorPlan Administrator with a recorded statement, affidavit, deposition or such other evidence regarding an occurrenceoccurrenceoccurrenceoccurrence as they may request. Failure to do so will result in forfeiture of all benefits under the PlanPlanPlanPlan. BBBB.... What happens after I make a cWhat happens after I make a cWhat happens after I make a cWhat happens after I make a claim?laim?laim?laim?

The CompanyCompanyCompanyCompany will designate one or more providerproviderproviderproviders s s s to administer youryouryouryour medical treatment and the CompanyCompanyCompanyCompany may change designated providerproviderproviderproviderssss at any time. Other than benefits paid for emergency medical expensesmedical expensesmedical expensesmedical expenses, no benefits will be paid under the PlanPlanPlanPlan for treatment received from a health care provider that has not been designated as a providerproviderproviderprovider in accordance with the PlanPlanPlanPlan. A CompanyCompanyCompanyCompany-designated providerproviderproviderprovider is not agent of any employemployemployemployerererer. YouYouYouYou may elect to use a hospitalhospitalhospitalhospital or other medical care provider who is not designated by the CompanyCompanyCompanyCompany, but the PlanPlanPlanPlan will not pay benefits for any medical expensesmedical expensesmedical expensesmedical expenses charged for such medical provider’s services.

Other than those required on an emergency basis, all medical procedures, including surgeries and rehabilitationrehabilitationrehabilitationrehabilitation procedures must be pre-approved as PrePrePrePre----Service claimsService claimsService claimsService claims by the Plan AdministratorPlan AdministratorPlan AdministratorPlan Administrator, or Claims Administrator (if any) in order for the charges for such services to be eligible for payment under the PlanPlanPlanPlan. Contact information for the Claims Administrator (if any) is contained in the Schedule of BenefitsSchedule of BenefitsSchedule of BenefitsSchedule of Benefits. YouYouYouYou must notify your your your your employeremployeremployeremployer of your your your your expected recovery time immediately after primary medical treatment and after each succeeding appointment with a providerproviderproviderprovider. YouYouYouYou must also follow fully and completely the advice and

course of medical treatment prescribed by a providerproviderproviderprovider. YouYouYouYou must keep and attend all scheduled appointments to fulfill the prescribed medical treatment plan. YouYouYouYou must submit to drug and/or alcohol testing as requested by your your your your employeremployeremployeremployer, the CompanyCompanyCompanyCompany, and/or the Plan Administrator,Plan Administrator,Plan Administrator,Plan Administrator, and/or examination by a providerproviderproviderprovider of the Plan Administrator’sPlan Administrator’sPlan Administrator’sPlan Administrator’s choice as often as is reasonably necessary. AAAA.... When and how When and how When and how When and how willwillwillwill my claim be p my claim be p my claim be p my claim be processed?rocessed?rocessed?rocessed?

The time period for the Plan Plan Plan Plan AdministratorAdministratorAdministratorAdministrator to accept or reject a properly filed claim depends on the type of claim (medical, disabilitydisabilitydisabilitydisability or other), and youryouryouryour situation (whether youyouyouyou are seeking urgent treatment, authorization for treatment after services have been rendered, during an ongoing course of treatment, or before the medical services have been rendered). The remainder of this Part discusses the deadlines and procedures applicable to youyouyouyou and the Plan Plan Plan Plan AdministratorAdministratorAdministratorAdministrator with respect to each type of claim.

12


In general, if any claim for benefits (including Urgent Care, Concurrent Care, PreUrgent Care, Concurrent Care, PreUrgent Care, Concurrent Care, PreUrgent Care, Concurrent Care, Pre----Service, Service, Service, Service, and Post Post Post Post----Service Service Service Service ClaimsClaimsClaimsClaims) is: (1) wholly or partially denied; or (2) the Plan AdministratorPlan AdministratorPlan AdministratorPlan Administrator otherwise makes an adverse benefit determination as defined in the Department of Labor regulations regarding claims procedures (in either case, referred to herein as an “adverse benefit determination”), see 29 C.F.R. § 2560.503-1(m)(4), the Plan AdministratorPlan AdministratorPlan AdministratorPlan Administrator

will notify youyouyouyou of the adverse benefit determination within a reasonable period of time, and no later than the timeframe specified by ERISA. The notification of any adverse benefit determination will be in writing and may be delivered electronically. The initial notification will include:

