UNUM PROVIDENT SUPPLEMENTAL DISABILITY BENEFIT PLAN

CSX Transportation

Plan No. 11 220-1 (M-948-ASO)

UNUM PROVIDENT CONTACTS:

Sr. Disability Benefit Specialist: Kim Porter 1-800-858-6843 EXT. 45625 Disability Benefit Specialist: Daryle Edmonds 1-800-858-6843 EXT. 46609 Claims Manager: Dan Vatt 1-800-858-6843 EXT. 44066

Coverage: Conductor and Trainmen employees only.

To speak with a UNUM Provident Representative regarding a general claim dial: 1-800-822-9103

To fax information to UNUM provident, including filing a claim by fax dial: 1-800-447-2498

TO CERTAIN EMPLOYEES OF THE CSX TRANSPORTATION, INC.

REPRESENTEDBYTHE UNITED TRANSPORTATION UNION

One of the most difficult problems confronting a worker is that of protecting himself against loss of income during periods of disability caused by accident or sickness.

The plan outlined in this booklet has been especially designed to give a disabled eligible employee an income for up to 12 months in addition to benefits available under the Railroad Unemployment lnsurance Act.

Please study this booklet carefully, so that you will become acquainted with the benefits to which you are entitled.

The Provident Life and Accident lnsurance Company are pleased to participate as the Administrator of this Benefit Program.

TABLE OF CONTENTS Page

IMPORTANT INFORMATION WITH RESPECT TO ELIGIBILITY Qualifying Employees ........................................................................................ 4 Eligibility for Benefits .......................................................................................... 4

When Is a Qualifying Employee Covered? .................................................. 4 When Does a Qualifying Employee Become Eligible for Benefits? ................................................................................... 5

DEFINITIONS ............................................................................................................. 6

MONTHLY BENEFIT FOR TOTAL DISABILITY ........................................................ 7 Indemnity Limits ................................................................................................. 7 Exclusions and Limitations ................................................................................. 7 Schedule of Benefits .......................................................................................... 8

TERMINATION OF COVERAGE .............................................................................. I I

CLAIM INFORMATION ............................................................................................. 12 Notice of Disability ........................................................................................... 12 Proof of Claim .................................................................................................. 12 Payment of Claim ............................................................................................. 12 Supplementary Plan Description ...................................................................... 14 How To File A Claim ........................................................................................ 19

QUESTIONS AND ANSWERS ................................................................................. 20

IMPORTANT INFORMATION WITH RESPECT TO ELIGIBILITY

Qualifying Employees

Benefit Program No. M-948-AS0 is applicable only to Qualifying Employees.

A Qualifying Employee is a train service employee of the CSXT who is in active train service on a portion of CSXT subject to a supplemental sickness benefit agreement with the United Transportation Union.

ELIGIBILITY FOR BENEFITS

When Is A Qualifying Employee Covered?

If you are a Qualifying Employee and have a minimum of six months of continuous active service on a portion of CSXT covered by a supplemental sickness benefit agreement, you will be covered for each month in which you rendered compensated service to or received vacation pay from CSXT or in which you did not render compensated service solely as a result of disability caused by accidental bodily injury or sickness.

No Employee shall be covered (a) after the date on which his employment relationship is terminated; (b) after the date he is granted a leave of absence; (c) after commencing work on a regular or permanent basis for CSXT on a position not covered by a supplemental sickness benefit agreement with the United Transportation Union (train service employees); or, (d) for a longer period than 12 months during any one period of disability.

IMPORTANT INFORMATION WITH RESPECT TO ELIGIBILITY

(Continued)

Qualifying Employees

An Employee will be considered in active service if he has a continuous employment relationship with the CSXT on a regular, relief, or extra position.

When Does a Qualifying Employee Become Eligible for Benefits?

An Employee shall be eligible for the benefits described in this booklet if he is unable to work in train service solely as a result of disability caused by accidental bodily injury occurring or sickness commencing while he is covered. The disability must be certified by a duly licensed physician or surgeon. Recertification may be required periodically in cases involving prolonged disabilities.

The Employees eligible for such benefits are hereinafter referred to as "Eligible Employees."