1. the specific reason or reasons for the adverse determination; 2. reference to the specific PlanPlanPlanPlan provisions on which the determination was based;

3. a description or any additional material or information necessary for youyouyouyou to fix the problem with the claim and an explanation of why such material or information is necessary;

4. a description of the Plan’sPlan’sPlan’sPlan’s review procedures, including a statement of youryouryouryour right to bring civil action under section 502(a) of ERISA following an adverse determination on review;

5. a description of any internal rule, guideline, protocol, or other criterion relied upon to make the adverse determination, and that a copy of such will be provided free of charge to youyouyouyou upon request;

6. an explanation of the scientific or clinical judgment for determining an adverse benefit determination based on the Plan’sPlan’sPlan’sPlan’s limitations or exclusions for medically necessarymedically necessarymedically necessarymedically necessary or experimental treatment;

7. in the case of an adverse benefit determination concerning an Urgent Care ClaimUrgent Care ClaimUrgent Care ClaimUrgent Care Claim, a description of the expedited review process applicable to such claims.

The initial notification of an adverse benefit determination will be provided to youyouyouyou as soon as possible after receipt of the claim, but not later than the time frames specified as follows:

1. For Urgent Care ClaimsUrgent Care ClaimsUrgent Care ClaimsUrgent Care Claims, if youyouyouyou fail to follow the PPPPlan’slan’slan’slan’s procedures for filing the Urgent Care Urgent Care Urgent Care Urgent Care ClaimClaimClaimClaim, youyouyouyou will

be notified of the failure and the proper procedures to be followed in filing a claim for benefits within twenty-four (24) hours following the failure. Notification may be oral, or if requested by youyouyouyou, in writing. The initial notification of an adverse benefit determination on an Urgent Care ClaimUrgent Care ClaimUrgent Care ClaimUrgent Care Claim must be made within 72 hours. The initial notification may be provided orally, provided that a written notification is furnished to youyouyouyou no later than 3 days after the oral notification.

If an Urgent Care ClaimUrgent Care ClaimUrgent Care ClaimUrgent Care Claim requires additional information in order for the Plan AdministratorPlan AdministratorPlan AdministratorPlan Administrator to render a decision, the Plan AdministratorPlan AdministratorPlan AdministratorPlan Administrator will notify youyouyouyou of the specific information necessary to complete the claim within twenty-four (24) hours of receipt of the Urgent Care ClaimUrgent Care ClaimUrgent Care ClaimUrgent Care Claim, and will give youyouyouyou at least forty-eight (48) hours to provide the specific information. The Plan AdministratorPlan AdministratorPlan AdministratorPlan Administrator must render a decision on an Urgent Care Urgent Care Urgent Care Urgent Care ClaimClaimClaimClaim that required additional information no later than forty-eight (48) hours after the earlier of the receipt

of the additional information or the end of the time period the Plan AdministratorPlan AdministratorPlan AdministratorPlan Administrator gave youyouyouyou to provide the additional information.

2. For PrePrePrePre----Service ClaimsService ClaimsService ClaimsService Claims, if youyouyouyou fail to follow the PPPPlan’slan’slan’slan’s procedures for filing the PrePrePrePre----Service ClaimService ClaimService ClaimService Claim, youyouyouyou will be notified of the failure and the proper procedures to be followed in filing a claim for benefits within five (5) days following the failure. Notification may be oral, or if requested by youyouyouyou, in writing. The initial notification of an adverse benefit determination with respect to a PrePrePrePre----Service ClaimService ClaimService ClaimService Claim must be made within 15

days. In the event circumstances outside of the Plan AdministratorPlan AdministratorPlan AdministratorPlan Administrator’s’s’s’s control require an extension of the period for rendering a decision and provided the Plan AdministratorPlan AdministratorPlan AdministratorPlan Administrator notifies youyouyouyou of the need for the extension prior to the expiration of the initial 15-day period, the period for determining the eligibility of the requested care may be extended one time for up to fifteen (15) days. If such an extension is necessary due to youryouryouryour failure to submit the information necessary to decide the claim, the notice of extension will specifically describe the required information, and youyouyouyou will be afforded at least 45 days from receipt of the notice within which to provide the specified information. In the event youyouyouyou are notified of the need for

additional information, the time period for processing the claim will not begin to run again until the additional information is received.