DEFINITIONS

1. The term "total disability" as used herein means the complete inability of an Employee, because of injury or sickness, to perform each and every duty pertaining to his occupation or employment.

Period of Total Disability - A period of total disability means the period of time during which a Covered Employee is totally disabled, as defined above, whether from one or more causes, beginning with the first full day of total disability following cessation of active work for the Employer and ending on the date such Employee ceases to be totally disabled.

The term "hospital" as used herein means an institution which meets all the following tests: (a) It is engaged primarily in providing medical care and treatment of sick and

injured persons on an in-patient basis at the patient's expense and maintains diagnostic and therapeutic facilities for surgical and medical diagnosis and treatment of such persons by or under the supervision of a staff of duly qualified physicians;

(b) It continuously provides 24 hour a day nursing service by or under the supervision of registered graduate nurses and is operated continuously with organized facilities for operative surgery; and

(c) It is not, other than incidentally, a place of rest, a place for the aged, a place for drug addicts, a place for alcoholics or a nursing home.

3. The term "Other Income Benefits" as used herein means income benefits under: (a) the Railroad Unemployment Insurance Act; (b) the Railroad Retirement Act; (c) the Federal Social Security Act; and, (d) any plan, fund or other arrangement, by whatever name called, providing

benefits for loss of time from employment because of disability pursuant to any compulsory benefit act or law of any government.

4. The term "average monthly earnings" as used herein means the average of the Employee's actual gross wages received from CSXT during the 12 calendar months immediately preceding the month in which disability commences.

MONTHLY BENEFIT FOR DISABILITY

If an Eligible Employee shall be disabled as a result of accidental bodily injury or sickness, the Administrator will pay to the Employee for the period for such disability a benefit as provided herein.

BENEFIT LIMITS - Benefits will be paid commencing with the fifth full day of disability and will be paid for not more than 12 months during any one period of disability, provided that no payment shall be made:

(1) for disability for which the Employee is not under treatment by a duly qualified physician or surgeon as certified by the physician or surgeon;

(2) during the first four days of an injury or sickness; (3) for disability due to intentionally self-inflicted injuries; (4) for disability for which the contributing cause was the commission or

attempted commission by the Employee of an assault, battery or felony; (5) for disability due to war or any act of war, insurrection, riot or rebellion; (6) for any day on which an Employee eligible to receive benefits under the

Disability provisions of the Railroad Unemployment Insurance Act is denied such benefits for any reason including failure by the Employee to make application for benefits;

(7) after the date the employment relationship ceases; (8) for disability which commences before the effective date of the Plan; (9) after the date of the employee's death or the date he ceases to be

disabled; or (1 0) after the date the employee is furloughed.

MONTHLY BENEFIT FOR DISABILITY

(Continued)

In determining the amount of monthly benefits payable, an Employee age 65 or over shall be considered eligible to receive extended or accelerated sickness benefits under the Railroad Unemployment Insurance Act if such employee would have been eligible to receive such benefits if under 65 years of age.

SCHEDULE OF BENEFITS

The following SCHEDULE OF BENEFITS is applicable for periods of disability commencing on and after June 1,2009:

(i) The amount of monthly benefit payable for each full month of total disability shall be determined by the Employee's average monthly earnings for the 12 month period preceding disability, subject to a maximum of: (a) $1,005.70 for each of the first six month of any one period of

disability; or (b) $1,273.87 for each of the 7th through 12th months of any one

period of disability.

The $1,005.70 shall be increased by $1 34.09 with respect to the first two months of any one period of disability while the Employee is confined as an in-patient in a hospital.

Benefits will be pro-rated whenever less than a full calendar month is involved.

A covered employee during his initial RUlA registration period after all certification requirements are met will receive:

(ii) Benefits for the 5th thru the 14th day of disability at the applicable basic benefit amount plus

(iii) An amount equal to the total RUlA benefit that would have been payable for days of sickness except for RUIA's "waiting period" requirement.

MONTHLY BENEFIT FOR DISABILITY (Continued)

SCHEDULE OF BENEFITS (Continued)

(iv) The maximum monthly benefit shall be $1,005.70 during any part of the 7th through 12th month during any one period of disability during which the Employee is eligible to receive disability benefits under the Railroad Unemployment lnsurance Act.

The monthly benefit will be reduced to the extent that it, plus any other income benefit available to an employee in the same month, exceeds the lesser of $1,881.03 or 70% of the employee's average monthly earnings in the 12 months preceding disability.

(v) When the benefits are reduced because of sickness benefits payable under the Railroad Unemployment lnsurance Act ($59 per day at the time this booklet was issued), the monthly benefits payable under the Benefit Program are based upon average monthly earnings for the 12-month period immediately preceding disability. The monthly RUlA benefit amount is calculated by multiplying the daily rate by 21.75.

Lower average monthly income than shown above will result in additional reduction in the monthly benefit.

MONTHLY BENEFIT FOR DISABILITY (Continued)

SCHEDULE OF BENEFITS (Continued)

Retroactive Payment of Other Income Benefit. If an employee receives any other income benefit on a retroactive basis for any part of a period of disability for which benefits were paid under this Benefit Program, the Administrator will have the right to recover the amount of benefits paid under this Benefit Program in excess of what the employee would have received had the retroactive payments been made when the benefits were paid.

Liability Cases. In case of a disability for which the employee may have a right of recovery, benefits will be paid under this Benefit Program pending final resolution of the matter so that the employee will not be exclusively dependent upon Railroad Unemployment lnsurance Sickness Benefits or other existing benefits. However, the benefits under this program are not to duplicate recovery for loss of wages. Accordingly, benefits paid under this Benefit Program will be offset against any claim for loss of wages the employee may have against the Company and may be recovered by the Company if lost wages are recovered from third parties. As a condition for payment of Benefits, Provident, the Administrator, may require the employee to assign to it the right to recover wages, to the amount of benefits paid, from third parties. Upon recovery, the employee will reimburse the Administrator for benefits paid under the Benefit Program.

Non-Governmental Plan for Sickness Insurance. Effectiveness of the Supplemental Sickness Benefit Plan is conditioned upon a favorable ruling from the Railroad Retirement Board that such Plan qualified as a "non-governmental plan for sickness insurance" under Section i(j) of the Railroad Unemployment lnsurance Act.

TERMINATION OF COVERAGE

Your coverage under the Plan will terminate on the earliest of the following dates:

(a) The date of termination of the Benefit Program;

(b) The date the Benefit Program is amended to terminate the coverage with respect to the class of Employees of which you are a member; or

(c) The date you cease to be a Covered Employee as defined on Page 5.

CLAIM INFORMATION

NOTICE OF DISABILITY A Notice of Disability form is included in this booklet. It may be used to report a claim for benefits under this Benefit Program. You may also obtain Notice of Disability forms from the Administrator's claim processing office or your supervisor. When you have been disabled and under the care of a physician for five days, complete the enclosed Notice of Disability Form and mail it promptly to the Administrator's claim processing office.

PROOF OF CLAIM Upon receipt of the Notice of Disability form, Provident will immediately furnish an attending Physician's Statement. This form contains detailed instructions for completion.

PAYMENT OF CLAIMS Benefits will be paid upon receipt of written proof on the Administrator's forms, or if such forms are not furnished by the Administrator within 15 days after demand therefore, then upon receipt of written proof covering the occurrence, character and extent of the event for which claim is made, the Administrator may require as part of the proof of claim, bills with respect to hospital confinement and to all other charges incurred. The Administrator will make any investigations necessary of claims and will make all payments in settlement of such claims.

The Administrator has the right to require an examination of the person of the Covered Employee by a licensed physician when and as often as it may reasonably require during the pendency of the claim, to the extent that such examination is necessary to the investigation of the pending claim.

Proof of loss on which claim may be based should be furnished to the Administrator no later than 90 days after the date of such loss.

If any time limitation applicable to the Benefit Program with respect to furnishing proof of loss or bringing of an action at law or in equity is less than the minimum permitted by the law of the state in which the Covered Employee resides at the date of the accident causing the injury on which claim is based or at the date of commencement of sickness disability or of other loss on which claim is based, such limitation is extended to agree with the minimum period permitted by such law.