3. For PostPostPostPost----Service ClaiService ClaiService ClaiService Claimsmsmsms, the initial notification must be made within 30 days. This period may be extended one time for up to 15 days, due to matters beyond the control of the Plan AdministratorPlan AdministratorPlan AdministratorPlan Administrator and provided notice is given to youyouyouyou prior to the expiration of the initial 30-day period of the circumstances requiring the

extension and the date by which the Plan AdministratorPlan AdministratorPlan AdministratorPlan Administrator expects to render a decision. If the extension is necessary because youyouyouyou failed to submit information necessary to decide the claim, the notice of extension will specifically describe the required information, and youyouyouyou will have at least 45 days from receipt of the notice to provide the specified information.

13


4. For Concurrent Care DecisionsConcurrent Care DecisionsConcurrent Care DecisionsConcurrent Care Decisions the initial notification will be made at a time sufficiently in advance of the reduction or termination of youryouryouryour ongoing course of treatment to allow youyouyouyou to appeal and obtain a determination on review of that adverse benefit determination before the benefit is reduced or terminated. Any request by youyouyouyou to extend the course of treatment beyond the period of time or number of treatments

that meets the definition of an Urgent Care ClaimUrgent Care ClaimUrgent Care ClaimUrgent Care Claim will be decided as soon as possible. The Plan Plan Plan Plan AdministratorAdministratorAdministratorAdministrator will notify youyouyouyou of the benefit determination on such Concurrent Urgent Care ClaimConcurrent Urgent Care ClaimConcurrent Urgent Care ClaimConcurrent Urgent Care Claim, whether adverse or not, within 24 hours after receipt of the claim by the Plan AdministratorPlan AdministratorPlan AdministratorPlan Administrator, provided that any such claim is made to the Plan AdministratorPlan AdministratorPlan AdministratorPlan Administrator at least 24 hours prior to the expiration of the prescribed period of time or number of treatments.

5. For ddddisabilityisabilityisabilityisability claims, the initial notification must be made within 45 days. In the case of a claim regarding

disabilitydisabilitydisabilitydisability benefits, if the Plan AdministratorPlan AdministratorPlan AdministratorPlan Administrator determines that an extension of time for processing the claim is necessary due to matters beyond its control, the Plan AdministratorPlan AdministratorPlan AdministratorPlan Administrator may extend the initial 45-day period for up to 30 days, provided it gives youyouyouyou written notice of such extension within the initial 45-day period. If, prior to the end of the first 30-day extension period, the Plan AdministPlan AdministPlan AdministPlan Administratorratorratorrator determines that, due to matters beyond its control, a decision cannot be rendered within that extension period, such determination period may be extended for a second period of up to an additional 30 days, provided it gives youyouyouyou written notice of

such extension within the first 30-day extension period. The extension notice will indicate the special circumstances requiring an extension of time and the date by which the Plan AdministratorPlan AdministratorPlan AdministratorPlan Administrator expects to render the determination. The extension notices for processing a claim for disabilitydisabilitydisabilitydisability benefits will contain:

a. the special circumstances requiring an extension of time; b. the date by which the Plan AdministratorPlan AdministratorPlan AdministratorPlan Administrator expects to render a decision; c. a specific explanation of the standards on which entitlement of a benefit is based; d. the unresolved issues that prevent a decision on the claim; and

e. the additional information needed to resolve those issues. YouYouYouYou will be afforded at least 45 days within which to provide the additional specified information. In the event youyouyouyou are notified of the need for additional information, the time period for processing the claim will not begin until the additional information is received. BBBB. WWWWhat if I disagree with a claim dhat if I disagree with a claim dhat if I disagree with a claim dhat if I disagree with a claim denial?enial?enial?enial?