CLAIM INFORMATION (Continued)

All benefits will be paid immediately after receipt of the due proof of loss, or upon the request of the Employee, and subject to due proof of loss. The accrued monthly benefit for which proof of loss has been furnished will be paid each month and any balance remaining unpaid at the termination of such period will be paid immediately after receipt of due proof.

All benefits will be payable to the Employee and any accrued benefits unpaid at his death shall be payable to his Estate.

SUPPLEMENTARY PLAN INFORMATION

The following information, together with this booklet, constitutes the Summary Plan Description required by the Employee Retirement Income Security Act of 1974 to be distributed to Employees covered under this Benefit Program.

1. Name of Plan: Supplemental Sickness Benefit Plan covering certain employees of CSX Transportation, Inc., represented by the United Transportation Union.

2. Name, Address and Telephone Number of the Plan Sponsor who is the agent for service of legal process of the Benefit Program:

CSX Transportation, Inc. 50 Water Street

Jacksonville, FL 32202 AC 904 - 359-2345

3. Employer Identification Number: 54-6000720

4. Type of Administration: AS0

5. Benefit Program records are maintained on a policy year basis ending December 31 st each year.

6. Source of Contributions: Employer

7. Claim Procedures and Payment of Benefits:

Claim for benefits under the Benefit Program is to be submitted to the Administrator as provided in your booklet. Payment of claim under the Benefit Program will be made by the Administrator. If your claim for benefits under the Benefit Program is denied, the Administrator will provide notice to you in writing of the denial within 90 days after receipt of the claim setting for the specific reasons for such denial; specific reference to pertinent plan provisions on which denial is based; a description of any additional information needed to perfect a claim and an explanation of why such information is needed; and appropriate information as to steps to be taken if you wish to have your claim reviewed.

SUPPLEMENTARY PLAN INFORMATION (Continued)

You or your duly authorized representative have the right to request review of your claim by the Administrator. You may request a review upon written application to the Administrator within 60 days of receipt of the claim denial. You may review pertinent documents and submit issues and comments in writing. Ordinarily the Administrator will make a final review and notify you in writing within 60 days. This notice shall contain specific reasons for the decision with references to appropriate plan provisions. If special circumstances warrant additional time for review, you will be notified in writing prior to the extension. In no case will the extension be more than an additional 60 days.

The Administrator's liability for claims review extends only to the benefits provided under the plan of coverage listed in Item 1. The Administrator will not review claims for any other benefits unless a separate contract specifically provides for this.

8. An Employee you are a participant in the Benefit Program and are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974. ERISA provides that all plan participants shall be entitled to:

Examine without charge, at the Plan Sponsor's office all Benefit Program documents, including contracts, and copies of all documents filed by the Benefit Program with the U.S. Department of Labor, such as annual reports and plan descriptions.

Obtain copies of all Benefit Program documents and other Benefit Program information upon written request to the Benefit Program Plan Sponsor. The Plan Sponsor may make a reasonable charge for copies.

Receive a summary of the Benefit Program's annual financial report. The Benefit Program Plan Sponsor is required by law to furnish each participant with a copy of this summary financial report.

SUPPLEMENTARY PLAN INFORMATION (Continued)

In addition to creating rights for Benefit Program participants, ERISA imposes duties upon people who are responsible for the operation of the Employee Benefit Program. The people who operate your Benefit Program, called "fiduciaries" of the Benefit Program, have a duty to do so prudently and in the interest of you and other Benefit Program participants and beneficiaries.

No one may fire you or otherwise discriminate against you in any way to prevent you from obtaining a benefit or exercising your rights under ERISA. If your claim for a benefit is denied in whole or in part you must receive a written explanation of the reason for the denial. You have the right to have the plan reviewed and your claim reconsidered. If you are not satisfied with the final claims decision, you may file suit in Federal or State Court.

Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request materials from the Benefit Program and do not receive them within 30 days, you may file suit in a Federal Court. In such a case, the court may require the Benefit Program Plan Sponsor to provide materials and pay you up to $1 10 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the Plan Sponsor. If you have a claim for benefits which is denied or ignored, in whole or in part, you may file suit in a state or federal court. If it should happen that Benefit Program fiduciaries misuse the Benefit Program's money, or if you are discriminated against for asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in a Federal Court. The court will decide who should pay court costs and legal fees. If you are successful the court may order the person you have sued to pay these costs and fees or, if it finds your claim is frivolous the court may order you to pay the costs and fees. If you have any questions about your plan, you should contact the Benefit Program Plan Sponsor.

If you have any questions about this statement or your rights under ERISA, you should contact the Benefit Program Plan Sponsor or the nearest Area Office of the U.S. Labor- Management Service Administration, Department of Labor.

The information contained in this Summary Plan Description is only a summary of several rights, benefits and administrative procedures contained in your Benefit Program. In case of any conflict, specific terms in the plan document will control over the summary.

IMPORTANT NOTICE FOR EMPLOYEESREPRESENTEDBY

UNITED TRANSPORTATION UNION ON

CSXT (FORMER B&OlB&OCT, C&O (PROPER) C&O (PMIHV)), WM, A&WP AND CERTAIN EMPLOYEES AT CONSOLIDATED GREATER RICHMOND TERMINAL

CSXT and the United Transportation Union have completed agreements to provide covered employees with a Supplemental Sickness Benefit Plan effective January 1, 1990 which provides monthly benefits payable during illness or injury and loss of time from work.

This new agreement applies to Train Service Employees represented by the United Transportation Union on the above-named portions of CSXT and covers disability commencing on or after June 1, 2009, provided the following requirements have been met:

(a) Employee has completed six months of continuous active service with CSXT under the collectively bargained agreement with the United Transportation Union to which he is subject.

(b) Employee is in active train service subject to the collectively bargained agreement with the United Transportation Union.

(c) Employee is eligible for sickness benefits as provided by the Railroad Unemployment Insurance Act.

(d) Employee is unable to work in train service solely because of illness or injury as certified by a licensed physician.

(e) Employee has met a four-day waiting period from the date of commencement of illness or injury.

(f) Employee is not subject to a wage continuation program as a result of an on-duty personal injury.

Plan benefit amounts are determined by an employee's average monthly earnings in the 12-month period immediately preceding disability, subject to a monthly maximum of $1,005.70.

The above brief description of benefits available is furnished in order to make employees aware of the existence of the Supplemental Sickness Benefit Plan. If there is any discrepancy between this notice and Plan documents, the Plan documents will govern.

IMPORTANT NOTICE FOR EMPLOYEESREPRESENTEDBY

UNITED TRANSPORTATION UNION ON

CSXT (FORMER B&OlB&OCT, C&O (PROPER) C&O (PMIHV)), WM, A&WP AND CERTAIN EMPLOYEES AT CONSOLIDATED GREATER RICHMOND TERMINAL

(Continued)

The Provident Life and Accident Insurance Company located at One Fountain Square, Chattanooga, Tennessee 37402 is the administrator of the Plan. Booklets describing the Plan will be distributed in the near future. If employees need to file a claim prior to receipt of the booklet they may request a claim form from their Supervising Officer.

HOW TO FILE A CLAIM For Certain Employees of CSX TRANSPORTATION Represented by the UTU

SUPPLEMENTAL SICKNESS BENEFIT PLAN

When you are disabled, your claim will receive prompt handling if you will do the following:

(1) See your doctor immediately.

(2) Obtain and fill in the green NOTICE OF DISABILITY (Form F-68667) and mail to Provident as soon as you know you will be disabled for more than 4 days.

Double check your Social Security Number and Employee ID Number that you show on the notice form. A "wrong number" will delay your claim.

It is important that the "Notice of Disability" form be sent promptly so that Provident can obtain certification from both your employer and the Railroad Retirement Board. This will enable Provident to pay your claim immediately when proof of your disability is received.

(3) Obtain and fill in the U. S. RAILROAD RETIREMENT BOARD "Application for Sickness Benefits" form, have your doctor complete the RAILROAD RETIREMENT BOARD "Statement of Sickness" form, and promptly mail both of those forms to the Bureau of Unemployment and Sickness Insurance, U. S. Railroad Retirement Board, 844 Rush Street, Chicago, Illinois 6061 1.

This is IMPORTANT because unless you file your claim with RUlA promptly, your Supplemental Sickness Benefit Payment will be delayed.