Timing and Information Required for Appeal: YouYouYouYou may appeal an adverse benefit determination within 180 days after the date on which youyouyouyou receive a written notice of the determination. The appeal must be in writing and should include comments, documents, records, and other information relating to the claim for benefits that youyouyouyou desire the Review CommitteeReview CommitteeReview CommitteeReview Committee to consider for a review of the adverse benefit determination. YouYouYouYou may request reasonable access to, and copies of, all documents, records, and other information relevant to youryouryouryour claim for

benefits. The PPPPlan Administratorlan Administratorlan Administratorlan Administrator will provide these to youyouyouyou free of charge. Review CommitteeReview CommitteeReview CommitteeReview Committee: YourYourYourYour appeal will be reviewed by the Review CommitteeReview CommitteeReview CommitteeReview Committee. The Review CommitteeReview CommitteeReview CommitteeReview Committee is one or more persons appointed by the CompanyCompanyCompanyCompany to review and determine all requests for review of an adverse benefit determination. The Review CommitteeReview CommitteeReview CommitteeReview Committee, at its option, can consult outside firms or internal resources with expertise in regard to benefits as the Review CommitteeReview CommitteeReview CommitteeReview Committee deems necessary or appropriate.

Timing of Review CommitteeReview CommitteeReview CommitteeReview Committee’s’s’s’s Decision: As with the Plan AdministratorPlan AdministratorPlan AdministratorPlan Administrator’s’s’s’s initial determination of youryouryouryour claim, the time period and procedures applicable to an appeal of any claim denial depend on the type of claim made and youryouryouryour situation. A decision will be rendered by the Review CommitteeReview CommitteeReview CommitteeReview Committee within 72 hours after youryouryouryour request for review is received for an Urgent Care ClaimUrgent Care ClaimUrgent Care ClaimUrgent Care Claim, and within 30 days for PrePrePrePre----Service ClaimsService ClaimsService ClaimsService Claims. In reviewing an adverse benefit determination on an Urgent Care ClaimUrgent Care ClaimUrgent Care ClaimUrgent Care Claim, the Review CommitteeReview CommitteeReview CommitteeReview Committee will provide youyouyouyou with an expedited review process

pursuant to which a request for an expedited appeal of an adverse benefit determination may be submitted orally or in writing, and all necessary information, including the Review CommitteeReview CommitteeReview CommitteeReview Committee’s’s’s’s benefit determination on review will be transmitted between youyouyouyou the PlanPlanPlanPlan by telephone, facsimile, or other available similarly expeditious method. A decision will be rendered on Concurrent CareConcurrent CareConcurrent CareConcurrent Care and Post Service ClaimsPost Service ClaimsPost Service ClaimsPost Service Claims within 60 days, and within 45 days on disabilitydisabilitydisabilitydisability claims, unless the Review CommitteeReview CommitteeReview CommitteeReview Committee determines that special circumstances require an extension of

time for processing the claim. If the Review CommitteeReview CommitteeReview CommitteeReview Committee determines that an extension of time for processing is required, written notice of the extension will be furnished to youyouyouyou prior to the termination of the initial 60-day period (or 45-day period for disabilitydisabilitydisabilitydisability claims). No extension will exceed a period of 60 days from the end of the initial period (or 45 days for disabilitydisabilitydisabilitydisability claims). The extension notice will indicate the special circumstances requiring an extension of time and the date by which the Review CommitteeReview CommitteeReview CommitteeReview Committee expects to render the determination on review.

14


The Review CommitteeReview CommitteeReview CommitteeReview Committee will notify youyouyouyou of its decision on the appeal in writing not later than 5 days after the decision is made.

What the Review CommitteeReview CommitteeReview CommitteeReview Committee Will Consider: The Review CommitteeReview CommitteeReview CommitteeReview Committee will provide a full and fair review of the claim, taking into account all comments, documents, records, and other information youyouyouyou submit relating to the claim, without regard as to whether such information was submitted or considered in the initial benefit determination. In conducting its review of an adverse benefit determination, the Review CommitteeReview CommitteeReview CommitteeReview Committee will not afford deference to the initial adverse benefit determination, and the review will not be conducted by the individual who made the initial adverse benefit determination or by the subordinate of such individual.

In reviewing an adverse benefit determination that is based in whole or in part on a medical judgment, including determinations, if applicable, with regard to whether a particular treatment, drug, or other item is experimental, investigational or not medically necessarymedically necessarymedically necessarymedically necessary, or that a requested service does not constitute appropriate care, the Review CommitteeReview CommitteeReview CommitteeReview Committee will consult with a health care professional who has appropriate training and experience. Any such health care professional will not be the individual who was consulted in connection with the initial adverse benefit determination or the subordinate of such individual.

In reviewing an adverse benefit determination on a claim for benefits, the Review CommitteeReview CommitteeReview CommitteeReview Committee will provide youyouyouyou with the identification of medical or vocational experts whose advice was obtained on behalf of the Review Review Review Review CommitteeCommitteeCommitteeCommittee in connection with youryouryouryour appeal, regardless of whether the advice was relied upon in making the benefit determination. Subject to the foregoing, the Review CommitteeReview CommitteeReview CommitteeReview Committee may, in its discretion, hold a hearing to make a benefit

determination. Contents of Review CommitteeReview CommitteeReview CommitteeReview Committee’s Decision: The decision of the Review CommitteeReview CommitteeReview CommitteeReview Committee on appeal (including appeals of Urgent CareUrgent CareUrgent CareUrgent Care, Concurrent Care Concurrent Care Concurrent Care Concurrent Care, Pre Pre Pre Pre----ServiceServiceServiceService, and PostPostPostPost----Service ClaimsService ClaimsService ClaimsService Claims) will be in writing, and will include:

1. the specific reason or reasons for the adverse determination; 2. reference to the specific PlaPlaPlaPlannnn provisions on which the determination was based; 3. a statement that youyouyouyou are entitled to receive upon request and free of charge, reasonable access to, and

copies of all documents, records, and other information relevant to youryouryouryour claim for benefits; 4. if an internal rule, guideline, protocol, or other criterion was relied upon to make the adverse determination,

a statement that youyouyouyou are entitled to a copy of such rule and it will be provided free of charge upon request; 5. if the determination was based upon the PPPPlan’slan’slan’slan’s limitations or exclusions for medically necessarymedically necessarymedically necessarymedically necessary or

experimental treatment, a statement to that effect, and a detailed scientific or clinical explanation of this judgment will be provided free of charge upon request;

6. a statement that youyouyouyou may have other voluntary alternative dispute resolution options, such as mediation and one way to find out what may be available is to contact the local U.S. Department of Labor or the Plan Plan Plan Plan AdministratorAdministratorAdministratorAdministrator;

7. a statement that youyouyouyou have the right to bring civil action under Section 502(a) of ERISA following an adverse determination on review.

Civil Action. If youyouyouyou desire to further appeal an adverse decision after youryouryouryour appeal to the PlanPlanPlanPlan, youyouyouyou may file a

lawsuit against the PlanPlanPlanPlan under the provisions of Section 502 of ERISA and other governing provisions. The standard of review to overturn the Plan’sPlan’sPlan’sPlan’s decision on appeal will be whether the decision to deny the claim or benefit was an abuse of discretion. However, no legal action can be brought under ERISA after the latter of one year from the filing of your your your your claim, or 45 days from the decision of the Review CommitteeReview CommitteeReview CommitteeReview Committee.

PART PART PART PART VVVV ERISA RightsERISA RightsERISA RightsERISA Rights

As a participantparticipantparticipantparticipant under the PlanPlanPlanPlan, youyouyouyou are entitled to certain rights and protections under the Employee

Retirement Income Security Act of 1974 (“ERISA”). ERISA provides that all Plan ParticipantsPlan ParticipantsPlan ParticipantsPlan Participants will be entitled to:

Receive Information About Receive Information About Receive Information About Receive Information About YourYourYourYour Plan and Benefits Plan and Benefits Plan and Benefits Plan and Benefits

YouYouYouYou may examine, without charge, at the Plan Plan Plan Plan Administrator'sAdministrator'sAdministrator'sAdministrator's office and at other specified locations, such as worksites and union halls, all documents governing the plan, including insurance contracts and collective bargaining agreements, and a copy of the latest annual report (Form 5500 Series) filed by the PlanPlanPlanPlan with the U.S. Department of Labor and available at the Public Disclosure Room of the Pension and Welfare Benefit Administration.

15


YouYouYouYou may obtain, upon written request to the Plan Plan Plan Plan AdministratorAdministratorAdministratorAdministrator, copies of documents governing the operation of the PlanPlanPlanPlan, including insurance contracts and collective bargaining agreements, and copies of the latest annual report (Form 5500 Series) and updated versions of this document, the Summary Plan Description. The Plan Plan Plan Plan AdministratorAdministratorAdministratorAdministrator may make a reasonable charge for the copies.