(4) The blue "PROOF OF DISABILITY" (Form F-68387) should be completed by you and your doctor at the end of each 30 day period of disability or at the end of your disability, whichever comes first.

Address of Claim Paying Office:

Provident Life and Accident Insurance Company Railroad Disability Claims

P. 0. Box 180135 Chattanooga, TN 37401 -7135

Telephone Number: 1-800-542-4231 FAX: 1-423-294-7857

SUPPLEMENTAL DISABILITY BENEFIT PLAN BENEFIT PROGRAM M-948-AS0

The following questions and answers are presented for the purpose of giving you a better understanding of your Supplemental Disability Benefit Plan.

Q. How and where can I obtain claim forms? A. Write to the Provident claim office located at:

Provident Life and Accident lnsurance Company Railroad Disability Claims P. 0. Box 180135 Chattanooga, Tennessee 37401 -71 35

Q. Why is it important that the green "Notice of Disability" Form F-68667 be completed and sent to the Provident office as soon as I know disability will extend beyond 4 days, rather than waiting until the end of my disability or the end of the first 30 days of disability?

A. Giving prompt notice will speed up your claim payment. After your "Notice of Disability" form is received, Provident will certify your eligibility from both your employer and the Railroad Retirement Board. If you give prompt notice, chances are that both your employer and the Railroad Retirement Board will have furnished certification by the time Provident receives your "Proof of Disability" Form F-68387 which is to be completed by you and your doctor.

Q. When should I send Provident the blue "Proof of Disability" form which is to be completed by me and my doctor?

A. At the end of the first 30 days or the end of your disability, whichever comes first.

Q. Do I have to be under the care of a physician to claim disability benefits? A. Yes.

Q. Under the terms of the Benefit Program, is it necessary to file for disability benefits under the Railroad Unemployment lnsurance Act in order to collect benefits under the Supplemental Disability Benefit Plan?

A. Yes. You should obtain and fill in the U. S. Railroad Retirement Board "Application for Sickness Benefits" form, have your doctor fill in the Railroad Retirement Board "Statement of Sickness" form, and promptly mail both of those forms on the Bureau of Unemployment and Sickness Insurance, U. S. Railroad Retirement Board, 844 Rush Street, Chicago, Illinois 6061 1.

SUPPLEMENTAL DISABILITY BENEFIT PLAN BENEFIT PROGRAM M-948-AS0

(Continued)

Is it necessary for one to actually be paid RUlA benefits in order to qualify for disability benefits under the Supplemental Disability Benefit Plan? If you are "late" filing for RUlA benefits, you could be penalized and disability benefits may not be payable under RUlA until the date you can actually file. If this happens, you will also lose disability benefits under the Supplemental Disability Benefit Plan, because Supplemental Benefits are not payable for any day for which you are denied RUlA benefits unless the reason for the denial is one of the following:

(1) You have exhausted your RUlA benefits during a benefit year, or (2) You are a "Qualified Employee" under RUIA, but are denied

benefits because you are receiving annuity benefits under Railroad Retirement, Social Security, or military services, etc.

In addition to being a "Qualified Employee" under RUIA, what other requirements must I meet in order to be eligible for benefits under the Supplemental Disability Benefit Plan? Generally speaking, an employee is a "Qualified Employee" under the Supplemental Disability Plan when he meets all of the following requirements:

(1) Is a train service employee of the CSXT who is in active train service on a portion of CSXT subject to a Supplemental Sickness Benefit Agreement with the United Transportation Union;

(2) and has a minimum of six months of continuous active train service on a portion of CSXT covered by a Supplemental Sickness Benefit Agreement with the UTU.

Suppose I am a "Qualified Employee" under the Supplemental Disability Benefit Plan, but my service is interrupted because of disability, furlough, leave of absence or discipline. If I return to work for the same railroad within 12 months, when will I again become a "Qualified Employee"? On the first day you render compensated service under a UTU Trainmen's schedule agreement.

How often are benefit payments made by Provident under the Supplemental Sickness Benefit Plan? Monthly.

How long are benefits payable? Up to 12 months in connection with any one period of total disability.