Prudent Actions by Plan FiduciariesPrudent Actions by Plan FiduciariesPrudent Actions by Plan FiduciariesPrudent Actions by Plan Fiduciaries

In addition to creating rights for Plan Participants, ERISA imposes duties upon the people who are responsible for the operation of the employee benefit plan. The people who operate youryouryouryour Plan Plan Plan Plan, called “fiduciaries” of the PlanPlanPlanPlan, have a duty to do so prudently and in the interest of youyouyouyou and other participantparticipantparticipantparticipants s s s and beneficiariesbeneficiariesbeneficiariesbeneficiaries. No one, including youryouryouryour EmployerEmployerEmployerEmployer, youryouryouryour union, or any other person, may fire youyouyouyou or otherwise discriminate against youyouyouyou in any way to prevent youyouyouyou from obtaining a welfare benefit or exercising youryouryouryour rights under ERISA.

Enforce Enforce Enforce Enforce YourYourYourYour Rights Rights Rights Rights

If youryouryouryour claim for a welfare benefit is denied or ignored, in whole or in part, youyouyouyou have a right to know why this was done, to obtain copies of documents relating to the decision without charge, and to appeal any denial, all within certain time schedules.

Under ERISA, there are steps youyouyouyou can take to enforce the above rights. For instance, if youyouyouyou request a copy of PlanPlanPlanPlan documents or the latest annual report from the PlanPlanPlanPlan and do not receive them within 30 days, youyouyouyou may file suit in a Federal court. In such a case, the court may require the Plan AdministratorPlan AdministratorPlan AdministratorPlan Administrator to provide the materials and pay youyouyouyou

up to $110 a day until youyouyouyou receive the materials, unless the materials were not sent because of reasons beyond the control of the Plan Plan Plan Plan AdministratorAdministratorAdministratorAdministrator. If youyouyouyou have a claim for benefits which is denied or ignored, in whole or in part, youyouyouyou may file suit in a state or Federal court. In addition, if youyouyouyou disagree with the Plan'sPlan'sPlan'sPlan's, decision or lack thereof, concerning the qualified status of a domestic relations order or a medical child support order, youyouyouyou may file suit in Federal court. If it should happen that PlanPlanPlanPlan fiduciaries misuse the PPPPlan'slan'slan'slan's money, or if youyouyouyou are discriminated against for asserting youryouryouryour rights, youyouyouyou may seek assistance from the U.S. Department of Labor, or youyouyouyou may file suit in a Federal court. The court will decide who should pay court costs and legal fees. If youyouyouyou are successful the court may

order the person youyouyouyou have sued to pay these costs and fees. If youyouyouyou lose, the court may order youyouyouyou to pay these costs and fees, for example, if it finds youryouryouryour claim is frivolous.

Assistance with Assistance with Assistance with Assistance with YourYourYourYour Questions Questions Questions Questions

If youyouyouyou have any questions about youryouryouryour Plan Plan Plan Plan, youyouyouyou should contact the Plan AdministratorPlan AdministratorPlan AdministratorPlan Administrator. If youyouyouyou have any questions about this statement or about youryouryouryour rights under ERISA, or if youyouyouyou need assistance in obtaining documents from the Plan AdministratorPlan AdministratorPlan AdministratorPlan Administrator, youyouyouyou should contact the nearest office of the Employee Benefits Security Administration, U.S. Department of Labor, listed in youryouryouryour telephone directory or the Division of Technical Assistance and Inquiries,

Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, D.C. 20210. YouYouYouYou may also obtain certain publications about youryouryouryour rights and responsibilities under ERISA by calling the publications hotline of the Employee Benefits Security Administration.

16


NOTIFICATION OFNOTIFICATION OFNOTIFICATION OFNOTIFICATION OF NO WORKERS’ COMPENSATIONNO WORKERS’ COMPENSATIONNO WORKERS’ COMPENSATIONNO WORKERS’ COMPENSATION

INSURANCE COVERAGEINSURANCE COVERAGEINSURANCE COVERAGEINSURANCE COVERAGE

[ABC COMPANY] DOES NOTDOES NOTDOES NOTDOES NOT have have have have workers’ compensation insurance coverage to compensate you for work-related injuries. However, the Company does maintain a Workplace Injury Benefit Plan that provides specified medical, wage replacement, and accidental death and dismemberment payments, if

you are injured on the job. You may also have rights under the common laws of Texas.

ACKNOWLEDGEMENT RECEIPTACKNOWLEDGEMENT RECEIPTACKNOWLEDGEMENT RECEIPTACKNOWLEDGEMENT RECEIPT

I, ___________________________, hereby certify that I have been informed that [ABC COMPANY] does not have workers’ compensation insurance, having rejected the Act effective 10/01/2011. I further certify that the

Schedule of Benefits and Summary Plan Description of the Workplace Injury Benefit Plan for [ABC COMPANY] have been read to me or by me, and the answers to all of my questions have been fully explained by the Plan Administrator. __________________________ Date

______________________________________ Employee Signature _______________________________________

Social Security Number _______________________________________ Witness (company representative)

_______________________________________ Witness (company representative) _______________________________________ Work Place

1

NOTICE OF MANDATORY ARBITRATION POLICY

Your employer, on behalf of itself, its related entities, and your fellow employees (hereinafter “Company”) maintains a mandatory arbitration policy. Under this policy it is a condition of your employment that you and Company agree to arbitrate all claims arising from any occupational injury, sickness or disease (including death) related to your employment with Company (the “Claims”), which occur after you sign or receive a copy of this Notice (the “Effective Date”). If you continue to work for Company on or after the Effective Date, you will have agreed to arbitrate all such Claims. Your acceptance of benefits under any employee welfare benefit plan sponsored by Company after the Effective Date is further consideration for this agreement.

Arbitration is Mandatory and Binding: Except for suits seeking temporary injunctive relief designed to maintain the status quo until an arbitration hearing on the merits of the parties Claims may be conducted, all Claims which arise in whole or in part after the Effective Date will be resolved exclusively through binding arbitration. You and Company both waive all rights which each may have to obtain a trial, whether jury or non-jury, in court. How to Make a Claim: Any person bound by this agreement may initiate arbitration by sending a demand for arbitration to the adverse party. The demand must be in writing, describe the Claim and how the claimant was harmed, state an estimate of the amount of the Claim, and demand that the Claim be arbitrated. Any demand for arbitration you make must be sent to the President of the Company via facsimile, overnight delivery, or certified mail. Any demand for arbitration the Company makes against you will be sent to your last known address in the same way. How The Arbitration Will Be Conducted: The parties agree the Federal Arbitration Act (“FAA”) governs all aspects of this Agreement. If for some reason the FAA is held to be inapplicable, the provisions of the Texas Arbitration Act (“TAA”) will apply.

1. Arbitrator Selection and Rules: All Claims will be arbitrated by a single, neutral arbitrator in accordance with the Employment Arbitration Rules of the American Arbitration Association (“AAA”), as modified by the terms of this Agreement. (The arbitration may be self-administered by the parties, and need not be administered by the AAA). The parties will attempt to agree on an arbitrator who must be an attorney in good standing and continually licensed to practice in Texas for at least ten (10) years, and who is either: (a) a former state civil District, federal District or County Court at Law Judge; or (b) who has been qualified as an arbitrator by a recognized arbitration body, such as the AAA. If the parties cannot agree on an arbitrator within sixty (60) days after a demand for arbitration is made, any party may file a statement of claim with the AAA to initiate arbitration in that forum. If either party files a statement claim with the AAA, the AAA will administer the arbitration, including the process of selecting the arbitrator. 2. Arbitration Fees and Expenses: Company will pay an amount equivalent to the amount of the filing fee necessary for any party to file a lawsuit on any Claim in a Texas state court. Thereafter, each side will each pay one half of the fees and costs of arbitration, including one half of the arbitrator’s compensation. Each party will pay its own costs and attorneys fees. On a showing of extreme financial hardship, the arbitrator or AAA (subject to final determination by the arbitrator) may require the Company to advance all or part of your share of the arbitration forum fees and arbitrator's compensation (not your legal fees), subject to a credit against any recovery you may be awarded by the arbitrator.

03/15/12 Midlands Arbitration

2

3. Limitations on Discovery: Discovery and pre-hearing proceedings shall be governed by the Texas Rules of Civil Procedure, except that there shall be no requests for admissions and each party’s right to take depositions is limited to the deposition of: (i) each opposing party; (ii) one additional fact witness; and (iii) all expert witnesses designated by any opposing party. These limitations may be modified by the arbitrator for good cause.