SUPPLEMENTAL DISABILITY BENEFIT PLAN BENEFIT PROGRAM M-948-AS0

(Continued)

Is 12 months the most I can ever draw for disability under the Supplemental Sickness Benefit Plan? No. If you are paid the full 12 month limit for a period of disability and later have a new period of disability which starts while you are a "Qualified Employee," you may qualify for additional disability benefits under the Supplemental Sickness Benefit Plan.

What determines the amount of the monthly benefit I receive under the Plan? The amount is determined by the employee's average monthly earnings for the 12 month period preceding disability subject to certain maximums.

Will my monthly benefits under the Supplemental Disability Benefit Plan be increased if I exhaust my benefits under RUlA in less than 12 months? Yes, your monthly benefits under the Plan will be increased an additional $200 per month but not to exceed the lesser of $1,273.87 or 70% of your average monthly earnings in the 12 months preceding disability.

Will my disability benefits under the Supplemental Disability Benefit Plan be reduced if I apply for and receive a disability annuity under the Railroad Retirement Act? Your Supplemental Disability Benefit Plan benefits will be reduced only if your total benefits exceed the lesser of $1,881.03 or 70% of your average monthly earnings for the 12 months preceding disability.

I have another disability policy for which I pay the entire premium. Will this reduce my Supplemental Sickness Plan benefits? No.

Are disabilities due to pregnancy covered? Yes.

Are disabilities for employees over age 65 but actively working covered? Yes. Benefits will be allowed to eligible employees up to 12 months.

Does the law require Provident to report Supplemental Disability Benefit Payments to the Internal Revenue Service? Yes. Public Law 96-601 requires that benefit payments made on or after May 1, 1981, be reported and that each employee be furnished with a W-2 form showing the amount of benefits he or she was paid each year.

SUPPLEMENTAL DISABILITY BENEFIT PLAN BENEFIT PROGRAM M-948-AS0

(Continued)

Q. Does the law require Provident to withhold Railroad Retirement Tier I taxes from Supplemental Sickness Benefits?

A. Yes. Public Law 97-123, which became effective January 1, 1982, requires that Railroad Retirement Tier I taxes be withheld from benefit payments made prior to the end of six months from the end of the month in which an employee last worked. The employer is required to pay a matching share of Railroad Retirement tax withheld from Supplemental Sickness Benefit Payments. State Income Tax must also be withheld if applicable.

Q. Does this Plan provide replacement of benefits that are not paid by the RRB for the first Registration Period during a Benefit Year?

A. Yes. The Plan provides replacement at the current daily level once during each Benefit Year, i.e., from July 1 through June 30 of the following year.

NOTICE O F DISABILITY Supplementa l S ickness Benef i t Plan Provident Life and Accident Insurance Company P.O. Box 180135 Chattanooga, TN 37401-7135

RAILROAD D l S A B l L l N CLAIMS IF YOU BECOME DISABLED. YOU AND YOUR AllENDiNG Customer Service Telephone Number: PHYSICIAN(S) SHOULD FULLY COMPLETE ALL PARTS ph: 1-800-822-9103 Fax: 1-800-447-2498 IMMEDIATELYAND RETURN TO UNUM.

, Employee's Address (Number) (Street) (city) (state) (Zip) 1 Telephone Number I Dale Em~loved 3 Please indicate if new address

. .

I ) I

( ) Date of First Treatment I Do vou currenllv hold a medical certiiication? I? Yes '1 No

fl i. ~echanic or comparable or higher rated position O 2. Helper or comparable position

3. Lower rated oosition Indicate gse of Disability

fl Accident (Comolete Part ill fl Sick- cause1 Have You Returned To Work?

. . I $

2. ( )

3.

..... - .. I u 'DOT o CRANE other Have you completed a total of at least 12 calendar months of Did you work forme Employer named above (or take vacation employment with one or more participating railroads? C Yes O N wilh pay) in the month beforevou became disabled? E Yes D NO

I . Name 01 Ail Trealing Physicians Telephone No. U Yes-if so, give date

Occupation

(It O Nwif not, when do you expect to return to work? Have you received vacation pay since your last day worked7 O Yes O No if yes. give date(s)

--

Date Of Accldent 1 Were vou at work when accldent haooened?