4. Remedies and Defenses: All parties may allege any cause of action, obtain any remedy, and assert any legal or equitable defense, otherwise available under applicable law. Dispositive motions will be allowed without obtaining prior permission from the arbitrator. HOWEVER, THE ARBITRATOR WILL NOT HAVE ANY AUTHORITY TO AWARD PUNITIVE, EXEMPLARY OR MULTIPLE DAMAGES, EXCEPT AS MAY BE MADE AVAILABLE TO A PARTY UNDER A CAUSE OF ACTION CREATED BY STATUTE.

5. Arbitration Hearing and Award: The hearing will be conducted in the county of the Company’s principal place of business in Texas, if within 100 miles of your residence on the date a Claim is asserted in a demand for arbitration or otherwise, or in your county of residence on the date a Claim is asserted, if on that date you live more than 100 miles from the county of the Company’s principal place of business in Texas. Within a reasonable time after the arbitration hearing is over, the arbitrator will issue an award and send a copy to all parties. Prior to opening statements at the arbitration hearing, any party may request in writing that the award be a reasoned or "explained" award. Absent such a timely, written request, the award need not be reasoned. The arbitrator’s award may be confirmed by any court of competent jurisdiction.

6. Confidentiality: Except as is necessary for the confirmation of, or challenge to, any arbitration award, all pleadings, discovery materials, transcripts of proceedings, awards, and the contents of all such materials, will be kept strictly confidential by the parties, their counsel, and all other persons under their control.

Severability; Modifications; At-Will Status: The arbitrator is empowered to decide the enforceability of any provision of this agreement and may sever or modify any provision found to be unenforceable. This agreement is irrevocable and may not be retroactively changed by Company, and may only be changed by Company in the future upon written notice to you of the changes. This is not a contract of employment, and you remain an at-will employee.

Failure to Arbitrate: If any party found to be bound by this agreement pursues a claim by litigation, rather than arbitration, the responding party will be entitled to an order staying or dismissing the lawsuit without prejudice, and the recovery of all attorney’s fees and costs incurred in connection with obtaining such an order as part of the subsequent arbitration proceedings.

I acknowledge receipt of, and agreement to, this Notice of Arbitration Policy. I also understand that binding arbitration under this agreement will be used to resolve all claims between, and is binding upon, Company and my spouse, children, beneficiaries, representatives, executors, administrators, guardians, heirs and assigns. I sign this agreement on behalf of myself and all those people.

Date: EMPLOYEE:

, 20 ___

Printed Name: _________________________

03/15/12 Midlands Arbitration

Post Office Box 22778, Oklahoma City, OK 73123

Phone: 800.800.4007 | Fax: 405.840.5432

03/15/12 Midlands Roll Out Confirmation

CONFIRMATION OF ERISA PLAN ADOPTION AND ROLL-OUT

This is to certify that on [Date on Plan] (effective date), [Insured Name]

(“the Company") adopted the Company's Occupational Injury Benefit Plan by duly-recorded vote of

it’s board of directors (or other applicable governing corporate body) and that on [ Roll- Out Date ]

(roll-out date), the Company presented the Plan's Summary Plan Description to the Company's

employees.

The Company understands the need to provide the “Certification of ERISA Plan Adoption

and Roll-Out” in order to be reimbursed for claims/benefits your Company pays, or claims paid on

your behalf, or liability claims which may be made against you under the Plan.

This further certifies that the Company will provide, at the time of hire, a copy of the

Summary Plan Description to each newly hired employee, and obtain their signature for your file.

This form must be returned to Midlands Management Corporation within 60 days of the

effective date of the policy. Failure to notify Midlands that the ERISA plan has been rolled out

could result in cancellation of your policy for non-compliance.

By: _________________________________

(Owner/Officer Signature)

Date: _______________________________

Print Name: __________________________

Print Title: __________________________

Return completed, signed form to:

Darlene White

Midlands Management Corporation

3503 N.W. 63rd

Street, Suite 305

Oklahoma City, OK 73116

[email protected]

employee injury benefit plan instructions · the purpose of the plan is to provide medical...

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