Indicate which Organization represents you: i3 Maintenance ot Way 5 Firemen & Oilers C Machinists E Electricians '! Sheet Metal Workers fl Carmen C Boilermakers, etc. CiSignalmen L? Other Indicate Occuoation Class:

Name of Employer

When Did You Become Disabled?O AM Date Time

1 O Yes 0 No If yes. forwhom? Explain How Accident Happened?

Department Last Worked

Supelvisor's Name Telephone No. ( 1

Was a railroad on-trackvehicle involved? 1 Did injury result from a traffic awident? I Will a Liability claim be made?

Location Last Worlted

Benelits under the Railroad Unemployment Insurance Act:

Date You Last Worked 1 Rate of Pav (oer hrJver monlh)

1. Have you appliedforsickness benefits underthe Railroad Unemployment Insurance Act? =! Yes 5 No 2. 11 not, why not? P Am not qualified under the Act. My benefits have been exhausted forthis benefit year.

D Other (explain) Other lncome Benevis:

Are any of the 'Other Income BenefitClisled below available to you whiiedisabled? L Yes 2 No (Ifyes,checkeachofthefollowingwhich is applicable, and show monthly amounts payable).

3 Railroad Retirement Act-Disability Annuity O Social Security Act (Are Benefits for Age o

......................... C Military Pension (Are Benefits for Years of Service or Disability? 1 .... $ 3 Wage Continuatio $

$ $

C Advancement f ....................................................................................... 6 $

F-68625 (12102) Prinled In U.S.A. 10 (4107)(0ver)

1. Name of Empioyee

2. Social Secum Number

7. Is patient receiving physical therapy? D y e s No it "Yes" iwJicat% Rame and address of IaCil@flheraQist

3. Diagnosis and concurrent condaions (If diagnosis code other than ICD9' used, give name):

8. Date symptoms first appeared or accident happened.

4. Dates of Treatment First: (If previous form submitted to this carrier. you need show only dates since last report)

9. Date patient first consulted you for this condition.

3. Dates of Hospital Confinement

Admitted Discharged

10.Patient ever had same or similar condiion? Yes No If "Yes" when and describe

5. Has patient had surgaryloutpatient procedures? (if so, date 1

6. Frequency of Treatment

11.Patient still under your care for this condition? OYes No if 'No', has patient been refened to anotter physician?

12,Patient was continuously unable lo perform the regular duties of hisher own occupation. From To

13.11 patient was released to restricted duty, please indicate all restrictions and applicable dates.

14.11 still disabled, date patient should be able to return to work

Date Completed Phy~ l r i ah Name (Pllnt) Sinalure OBwen Tarpner's Account No.

X treet Address Ciy or Town State or Province Zip Code Telephone No.

Fax NO.

Any person who knowingly and with intent to defraud any insurance company or other person hies a statement of claim containing any materiiiiy false information, or conceals for lhe purpose of misleading; information concerning any fact materiel thereto, commits a fraudulent insurance act which is a crime, in Florida, a felony of the third degree. The undersigned certifies Mat the information disclosed above is a correct declaration of facts upon which claim is based lor benefits and furltier hereby acknowledges Me limitations and provisions of the plan.

AUTHORIZATIOW Solely to assist Provident Lifeand Accident Insurance Company in administering an insurance claim. I hereby authorize any providar of health care inciud- ing but not limited to any institution, or person possessing information concerning:

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to permitthe abocnamed insurance company and its representative, insurance suppottGnization, reinsurance companies or other persons performing business or ieaaise~ices in connection with the claim, to view, coov. be furnished cooies or be aiven details of allsuch Dhvsicai or mental medical-record information including but not limited to drug, alcohol or psychiatrictreatment or condition, askell as information reg'aiing employment income, other insurance coverage, andlor any otherwise personal or privileged information, including but not limited to any other claim for insurance benefits, or any records concerning civil or criminal proceedings. Any copy of the authorization shall have the same authority as the original. I understand I, or my authorized representative, may reeeive a copy of this authorizatlon upon request. This authorization is valid for the duration of the claim.

Signature Date

Unum is a registered irademark and marketing brand of Unum Group and its insuring subsidiaries.